Pediatric Hematology/Oncology
Clinical discussions on pediatric blood disorders, childhood cancers, and specialized treatment protocols.
Recent Discussions
When (if ever) do you check for anti-platelet antibodies for workup of thrombocytopenia?
Routinely available anti-platelet antibody tests have a sensitivity too high and specificity too low to be of much clinical use. A patient's response to first line therapy (steroids or IVIg) is most telling and if there is no response, a bone marrow is warranted as it would be atypical for ITP. Ther...
How would you adjust the steroid dose for steroid-induced psychosis in a patient being treated for secondary HLH with the HLH-94 protocol?
If disease status allows weaning, we slowly wean per recommendations in HLH94. If they need steroids because of significant hyperinflammation that is damaging, then we add risperidone, which generally works very well.
Would you anticoagulate a patient with splenic infarctions in the setting of CMV viremia?
Based on my general knowledge/experience, I would consider CMV viremia as temporary, short-lived risk factor for a thrombotic event on a part of other inflammatory conditions, and outside of other indications for anticoagulation (e.g., atrial fibrillation, etc), my inclination would be to conclude ...
Does the presence of asparaginase antibodies on Granger Genetics testing indicate need to switch asparaginase formulations?
I would rely on the serum asparaginase activity (SAA) assay rather than the antibody testing. SAA has proven to be a reliable predictor of asparagine depletion and is a widely acceptable method for therapeutic drug monitoring. On the other hand, asparaginase antibody testing has not been consistentl...
Would you recommend hematopoietic stem cell transplant for AYAs with Ph-like ALL?
There are very scarce data about transplant outcomes in patients with Philadelphia chromosome–like B ALL; therefore, the EBMT and ASTCT have no clear indications for HCT in patients with Philadelphia chromosome–like B ALL in CR1. There are multiple factors that can affect the decision on when to pro...
How do you approach evaluation and management of arthralgia in a patient after CAR-T cell therapy?
This is a great question - part of cytokine release at syndrome includes joint pain. So my questions are: How far after? What was the reason for the CAR-T? These are vital questions to understand first. To that be said - the answers will determine if you give a one-and-done treatment or long-term....
What is your approach to working up diarrhea in an immunocompromised patient?
Tough question and very common in clinical and research management. The approach is going to mirror any new complaint and start with a history. Diarrhea means many things to many patients/clinical trial subjects, so characterizing duration, frequency in a day, nocturnal events (diarrhea that occurs ...
How do you approach treatment of sub-total resected ZFTA fusion ependymoma after radiation therapy in a young adult?
Thank you for asking.ACNS0831 has shown that there is no benefit of adjuvant chemotherapy in patients with incomplete resection. This was based on a comparison between ACNS0121 where patients did not receive any chemo after XRT and ACNS0831 where all patients with residual received adjuvant chemothe...
How do you approach delivering ISRT to nodular lymphocyte predominant Hodgkin Lymphoma that has responded on FDG-PET/CT after chemotherapy?
The therapeutic algorithm in stage >I lymphocyte predominant HL is extrapolated from data on classic HL. Thus, I would use the same algorithm as in HL when evaluating RT indication and dose. Omitting radiotherapy is safe, if a favorable response has been documented on PET-CT and the patient has rece...
Does the presence of anaplasia in embryonal rhabdomyosarcoma change your treatment approach?
No. While there was concern in the past that ERMS with anaplasia may demonstrate a worse prognosis, more recent analyses have shown that isn't the case. A recent publication of the Children's Oncology Group experience by Shenoy et al. nicely summarizes the data from 5 recent RMS trials involving bot...