Pediatric Hematology/Oncology
Clinical discussions on pediatric blood disorders, childhood cancers, and specialized treatment protocols.
Recent Discussions
Would you recommend prophylactic cranial irradiation (PCI) for a teenager with a T cell acute lymphoblastic leukemia in remission?
No—modern systemic and CNS directed therapy is sufficient to mitigate the historic higher risk of CNS relapse (Vora et al., JCO 2016). While there is still a small risk of cranial relapse with modern systemic therapy, the improved success of response and risk adapted strategies utilizing varying deg...
What is your therapy of choice for relapsed metastatic alveolar rhabdomyosarcoma?
I will make just a couple of presumptions. First, I will presume that this alveolar rhabdo is FOXO1-fusion positive. If not, I would treat as I would an embryonal (fusion negative) rhabdo with vinorelbine/PO cyclophosphamide, vinorelbine/cyclo/temsirolimus, vincristine/irinotecan +/- temozolomide, c...
In the management of the primary site in high risk neuroblastoma, is there a role for a cone-down to residual disease (boost), following treatment of the post-chemo, pre-surgical extent to 21.6 Gy?
Patients who were enrolled in ANBL 0532 who received a 14.4 Gy boost to the primary site were compared with patients who received no boost enrolled on COG A3973. Five year CILP (cumulative incidence of local progression), EFS, and OS were the same between the two groups of patients. This was present...
How do you approach the decision of whether and when to initiate therapy in patients who remain COVID-19 positive >2 weeks after infection but are asymptomatic from the virus?
If the patient is asymptomatic or minimally symptomatic, we have elected to initiate therapy for the patient. We have treated the patient in full PPE at the end of the day with no other patients in the clinic. Efforts should be made to minimize patient contact throughout the clinic. We have the pat...
When would you consider obtaining tumor tissue in NF-1 associated pediatric low grade glioma?
This is definitely an evolving field. Recently, a consensus paper discussing this and other NF-related topics was published that may be helpful as below: Packer RJ et al., Implications of new understandings of gliomas in children and adults with NF1: report of a consensus conference. Neuro Oncol. 20...
How do you approach myeloablative chemotherapy for high-risk Ewing sarcoma patients?
This question has been discussed and debated in the literature for many years. This is largely due to the lack of prospective randomized trials to properly answer the question. Even when studied in this manner, the variable definition of high-risk and study design has made establishing generalizable...
How should patients be selected for metastatic-site directed radiotherapy in rhabdomyosarcoma?
Definitive therapy to sites of metastases at the time of diagnosis is recommended for all patients with metastatic disease on the most recent COG trials (both ARST1431 including intermediate risk patients and ARST0431 including high risk patients). We typically treat the metastatic sites at the end ...
How would you manage a pediatric patient with hypodiploid acute lymphoblastic leukemia?
There is some evidence that patients with hypodiploid ALL do not benefit from HSCT (Pui et al., JCO 2019, McNeer et al., JCO 2019), but it is important to keep in mind that these two studies were retrospective.
How do you approach treatment in an infant with metastatic atypical teratoid/rhabdoid tumor (ATRT) of the brain?
The term infants is, sometimes, used to describe children less than 3 years of age in the context of a brain tumor management. Hence, this response will cover the management of a child less than 3 years of age with metastatic ATRT with additional comments on infants less than 1 year of age.Unfortuna...
When do you offer hyperbaric oxygen therapy to a pediatric brain tumor patient with radiation injury/necrosis?
I really think it depends as much on the clinical setting as it does the imaging appearance. If you have a case where you are on the early end of the timeline for a CNS RN event (i.e. 3-4 mo post-RT) and the patient is high risk (due to location dose, re-RT, concurrent chemo, etc), then it's worth c...