Pediatric Hematology/Oncology
Clinical discussions on pediatric blood disorders, childhood cancers, and specialized treatment protocols.
Recent Discussions
What is your standard diagnostic workup to confirm GVHD in a patient post-BMT with skin rash and jaundice?
I assume there is no diarrhea, so sigmoidoscopy would not be helpful. Gut and liver pathology are useful. Skin biopsy is less helpful. It can be fairly nonspecific, but we do it to rule out other diagnoses that have more definitive pathology. Ultimately, it is a clinical diagnosis. Liver biopsy woul...
Does the use of A+AVD versus ABVD affect your decision for consolidation RT for bulky Hodgkin lymphoma?
A+AVD is an acceptable regimen for advanced HL based on results from the ECHELON-1 study (Ansell et al., PMID 35830649) showing an improvement in both PFS (82% vs 75% at 6 years) and OS (94% vs 89%) compared with ABVD. Radiation therapy was not incorporated into this study.In advanced HL, regardless...
How do you approach conversations regarding discontinuation of transfusions in patients with advanced hematologic malignancies who are otherwise appropriate for hospice?
While not an expert in leukemia care or MDS, the answer is nuanced (both in the care of patients and to hospice agencies). Some hospice programs will make exceptions to blood transfusions depending on how frequent - so it is always good to ask. From a clinical perspective, important to consider whet...
What is your surveillance approach for outpatient monitoring of ICI myocarditis?
Screening and surveillance strategies for outpatient monitoring of ICI myocarditis are not well-defined. The best surveillance approach would be based on clinical risk assessment, followed by biomarker and imaging data. The risk factors for ICI myocarditis remain to be clarified, but the most valida...
Which biomarkers or diagnostic tools do you prioritize to support the decision to start antifungal treatment in septic patients with no clear source of infection but at high risk for fungal infections?
In general terms we do not use biomarkers to decide to start antifungals in a septic patient. We use them to confirm or rule out the infection once the antifungals were started based on clinical suspicion/presentation. BDG in particular has very good negative predictive value for candidemia, but due...
What is your strategy for managing immunosuppression in patients with a kidney transplant who develop metastatic cancer?
This is a difficult situation. I presume this question refers to cancers for which there is no option of cure. We always discuss the goals of care and review with the patient and their treating oncologist what the prognosis might be. If chemotherapy or check-point inhibitor treatment is planned we ...
Do you adjust chemotherapy dose if >=10% change in calculated dose, weight, BSA, or if any of these three parameters are met?
Our institution has a policy of adjusting chemotherapy doses if there is a 10% change in calculated dose. Since some drugs are based on weight and some on BSA, it gets complicated if we stick with one versus the other. Also, this practice aligns with ASCO recommendations.
How will you treat an uterine embryonal rhabdomyosarcoma with regional node involvement resected to involved parametrial margins?
It's hard for me to say how I would treat the patient as described without a bit more information and review of the case. So, I will make a few general comments. One major question is, "What is the age of the patient?". And I assume from the question that the parametrial margins were involved. Two t...
How would you manage a patient with sickle cell disease who is infected with COVID-19?
We have limited knowledge about this management. The Sickle Cell Disease Association of America's Medical and Research Advisory Committee has issued a provider advisory. Also, Dr. Julie Paniepento has created a registry that can be viewed in real time here: https://covidsicklecell.org/ In general, t...
Is there evidence to support or argue against intermittent fasting for cancer patients?
This is a complex topic with many permutations of dietary interventions similar to fasting such as calorie restriction and “fasting mimicking”, but as it pertains to pure fasting, I know of a few small studies which characterize fasting around the time of chemotherapy infusions (Raffaghello et al., ...