Pediatric Hematology/Oncology
Clinical discussions on pediatric blood disorders, childhood cancers, and specialized treatment protocols.
Recent Discussions
Should post-op RT be delayed for children < 3yo after a GTR resection for a posterior fossa or supratentorial ependymoma?
Standard of care for a GTR posterior fossa ependymoma of any histologic grade is immediate adjuvant radiotherapy. If a STR is encountered, chemotherapy may be considered to try and facilitate a second look surgery. The current protocol allows patients with supratentorial ependymomas that have receiv...
What is the value and potential morbidity of second look surgery in patients with sub-totally resected ependymoma?
Since gross resection of ependymoma is associated with improved prognosis, chemotherapy is frequently used to render sub-totally resected ependymoma potentially resected totally during second look surgery (thereby improving prognosis). One of the main reasons that the tumor in the posterior fossa is...
Do you boost residual lung disease after chemotherapy after whole lung irradiation for patients with Ewings, Rhabdomyosarcoma or Wilms?
A patient who did not undergone a resection for the gross residual pulmonary metastatic disease in either Ewings or RMS may receive a boost at the completion of the whole lung portion of their radiotherapy. It is infrequent that this occurs at our institution as our bias is to resect the gross resid...
For extremity rhabdomyosarcomas (hand) with positive epitrochlear and axillary lymph nodes, do you treat the lymph nodes or just the primary?
Treatment of extremity RMS (either hand or foot) requires either resection or radiation for local treatment, in the setting of effective systemic therapy. There are good data in the literature showing that the primary tumor can be effectively irradiated, while retaining function and form so to avoid...
For high risk, stage I, non-seminomatous testicular germ cell tumors, are there particular circumstances under which RPLND is clearly preferred over chemotherapy or surveillance?
There are few indications for primary RPLND in pure nonseminomatous CSI. The only one I can currently think of is someone who has a strong contraindication to ever receiving chemotherapy.... renal failure or the like. The only time I consider it general is for patients with high risk Leydig or Serto...
When treating patients with immune checkpoint inhibitors, do you routinely check markers of endocrinopathies such as TSH/ACTH, or only when a patient has symptoms?
There are clearly defined parameters for routine monitoring that are outlined in the NCCN guidelines. We have incorporated these into our treatment plans. https://www.nccn.org/professionals/physician_gls/pdf/immunotherapy.pdf
Do you routinely use tumor lysis prophylaxis when starting chemotherapy for germ cell tumors?
THere is not reason to use tumor lysis prophylaxis. Hydration of course is required for the cisplatin. I am not aware of anyone using allopurinol or other TLS approaches
Is there a role for hyperbaric oxygen treatment concurrent with radiotherapy in the treatment of pediatric glioblastoma?
HBO has been used primarily in the treatment of radiation induced injury in patients with controlled intracranial disease. The application of HBO in the post-treatment setting has been limited by fears of latent reactivation of tumor metabolism and therefore progression. There are countless manuscri...
How do you manage severe cytarabine syndrome in AML patients, manifesting as severe hypotension, fevers, rash, and myalgias?
The cytarabine syndrome is a well-described (Castleberry et al. (1981) Medical and Pediatric Oncology 9:257) syndrome mediated by pro-inflammatory cytokines that are associated with fever, hypotension, rash, and often renal failure. In my experience, its most severe manifestations occur when a patie...
Would it be appropriate to treat an adult with a pure germinoma at 1.8 Gy/ fraction instead of the pediatric dose of 1.5 Gy/ fx when treating with radiation alone to the whole ventricle (with cone down to primary)?
We have utilized 1.8Gy per fraction as part of an institutional protocol for CNS germinomas since the 1990s with excellent results (Buckner J JCO 1999). Although the protocol was designed to examine the safety of focal radiotherapy in the setting of CR to induction chemotherapy, this protocol also i...