Pediatric Hematology/Oncology
Clinical discussions on pediatric blood disorders, childhood cancers, and specialized treatment protocols.
Recent Discussions
How do you manage drug-induced thrombocytopenia when the implicated drug is essential?
I feel obliged to answer this one as a question of medical sociology as much as a direct medical question, because "essentialness" is nearly always in the eye of the beholder, and I have not personally been in the position of the hematologist who has to confront this question with an interventional ...
In a patient with a heterozygous prothrombin gene mutation who has COVID with minimal symptoms, do you recommend prophylactic and/or therapeutic anticoagulation?
If the patient has no history of VTE, I would not recommend any anticoagulant treatment. Heterozygous prothrombin G20210A polymorphism is a relatively weak risk factor for VTE in comparison to antithrombin, protein C, or protein S deficiency, and in general, is not a finding that should guide decisi...
In what situations do you recommend upfront haploidentical transplant in a pediatric patient with newly diagnosed idiopathic severe aplastic anemia who does not have a MSD/MUD donor?
The use of haplo is still investigational upfront. Would, in all likelihood, go with IST upfront without an obvious MUD or MSD.
Why do we use dexamethasone for CNS edema and prednisone for pneumonitis?
Dexamethasone has better CNS penetration compared to prednisone and thus its established use for managing vasogenic edema. However, it has the most suppressive effect on ACTH, causes relatively more steroid myopathy and has less mineralocorticoid effect compared to prednisone hence, the general use ...
When would you consider an umbilical cord blood transplant over a haploidentical transplant with post-transplant cyclophosphamide, or using a desensitization protocol for high donor-specific antibodies?
High DSA are a real problem. We generally use an MFI of 1000 as a threshold - below that there is less concern. Confusingly, even with high DSA, the rejection rate is not 100% so it is often tough to make a decision. UCB transplantation is somewhat inferior to haplotransplant in terms of overall out...
How would you approach breast cancer screening in an adolescent patient with a CDH1 mutation?
The timing of initiation of breast cancer screening in an adolescent female with a germline CDH1 pathogenic variant will depend on family history. Initially, I follow the NCCN guidelines which recommend starting screening mammograms +/- breast MRIs annually at age 30. If there is a family history of...
How do you approach heparin management in patients who have suprathetherapeutic Xa levels on minimal heparin?
Assuming heparin is administered using standard weight-based dosing, that the infusion rate is being accurately monitored, and that the assay was done properly, very high anti-Xa levels that persist despite lowering the heparin dose would be most unusual. In that setting, I would suspect that either...
How has Wilms' tumor therapy evolved over the years?
Wilms' tumor therapy has studied different combinations of vincristine, dactinomycin, anthracyclines, and radiation in several different trials and protocols. The initial trial arm designations were based simply on the letters in the alphabet. We have found that pulse-intensive regimens of shorter t...
How do you manage real-time release of pathology and radiology results to oncology patients following enaction of the CURES act?
Even prior to the Cures Act, I worked in a place where lab and imaging results were immediately available to patients through their smartphone app. A few memorable encounters: Patient 1 - told me his favorable PSA result when I walked in the room and basically told me the plan going forward, (which ...
How do you interpret a Deauville score of 3 on PET when performing mid-treatment assessments in patients with Hodgkin lymphoma?
A Deauville score of 3 or less in an area of disease previously positive (Deauville score of 4 or 5) at interim assessment is considered to be a complete metabolic response (Lugano criteria, Cheson et al. JCO 2014). Some studies evaluating a de-escalation of therapy based on interim assessment may c...