Pediatric Hematology/Oncology
Questions discussed in this category
My patient’s family has asked that I don’t tell her that she has metastatic cancer because it will devastate her. I am planning on palliat...
How often does this occur and does this lower your suspicion for a "true" or clinically significant lupus anticoagulant?
Is there a role for immunotherapy, anti-angiogenesis, or TKIs? Can you use immune checkpoint inhibitors in combination with lenvatinib?
vWF and FVIII activities ~200% and were checked because of the patient's family history of "coagulopathy".
Is there any utility in repeating the test...
Specifically, headaches thought not to be related to increased ICP.
Is there a target IgG level to aim for?
What should hematologists be aware of in monitoring these patients?
Mediastinal GCT outside of the congenital window are considered poor risk, but patients with congenital GCT tend to fare well. How does this affect yo...
If so, how long do you continue medication and when do you discontinue? Does treatment with surgical resection versus radiation alone change your mana...
Labs with normal PT, but prolonged PTT (47 sec, ULN 40 sec) that does not correct on immediate mix. Lupus anticoagulant negative (DRVVT and hexagonal ...
Per the NCCN guideline for HR HD, if treated per OEPA-COPDAC, you can omit ISRT. This patient received treatment per AHOD1331, which recommends ISRT f...
Assume the patient has infrequent bleeding events every few years, with use of FIX replacement for acute bleeds only.
Presuming good medication adherence.
Do you consider starting Ursodiol? Do you perform routine abdominal ultrasound to monitor for cholelithiasis?
Is there a role for nelarabine and venetoclax in this setting?
Is parasitemia >10% and severe hemolysis with Hb less than 7 enough to initiate this?
After what time period would you consider adding a second iron chelator?
Do you discuss the risk of sickle cell crises with G-CSF? What about for patients with sickle cell trait?
How do you advise patients who strongly desire chemotherapy?
Is there a role for non-myeloablative regimens?
Thrombophilia testing, including JAK2 is negative. When would you stop anticoagulation?
Chemotherapy is associated with acquiring C diff colitis. Does immunotherapy share that same risk and necessitate ruling out infection prior to anti-d...
If not, has your practice changed to use vWF replacement therapy more routinely for perioperative or acute bleeding management? Do you still perform D...
Would you consider chronic RBC exchange versus HU?
Are there specific guidelines for managing this patient population?
When do you determine SSRI therapy is unsafe to pursue in such situations?
rWGS did not demonstrate any HLH definable or associated mutations.
qPCR for BCR/ABL was negative. FISH remained positive.
Would you offer radiation and chemotherapy, vorasidenib, or observation?
Hb at goal of 9-10
No clear inciting etiology found.
Would you consider dexamethasone +/- cytokine blockade (IL-1, IL-6, or IFN-g)? What do you think about the data for...
Are the INRs reliable? In what scenarios would you not recommend POC INR use for warfarin monitoring?
Are these typically covered by insurance? Are t...
Given nationwide shortage in vinblastine, several of my patients under active therapy are facing delays in their therapies. Is it appropriate to subst...
Do you do additional workup for venous obstruction or any other different testing/evaluation?
Do social or economic factors (i.e., relative cost of acquiring LMWH, the patient being injection averse) affect your decision to use DOACs?
Do you s...
Is there a factor XI goal that you target? Would you consider FVIIa products instead?
Additional risk factors could be family history of VTE or thrombophilia, such as antithrombin deficiency.
Should they be context/disease specific?
Should the use of chemotherapy before/after, or during radiotherapy modify these tolerances?
Contexts...
Should adult hemoglobin targets be different than pediatrics?
Are there specific safety concerns or long-term risks that should be accounted for when considering drug holidays or overall treatment duration?
How will you implement response assessments in patients starting tovorafenib given potential for pseudoprogression vs true progression?
Is it merely another option to try or will it become the standard choice for patients experiencing relapsed/refractory disease?
Does this hold true when the patient has significant inflammation?
Is there utility when classic inflammatory markers (ESR,CRP) or disease specific markers (C3, C4, dsDNA) do not correlate with patients disease activi...
