Pediatric Hematology/Oncology
Clinical discussions on pediatric blood disorders, childhood cancers, and specialized treatment protocols.
Recent Discussions
How do you choose your systemic treatment for primary mediastinal grey zone lymphomas?
Most of the literature (although not prospective) supports treating with an R-CHOP/EPOCH vs. traditional ABVD. As such, I tend to treat with R-DA-EPOCH. When I have had the unfortunate case of a relapsed/refractory patient, I have tended to treat with some of the newer HL salvage regimens.
Should high-dose methotrexate be used in the treatment of AYA patients with osteosarcoma?
It has been our practice to use high dose methotrexate (HDMTX) in the treatment of our AYA osteosarcoma patients. Methotrexate has been an important component of most osteosarcoma treatment protocols for many years and is generally considered part of the standard of care for this disease (Grem et al...
What is the preferred treatment approach for an AYA patient with intermediate to high risk Hodgkin lymphoma: The pediatric approach (ABVE-PC +/- radiation) or the adult approach (ABVD with possible escalation to BEACOPP)?
The question of which regimen is preferred needs to be individualized for a given AYA patient. The recent development of pediatric specific NCCN guidelines with some overlap with adult guidelines for Hodgkin Lymphoma can provide a guide. The acute toxicity tradeoffs of myelosuppression with ABVE-PC ...
What workup do you perform to evaluate for underlying triggers/associated conditions in a pediatric patient with autoimmune hemolytic anemia?
The diagnostic workup that I would recommend in order to rule out a possible underlying condition includes the following: Extensive red blood cell typing in anticipation of possible transfusion. Further immune-haematological investigations: C3, C4, CH50 Auto-antibodies (ANA, anti DNA), antiphosp...
Is there a contraindication to orthodonture in an AYA after high dose head and neck radiation where the mandible got close to full dose (e.g., 60 Gy for nasopharyngeal carcinoma)?
I don't consider prior H&N radiation as a child or adolescent as a contraindication to forms of orthodontics. Having a dental professional with some experience in higher risk dentistry may be of benefit. During times of active imaging (e.g. the first 3-5 years post treatment), there may be a need to...
What are your next steps in workup for a pediatric patient with microcytic anemia with normal iron levels, normal hemoglobin analysis, and normal alpha thal trait testing?
It is a bit difficult to answer this without more information like age, H&P, the actual blood counts, a description of the peripheral blood smear, and the quantitative results of hemoglobin HPLC. If iron deficient and the many different genotypes of thalassemia are excluded and there is no chronic d...
How do you manage patients with a history of severe ifosfamide neurotoxicity who need additional ifosfamide?
Ifosfamide neurotoxicity is an idiosyncratic reaction. Methylene blue has been shown to be effective in this situation but has not been studied prophylactically. Given that there are no evidence-based guidelines for re-challenging a patient with prior ifosfamide neurotoxicity who again requires the ...
Is there data to support holding the 5th cycle of intensification for an AML patient with good prognosis and a history of significant infections and/or prolonged count recovery?
Great question. The answer is kind of. The COG studies AAML03P1 and AAML0531 gave 5 chemotherapy cycles to patients who did not go to transplant in first remission, but we know that some patients did not get the 5th cycle. As you suggested, most of the time the reason for stopping after 4 cycles was...
When can defibrotide be discontinued before the 21-day treatment course is completed in a pediatric patient with SOS?
There is no data to support the 21-day use in everyone. Also, some patients might even need a longer course than the prescribed 21 days if manifestations are ongoing. A good general rule of thumb would be to continue (provided no bleeding or other toxicities) for 3-5-7 days post resolution of ong...
What additional testing, if any, should be performed for an adolescent patient with heavy menstrual bleeding and a negative von Willebrand disease evaluation?
I presume that the adolescent with heavy menstrual bleeding whose von Willebrand panel is negative has already had a CBC and baseline coagulation screen (prothrombin time, activated partial thromboplastin time, and fibrinogen or thrombin time) performed. If that is the case, I would suggest evaluati...