Pediatric Oncology   

Questions discussed in this category


Is an LP only recommended in the setting of particular subtypes of lymphoma or symptoms of CNS disease?

For patients not on study, would you consider replacing missed doses of peg with a non-asparaginase based chemotherapy?

The patient initially presented with an large renal tumor encasing the IVC and abutting the abdominal aorta. Given this, the patient received inductio...

Would you offer liver transplant in the setting of metastatic disease? 

Do your recommendations differ between those who receive ABVD and escalated BEACOPP? Do you recommend consultation with fertility specialists for all...

While building a trusting patient-physician relationship, what therapies could be discussed that may be aligned with naturopathic medicine? (i.e. L-gl...

There are multiple difficulties that could be seen: steroids can precipitate a sickle cell crisis, vasculitis and sickle cell can produce similar clin...

Does manipulation of blood products (leukoreduction, irradiated) affect your approach? There is growing evidence that routine premedication (at least ...

In particular, is there any data on the efficacy of Ipilimumab/Nivolumab?

While this is a known risk factor for venous [Meijers et al NEJM 2000] and potentially arterial [Yang et al, Am J Clin Pathol 2006] thrombosis, it is ...

Are there major differences in standard conditioning and/or GVHD prophylaxis regimens utilized? Does the non-relapse mortality different significantl...

To minimize the likelihood of asymmetrical growth, when is it of sufficient concern to necessitate altering planning objects? When planning paediatri...

Results of AHOD1331 are not yet known, but adults have started using Brentuximab upfront for high risk patients  

Such as patients who are frail, elderly, renally impaired? Would you consider sirolimus over cyclosporine or tacrolimus for safer nephrotoxicity prof...

How often do you monitor ADAMTS-13 levels off therapy?

For example, do we prefer one regimen over the other in patients with a bleeding history or who have relapsed after a lengthy remission?

NCCN guideline V4.2021 DLBCL page BCEL-3 states stage I-II, bulky >= 7.5cm should be treated with 6 cycles of RCHOP, but most bone lymphoma studies...

Both the patient's nasopharyngeal swab and stem cells themselves resulted COVID positive post-harvesting.

This type of etoposide sparing therapy has been previously described in a case series at https://pubmed.ncbi.nlm.nih.gov/32725881/

Would you plan straight pediatric dosing using 2500 Units/m2 or a cap of 3750 Units as used in some adult ALL regimens due to excess liver/pancreas to...

It used to be a contraindication for G-CSF use for AML patients, but currently, several protocols include it to decrease neutropenic duration.

s/p optimal debulking. If this was an early-stage cancer would it change your adjuvant therapy recommendations?

While benefits outweigh known harms and limited data, do you worry about vaccination in patients with a history of or active autoimmune cytopenias (e....

Adults tend to do this procedure earlier in the course, but it is unclear when it is appropriate for a pediatric patient, and is often considered too ...

What is the best way to counsel families in regards to their child's risk of infertility and need for fertility preservation?

Would you use ALK inhibitors such as crizotinib based on recent phase II data? Are there any research efforts to combine ALK inhibitors with current ...

Would your counseling change if she reported a history of unplanned pregnancy? Is there any wording or waiver you might be able to use warning her of ...

Do you always treat with the full 21-day treatment course, or can defibrotide be stopped if certain criteria are met sooner?

Based on St. Judes, DFCI, and BFM data, COG has recently decreased the length of therapy for males with B-Cell ALL.  Can this be extrapolated to ...

Do you prefer a cHL chemotherapy backbone or PMBL chemotherapy backbone?

What is the timing and role of surgery and RT at salvage for a lung recurrence?  Patient initially presented with lung metastases, but achieved ...

While thrombophilia testing is not routinely recommended prior to starting OCPs, how about after the development of a VTE?

Would you have reservations in treating patients with breast, GI, or pelvic malignancies with radiation alone or concurrent chemoradiation?

Especially in a triple-positive patient with an acute ischemic stroke who may have urgency for anticoagulation with high bleeding risk and severe thro...

How should the need for dose homogeneity be managed relative to the proximity of these target volumes to the spine?   Are AREN0321(HR), 0532(...

The patient who has not responded to steroids, rituximab/bendamustine, and splenectomy?

Is chemotherapy recommended for M+ germinoma? CR to chemo; Spine MRI negative; CSF negative Is CSI required or whole brain radiation is sufficient f...

Would you give a trial of IST first or immediately refer for SCT if the patient has matched siblings?

Has your medical practice taken any steps either in community outreach or within the clinic to show support for this medically vulnerable population, ...

What if there is residual soft tissue disease?  Would you treat a distant metastatic site if only 1 or 2 metastatic sites total with gross residu...