Tumor measures 4 cm after STR. Is NF1 a contraindication for adjuvant RT?
I've seen a handful of fatal radiation pneumonitis associated with rapid steroid tapers by the non-treating physicians. How do you recommend prescribi...
Patients sometimes ask for annual urinalysis and ultrasound to monitor, but it is unclear if this is indicated.
How would your recommendation change if the patient has H63 homozygous mutation?
Do you treat this similarly to IDH-Wildtype GBM with the STUPP regimen? Is there any role of less-intensive paradigms, such as 59.4 Gy/33 fx?
How do we approach patients with rare tumors given the paucity of data?
Is a BM biopsy a must when there is skin involvement?
If tryptase level is mildly elevated but less than 20 would you recommend a BM biopsy?
The ASH 2020 guidelines have "recommended that adults with HbSS or HbSβ0 thalassemia be screened at least once for silent cerebral infarcts even ...
Does the stage at diagnosis affect your decision?
There was a recall on viscous lidocaine and many of our patients cannot find it. What would you recommend as alternatives?
Do you insist on ambulatory/home blood pressures to rule in/out white coat hypertension? Does your practice have a system to log patients' BPs to supp...
What criteria do you use to define steroid-refractory disease?
Does your management different by organ system involved - GI vs skin vs other?
Are there other measures, pharmocologic or adjunctive, that can be used or are under investigation to mitigate cardiotoxicity related to chemo- or rad...
The patient presented with a numb chin, more to the right of his face; an MRI did report mandibular nerve opacity, which is non-specific per neuro-rad...
For example, if patients are unable to receive continuous infusion from home health agencies, or if prolonged hospitalization is cost-prohibitive.&nbs...
How do you choose between RIC compared to MAC? Is there evidence for one over the other in an otherwise healthy, young patient?
Do you include hypome...
NCCN says "consider autologous HCT" while retrospective data seems to support SCT in most histologies like AITL
Have you changed your practice given BMT-CTN 1506/Morpho results?
Would you utilize maintenance therapy in patients who achieve MRD- remission?
Do you recommend adjuvant chemotherapy after radiation treatment?
Would you consider stopping therapy versus doxorubicin + dacarbazine/doxorubicin alone versus alternative chemotherapy ?
Have you been able to deliver standard of care treatment?
How does graft source, conditioning regimen, and indication for transplant affect your decision regarding G-CSF?
At the time of count recovery or do you continue it throughout induction and consolidation?
NGS results are pending
The patient was recently diagnosed with pre-B ALL and is on day 10 of CALGB 10403. He is expectedly neutropenic as he received daunorubicin and vincri...
Is completing nodal dissection warranted for surgical management?
Antifibrinolytic therapy alone +/- DDAVP?
Ferritin >2200, TSAT >80%
There are various formulations of intravenous iron; each with varying costs, test dose requirement, elemental dose, and number or time of infusions ne...
While follow up ultrasound is not usually recommended in provoked DVT, it often is done either for other reasons or by other physicians. Would this in...
How do you counsel patients and caregivers? Do you prescribe medications (''appetite stimulants'') with the goal to improve appetite even if they do n...
How would you counsel the patient if he/she wants to continue on steroids?
Common thought is that FVIII may be used for differentiating coagulopathy in liver disease (normal to increased, from reduced clearance of VWF/FVIII) ...
I.e. platelet count <30. Would your management change if HIT were only suspected rather than confirmed?
For instance, do you factor availability of RNAseq, inclusion of normal blood controls, and QNS rates into your decision?
Or offer resection followed by adjuvant therapy?
Anemia is secondary to menorrhagia. No gynecologic interventions were possible.
Practice varies among oncologists and institutions
How should IVIG and either biologic injections or infusions be spaced?
For a pediatric patient with B-ALL who needs elective surgery during maintenance, what are potential treatment options during the month recommended fo...
What is the best way to counsel families in regards to their child's risk of infertility and need for fertility preservation?
If so, for how long?
