Pediatric Hematology/Oncology
Clinical discussions on pediatric blood disorders, childhood cancers, and specialized treatment protocols.
Recent Discussions
How would you approach radiotherapy planning for a pediatric patient with Ewing sarcoma of the spine (vertebral body primary)?
Per the recent AEWS 1031 protocol: GTV1 is defined as the visible and/or palpable disease defined by physical examination, CT, MRI, and/or PET prior to any surgical debulking or chemotherapy. GTV2 is defined as a residual visible or palpable tumor as assessed by CT, MRI, PET, or physical exam after ...
How would you manage elevated vWF and FVIII levels in a patient with a family history of coagulopathy?
Hard to be specific without more clinical details. I would not repeat levels. Although the higher the FVIII and VWF levels, the higher the risk of thrombosis, but there is no known specific cut-off. Currently, there is no role for empiric anticoagulation. As with all patients, DVT prophylaxis in hig...
With the data from AALL1731, how is blinatumomab being implemented for SR and HR leukemia patients not previously planned/randomized to receive blinatumomab?
We have incorporated blinatumomab for most patients as two non-consecutive cycles. Once in maintenance, we have not uniformly added blinatumomab, although we have interrupted maintenance to offer blinatumomab to select patients (high-risk genetics or those who had significant treatment modifications...
Is it unusual to have isolated LDH elevation and normal HCG and AFP in non-seminomatous germ cell tumor (embryonal carcinoma)?
It's hard to generalize: the details of the case matter. It is not very unusual to have an isolated LDH elevation. LDH is extremely non-specific. 101 different things can make LDH go up and this limits its usefulness as a tumor marker. Elevation of LDH on day 1 of cycle one of first-line chemotherap...
What is your strategy for treating headaches in patients with history of brain tumor?
Not all headaches in patients with brain tumors arise in the context of elevated ICP, but there are other mechanisms (dural irritation, traction on blood vessels, post-craniotomy pain, for example) by which they can be related. If the headache otherwise seems migrainous, I would treat it as migraine...
Should all pediatric CNS cases be referred to a proton center?
I hope there will be a substantial amount of debate on this question, and so I have invited several pediatric radiation oncologists treating patients at institutions where protons are and are not utilized. The weight of the building data on this topic in the literature is mounting such that more and...
How do you manage incidentally identified pituitary lesions on brain imaging?
Pituitary lesions are among the most common incidentalomas seen on brain MRIs. Various studies cite numbers as high as 10- >30% for pituitary lesions found incidentally on brain imaging, with the higher incidence rates emerging in the era of high-resolution MRIs. In pediatric neurology/neuro-oncolog...
Under what circumstances would you consider omitting radiation in patients with early stage, unfavorable (bulky) Hodgkin Lymphoma?
We should first acknowledge that combined modality therapy improves progression-free survival in early-stage HL compared with chemotherapy alone. Stated more succinctly- if you give combined modality therapy, there is a lower risk of relapse; if you give chemotherapy alone, there is a higher risk of...
What is your strategy for optimizing hydroxyurea dosage in patients with symptomatic sickle cell disease, particularly for genotypes HbSS and HbS/Beta thal?
I am far, far more worried about underdosing than overdosing. Although HgF is the traditional lab parameter, it may not go up in all patients. I also look for a decrease in reticulocytes, LDH, indirect bili (less hemolysis), less inflammation (WBC and platelets), and a lowering of MCHC (i.e., fewer ...
How would you approach an adolescent patient with stage IIIC serous borderline tumor, s/p fertility sparing surgical staging with unilateral salpingo-oophorectromy, who presents with an enlarging contralateral ovarian mass and additional pelvic disease on imaging?
I would attempt cystectomy and debulking of pelvic disease. If ovarian salvage is not possible, then I would prioritize saving the uterus. If final pathology continued to show borderline tumor, then I would observe. If low-grade serous or high grade serous on final pathology, then I would treat with...