Pediatric Hematology/Oncology
Clinical discussions on pediatric blood disorders, childhood cancers, and specialized treatment protocols.
Recent Discussions
How do you mitigate 6-MP-induced GI toxicity in pediatric and AYA patients with leukemia?
This is a great question as GI toxicities are commonly encountered in children, adolescents, and young adults being treated with 6MP including elevated transaminases, pancreatitis, and hypoglycemia. These GI toxicities are likely due to a skewing of 6MP metabolites with an accumulation of the GI tox...
How can oncologists be more collaborative with palliative care physicians?
First and foremost, for oncologists to be collaborative with palliative care physicians, a trusting relationship is a must (good communication amongst teams is key to optimal patient care). This is akin to PCP-Oncologist (or even PCP-any other specialist relationship). Before advances in science and...
What is your ferritin threshold to prescribe iron to female adolescent athletes who have symptomatic iron deficiency without anemia?
Since ferritin should be truly reflective of iron levels as we should not expect elevated hepcidin levels in a young athlete. There, I would use 30 ng/mL which has a 98% specificity and 92% sensitivity for absent marrow hemosiderin. Also, since there is expected ongoing iron loss (0.6 mg/L of sweat ...
How would you treat an essential-like tremor secondary to tumor (e.g. glioma)?
This is a great question. The first step in managing tremor in the setting of a tumor or underlying mass is to first determine the phenomenology. It is not uncommon for dyskinesias like chorea or dystonia to arise after onset of tumor or treatment of tumor. Thus, looking for subtle (or not so subtle...
Would you consider TPO mimetics for chemotherapy induced thrombocytopenia that persists despite dose reductions?
The reported evidence on using a TPO-RA in chemotherapy-induced thrombocytopenia (CIT) is complicated but this seems like a situation where it is worth trying a TPO-RA. Repeated dose reduction and/or delay is not good for treatment of a cancer in general. It is very important to individualize the ca...
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...