Pediatric Hematology/Oncology
Clinical discussions on pediatric blood disorders, childhood cancers, and specialized treatment protocols.
Recent Discussions
For pediatric patients with localized diffuse large B-cell lymphoma being treated per COG ANHL 1131 in group B, do you feel it is necessary to complete all lumbar punctures with IT therapy?
For unresected group B/DLBL patients, most centers continue to give the IT therapy which included 9 prophylactic IT therapies. There is no published data that I am aware of reducing the IT dosing. We recently completed a pilot reducing the number of ITs to 5 by incorporating 2 doses of depocyt (whic...
What is your current approach to maintenance therapy in FLT3-mutant AML post allogeneic HCT?
I would offer maintenance with FLT3 inhibitor with gilteritinib (NCT02997202: MORPHO trial, not yet published), sorafenib (SORMAIN trial), or midostaurin (RADIUS trial), whichever agent is available. In my experience, gilteritinib appears to be the most tolerable. I suggest beginning maintenance as ...
How do you counsel sickle cell patients on the use of G-CSF to treat neutropenia from other causes, like malignancy?
G-CSF is contraindicated in sickle cell disease. There have been many case reports of severe complications, including death in patients with SCD receiving G-CSF. I would only use it in neutropenic sepsis with transfusion support to prevent vaso-occlusive complications and after a discussion about it...
How often do you monitor AML patients after transplant for recurrence?
Assuming that your patient was transplanted in CR and there is no plan for maintenance treatment, we typically repeat BM A/Bx at D100, 6 and 12 months after alloSCT. We continue to follow PB myeloid R/D chimerism studies regularly after (q 2-3 months for the next 2 years), obviously with CBC. We do ...
How would you treat a pediatric or AYA patient with Ph-like ALL with induction failure?
This is a bit of a complicated discussion. There are 2 major subtypes of Ph-like ALL, 1) CRLF2-rearranged B-ALL; 2) non-CRFL2 B-ALL which is characterized by fusions in a variety of genes including ABL1, ABL2, JAK2, etc. If you have a patient with a documented fusion in ABL1, ABL2, and others which...
What is your preferred graft source and conditioning regimen in a patient with Fanconi anemia and AML undergoing stem cell transplant?
I'm assuming that the patient has now secondary AML evolving from FA. If this is the case, I would suggest a reduced-toxicity MAC with Flu-based regimen and avoiding TBI (for obvious reasons). An IV BU PK-directed regimen such as Bu4Flu seems to be a reasonable regimen. As for the source, BM is pref...
For pediatric Ewing sarcoma, what is the role of metastatic site consolidation?
The COG protocols recommend that all sites of disease including metastatic sites are addressed with local modality measures (obviously this may not be always feasible, e.g. bone marrow disease). Metastatic sites are usually radiated at the end of treatment after systemic chemotherapy.
How do you approach a young patient with metastatic poorly differentiated thyroid cancer with rhabdoid/non-anaplastic features?
Unfortunately, this patient has a very poor prognosis. Due to the nature of her tumor being poorly differentiated, her disease is more likely than not to be refractory to radioiodine. If her disease in the thyroid and neck has not been addressed, external beam radiation therapy should be offered for...
How do you manage hemophilia A carriers with no history of bleeding complications but with mildly low factor VIII activity (6-40%)?
This is a wide range, if no history of bleeding then do not need factor on a regular basis. But for invasive procedures/surgery/trauma depending on what their levels are at baseline and the bleeding risk of the procedure, you will need to use factor 8, antifibrinolytic agents, or DDAVP. Same about t...
When would you consider using G-CSF in patients with rheumatic disease who have received cyclophosphamide?
Our primary concern would be our patients with systemic lupus erythematosus. There are reports of severe flares in SLE patients treated with G-CSF (vasculitis and nephritis; Vasiliu et al, PMID 16832843) and even reports of cardiac arrest (Ragsdale & Hall Zimmerman, PMID 34748466).Of course, this ne...