Pediatric Hematology/Oncology
Clinical discussions on pediatric blood disorders, childhood cancers, and specialized treatment protocols.
Recent Discussions
How do you approach perioperative hemostatic management for a patient with severe factor 11 deficiency <1%, without inhibitor, who has a significant postoperative bleeding history despite FFP prophylaxis who is undergoing major ENT/skull-base surgery?
This is a complex group of patients. There are systematic reviews that one could look up (Al-Housni et al., PMID 42189746). They involve various combinations of FFP transfusion, rFVIIa, and antifibrinolytics. Our practice has been to risk stratify the surgery based on the patient's personal bleeding...
Is there any indication for IVIG in immunocompromised patients with only decreased IgM and/or IgA levels?
Nope. IVIG preparations contain IgG not IgA or IgM. Low serum IgA may or may not be associated with low IgA levels in mucosal surfaces leading to a risk of local infections. Low levels of one or both may be asymptomatic but in the right setting might suggest a need for evaluation of plasma cell dysc...
For iron deficiency anemia due to heavy menstrual bleeding, what is your preferred method of controlling heavy menses?
I definitely loop in my GYN friends for this one! According to ACOG: "Heavy menstrual bleeding is defined as excessive menstrual blood loss that interferes with a woman's physical, social, emotional, or material quality of life." The consequences of HMB are substantial and multifaceted, and, as we f...
How do you manage cancer treatment-related cognitive change or "chemo brain?"
Chemo-brain is a vexing and complicated diagnosis. In most cases, you don't know the baseline neurocognitive function of individuals with cancer. Many conditions that are associated with chemotherapy like fatigue, depression, and aging can mimic chemo-brain. Estimates are that about 20% of individua...
What criteria is needed in relapsed/refractory B-cell ALL to choose CAR-T therapy over conventional stem cell transplant as destination therapy?
Currently, there are no standard criteria used to choose CAR-T over conventional stem cell transplant as destination therapy. However, there are many factors that often push us in one direction or the other. As we learn more about outcomes after CAR-T cell therapy, there are many factors we know are...
Would you treat patient with early stage unfavorable classic Hodgkin lymphoma with 6 cycles instead of 4 cycles of Nivo-AVD to avoid mediastinal radiation in young female?
I would tailor the number of cycles to the clearance of PET positivity. If one is considering stopping at 4 cycles, I would do a PET scan after 2 cycles and only stop at 4 if it was negative. If it is positive after 2 cycles, I would repeat the PET scan after 4 cycles. If it is still positive, an al...
How would you work up a patient with cutaneous mastocytosis?
In adults, consider mastocytosis as being systemic until you prove it is not. A single normal or low-elevated tryptase does not eliminate the possibility of systemic mastocytosis. All patients should go to Heme/Onc for consideration of bone marrow biopsy and ideally high-sensitivity PCR to look for ...
In a pregnant patient with cyclic neutropenia who has ANC nadirs <500/µL but no history of significant infections or other neutropenia-related complications, would you initiate G-CSF during pregnancy?
Understand that I am not an expert, but no, I would not. As long as she is asymptomatic, I would manage expectantly. If an expert recommends otherwise, I would defer without question.
How do you approach cardiac surveillance in an asymptomatic adult who received anthracycline-based chemotherapy for a childhood cancer and presents to you without an active survivorship program?
At our children's hospital, we are not allowed to follow patients >23 years old if they were not diagnosed and treated at our institution. However, we do offer a 1 time courtesy consultation in the survivor clinic. We request roadmaps and create a treatment summary for the patient, perform a history...
Do you routinely evaluate patients with collagen disorders or Ehlers-Danlos for platelet defects?
Yes, I routinely carry out a full hemostasis evaluation, including platelet aggregation and release studies, in patients referred to me with easy bruising and hypermobility with an increased Beighton score suggesting EDS and in those already diagnosed genetically with EDS. EDS patients typically hav...