Pediatric Hematology/Oncology
Clinical discussions on pediatric blood disorders, childhood cancers, and specialized treatment protocols.
Recent Discussions
What is your standard for monitoring triglyceride level during therapy for ALL, particularly in regards to receiving pegaspargase?
Routine monitoring of triglyceride levels is not considered standard practice during pegaspargase therapy. Although hypertriglyceridemia is a common side effect of asparaginase treatment, it typically has no significant clinical impact on management decisions or future use of asparaginase. The condi...
Do normal methylmalonic acid levels absolutely rule out vitamin B12 deficiency?
An elevated MMA is a good indicator of B-12 deficiency but a normal level does not argue strongly against B-12 deficiency. Normal MMA levels have been reported in 10-25% of patients with known B-12 deficiency (B-12 levels below 100). Testing for an elevated homocysteine level might help but this tes...
How do you prescribe a steroid taper for radiation and checkpoint inhibitor related pneumonitis?
I subscribe to the philosophy of "hitting hard, tapering slowly" for cases of pneumonitis, either radiation pneumonitis, or checkpoint inhibitor-related pneumonitis (some of those cases probably have mixed origin, with contributions from radiation and/or checkpoint inhibitors). For severely symptoma...
What is your surveillance protocol for patients with common variable immunodeficiency receiving chronic IVIG therapy?
No target IgG level per se- dose/interval should be titrated to clinical condition. In general, trough IgG on treatment should be higher than 500 mg/dL, or 500 mg/dL higher than baseline. Most patients will not be in optimal clinical condition (minimal fatigue, arthralgias, absence of chronic cough,...
How do you address non-adherence to medical treatment in adolescent and young adult oncology patients due to mental illness such as depression?
The best answer, I think, is to obtain a thorough child psychiatric evaluation. Noncompliance may arise from a number of different issues, some of which may relate to major mental illnesses such as major depression or anxiety disorders, or more cognitively based concerns such as ADHD or executive fu...
How would you counsel a woman with a strong family history of thrombosis about oral contraceptives?
This can be a complex question for which there are likely no specific data or guidelines upon which to base a recommendation. ASH has published guidelines on thrombophilia testing in VTE (Middeldorp et al., PMID 37195076). They specifically recommend against testing prior to COC prescription. The ra...
How do you approach the work-up for a patient with iron deficiency anemia who is not responding to oral iron therapy?
Have the patient's iron loss sources been controlled? GI blood loss due to gastritis, IBD, and other issues is the number one cause. Menstrual bleeding is common in post-menarchal girls. I really like the menstrual chart in the Better You Know campaign from the CDC and NBDF. This can identify bleedi...
For a patient with May-Thurner syndrome and DVT, would you recommend anticoagulation for 3-6 months or indefinitely?
This is a very good question, there is little data on this and there are only a few case series. One case series of 8 patients showed a 25% risk of recurrence in one year with May-Thurner syndrome but too small of a sample to really know what the risk is, plus this probably included a heterogenous m...
How will you use Pola-R-CHP in the frontline treatment of DLBCL?
Given the comparable toxicity profile and the lower rate of treatment failure, the number needed to treat (n=16) is low enough that this is very appropriate to be the new standard of care. Although overall survival was not different, fewer patients treated with the Pola-R-CHP required subsequent tre...
In the era of MEK inhibitors and BRAF V600E-targeted therapy, what is the role of traditional vinorelbine/prednisone in the management of Langerhans cell histiocytosis?
A similar question came up during rounds this week, and I recalled seeing this question here.I assume the asker meant vinblastine, and not vinorelbine; the combination of vinblastine and prednisone is considered standard therapy, whereas vinorelbine has not generally been used in LCH.Let's first bet...