During the Stimate recall, how are we performing DDAVP challenges for newly diagnosed hemophilia A or von Willebrand disease?

Are most places administering oral iron as once daily or every other day dosing due to upregulation of hepicidin receptors following oral iron adminis...

How do you "have the talk" in a way that is straightforward without emotionally crushing the patient?

There is no uniform guideline in the literature. AAP recommends until 5 years old or 1-year post-splenectomy. Some for 5 years post-splectomy.

Do you cone down to gross residual (and stop elective nodal coverage) after 36Gy or 41.4Gy? Parameningeal group III, stage III alveolar rhabdo.

Specifically, are there strategies you use to 1) empower patients to participate in decision-making and 2) reassure patients who may be skeptical?

Does tumor type matter? Are there issues are associated with overcorrecting anemia during radiation?

ARST 1431 indicated: 30Gy (PTV2=GTV2); 25Gy (PTV1=CTV2+2mm) in 5 fractions. With complete response to chemo, how do you defined GTV2?

There is evidence that parents do not adequately understand the purpose of phase I pediatric cancer trials (https://pubmed.ncbi.nlm.nih.gov/23071225/)...

Given the high cost of eculizumab, are there patient characteristics that inform which patients, if any, should be on indefinite therapy versus a time...

For example, a patient with hypogonadism unless it matters which organ is involved. Are other markers of iron storage useful in guiding therapy?

When offering ifosfamide / etoposide for relapsed osteosarcoma, patient is being given 2.8mg/m2 of ifosfamide. Is 6-8 cycles exceeding any known lifet...

For example, in a patient who is steroid-refractory, requiring regular transfusion, and has not had response to rituximab after several weeks.

AREN 0532 kidney constraint is whole kidney <14.4Gy and 50% kidney <19.8Gy. If treating whole abdomen to 21Gy for diffuse unresectable peritonea...

Is radiation always indicated? AREN 0532 specified 10.8Gy flank with 10.8Gy boost to gross residual in all recurrent Wilms patients. However, NWTS-5 ...

If standard of care BEP chemo, tandem transplant, and radiation to primary site have been done previously.

Would extent of surgical resection matter? Do these patients need CSI (like Pineoblastoma), just local radiation, or something in-between (say whole ...

When the original tumor extent is substantial (displaces normal abdominopelvic organs), but responds well to therapy (i.e. as of week 12) - How would ...

If autoimmune neutropenia already suspected, is this test informative or unnecessary?

What is the lowest level you have seen with uncomplicated or complicated crises?

ACNS1123 classified patients as NGGCT if serum & CSF AFP >10 ng/mL or bHCG >100 mIU/ml irrespective of biopsy results & did not mandate ...

There are various formulations of intravenous iron; each with varying costs, test dose requirement, elemental dose, and number or time of infusions ne...

There are mixed recommendations about re-testing vs simply waiting for a quarantine period prior to resuming therapy. 

Is there a preferred strategy of transfusional support versus reduced-dose anticoagulation during the duration of thrombocytopenia?

With the new COG leukemia studies, it is difficult to interpret these results in the context of their clinical status and conventional MRD 

Are there other practical tips for improving the patient setup in this patient population to minimize potential acute and late effects?

We have a patient with stage IIa Hodgkin's disease with a cluster of lymphadenopathy in the cervical area. The diameter of the cluster is 6.1cm per CT...

Hydroxyurea is demonstrated to reduce complications and improve long-term outcomes in severe genotypes HbSS and sickle beta0 thalassemia. What clinica...

While L-glutamine has minimal side effects and would likely be added after hydrea, how do you decide between the use of voxelotor and crizanlizumab?

Do you give RT to the entire extent of disease at presentation or just regions with slow early response? Is it necessary to irradiate all known extent...

Do you radiate the paraaortic chain to 10.8Gy then boost gross residual with 1cm block edge margin to 19.8Gy or simply treat the entire paraaortic cha...

The NCI PDQ on pediatric NHL (https://www.cancer.gov/types/lymphoma/hp/child-nhl-treatment-pdq#_764_toc) indicates that bone marrow biopsy and aspirat...

Do you treat in a response adjusted fashion as per ACNS1123 Stratum 2: 18-24 Gy whole ventricle with 12 Gy boost? Are there any situations where you d...

Is there a role for dose escalation? Would you recommend sequential or SIB? Is there more of a role for surgery vs. dose escalated RT in EWSR1-non-ET...

The new mass was noted on imaging after primary tumor resection and 3 cycles of BEP chemotherapy.

-Are there settings where group II disease does not need RT?-Are there additional genetic alterations in fusion negative RMS patients that can be used...

I have heard <20% MRD. What about proceeding if patient is hypoplastic after chemotherapy?

If proton therapy is not available would you consider radiosurgery? How would your management differ if residual disease is present?

