Pediatric Hematology/Oncology
Clinical discussions on pediatric blood disorders, childhood cancers, and specialized treatment protocols.
Recent Discussions
How would you optimally manage a patient with a MDS/MPN overlap syndrome who has both transfusion-dependent anemia and marked thrombocytosis?
Patients with MDS/MPN marked by severe anemia and thrombocytosis likely have the MDS with ring sideroblast with thrombocytosis (MDS-RS-T) subtype and have a high frequency of SF3B1 and JAK2 mutations. Clinically, they resemble a fusion of MDS-RS and essential thrombocythemia (ET), both of which tend...
What is your threshold for pursuing bone marrow biopsy in a lupus patient with cytopenias?
I rarely do bone marrow biopsies in patients with SLE as cytopenias are caused primarily by the disease itself and/or medications, primarily Azathioprine and Cyclophosphamide. SLE patients routinely have profound lymphopenia, neutropenia, and thrombocytopenia. I consider bone marrow biopsy in patien...
In a patient with sickle cell disease on hydroxyurea who is planning to have a family, for how long should they be off the drug before trying to conceive?
There is some consensus that pregnant women should not take hydroxyurea and should stop taking this when found to be pregnant. (Smith-Whitley, PMID 25472967) As far as I know, there is no data on how long hydroxyurea should be discontinued in either men or women before attempting pregnancy. In fact,...
In sickle cell patients with continued pain crises despite hydroxyurea, how do we sequence the use of newer agents?
As the data supporting the approval of crizanlizumab in NEJM by Ataga et al demonstrated improvement in pain, that is our usual next agent based on the question of pain crises. The approval data around voxelotor related to an increase in hemoglobin of about 1gm/dl, so it may have a different role an...
Would you offer intensive CNS prophylaxis to Ph negative B-ALL patients who have possible mandibular nerve involvement on MRI face?
I would be inclined to treat this patient according to the CNS3 schedule of CNS-directed prophylaxis.Mental nerve neuropathy (or "numb chin syndrome," a rather pedestrian-sounding term for which I cannot take credit) can be a sign of leptomeningeal disease, presumably due to more focal involvement a...
How long should patients treated with frontline therapy for Hodgkin lymphoma wait before attempting to conceive a child?
For males: All patients should have a fertility consultation to discuss fertility preservation prior to initiation of chemotherapy ABVD and BEACOPP regimens significantly reduce male fertility to varying effects depending on treatment duration. ABVD temporarily causes significant reductions in male ...
For patients with suspected complement-mediated TMA, are there specific clinical or laboratory parameters that can help guide the decision for starting empirical treatment (e.g., eculizumab) while awaiting the results of complement testing?
I just want to point out that hemolytic microangiopathy (as seen on the peripheral smear by our Hematology colleague) is paramountly important in determining the presence of TMA. Laboratory parameters may be misleading. I have seen even ADAMT13 levels very low in sepsis and DIC process. Therefore lo...
What are magic mouthwash alternatives that you would recommend?
Many of our patients will make their own DIY MMW per Phil's My Pharmacist (YouTube) instructions -- uses benzocaine/Cepacol lozenges -- they say it's much more effective than the compounded one from the pharmacy. It is also more economical.If the majority of bothersome mucositis is in the oral cavit...
How would you manage a patient with antiphospholipid syndrome in the setting of severe steroid-refractory thrombocytopenia?
Dr. @Dr. First Last answered the question of severe thrombocytopenia in a patient with APS and an acute thrombotic stroke. I agree with his approach. However, this “between a rock and a hard place” clinical scenario does also appear not infrequently during the chronic management of patients with APS...
For AML patients, when do you stop antiinfective agents?
Our practice is typically to continue an anti-viral throughout induction/consolidation without stopping the agent. We typically utilize anti-bacterial and anti-fungal when the absolute neutrophil count (ANC) is under 500 and then stop them once the ANC recovers to above 500. Our preferred anti-funga...