Pediatric Hematology/Oncology
Clinical discussions on pediatric blood disorders, childhood cancers, and specialized treatment protocols.
Recent Discussions
How do you approach a young patient with metastatic poorly differentiated thyroid cancer with rhabdoid/non-anaplastic features?
Unfortunately, this patient has a very poor prognosis. Due to the nature of her tumor being poorly differentiated, her disease is more likely than not to be refractory to radioiodine. If her disease in the thyroid and neck has not been addressed, external beam radiation therapy should be offered for...
How do you manage hemophilia A carriers with no history of bleeding complications but with mildly low factor VIII activity (6-40%)?
This is a wide range, if no history of bleeding then do not need factor on a regular basis. But for invasive procedures/surgery/trauma depending on what their levels are at baseline and the bleeding risk of the procedure, you will need to use factor 8, antifibrinolytic agents, or DDAVP. Same about t...
When would you consider using G-CSF in patients with rheumatic disease who have received cyclophosphamide?
Our primary concern would be our patients with systemic lupus erythematosus. There are reports of severe flares in SLE patients treated with G-CSF (vasculitis and nephritis; Vasiliu et al, PMID 16832843) and even reports of cardiac arrest (Ragsdale & Hall Zimmerman, PMID 34748466).Of course, this ne...
How would you define the primary site GTV and CTV volumes in a high risk neuroblastoma patient who obtained a complete response to induction chemo?
This scenario is exceedingly rare. My opinion would probably depend on staging/histology/MYCN status. Some of the historic HR NBL cases are now being shifted into Intermediate Risk and there have been favorable outcomes without the routine use of RT. So if it was a Stage 3 365-547d, MYCN-NA, UH, any...
Is there any benefit to using desmopressin over vWF replacement therapy for vWD?
For mild type 1 and 2A, we do offer DDAVP testing and use. It was a much more useful drug when it was widely available as a nasal spray. It still has its place, but with patients whose level of VWF is <20% baseline, we have a lot of treatment failures and end up using factor.
Do you recommend menstrual suppression for post-menarchal adolescents and young adults receiving myelosuppressive chemotherapy?
One other point of consideration is the potential benefit of GnRH agonists (i.e., Lupron) on the reproductive potential of post-pubertal females given the risk of chemotherapy in decreasing years of fertility (i.e., earlier menopause). Though data on GnRH agonists is limited to females with breast c...
How do you approach isolated CNS recurrence in previously treated neuroblastoma?
As with other pediatric cancers, the CNS can be a sanctuary site for relapse given the poor CNS penetration of many conventional therapeutics used in the front line setting. As such, there has been an increasing frequency of CNS failures which can occur as early as a year to as late as 5-10 years in...
Do you recommend routine use of Evusheld for pre-exposure prophylaxis for patients on immunosuppression?
The use of monoclonal antibodies as passive immunity for pre-exposure prophylaxis is an exciting development for vulnerable patients, including immunosuppressed patients (either primary or through medications such as for autoimmune diseases), cancer patients, and organ transplant recipients. Evushel...
How would you treat a solitary intracranial oligometastasis from Ewing's sarcoma that has been resected?
While an uncommon occurrence in pediatric sarcomas, as much as 2-3% of pediatric RMS and EWS cases can metastasize to the CNS. The optimal management strategy has not been evaluated systematically in prior trials due to the rarity of the event. It’s worth noting that many patients with oligometast...
Do you use FVIII levels to differentiate between DIC and coagulopathy of liver disease?
DIC is a clinical diagnosis that is difficult to establish in the absence of bleeding or thrombosis, particularly in patients with liver disease. I do think that following DIC laboratory markers (FDP, fibrinogen, D-dimer) serially may be helpful as you would not expect them to acutely drop simply be...