Pediatric Hematology/Oncology
Clinical discussions on pediatric blood disorders, childhood cancers, and specialized treatment protocols.
Recent Discussions
What is the risk of breast cancer that you quote to young women with early stage Hodgkin's lymphoma receiving involved field/site radiation therapy?
The risk depends on many different factors, including the amount of breast exposure to radiation, age of the patient, chemotherapy regimen, etc. Patients at greatest risk are likely those with axillary involvement who are < 30, where a large portion of their breast maybe unintentionally irradiated. ...
How do you manage a patient with a history of non-seminomatous germ cell tumor who has a rising AFP after primary chemotherapy without any imaging evidence of recurrence?
It would depend on the timing of the rise of AFP after chemotherapy, how elevated it is, whether they were good or poor risk patients at the time of chemotherapy, whether they had liver disease and whether the AFP was definitively elevated prior to chemo In most cases, we sort of ignore AFP < 25 or ...
Is there a benefit to metastatic & primary site RT in RMS w/ persistent marrow disease?
While I agree with the response by Dr Ermoian, I believe the case is more complicated than simply irradiating the gross disease at the primary site. Overall survival and Progression Free Survival for Stage 4, Group IV RMS has not changed substantially over the past almost 5 decades, despite many suc...
Would you give post operative radiation for a pT1N0 parotid low grade mucoepidermoid carcinoma with positive margin on the facial nerve to an adolescent?
Yes. Unfortunately, while the risk of second malignancy is not insignificant in an adolescent, the risk of recurrence on the facial nerve margins is expected to be quite high. Recurrence in the future along the nerve would most likely lead to sacrifice of the nerve and the need for adjuvant RT.
How would you treat a pediatric embryonal rhabdomyosarcoma of the kidney with preoperative rupture s/p nephrectomy and getting VAC/VI chemotherapy?
This is an uncommon clinical presentation. If there was diffuse abdominal spill, then whole abdominal radiotherapy would be indicated. Though recent COG study guidelines specify 24 Gy whole abdomen radiotherapy dose, that may not be adequate for microscopic tumor. In other tumors (ie, diffuse small ...
What is a standard field for LN+ paratesticular rhabdomyosarcoma (ie aorta + ivc + ipsi common iliac)?
Though there is some variation, most clinicians who have enrolled patients on the IRSG or COG studies use a "hockey-stick" field that parallels what would be used for seminoma. These would include the para-aortic and ipsilateral iliac nodes. A minority of clinicians exclude the iliac nodes if they a...
At what dose would you recommend future audiogram screening for pediatric patients treated with radiotherapy?
I would refer to the COG Late Effects report on Auditory Late Effects (PMID: 20194279). This reference has many relevant papers in its citation list that would aid the evaluation of hearing in specific childhood cancer patient populations. They recommend audiologic evaluation including air and bone ...
Does your institution omit prophylactic cranial irradiation in high risk ALL patients greater than 3 years of age?
The general trend worldwide has been to continue to reduce the proportion of patients receiving preemptive CNS directed radiotherapy, although some groups still utilize cranial radiotherapy in the front line setting for small subsets of patients with CNS3 disease at diagnosis, T-cell immunophenotype...
Is there any mature data about cognitive outcomes in 12 Gy vs 18 Gy in the setting of prophylactic cranial irradiation for ALL in children?
There is some data on AML showing some differences between 12 vs. 18 Gy, yet still quite a low incidence.https://www.ncbi.nlm.nih.gov/pubmed/214804694/134 (3%) of patients treated with 12 Gy versus 8/108 (7%) of patients treated with 18 Gy demonstrated behavioral disorders and cognitive impairment. ...
When would you consider treating a testicular relapse with definitive radiation in a child with ALL?
I would strongly advise against treating with testicular radiotherapy alone at relapse given that testicular relapse is often a harbinger for systemic relapse (depending on the length of first clinical remission) which radiotherapy alone strategies will fail to address (PMID: 8275428). Radiotherapy ...