Pediatric Hematology/Oncology
Clinical discussions on pediatric blood disorders, childhood cancers, and specialized treatment protocols.
Recent Discussions
For T cell ALL treated in CR (without transplant), how often do you do BM biopsies as part of surveillance, and for how long?
The role of surveillance bone marrow exams in ALL (either B or T-lineage) is a matter of some debate. Thoughtful clinicians can disagree, but in my practice, I do NOT routinely perform these procedures, instead reserving them for signs or symptoms suspicious for relapse. This is analogous to how the...
How do you perform fertility counseling for a patient with a duplication of one of the alpha genes and their partner who has a beta chain point mutation?
There is a 25% chance that a fetus would inherit the alpha-globin genotype ααα:αα and a 25% chance of inheriting the beta-globin genotype βT:β. One family study suggested that the compound heterozygous genotype ααα:αα/βT:β had no clinical manifestations and resembled beta-thalassemia trait. (1) Howe...
Would you recommend adding a TKI to a pediatric regimen for a AYA B-ALL patient with IKZF1 mutation?
I would not add a TKI to standard chemotherapy in this situation. Background/Rationale: IKZF1 mutations (specifically deletions) are associated with inferior prognosis. Specifically, the prognosis appears to be worst with mutations that lead to loss-of-function (e.g., focal deletions [Beldjord et al...
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...
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.