For example, if the patient was on dasatinib before relapse, would you consider other second generation or third generation TKIs?

After optimizing symptoms and reversible factors, and attempting cognitive-behavioral interventions and exercise, do you recommend pharmacologic agent...

Parameningeal disease with distant metastatic deposits to lymph nodes and lungs, fusion negative. What are the considerations for cyclophosphamide dos...

Should the goal always be to proceed to a second transplant? 

Are there general ages that you refer to in terms of risk of secondary malignancy or points dropped for IQ over time after treatment, or particular he...

Should they be context/disease specific?  Should use of chemotherapy before/after, or during radiotherapy modify these tolerances? Contexts: ex...

Stage 4/group 4 due to dissemination in peritoneal fluid. Translocation negative; treated per intermediate risk protocol on study arm ARST1431 VAC/VI ...

Would you recommend screening MRIs for children who have RB1 mutations but have not yet developed retinoblastoma?

Is it at neutrophil recovery, at documentation of CR on bone marrow biopsy, or is there a different point in time?

If so, what dose would you consider in the setting of complete and incomplete repeat surgical resection? How would you sequence this with salvage sys...

Should this be based off of the response? or the site of disease such as bone vs soft tissue?What data are there to dictate that the prior (response, ...

Assuming CBC w/ different and complete metabolic panel are within normal limits, what (if any) further evaluation or management is needed?

If you had to recommend two options, one of which was palliation, what would your second option be?

i.e. Should concurrent therapy be given?, Does MGMT matter? What are the current most promising therapeutic approaches? Should we always treat based o...

How are you changing your parent/visitor policies?  Are you testing for COVID-19 in all febrile patients? Has COVID-19 changed the care settings...

Would you manage this histology any differently relative to other low grade gliomas? Is a STR a definite indication for postoperative XRT?

What if the patient has a history of confirmed COVID-19 but has since recovered?

Discussion of treatment options for midline low-grade glioma causing life-altering symptoms in a pregnant patient to avoid teratogenicity.

At what age would you treat an early stage hodgkins lymphoma patient with ABVD + RT (adult treatment) vs OEPA x 2 or AV-PC x 3 (pediatric paradigm)?&n...

Outcomes for these patients are dismal, so looking for any insight on how to optimize outcomes for these patients.

Do you limit it to post-pubertal patients? Do you offer it only if they will proceed with bone marrow transplantation after CAR-T?

Obviously, patient and caregiver preferences are paramount. But, what factors do you consider? Does expanded hospice (e.g., Medicare Care Choices) inf...

How would you approach a patient who is receiving chemoRT but has confirmed COVID-19 with minor symptoms, as breaking treatment for 2 weeks quarantine...

A case report (https://www.ncbi.nlm.nih.gov/pubmed/32149486) describes severe COVID-19 infection in a pediatric oncology patient. Have you seen simil...

Scanning beam only machines are being increasingly marketed, it could be problematic if you can't use them to treat the one site which is most appropr...

The more recent NWTS trials do not include these tumors, since rhabdoid are recognized to not be similar to Wilms, and the AREN0321 does not provide s...

Should the patient be admitted for observation which will risk exposing other immunocompromised patients to COVID-19, or should the patient be quarant...

How do you prevent early menopause in women? Please comment on freezing of eggs, oophopexy, supine vs prone position, vaginal dialator. 

Guidelines indicate RCHOPx3 +RT as category I and RCHOP x 6 below that; long term f/u for SWOG 8736 showed similar PFS and OS. Do you have and approac...

-The data on induction for adult H&N ca has been mixed (excluded NPX) but recent data suggest a benefit for adult NPX. -Given that this is standa...

When covering with radiation what dose and technique do you favor, electrons, IMRT, brachytherapy, protons?

Some emerging data of improved up front therapy shifting recurrence to CNS as sanctuary site, is focal RT approach (i.e. SRS) reasonable or is CSI a s...

Assuming it has previously been treated with excision and steroid injections? Is it reasonable to treat a bothersome keloid in a pediatric patient aft...

With the recent publication of multi-institutional trial data, should this now become standard of care?

Would the translocation status influence your decision? Are there specific subsites where elective radiotherapy likely offers a higher therapeutic rat...

Would you consider radical cystectomy equivelant in terms of local control and how do you balance morbidity of radiation with morbidity of non-organ p...

In a patient with high risk rhabdomyosarcoma with significant marrow involvement (Stage IV), who has responded completely on imaging to all known site...

Would you treat this with whole-abdomen RT with a boost? What dose would you recommend? This would be Stage 1, Group 2 (R1 resection), low risk; but l...

Does the St. Jude's Experience (NEJM 2009, PMID: 19553647) provide sufficient justification for routine omission in high risk patients?

