Pediatric Hematology/Oncology
Clinical discussions on pediatric blood disorders, childhood cancers, and specialized treatment protocols.
Recent Discussions
Is there a utility to initiating maintenance azacitidine therapy for a patient with a history of refractory AML who is now post-transplant?
This is an interesting question and unfortunately, there is no solid answer for it. There have been some studies of aza post-SCT for adults with AML or MDS. Most of these were small and not randomized, and different dosing schedules were used, so it's hard to draw firm conclusions. The balance of th...
At what point in a pediatric patient's cancer treatment should palliative care teams become involved in their care?
I believe palliative care involvement for newly diagnosed children with cancer should be the rule, not the exception. The concept of early involvement of palliative care teams for newly diagnosed patients with cancer stems largely from a landmark paper in the New England Journal of Medicine 10 years...
When do you evaluate or refer for a cancer predisposition syndrome in a young child diagnosed with a sarcoma?
There are a number of hereditary cancer syndromes associated with development of sarcoma in children, including Li-Fraumeni syndrome (LFS), DICER1 syndrome, Constitutional Mismatch Repair Deficiency (CMMRD), Neurofibromatosis 1, hereditary retinoblastoma, Beckwith Wiedemann syndrome, the RASopathies...
Is there a maximum ifosfamide cumulative dose in patients with normal kidney function?
Here are a number of references from osteosarcoma as well as rhabdo patients. There is no "lifetime limit" but the more you give the higher the risk of renal Fanconis or other renal dysfunction. 72 g/m2 is generally well-tolerated, but not in everyone. There is also no data comparing 14 g/m2/cycle t...
How would you modify Ewing sarcoma chemotherapy and timing of dialysis for a dialysis-dependent patient?
I would recommend a multidisciplinary approach from oncology, nephrology, and pharmacology to maximize drug exposure and minimize chemotherapy clearance. While EWS protocols do contain information about renal toxicity in the dose-modification sections, dialysis is not specifically addressed and more...
How do you approach anticoagulation in patients with catastrophic antiphospholipid syndrome and thrombocytopenia?
Due to the rarity of CAPS, there are no evidence-based guidelines available and most treatment is empiric or based on expert guidance. Most would agree that the mainstay of treatment is anticoagulation, and the preferred anticoagulant is unfractionated heparin. In a recent guideline paper, therapeut...
How do you manage a delayed hemolytic transfusion reaction in a patient with sickle cell disease?
The diagnosis and management of a delayed hemolytic transfusion reaction (DHTR) requires a high index of suspicion. In those patients in whom a DHTR is suspected or confirmed, further RBC transfusion should be withheld unless absolutely necessary, and if then only with the most compatible RBC units....
What is your hemoglobin transfusion threshold for asymptomatic pediatric solid tumor patients during radiation?
We aim for a Hb of 10g/dL whenever possible. This is not based on any data from pediatrics, but from data in adult patients (Prognostic value of hemoglobin concentrations and blood transfusions in a retrospective study of 386 patients).
How many years of oral antibiotics prophylaxis do you recommend for a teenager with hereditary spherocytosis post-splenectomy?
If older than 5 and vaccinated, no proph.
How do you counsel patients who are candidates for a clinical trial regarding their options?
I typically discuss the option with patients as early as possible in their diagnosis, and explain that at some point during their treatment they may become a candidate for a clinical trial. I discuss resources to look into clinical trials and what they mean for patients. We discuss patient website r...