Pediatric Hematology/Oncology
Clinical discussions on pediatric blood disorders, childhood cancers, and specialized treatment protocols.
Recent Discussions
What modality (urine catecholamines, PET, MIBG) is the most sensitive for evaluation of treatment response in a patient with high-risk neuroblastoma?
Assessment of treatment response for patients with neuroblastoma has been formally defined with the International Neuroblastoma Response Criteria (INRC), most recently updated by Park et al., in 2017 (PMID 28471719). Overall response integrates tumor response in the primary tumor (by CT or MRI), sof...
What are your thoughts on adding mycophenolate to steroids in the first line treatment of ITP based on the results of the FLIGHT trial?
This was an impressive study that should alter how upfront ITP is managed. The study was well designed, with randomization against the current standard of care. Efficacy was clear with HR for treatment failure of 0.37 (p=0.0029). What is also nice is that unlike TPO agonists which do not have define...
How would you treat osteosarcoma that has relapsed with unresectable pulmonary metastatic disease?
Typically, I will discuss with the medical oncology team regarding systemic therapy options available as well as clinical trial options. With limited numbers of pulmonary metastases, you can consider SBRT and I have used a regimen of 60 Gy/5 fx.
How do you counsel male-to-female transgender patients on the VTE risk of hormonal therapy?
Overall, there are minimal data in pediatric populations, but the data from adult populations suggests that in the vast majority of cases, it is safe from a VTE standpoint to administer estrogen therapy in male-to-female transgender patients. The current formulations of estrogen that are recommende...
When would you consider splenectomy or other immunosuppressive/cytotoxic therapy for steroid-refractory warm autoimmune hemolytic anemia?
If it is refractory to prednisone, my next approach is Rituxan. If it fails to respond to Rituxan, I have had luck with Daratumumab. I avoid splenectomy since the response rate is no better than 30%.
What are your indications for pursuing a rheumatologic workup in a pediatric patient with ITP?
In regard to pediatric ITP patients and a rheumatologic workup, first, there is no data comparing pediatric ITP patients of all ages and both genders as to the exact rates of positivity and the implications of the positivity in any group. Having said that, there is some consensus that adolescent fem...
How do you incorporate denosumab into the surgical management of giant cell tumor of bone?
Denosumab forever. Giant cell tumors of bone have a clonal cancer component and then osteoclasts that are hypnotized by the cancer. Denosumab works on the osteoclasts so they quit listening to the cancer and then the whole thing turns to bone. Denosumab does not kill anything and the cancer cells ar...
When should a gallium-dotatate scan be incorporated into the initial evaluation of a patient with a carcinoid tumor of the appendix?
Good question! I would first refer the reader to my two favorite papers on appendiceal NETs (Rault-Petit et al., PMID 29557879; Landry et al., PMID 18645109) to understand and help determine: 1) which patients are at highest risk of lymph node metastasis and thus require a right hemicolectomy, and 2...
How would you treat an adolescent or young adult with newly diagnosed hepatosplenic T-cell lymphoma?
HSTCL accounts for <1% of lymphomas. It typically presents in young males, 10-20% of whom are on chronic immunosuppression such as TNF alpha inhibitors. The prognosis for hepatosplenic t-cell lymphoma is grim. Patients can achieve a CR, but relapse quickly with a short median OS. When possible, pati...
What is the flank radiation dose for recurrent Wilms?
For children with recurrent Wilms who had NO treatment with either chemo or RT, we recommend the lower doses mentioned in AREN0532 (NCT00352534). All treatment- recurrent Wilms should receive higher doses as stated in NWTS5 (NCT00002611).