Is it recommended in every pediatric patient?  Are there any guidelines for organ-specific surveillance after XRT for children based on age, dose...

For example, if there was a common iliac node, does external iliac nodal region also need to be included? When, if ever, do you include the exter...

Assuming CSF is negative for neoplastic cells would you: Re-irradiate gross disease only? Re-irradiate posterior fossa only? Re-irradiate the entir...

Is there any role for consolidative RT/CRT to the lung and mediastinum after initial chemo? What dose and fractionation would be most appropriate for ...

We often see young women with favorable, early stage disease in the mediastinum who have had a complete response to chemotherapy. With current smaller...

 If so in what circumstances and what margin is acceptable? ACNS 0331 recently showed no difference in outcomes when comparing IFRTboost vs ...

After ABVE-PC X4 and Ifos/vinorelbine x 2 per AHOD 0831 (and is unable to have these sites biopsied), what dose would you treat to and what volume wou...

AREN0533 schema requires knowledge of 1p16q status, though this test is not available off-protocol. How does this affect management for patients treat...

It seems that with the arms up, you get better lung blocking but with arms akimbo, you might have a lower dose to the humeral head. 


Papers discussed in this category


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JAMA,

Clinical lung cancer, 2016-01

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Br J Radiol,

Burns, 2014 Apr 24

Pediatrics, 2013-01

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Cancer, 2004-08-15

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Cancer, 1990-11-15

Radiother Oncol, 1990-01-01

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Nature, 2014-02-27

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Pediatric blood & cancer, 2007-12

Lancet (London, England), 2010-07-24

Neuro-oncology, 2016-10

BMC cancer, 2014-04-12

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2016-07-01

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Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2018-04-01

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Blood, 2018-10-18

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Neuro-oncology,

Neuro-oncology, 2014-01

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The New England journal of medicine, 2005-03-10

The Lancet. Oncology, 2018-06

J Clin Oncol, 2018 Aug 09

J Clin Oncol, 2020 Apr 24

Br. J. Haematol., 2020 Apr 30

JAMA Oncol, 2020 Jan 16

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Pediatr Blood Cancer, 2019 Jun 19

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J. Neurooncol., 2017 Nov 15

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The American journal of surgical pathology, 2017-07

Pediatr Blood Cancer,

Pediatr Blood Cancer, 2014 Aug 31

Clin Cancer Res, 2018 May 15

Eur. J. Cancer, 2014 Dec 13

Am. J. Surg. Pathol.,

The Lancet. Oncology, 2013-09

Neuro-oncology,

Cancer Cell,

J. Clin. Oncol., 2018 Sep 06

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N Engl J Med,

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World Neurosurg, 2017 Apr 28

Lancet Oncol., 2014 Aug 07

Haematologica, 2020

Nature, 2019-03

Blood, 2018 May 02

Leuk Lymphoma, 2019 Dec 26

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Pediatric blood & cancer, 2014-03

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Pediatrics, 2009-01

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Sarcoma, 2014

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Blood, 2018 Jul 12

Ann. Intern. Med., 2019 Oct 15

Blood, 2018-07-19

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Nature genetics, 2014-06

The American journal of surgical pathology, 2016-02

Cancer, 2017-06-15

Pediatric blood & cancer, 2017-09

International journal of radiation oncology, biology, physics, 2019-01-01

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The journal of allergy and clinical immunology. In practice, 2017

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Pediatric blood & cancer, 2010-10

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American journal of hematology, 2019-07

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The New England journal of medicine, 2010-08-19

Pediatric blood & cancer, 2016-08

JAMA oncology, 2017-09-01

JAMA Oncol,

JAMA, 2015-09-01

JAMA oncology, 2016-05-01

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N Engl J Med, 2015 Nov 18

Cancer chemotherapy and pharmacology, 1994

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Journal of thrombosis and haemostasis : JTH, 2018-06-07

American journal of hematology, 2008-08

Blood, 2010-07-22

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N. Engl. J. Med., 2015-04-23

Blood, 2018 Sep 6

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Clin J Am Soc Nephrol, 2016 Oct 31

Blood, 2020 Dec 03

Rheumatol Int, 2019 Apr 30

Clin Exp Rheumatol, 2012 Sep 25

Wien Klin Wochenschr,

Int J Radiat Oncol Biol Phys,

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Semin Arthritis Rheum,

Lancet Haematol, 2019 Nov 05

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The Lancet. Oncology, 2018-03

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Blood, 2013-12-05

Blood Adv,

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Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2015-08-20

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Pediatric blood & cancer, 2014-04

The Lancet. Haematology, 2015-09

Haematologica, 2017-07

Blood, 2018 Jun 13

Blood, 2010 Jul 15

Journal of the National Comprehensive Cancer Network : JNCCN, 2018-01

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