Pediatric Hematology/Oncology
Clinical discussions on pediatric blood disorders, childhood cancers, and specialized treatment protocols.
Recent Discussions
When do you consider testing with stroke gene panels in young stroke patients?
Broadly, I ask for genetic testing only when I have a specific diagnosis in mind. This testing is not routine in my practice. Examples are: A patient is referred for white matter lesions found on brain MR and a transient neurological episode. The question of CADASIL(NOTCH-3) or related disorders is...
How would you manage a patient less than 40 years old with an incidentally found LGG, IDH mutated, 1p19q intact, s/p STR?
Update: On August 6, 2024, the FDA approved Vorasidenib for IDH-mutant low-grade gliomas based on findings from the INDIGO trial. This decision highlights the FDA's incompetence and lack of scientific integrity, clearly demonstrating that the agency prioritizes pharmaceutical companies' interests ov...
Would you use the pneumococcal conjugate-21 vaccine (Capvaxive) instead of the conjugate-20 (Prevnar-20) for routine vaccinations in immunosuppressed patients?
PCV-21 was recently approved by the FDA and supported by ACIP. At this early stage (August 2024), CDC has not finalized guidance on PCV-21, so we do not know how the vaccine schedule will be changed. An important distinction is that PCV-21 covers different serotypes of pneumococcus, as outlined in t...
Is there any benefit of using aspirin to mitigate VTE risk in testosterone-induced polycythemia?
Erythrocytosis is a common adverse effect of testosterone therapy, and results from several studies suggest an association between elevated hematocrit (Hct) and risk of VTE (Braekkan et al., PMID 19833630; Ory et al., PMID 35050717). There is currently no data to support the routine use of aspirin o...
When do you consider including Rituximab into the treatment regimen for a pediatric or AYA patient with intermediate and advanced-stage nodular lymphocyte-predominant Hodgkin lymphoma?
First, I would want to make sure the diagnosis is correct as advanced stage NLPHL is extremely rare. T-cell rich B-cell lymphoma can look identical histologically. Either way, R-CHOP therapy is good therapy for both.
What is your approach to an infant (<12 mo) with new onset petechiae and thrombocytopenia, with labs consistent with ITP?
In an older (1-6 year old) child with apparent ITP, less work up might be needed. While many tests are possible, in this case, labs consistent with ITP, I would interpret as including a CBC otherwise normal for age without blasts on a smear (if this is not true, the differential is much wider). If i...
Do you recommend salvage radiation therapy to limited recurrent Ewing's sarcoma bony lesions?
Depending on the age of the patient, size, and location of the tumor, SBRT is often an attractive option for re-irradiation for a limited volume recurrence from Ewing sarcoma that failed to respond to prior conventional treatment. There is data from Mayo Clinic (Brown et al., PMID 25548538) and MSK ...
What adverse events would make you switch off nivo + AVD therapy and to what second line therapy in patients with Hodgkin Lymphoma?
The question of how to handle severe IRAEs when using the N+AVD regimen is an important one. First, of course, is to hold CPI therapy, empirically treat as indicated to avoid ongoing or worsening organ injury, and concurrently ensure that there is no other cause for the observed event(s). But if you...
Have you used oral vancomycin as prophylaxis for C difficile infection in patients admitted for allogeneic hematopoietic cell transplant?
Yes, but only in patients with a history of C difficile in the previous year and starting at the time of initiation of broad-spectrum antibiotics (e.g., for fever and neutropenia). We use 125 mg daily.We are aware this practice may be controversial. To my knowledge, there is only one randomized tria...
How do you consider SBRT relative to other emerging therapies for pediatric sarcomas, such as proton therapy or immunotherapy, in terms of efficacy and safety?
Treatment paradigms for pediatric malignancies have evolved through group trials over the past 5 decades, both in the US (e.g., COG) and abroad (SIOP). Sequential improvements have been made over the years to the quality of radiation for both pediatric and young adults, a population at risk for majo...