Pediatric Hematology/Oncology
Clinical discussions on pediatric blood disorders, childhood cancers, and specialized treatment protocols.
Recent Discussions
What adverse events would make you switch off nivo + AVD therapy and to what second line therapy in patients with Hodgkin Lymphoma?
The question of how to handle severe IRAEs when using the N+AVD regimen is an important one. First, of course, is to hold CPI therapy, empirically treat as indicated to avoid ongoing or worsening organ injury, and concurrently ensure that there is no other cause for the observed event(s). But if you...
Have you used oral vancomycin as prophylaxis for C difficile infection in patients admitted for allogeneic hematopoietic cell transplant?
Yes, but only in patients with a history of C difficile in the previous year and starting at the time of initiation of broad-spectrum antibiotics (e.g., for fever and neutropenia). We use 125 mg daily.We are aware this practice may be controversial. To my knowledge, there is only one randomized tria...
How do you consider SBRT relative to other emerging therapies for pediatric sarcomas, such as proton therapy or immunotherapy, in terms of efficacy and safety?
Treatment paradigms for pediatric malignancies have evolved through group trials over the past 5 decades, both in the US (e.g., COG) and abroad (SIOP). Sequential improvements have been made over the years to the quality of radiation for both pediatric and young adults, a population at risk for majo...
What is your recommended long term management of extensive dural venous sinus thrombosis in an otherwise healthy young patient?
From a Vascular Neurology perspective, there are two considerations when faced with patients with venous sinus thrombosis. First is the status of the intracranial venous circulation and whether or not there has been adequate reconstitution of venous outflow, either through recanalization or collater...
Do you use direct oral anticoagulants to treat port-a-cath related VTE in patients with an active malignancy?
The initial trials that established DOACs as effective and safe in most patients with cancer-associated thrombosis (Agnelli et al., PMID 32223112, Planquette et al., PMID 34627853) only included patients with lower-extremity DVT or PE but clearly showed equivalence to low-molecular weight heparin (w...
Do you screen for VWD in all women with menorrhagia severe enough to cause iron deficiency anemia?
Yes, testing vWF is needed in this situation of severe menometrorrhagia. Excessive menstrual bleeding, especially when severe enough to cause anemia, is a common presenting symptom of vWD in women. The testing should be done as part of a comprehensive workup for gynecologic etiologies and other coag...
What would your next line of treatment be for a patient with Hb SC with history of recurrent VOC and new bone infarct who is already on hydroxyurea and phlebotomy?
HbSC disease is the stepchild of sickle hemoglobinopathies with almost no studies of its treatment, so that any recommendation is not data based. One might consider adding crizanlizumab that blocks red cell-endothelial cell adherence. Each treatment group of the crizanlizumab study that led to its F...
In patients with VOD post-HSCT, what would be the role of TPO agonists instead of platelet transfusions, given their platelet refractoriness and concerns for fluid overload?
This is an insightful question, as it addresses a key issue in the management of veno-occlusive disease (VOD) - chiefly, how does one minimize the amount of fluid being given, but at the same time, support patients with persistently low platelet counts, the majority of whom will be on a therapy whic...
How would you treat suspected secondary HLH in patients whom etoposide is contraindicated?
Thank you for the interesting question. It would be helpful to understand why etoposide is contraindicated. My general approach for these patients is to first ensure that there is no evidence of malignancy as a trigger as you do not want to mask that with steroids (I strongly recommend obtaining a P...
How do different inflammatory markers like CRP and ferritin contribute differently, if at all, to the monitoring of CART neurotoxicity?
These markers are routinely monitored as they are seen in association with CRS (cytokine release syndrome). Not all patients with CRS will also develop neurotoxicity (ICANS), but most patients with ICANS have antecedent CRS, so in an encephalopathic patient post-CART who does not have significant el...