Pediatric Hematology/Oncology
Clinical discussions on pediatric blood disorders, childhood cancers, and specialized treatment protocols.
Recent Discussions
What is the role of radiotherapy in a newly diagnosed patient with parameningeal rhabdomyosarcoma w/ intracranial extension, a positive CSF but no extra-CNS metastases?
The question as to the role of RT in patients with parameningeal (PM) RMS with CNS leptomeningeal disease is complex and one lacking scientific evidence to support one’s answer. My response represents a historic viewpoint gained from hearing the discussions of the Intergroup Rhabdomyosarcoma Group (...
How do you approach relapsed idiopathic HLH?
If the patient was previously in remission after etoposide and steroids, they may well respond to etoposide and steroids again. I strongly consider hematopoietic stem cell transplant in anyone who relapses after an episode of HLH, since it is usually a harbinger of recurrent and potentially life-thr...
Do you initiate anticoagulation prophylaxis for pediatric patients with vascular compression secondary to solid tumor/lymphoma?
It is an interesting question, but lacks critical details. Of course, most cancers are prothrombotic, and anticoagulation can have risks: Is it arterial or venous compression? Complete obstruction? Acute or chronic? Collaterals? Is it compromising an organ? Is thrombus seen, or is there blood flow?...
Do you utilize D-dimer to inform anticoagulation duration in the treatment of VTE?
I had developed a policy during my last eight or ten years of practice evaluating how long patients should be treated after a thrombosis and I'd like to share some impressions over these years as well as conclusions that I reached. These conclusions formed the basis of my approach to this problem. I...
What is your escalation strategy for chronic GvHD?
There are now several available options for steroid resistant cGVHD. The old standbys - ECP and rituxan are useful in about 30% of patients. Ibrutinib was the first new drug to get FDA approval. Unfortunately, I don't think the real-world experience is anywhere near as good as the trial (Chin et al....
What factors should be considered when deciding whether to omit radiation in pediatric/AYA patients receiving N+AVD, particularly regarding long-term outcomes and second malignancy risks?
Based on the early data from S1826, it appears that radiation can be omitted if end-of-therapy scans (after 6 cycles of therapy) show metabolic remission of disease. The ability to limit RT to 1% of patients is encouraging for potential reduction in late effects such as cardiovascular disease and SM...
What factors determine whether a patient in their 20s with a new oncologic diagnosis is better served by an adult or pediatric center?
It's been 30 years since Dr. Archie Bleyer first pointed out that adolescents and young adults had not enjoyed an increase in survival over a 50-year period that had been seen in pediatric and older adults with cancer.Since then, every study has shown superior outcomes for young adults treated at pe...
In pediatric patients with Hodgkin lymphoma who have a partial response after chemotherapy and multiple disease sites above and below the diaphragm, how do you approach radiotherapy planning considering cumulative dose and toxicity?
RT dose and target volume in pediatric Hodgkin lymphoma are determined according to the systemic therapy protocol being used. For example, your case suggests a patient with Stage III or IV disease. In the COG study AHOD1331, patients received either Bv-AVE-PC or ABVE-PC systemic therapy x 5 cycles a...
What areas do you treat with RT for an intermediate or high risk pediatric Hodgkin Lymphoma with a slow early response?
For pediatric Hodgkin lymphoma, radiation fields are really based according to the treatment protocol. If the patient was being treated per AHOD 0031, then the radiation fields would include all sites of initial involvement, assuming they don't meet the criteria for omission of RT (RER and then a CR...
What is the optimal timing for PET/CT to assess disease and treatment response with nivo + AVD?
The S1826 study did not require interim imaging. Despite this, I routinely order an imaging test prior to cycle 3, day 1 for patients on the N-AVD regimen. In most cases, I order PET/CT scans. I continue therapy in patients with a Deauville score of 4 or less (partial or complete response) rather th...