Pediatric Hematology/Oncology
Clinical discussions on pediatric blood disorders, childhood cancers, and specialized treatment protocols.
Recent Discussions
How do you present the trade off between a small chance of a sustained response for a new drug at the expense of potential worsening quality of life?
Since we now have an increasing number of treatments at our disposal, this becomes an ever more frequent conversation in oncology. This question gets at several Shared Decision Making (SDM) model steps. Usually in this scenario, there are not routine standard of care options and highlighting the pat...
Is there any consensus or guidance on how to manage germ cell tumor patients in the COVID-19 era?
Germ Cell Tumor Management in face of SARS-CoV-2: Safe, Rational Modifications to Standard GCT Practice to Protect Public Health, GCT Outcomes, GCT Patients, and Health Systems. This bulletin has been produced by a concerned group of international experts in germ cell tumors, has not undergone exten...
Can the Fishbane reaction happen with an initial test dose of low molecular weight iron dextran, i.e., infed?
Yes, the fishbane reaction can occur with no prior exposure. This applies to any of the formulations. The reaction is more frequent with generic ferumoxytol, which should be avoided. Otherwise, the incidence is equally frequent. It is definitely not unique to iron dextran, as the question implies. W...
Do you routinely recommend loratadine for pegfilgrastim pain?
Despite its popularity, there is not good evidence that Loratadine improves bone pain from pegfilgrastim. There are small, uncontrolled studies that suggest a benefit, however a randomized trial of Loratadine vs. placebo did not show a difference between groups in bone pain or quality of life.
Is there an age cut off below you would not treat a keloid with radiation post surgical excision?
While radiotherapy is considered an extremely useful modality in the treatment of recurrent keloids in the adult population, most would contend that the risks do not justify the application of adjuvant radiotherapy in the pediatric population (Botwood et al., PMID 10703484) for a benign condition wh...
Would you supplement iron for low iron studies in absence of anemia?
The answer is absolutely and positively. Iron deficiency causes symptoms independent of anemia which include fatigue, brain fog, restless legs syndrome, and pagophagia and other forms of pica. You simply cannot dignify waiting for overt iron deficiency to develop in someone with symptomatic iron def...
What is your approach to iron supplementation in patients with an active infection?
In patients with active infections, I generally avoid intravenous iron due to the potential for promoting pathogen growth, a practice supported by cautions from nephrology and gastroenterology society guidelines. However, evidence for the risk of infection with IV iron is inconsistent, underpowered,...
How do you approach laboratory assessment for anticoagulation adherence when working up anticoagulation failure?
When faced with an anticoagulation failure, my go-to test for adherence is looking at the medication-dispense report (if you have this available at your institution, it is very handy for understanding the patient's adherence to anticoagulation). Typically, this will either show intermittent dispensi...
When do you pursue MRI iron quantification for elevated ferritin with normal TSat, and when do you consider rare diagnoses like ferroportin disease or aceruloplasminemia?
Serum ferritin is an acute-phase reactant, so it can often be elevated without true iron overload, especially in the setting of viral illnesses or other inflammatory events. It is best not to do the test when something like that has occurred in the past 3-4 weeks or so. Overnight fasting is key to t...
How do you weigh the disease control advantage of SBRT for bone metastases in Ewing sarcoma against potential late skeletal effects of high-dose-per-fraction radiation in a growing child, given limited long-term data in this population?
SBRT with a higher dose per fraction is likely to be similarly stunting in growth potential as conventionally fractionated high-dose radiation to 50-55.8 Gy. There is likely to be essentially no difference in growth stunting potential, and SBRT has the advantage of smaller margins added (less normal...