Pediatric Hematology/Oncology
Clinical discussions on pediatric blood disorders, childhood cancers, and specialized treatment protocols.
Recent Discussions
Is there a maximum ifosfamide cumulative dose in patients with normal kidney function?
Here are a number of references from osteosarcoma as well as rhabdo patients. There is no "lifetime limit" but the more you give the higher the risk of renal Fanconis or other renal dysfunction. 72 g/m2 is generally well-tolerated, but not in everyone. There is also no data comparing 14 g/m2/cycle t...
How would you modify Ewing sarcoma chemotherapy and timing of dialysis for a dialysis-dependent patient?
I would recommend a multidisciplinary approach from oncology, nephrology, and pharmacology to maximize drug exposure and minimize chemotherapy clearance. While EWS protocols do contain information about renal toxicity in the dose-modification sections, dialysis is not specifically addressed and more...
How do you approach anticoagulation in patients with catastrophic antiphospholipid syndrome and thrombocytopenia?
Due to the rarity of CAPS, there are no evidence-based guidelines available and most treatment is empiric or based on expert guidance. Most would agree that the mainstay of treatment is anticoagulation, and the preferred anticoagulant is unfractionated heparin. In a recent guideline paper, therapeut...
How do you manage a delayed hemolytic transfusion reaction in a patient with sickle cell disease?
The diagnosis and management of a delayed hemolytic transfusion reaction (DHTR) requires a high index of suspicion. In those patients in whom a DHTR is suspected or confirmed, further RBC transfusion should be withheld unless absolutely necessary, and if then only with the most compatible RBC units....
What is your hemoglobin transfusion threshold for asymptomatic pediatric solid tumor patients during radiation?
We aim for a Hb of 10g/dL whenever possible. This is not based on any data from pediatrics, but from data in adult patients (Prognostic value of hemoglobin concentrations and blood transfusions in a retrospective study of 386 patients).
How many years of oral antibiotics prophylaxis do you recommend for a teenager with hereditary spherocytosis post-splenectomy?
If older than 5 and vaccinated, no proph.
How do you counsel patients who are candidates for a clinical trial regarding their options?
I typically discuss the option with patients as early as possible in their diagnosis, and explain that at some point during their treatment they may become a candidate for a clinical trial. I discuss resources to look into clinical trials and what they mean for patients. We discuss patient website r...
In patients with autoimmune cytopenias, is there any reservation for COVID vaccination?
No... benefit outweighs risk. Evidence of benefit (and its magnitude) is clear without proven evidence of risk in this population (save for potential for increased bruising in setting of severe thrombocytopenia).
What is the evidence/rationale for not treating neuroblastoma metastatic sites which are MIBG negative after induction chemo?
A clinically meaningful number of high-risk neuroblastoma patients are curable, which in part justifies metastasis-directed local therapy. It can be difficult though to balance the toxicity of multi-site irradiation with maximum control of sites of metastatic disease. Metastases that persist after i...
What is the volume and dose for a rhabdo bone met showing complete response to chemo?
On ARST1431, the GTV2 for a bone met in CR should be defined as the residual bone abnormality as seen by CT/MRI at the time of RT planning. SBRT to bony metastases is optional on 1431 and the decision may vary based on patient age and other factors. On the upcoming high risk protocol, where SBRT to ...