Pediatric Hematology/Oncology
Clinical discussions on pediatric blood disorders, childhood cancers, and specialized treatment protocols.
Recent Discussions
What scenario would prophylactic Tocilizumab be considered to prevent Ipilimumab+Nivolumab (immunotherapy) induced toxicity in malignant melanoma?
Currently, there is no indication for prophylactic Tocilizumab with the data that is available. As a matter of fact, Tocilizumab is off-label for the treatment of immunotherapy-related toxicities (it’s indicated for the treatment of CAR-T-induced toxicities and cytokine release syndrome, though not ...
How do you approach a patient with chronic low ADAMTS13 activity and low level of inhibitor without signs of thrombocytopenia or hemolysis?
I'm assuming there is a history of overt TTP that led to the ADAMTS13 level being measured.In patients with a history of TTP, I monitor the ADAMTS13 level every 1-6 months (more often if the level is lower or dropping) and administer a single dose of rituximab if it drops below 20%. In my experience...
When should I consider anticoagulation in an unprovoked upper extremity superficial venous thrombosis?
I would consider anticoagulation when there are significant risk factors for extension to the deep vein system such as proximity to the deep veins, underlying thrombophilia (cancer in particular), symptoms, and large clot burden.
Would you use PCC for clotting factor repletion in acute life threatening hemorrhage in a patient with elevated INR from coagulopathy of liver disease?
I do not use KCentra in this clinical situation. Firstly, the INR is validated for vitamin K antagonists (VKA) therapy only. The VKAs inhibit the synthesis of factors II, VII, IX, and X while the liver produces more clotting factors such as fibrinogen, II, V, VII, IX, X, XI, XII, etc. The INR has no...
How would you treat a woman with iron deficiency anemia, unresponsive to iron sulfate, and with allergic reaction to iron sucrose?
Needs more information. Is the issue unresponsiveness or intolerance? Frequently, patients report GI intolerance and don't really take it. It's crucial to inquire about this and consider trying different preparations to find a suitable option. What was the nature of the iron sucrose allergy? Sometim...
In a patient hospitalized for several days with a refractory pain crisis would you ever consider transfusion, either simple or possibly exchange in an attempt to get the patient over the crisis?
While chronic transfusion therapy has been shown to prevent acute vaso-occlusive pain episodes (see studies that used chronic transfusion to prevent primary and secondary stroke), there are limited data to determine if they are effective for treatment of acute pain caused by vaso-occlusion. There ha...
What is your local control approach to localized relapse of Ewing sarcoma in a site that was previously unresectable and received definitive radiation?
It depends obviously on some other factors including disease-free interval, the site itself, the dose of radiation received, symptoms, etc... Generally, a combined modality approach is attempted. Second-line chemotherapy with either high-dose ifosfamide, irinotecan/temozolomide, or topotecan/cycloph...
Would you use a matched sibling donor with a germline heterozygous BRCA1 mutation for stem cell transplant?
This is a challenging question due to the lack of clarity around the risk of hematologic cancers in patients who have BRCA1 mutations if patients with Fanconi Anemia are excluded. The role of BRCA haploinsufficiency in marrow hematologic function in otherwise healthy donors is unclear. Multiple stud...
How do you approach diagnosis and treatment of HLH/MAS following CAR T-cell therapy?
I maintain that immune effector cell associated hyperinflammatory syndrome is NOT HLH. Most patients post CAR-T cell therapy fulfill the criteria for HLH even if they don’t have hyperinflammatory syndrome, so it makes diagnosis very challenging. Many patients with this “HLH-like” hyperinflammatory s...
In the setting of secondary HLH associated with initial diagnosis of lymphoma, would you adjust steroid dose and type to account for differences in HLH and lymphoma treatment protocols?
I don’t necessarily recommend changing the steroid dose, unless symptoms don’t resolve with chemotherapy. I do recommend using an etoposide-containing lymphoma therapy. Many patients will respond well to lymphoma therapy and have recurrent symptoms before the next cycle is due; in those patients, I ...