Pediatric Hematology/Oncology
Clinical discussions on pediatric blood disorders, childhood cancers, and specialized treatment protocols.
Recent Discussions
Is there utility in administering adjuvant chemotherapy to a patient with relapsed osteosarcoma for whom CR2 is achieved after surgical resection alone?
Multiple trials have attempted to improve DFS/OS by implementing adjuvant chemotherapy or targeted agents in this scenario. All of these trials have been NEGATIVE. There is no evidence to support the use of adjuvant chemotherapy in patients who achieve complete surgical response after relapse. Nonet...
What is the maximum pRBC volume you can transfuse when performing a manual exchange transfusion in an adult-sized patient with sickle cell disease?
It depends on how much hemodynamic stress the patient can tolerate and the rate of the phlebotomy. The rate is usually 30 minutes for every 500 cc whole blood, but may need to slow down in smaller-sized patients (e.g. 50 kg or less), patients with history of pre-syncope or syncope with phlebotomy, a...
How do you approach management of sickle cell patients who mistrust Western medicine and prefer naturopathic therapies?
With compassion and understanding, I would explain that the lifespan of patients with SCD in regions with access to Western medicine far exceeds that where the disease is most prevalent. Controlled clinical trials have proven the utility of hydroxyurea to alter beneficially the course of disease and...
In which patients with oncologic or hematologic disorders are you recommending a 3rd dose of mRNA COVID vaccine?
In the ideal world, we would tailor the need for booster shots based on whether or not a patient achieves an appropriate immunologic response and maintains that response for long periods of time. This would include both seroconversion and T-cell-mediated immunity. However, we have neither routine no...
What is the preferred treatment regimen for an adolescent or young adult patient with treatment-related AML?
Good question, and the truth is no one really knows. Treatment-related AML in children and AYAs is uncommon so we don't really have any studies to point to. We do know that the prognosis is generally poor, and most experts will say that cure is not possible without an allo stem cell transplant. But ...
What regimen would you offer a young patient with T-cell ALL who recurred a short time after allo-transplant and was initially treated with CALGB10403?
The answer is always clinical trial if feasible. If only commercial options: Assuming morphologic relapse, I tend to favor peg-asp containing regimen if the patient is fit enough to receive – especially if ETP variant. I like SMILE, but important to stress that regimen may come with considerable mye...
Should we recommend the COVID-19 booster vaccine to patients who had a DVT or any other complications such as hemolytic anemia or thrombocytopenia from prior vaccine doses?
There are a few case reports of VTE following COVID-19 vaccinations (approximately 10 based on my PubMed review today). However, VTE has a high incidence of 0.1% in the general population and much higher after age 45 (Mary Cushman, PMID 17433897), so determining a causal relationship between the vac...
In a patient with HR B ALL and severe pancreatitis due to peg-asparaginase, how do you assess the impact of peg discontinuation on risk of relapse?
We know from Gupta et al., PMID 32275469 that omission of asparaginase courses from a mBFM chemotherapy backbone has an adverse prognostic impact among NCI HR patients. In fact, complete discontinuation of asparaginase was associated with a 50% increased risk of an event among HR patients. Thus, whe...
Would you give whole-abdomen RT for preoperative rupture of favorable histology Wilm's Tumor treated with induction chemotherapy followed by GTR?
The short answer is yes, if you saw free fluid in the pelvis pre-treatment, and there were other signs of pre-operative rupture at the time of resection following chemotherapy, then WART should be considered.Given that the patient had positive LN at diagnosis, I would review the path report to see i...
How would you manage VTE in a patient with bleeding disorder such as hemophilia?
Management of VTE in a patient with an inherited bleeding disorder depends on the specific disease, the severity of the bleeding disorder, and the past history of bleeding in that patient. In patients with serious past bleeding and low levels of factor, anticoagulants may be contraindicated and loca...