E.g. Normal F8, VWF activity ~50%, VWF antigen ~100%, ratio 0.5 sent in a patient with positive bleeding history
Is there any clinical significance t...
Specifically, asymptomatic subsegmental PE diagnosed within a month from planned bilateral mastectomy for breast cancer.
What workup do you typically recommend?
How do you choose between Avastin, hyperbaric O2 and other therapies?
Does the St. Jude's Experience (NEJM 2009, PMID: 19553647) provide sufficient justification for routine omission in high risk patients?
Does the fact that the patient is on methotrexate alter your choice?
Would you test for bone marrow failure syndromes before beginning the conditioning regimen?
Provided that the platelet count is normal, do you usually consider this to be a potential erroneous result or do you pursue additional workup for RBC...
Is it necessary to delay the start of radiation therapy for males planning on sperm banking for fertility preservation?
Assuming patient is <45 years old with cervical, vulvar, vaginal, anal, or head/neck cancers, or with CIN/VIN/VaIN/AIN/oropharyngeal precancerous l...
How often do you see non transfusion-dependent thalassemia and how do you approach the treatment?
Although TIBC is negative acute phase reactant, would it be a better indicator of iron deficiency (in combination with ferritin)?
What volume and dose do you treat a bone met that has completely responded to chemo?
Would a negative NGS eliminate the possibility of MDS?
Is bone marrow biopsy indicated in a patient with pancytopenia with a negative NGS panel?
What else would you consider in your differential?
How would the risk of VTE associated with crizotinib affect your decision? Should we consider using crizotinib in combination with brentuximab?
Is this an artifact of what agent prior clinical trials used or something to do with the mechanism of action (i.e., less mineralocorticoid effect of d...
Such as the case in which a patient is unresponsive to steroids, IVIG, TPO-agonist, rituximab, splenectomy, and even fostamitinib.
Do you re-challenge them? If so, what pre-medications do you give? Do you dose reduce the cytarabine? Or do you switch another regimen?
Would you consider low dose indefinite anticoagulation in any scenario? Any difference in approach between hematological malignancy and solid tum...
No prior thrombosis; no family history of thrombosis. As per endocrine, the only useful therapy for the osteoporosis is estrogen.
How is this entity distinct from other secondary HLH entities?
Patient initially achieved CR with VAC-IE with resolution of presumed lung mets and 100% necrosis in LLE primary tumor on BKA. Then was NED again afte...
Bleomycin omitted due to asymptomatic decline in DLCO
If so, what treatment regimen would you recommend?
Please specify how your institution is allocating resources now or will be soon.
Observe versus adjuvant chemotherapy?
(i.e. frequency of serial BNP, troponin, cMRI)
Would it change your management if the thrombus was symptomatic? Or if larger >3 cm?
For example, a patient with a bone marrow biopsy that shows normocellular bone marrow. Prior management with leflunomide and HCQ with neutropenia attr...
What would your next line therapy be? If the patient had no matched related or unrelated donors, would you consider haploidentical transplant?
Presuming there are no matched unrelated donors.
If hydroxyurea modifies the course of sickle cell disease by increasing fetal hemoglobin, is there any benefit to using it in patients with fetal hemo...
Would you give a trial of IST first or immediately refer for SCT if the patient has matched siblings?
How do you "have the talk" in a way that is straightforward without emotionally crushing the patient?
Is your approach different than that to a primary essential tremor?
What would you want community oncologists to know when following these patients? Are there any other special issues to follow especially in AYA?
ADAMTS13 level <5%
Inhibitor level <1
How can these interactions be improved?
There is evidence that parents do not adequately understand the purpose of phase I pediatric cancer trials (Cousino et al., PMID 23071225).
E.g. pulmonary embolism, portal vein thrombosis, cerebral venous sinus thrombosis
If so, what platelet count threshold would you use? Would age impact your decision? Would you do a bone marrow to rule out primary MPD in adults if th...
What is the ideal approach for female adolescent athletes if they have complaints of fatigue and dizziness and are diagnosed with mild iron deficiency...
