Pediatric Hematology/Oncology
Clinical discussions on pediatric blood disorders, childhood cancers, and specialized treatment protocols.
Recent Discussions
How do you counsel patients with locally advanced malignancies who have ECOG 3-4?
I agree with @Dr. First Last and @Dr. First Last's comments about the implications of PS and specific situations where medical therapies have the potential to improve PS (heme malignancies small cell) and/or extend quality of life. I have two goals in this conversation. To make sure I understand the...
What is your strategy for breakthrough chemotherapy induced N&V in patients receiving highly emetogenic chemotherapy and already received a NK-1 antagonist, 5-HT3 antagonist, dexamethasone, and olanzapine?
I find the MASCC anti-emetic guidelines to be very well written Davis et al., PMID 34398289.Very few randomized clinical trials in cancer for antiemetics (with positive trials associated with metoclopramide (D2 receptor antagonist) and olanzapine).So - most are based on trial and error + clinician p...
Do you routinely check Pulmonary function testing prior to each cycle of BEP for young patients with testicular cancer with no pulmonary risk factors?
A few comments: I do not check DLCO or PFTs in general in patients under age 50 getting just 3 courses of BEP. We tend to avoid bleo if over age 50. If a patient is getting 12 weeks of bleo, I check DLCO just prior to the start of the 4th course, and if DLCO < 60%, I give VIP for the 4th course. Ad...
When would you initiate chronic therapeutic phlebotomy in a patient with erythrocytosis secondary to a high hemoglobin-oxygen affinity hemoglobinopathy?
The large majority of patients with high oxygen affinity hemoglobinopathy do not require therapeutic phlebotomy. There is a subset of patients who develop symptoms (generally these are non-specific such as headache) or complications such as thrombosis. There seems to be no correlation between hemato...
Do you recommend lifelong antibiotic prophylaxis, or do you prefer a more selective approach based on risk factors in asplenic patients without a history of severe infections?
The advice is limited by the fact that there are no randomized controlled trials in adults on daily antibiotic prophylaxis post-splenectomy. There are trials in children with sickle-cell disease that do show a benefit, but it is not clear that these can be extrapolated to splenectomized adults. Furt...
Should post-transplant cyclophosphamide be utilized for all matched unrelated donor peripheral blood stem cell transplants for hematologic malignancy?
In myeloablative transplantation, PTCY did not have an advantage over Tac/MTX as demonstrated in the BMT-CTN 1301 study which compared PTCY, Tac/MTX, and T cell depletion (Luznik et al., PMID 34855460). One caveat is that in this trial, PTCY based prophylaxis did not include Tac or Tac/MMF.BMT-CTN 1...
How do you counsel patients with acute intermittent porphyria when it comes to fasting for religious reasons?
This is a very difficult question and it depends on the individual patient, their disease severity, their particular triggers, and how they have done in the past with caloric restriction. The patient may want to speak with a clergy member for guidance in this situation as well. For inst...
How do you workup splenomegaly related to possible hematologic etiology in the absence of abnormal blood counts, adenopathy or severe constitutional symptoms?
The presence of splenomegaly is an important finding found either on physical exams or by imaging. As noted in the question, the initial work up includes physical exam looking for lymphadenopathy. In addition, laboratory evaluation, including absolute white count, and differential may help explain w...
In pediatric patients with low-grade gliomas showing prolonged response or stable disease on tovorafenib, how would you adjust the duration of therapy?
This is a one-million-dollar question. As far as I know, the design of FIREFLY-2 includes a fixed duration of treatment, and this is also the case for ACSN1833 (selumetinib trial). It will be important to look at the PFS of the patients who discontinued tovorafenib and compare with the results of ch...
Do you recommend using BRAFV600E mutation status to risk stratify treatment for a pediatric patient with langerhans cell histiocytosis?
It’s certainly useful information. Even if you don’t use a BRAF inhibitor as first line therapy, you will have that option in your back pocket.