Pediatric Hematology/Oncology
Clinical discussions on pediatric blood disorders, childhood cancers, and specialized treatment protocols.
Recent Discussions
When should you use caplacizumab in the treatment of acute TTP patients?
Whenever I encounter a patient with features of thrombotic microangiopathy and a normal coagulation panel (that rules out DIC), I consider the possibility they may have immune TTP.If my suspicion of immune TTP is high (e.g. history of autoimmune disease, possible relapse of immune TTP) and there is ...
Do you routinely recommend completion hysterectomy with contralateral salpingo-oophorectomy for patients with a history of fertility-sparing staging for borderline tumor of the ovary who have since completed childbearing?
Borderline ovarian tumors, also known as atypical proliferative tumors by WHO classification, account for about 10-20% of epithelial ovarian tumors, have histologic subtypes similar to invasive ovarian cancer, and are characterized pathologically by a high degree of proliferation of the epithelial c...
What is your approach to IV fluid resuscitation during a sickle cell vaso-occlusive crisis?
My approach to IV fluid resuscitation in vaso-occlusive crisis is cautious and individualized. Adequate hydration is important to prevent further sickling, but I avoid aggressive fluid loading because of the risks of pulmonary edema and acute chest syndrome. I typically use isotonic balanced crystal...
Would you recommend a specific workup or change in management for patients with severe, persistent deficits from methotrexate leukoencephalopathy?
In my practice setting, I typically see this as delayed toxicity in adults that is not reversible. In the acute, and particularly pediatric settings, there may be some limited evidence for leucovorin, aminophylline, drugs that modulate NMDA neurotransmission, etc., but usually in adult patients, tre...
When would you consider additional testing for NUDT15 and other polymorphisms related to 6-MP/6-TG metabolism, if not guided by a study protocol?
My practice is to send a pharmacogenetic panel that includes TPMT and NUDT15 (as well as some other useful tidbits such as UGT1A! for Gilbert's syndrome) when patients with ALL are diagnosed. The cost-effectiveness of this strategy has been addressed, with different conclusions (van den Akker-van Ma...
When following current COG ALL protocols with the addition of two courses of blinatumomab to treatment for SR and HR patients, how frequently should surveillance bone marrow and MRD evaluations be performed?
With the caveat that I only treat adults, but the general concepts are similar:In our practice, we routinely do bone marrow exams with MRD assessment after the first cycle of blinatumomab. Assuming this shows no detectable disease, we typically will then perform the same before transitioning to main...
Do you use premedications (acetaminophen, diphenhydramine) before pRBC and plt transfusions to prevent febrile nonhemolytic transfusion reactions and allergic reactions?
I do not routinely premedicate patients. There is a recent meta-analysis that shows no benefit. I only premedicate those who have had a prior transfusion reaction. Old studies showed this was a common practice but those studies were performed before universal leukoreduction and other strategies aimi...
What is the recommended fungal workup in an immunocompromised patient after 5 days of persistent fever?
For any patient with fevers, I focus significantly on any symptoms that a patient might have, like headache, diarrhea, and sinus symptoms, and work up a differential diagnosis based on possible pathogens in this area. If I am not finding anything, I would obtain a CT chest/abd/pelvis, as both invasi...
How do you choose between blinatumomab and CAR-T cell therapy for relapsed or refractory pre B-ALL?
Many of the cellular therapy products are limited in indication which can help with making the decision, as well as the plan to go to transplant or not. Blinatumomab would have to be consolidated with HSCT while CAR-T can be curative in about 50% of patients without consolidative HSCT, which would b...
How do you approach prophylactic antibiotics in patients who continue to have recurrent neutropenic fever following chemotherapy for solid tumors despite chemotherapy dose reduction and growth factor support?
This has to be individualized to the patient. It depends on the length of neutropenia, previous infections, and local antibiotic resistance. If the patient develops neutropenic fever after every cycle of chemotherapy and no obvious nidus of infection has been identified, a trial of a fluoroquinolone...