Pediatric Hematology/Oncology
Clinical discussions on pediatric blood disorders, childhood cancers, and specialized treatment protocols.
Recent Discussions
How do you approach prophylactic antibiotics in patients who continue to have recurrent neutropenic fever following chemotherapy for solid tumors despite chemotherapy dose reduction and growth factor support?
This has to be individualized to the patient. It depends on the length of neutropenia, previous infections, and local antibiotic resistance. If the patient develops neutropenic fever after every cycle of chemotherapy and no obvious nidus of infection has been identified, a trial of a fluoroquinolone...
Which patients with relapsed/refractory NHL are appropriate for pre-CAR-T bridging radiation therapy?
Before answering this important question, I think that we, as Radiation Oncologists, should give serious consideration to moving past the terminology of "bridging radiation therapy" and instead refer to it as "pre-CAR-T infusion radiation therapy." Bridging therapy was initially an apt name; we were...
When do you refer a patient with recurrent glioma for reoperation?
This question is a nuanced one that is dependent on many factors. When a patient has a recurrent glioma, the treatment options are generally re-resection, medical therapy (traditional chemotherapy or targeted agents, depending on the tumor), or radiation. Which treatment modality, or combination of ...
For which rituximab infusion reaction symptoms do you consider it safe to re-challenge in the office with adjusted rates and pre-medications?
When deciding whether it is safe to re-challenge with rituximab after an infusion reaction, the most important consideration is the type of reaction that the patient experienced. This will help to risk stratify and determine whether same day or future infusions of RTX should be used. Importantly, th...
How do you choose between the different available CAR-T cell therapy products for the treatment of relapsed Ph-negative ALL?
As implied by the question, there are now three (3) CD19 CAR-T cell products approved by the FDA for adults with relapsed/refractory B-ALL: tisagenlecleucel (tisa-cel), brexucabtagene autoleucel (brexu-cel), and obecabtagene autoleucel (obe-cel). They were all approved after single-arm prospective t...
What is your approach to cancer patients who inquire about alternative or complementary treatments?
It depends a little bit on what specifically they want to use, and if they are truly investigating alternative medicine or complementary medicine. For people seeking full alternative medicine without any conventional treatment, I tell them that a research study showed that people who pursued the alt...
For post-operative radiation of resected high grade soft tissue sarcoma, how long of a delay do you tolerate before starting radiation?
The default/ideal answer is 4-6 weeks, but agreed that is often not feasible. In those circumstances, actively maximize wound healing efforts (plastic surgery, wound care service, lymphedema PT, etc) and start as soon as the surgeon feels it is safe to do so. But it does need to be safe, and ok by t...
What is the preferred approach for an AYA patient with VHR B-ALL with iAMP21 mutation with an isolated early CNS relapse?
For relapsed high-risk disease such as iAMP21, the recommended approach is to achieve remission followed by consolidation with allogeneic stem cell transplantation. However, in cases of isolated CNS relapse, I favor CAR T-cell therapy first to achieve and deepen CNS remission, as it has demonstrated...
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...