Pediatric Hematology/Oncology
Clinical discussions on pediatric blood disorders, childhood cancers, and specialized treatment protocols.
Recent Discussions
What features help distinguish thyroid myopathy from immune checkpoint inhibitor-associated myopathy?
Immune checkpoint inhibitors (ICIs) can cause myositis (ICI-myositis). Since ICIs can also induce hypothyroidism, myopathy secondary from hypothyroidism can also be associated with ICI therapy. Different from thyroid myopathy, patients with ICI-myositis barely have myoedema or muscle pseudohypertrop...
For treatment of ITP, what would you add to dexamethasone to achieve the fastest recovery in a patient waiting for a procedure?
I usually use IVIG, particularly if the patient has responded in the past.
How do you approach therapy for a patient with stage IIIA NSGCT who received 4 cycles of EP followed by RPLND which revealed residual mixed teratoma and embryonal carcinoma?
This is a query that can never be answered by evidence based medicine. Instead, all we have is (very old) historical data and perhaps common sense and logic. In 1974, we initiated our phase II study of PVB, with 4 courses of induction chemo followed by 2 years of maintenance vinblastine. That was ou...
How do you manage drug-induced thrombocytopenia when the implicated drug is essential?
I feel obliged to answer this one as a question of medical sociology as much as a direct medical question, because "essentialness" is nearly always in the eye of the beholder, and I have not personally been in the position of the hematologist who has to confront this question with an interventional ...
In a patient with a heterozygous prothrombin gene mutation who has COVID with minimal symptoms, do you recommend prophylactic and/or therapeutic anticoagulation?
If the patient has no history of VTE, I would not recommend any anticoagulant treatment. Heterozygous prothrombin G20210A polymorphism is a relatively weak risk factor for VTE in comparison to antithrombin, protein C, or protein S deficiency, and in general, is not a finding that should guide decisi...
In what situations do you recommend upfront haploidentical transplant in a pediatric patient with newly diagnosed idiopathic severe aplastic anemia who does not have a MSD/MUD donor?
The use of haplo is still investigational upfront. Would, in all likelihood, go with IST upfront without an obvious MUD or MSD.
Why do we use dexamethasone for CNS edema and prednisone for pneumonitis?
Dexamethasone has better CNS penetration compared to prednisone and thus its established use for managing vasogenic edema. However, it has the most suppressive effect on ACTH, causes relatively more steroid myopathy and has less mineralocorticoid effect compared to prednisone hence, the general use ...
When would you consider an umbilical cord blood transplant over a haploidentical transplant with post-transplant cyclophosphamide, or using a desensitization protocol for high donor-specific antibodies?
High DSA are a real problem. We generally use an MFI of 1000 as a threshold - below that there is less concern. Confusingly, even with high DSA, the rejection rate is not 100% so it is often tough to make a decision. UCB transplantation is somewhat inferior to haplotransplant in terms of overall out...
How would you approach breast cancer screening in an adolescent patient with a CDH1 mutation?
The timing of initiation of breast cancer screening in an adolescent female with a germline CDH1 pathogenic variant will depend on family history. Initially, I follow the NCCN guidelines which recommend starting screening mammograms +/- breast MRIs annually at age 30. If there is a family history of...
How do you approach heparin management in patients who have suprathetherapeutic Xa levels on minimal heparin?
Assuming heparin is administered using standard weight-based dosing, that the infusion rate is being accurately monitored, and that the assay was done properly, very high anti-Xa levels that persist despite lowering the heparin dose would be most unusual. In that setting, I would suspect that either...