Pediatric Hematology/Oncology
Clinical discussions on pediatric blood disorders, childhood cancers, and specialized treatment protocols.
Recent Discussions
How would you work up and manage persistent lymphopenia in an asymptomatic patient?
Simple answer: refer to an immunologist, as this degree of lymphopenia is quite likely to represent a serious immunodeficiency. I would also send a next generation sequencing panel of immunodeficiency/immunoregulatory genes to be in process while awaiting the immunology consultation. Long answer (fr...
What are best practices for oncologists during the national platinum shortage?
In breast cancer, we are prioritizing patients with curable disease in which platinum agents are a critical part of the regimen or have actually shown a clear advantage (the only example of this is shown below in bold).Use an alternative to a carboplatin-based regimen whenever possible. If no altern...
Do you screen adults in your practice with sickle cell disease for silent cerebral infarcts?
The details of the ASH guidelines regarding adults are complex. It was not my practice to screen all patients. More than 50% of adults have silent infarction. Screening requires MRI and this, according to the guidelines, needs careful attention to many details before it is reliable. There are no pro...
Do you give post-operative radiation to Ewing sarcoma if there is poor histologic response to neoadjuvant therapy in a completely resected tumor?
US Ewing studies conducted through COG have used histologic response in more recent protocols to play a key role in how margins are assessed, such that patients with >90% necrosis and inflammatory or coagulative necrosis at the margin require RT, while those with bland scar or fibrous tissue do not....
What is your follow up schedule after completion of RT for pediatric rhabdomyosarcoma?
Imaging surveillance is an interesting and yet complicated issue. If a child is enrolled upon a prospective randomized trial for which informed consent has been given, then every effort should be made to follow the protocol guidelines, which are designed to answer a protocol question. However, patie...
Would you recommend prophylactic retro-peritoneal RT in an adolescent with paratesticular rhabdomyosarcoma, s/p radical inguinal orchiectomy without a lymph node dissection?
Ideally, in children over 10 years of age with a diagnosis of paratesticular RMS, a retroperitoneal LN sampling (taking 7-12 LNs) at diagnosis should be performed unless obvious gross disease in the nodal region is present. The risk of occult LN involvement is higher in those children 10 years or ol...
How do you manage patients blood pressures while on anti-angiogenic TKIs?
Advise patients to take BP daily, and inform us if the BP is high.
For a recurrent medulloblastoma in the posterior fossa several years after initial standard risk therapy (23.4 Gy CSI), and in which the patient is still less than 18, how would you approach re-irradiation?
If the recurrences are localized to the resection bed, I would re-irradiate only the recurrences (and possibly the entire resection bed depending on number of recurrences). If there is evidence of CSF dissemination (recurrences not associated with primary--whether in posterior fossa or not) then CSI...
During induction therapy for acute leukemia, when do you decide to discontinue the antimicrobial prophylaxis?
Antimicrobial prophylaxis (PPX) during treatment of acute leukemia can take several forms, and it is not always directly associated with blood counts.Fungal PPXDuring induction for AML, there are randomized data supporting posaconazole over fluconazole or itraconazole (Cornely, et al. New Engl J Med...
How do you approach a young patient with undifferentiated pleomorphic sarcoma of the upper extremity who developed ifosfamide-induced nephrotoxicity after two cycles of adjuvant AIM chemotherapy?
In the adjuvant setting, I would suggest to stop further therapy and observe the patient. There is no clear survival benefit with the use of adjuvant therapy. However, I do say this with the knowledge that Sarculator-based analysis of EORTC-STBSG 62931 has demonstrated an OS benefit in patients rece...