Pediatric Hematology/Oncology
Clinical discussions on pediatric blood disorders, childhood cancers, and specialized treatment protocols.
Recent Discussions
What regimen would you offer a young patient with T-cell ALL who recurred a short time after allo-transplant and was initially treated with CALGB10403?
The answer is always clinical trial if feasible. If only commercial options: Assuming morphologic relapse, I tend to favor peg-asp containing regimen if the patient is fit enough to receive – especially if ETP variant. I like SMILE, but important to stress that regimen may come with considerable mye...
Should we recommend the COVID-19 booster vaccine to patients who had a DVT or any other complications such as hemolytic anemia or thrombocytopenia from prior vaccine doses?
There are a few case reports of VTE following COVID-19 vaccinations (approximately 10 based on my PubMed review today). However, VTE has a high incidence of 0.1% in the general population and much higher after age 45 (Mary Cushman, PMID 17433897), so determining a causal relationship between the vac...
In a patient with HR B ALL and severe pancreatitis due to peg-asparaginase, how do you assess the impact of peg discontinuation on risk of relapse?
We know from Gupta et al., PMID 32275469 that omission of asparaginase courses from a mBFM chemotherapy backbone has an adverse prognostic impact among NCI HR patients. In fact, complete discontinuation of asparaginase was associated with a 50% increased risk of an event among HR patients. Thus, whe...
Would you give whole-abdomen RT for preoperative rupture of favorable histology Wilm's Tumor treated with induction chemotherapy followed by GTR?
The short answer is yes, if you saw free fluid in the pelvis pre-treatment, and there were other signs of pre-operative rupture at the time of resection following chemotherapy, then WART should be considered.Given that the patient had positive LN at diagnosis, I would review the path report to see i...
How would you manage VTE in a patient with bleeding disorder such as hemophilia?
Management of VTE in a patient with an inherited bleeding disorder depends on the specific disease, the severity of the bleeding disorder, and the past history of bleeding in that patient. In patients with serious past bleeding and low levels of factor, anticoagulants may be contraindicated and loca...
When is a lumbar puncture indicated in a lymphoma staging work up for a pediatric or AYA patient?
LP is not necessary in any Hodgkin patient irrespective of stage. LP plus IT chemo is indicated in all advanced stage NHL. The one exception to that is primary mediastinal B-cell with sclerosis which is an intermediate grade lymphoma (similar to Hodgkin) and rarely spreads to CNS. It is true that ...
In what circumstances would you give G-CSF to a patient with severe neutropenia and HLH?
I am not aware of any direct clinical evidence that addresses this question. That said, I would be very reluctant to treat with G-CSF in the setting of HLH. G-CSF is an inflammatory cytokine that might aggravate HLH. Moreover, since the mechanism of neutropenia in HLH is thought to be increased neut...
What treatment approach would you use for patients with localized Wilms tumor which is unilateral, favorable histology, negative LOH, who develop a new lung nodule at the end of therapy?
First, I would confirm whether the new lung nodule represents recurrent disease by biopsy or resection. If positive for tumor, the treatment recommendation would depend on the initial therapy. For relapse after vincristine/dactinomycin (low-risk relapse), an accepted standard is "Regimen I" (vincris...
At what platelet count would you feel comfortable dosing aspirin 81 mg for coronary artery disease in a patient with ITP?
In a patient with ITP, I would certainly feel comfortable dosing aspirin 81mg daily at a platelet of 50,000 or greater. As you know, the risk of bleeding in a patient with ITP is less than would be expected at a particular platelet count because the circulating platelets in ITP are young and large. ...
Would you provide treatment dosing anti-coagulation for a pediatric patient who had an ischemic stroke and was found to have a heterozygous prothrombin gene mutation?
For sure, although it would be important to try to ascertain what kind of stroke this was: hemorrhagic? Thrombotic? Arterial? Precipitating factors? Anticoagulation is clear cut for VTE but not so much for the other types.