Pediatric Hematology/Oncology
Clinical discussions on pediatric blood disorders, childhood cancers, and specialized treatment protocols.
Recent Discussions
For a pediatric patient with B-ALL who requires surgery during maintenance, what therapy modifications do you recommend to allow for optimal healing and minimal treatment disruption?
If the patient has a history of stable ANC and platelet count while on mercaptopurine and methotrexate, no change in treatment is necessary. For a patient with unpredictable fluctuations in ANC and platelet count while on mercaptopurine and methotrexate, I recommend stopping oral antimetabolites two...
At what ferritin threshold would a patient with anemia of inflammation or malignancy no longer benefit from iron supplementation for functional iron deficiency?
There is no level. I have given IV iron to people with low TSATs and ferritins in the thousands. 200 isn't even close to too high.
How do you manage AEDs in patients with malignant brain tumors?
Use of prophylactic anti-seizure drugs in patients with primary malignant brain tumors is not recommended and has been evaluated in multiple systematic reviews and guidelines including a recent systematic review and well-done guideline paper from SNO and EANO published by Tobias Walbert, Elizabeth G...
What radiation dose constraints should be used for the spinal cord in pediatrics?
As part of the PENTEC project (Constine et al., PMID 37999712), I had the privilege of finding all of the cases of pediatric radiation myelitis in the literature. This is modified from our published findings, I encourage you to read the full manuscript if you would like further details (Cooper et al...
What is your approach to treatment of infection-triggered HLH that does not respond to treatment of the underlying infection?
The algorithm our center follows is to Recognize hyperinflammation (see answer to question above -- in addition to baseline labs, we obtain an infectious disease consult) Look for and treat the trigger. A concern, if the patient is responding, is that we are missing a trigger (HLH does not occur sp...
Is there a concern for the potential of future congenital malformations in offspring when preservation of eggs and sperm is done AFTER cyclophosphamide treatment given that it is an alkylating agent?
No, there is not a significant risk of congenital malformations in embryos created with cryopreserved gametes or unassisted pregnancies AFTER cyclophosphamide use. While alkylating agents lead to both male and female infertility, congenital malformations from cyclophosphamide occur when conception h...
Is there an age cut off below you would not treat a keloid with radiation post surgical excision?
While radiotherapy is considered an extremely useful modality in the treatment of recurrent keloids in the adult population, most would contend that the risks do not justify the application of adjuvant radiotherapy in the pediatric population (PMID: 10703484) for a benign condition when other modali...
Can defibrotide be given safely for VOD in patients with refractory thrombocytopenia to platelet transfusions?
The short answer is "yes."The slightly longer answer is: “Yes, and in patients with veno-occlusive disease (VOD), the use of defibrotide is potentially life-saving (Richardson et al., PMID 26825712).” In the cited study, which led to its FDA approval for this indication, there was no significant dif...
What is the utility of granulocyte infusions in patients with neutropenia and severe infection?
Granulocyte transfusion is infrequently used for septic neutropenic patients given that the randomized trial (RING) that looked at this question did not show improved outcomes (with the caveat that the trial did not finish accrual (Price et al., PMID 26333778). Having said that, the criteria to cons...
What is your practice regarding giving G-CSF to patients with ALL during initial induction?
My colleagues and I do not use G-CSF in either ALL or AML unless the neutropenia is unusual and prolonged and associated with infection. The use of G-CSF has been shown to shorten neutropenia by a few days but does not prevent the drop and theoretically, at least it may prolong thrombocytopenia by p...