That is, extra copy of one of the alpha genes resulting in an atypical alpha thalassemia for the patient, and beta thalassemia heterozygous carrier fo...
Please comment on temperature recommendations and role of exchange transfusion.
For patients not on study, would you consider replacing missed doses of peg with a non-asparaginase based chemotherapy?
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?
There are conflicting reports whether it contributes to renal insufficiency. If you do switch, what is your preferred TKI in this scenario?
J Clin Oncol 40, 2022 (suppl 17; abstr LBA2). https://meetings.asco.org/abstracts-presentations/209024
In the absence of concerning bleeding or thrombosis, family history of coagulopathy, current anticoagulant use, or malnutrition
Although testing was not indicated, what do u do with these results?
Other hypercoagulability work up negative
If so, how often do you check these labs?
Would the answer differ if the index event was arterial vs venous?
How is your approach different from or similar to those who undergo surgical menopause?
Do you advise against combination OCPs?
What type, dosage, and duration of treatment do you use? How does your practice change when there is an inhibitor?
What are indications to order gene mutation studies (e.g. ELANE) and how would it help the patient?
What would you recommend within the first year after ATG and thereafter if still maintained on cyclosporine?
Such as the scoring system described by Summers et al, "Comprehensive Genomic Profiling of High-Risk Pediatric Cancer Patients Has a Measurable Impact...
Increased genomic testing is likely to increase the frequency with which we encounter these mutations, which we might not otherwise have tested for. H...
Ferritin uptrending >1000, no additional lab abnormalities. HFE wildtype. Too young for age-appropriate cancer screening. Asymptomatic except fatig...
Is thrombotic risk too significant? Patient failed OCPs.
What would be your next treatment for a young adult patient with medulloblastoma refractory to repeat resection, craniospinal irradiation, and initial...
What are the differences in approach to B lymphoid/myeloid and T lymphoid/myeloid MPAL?
For example, if TSAT is less than 20% but ferritin is over 200.
Would surgical margins, evidence of angiolymphatic spread, number of lymph nodes removed during surgery inform your decision?
Do you just use antibiotic prophylaxis if therapy is started prior to meningococcal vaccination?
If not, how do you choose GVHD prophylaxis regimen? Is there a preference?
Wu et al., PMID 34665865
Do you plan to change your practice based on the data presented in this JCO paper by Summers et al?
E.g. would you dose-reduce or continue at same dose?
Baseline ANC was in the normal range
What if the spillage is noted to be limited to the tumor bed, per the surgeon?
What is the role of PD-1 inhibitors after CAR-T infusion, either as maintenance therapy or in the setting of relapsed disease?
Patient with high titer acquired FVIII inhibitor with no causative etiology. Bleeding is well-controlled on emicizumab, but inhibitor has failed...
How reliable is somatic testing to detect an underlying germline predisposition?
The patient has no personal history of VTE, but has positive family history of VTE.
Any prophylactic anticoagulation options?
How would manage...
Is skin testing advised prior to trialing alternative?
For instance, if clonal hematopoiesis of indeterminate potential (CHIP) suspected
iPET2 and iPET4 showed Deauville 5 response. CT biopsy after 4 cycles was negative. Patient is currently scheduled for 2 additional cycles of ABVD.
Ewing sarcoma of the right lung, status post bi-lobectomy and adjuvant VDC/IE, with recurrence 6 years in the right lung only. He has reached a cumula...
I.e., what constitutes well-controlled cancer, IBD, nephrotic syndrome, etc. What other diseases do you put in this category (obesity, autoimmune dise...
ALC<200
i.e. long car rides or plane rides
Do you ever add prophylactic Keppra (levetiracetam) for glioblastoma patients without a seizure history based on data such as this study (nature.com) ...
CRP 39 mg/L (normal < 10) and normal ESR
Are there particular drugs you avoid or dose-adjustments that are recommended?
Do you use a cutoff of 10 cm? Do you measure the size of the largest node or measure the largest conglomerate or measure the total length of the entir...
How does graft function play into your decision making? How do you utilize post allogeneic transplant chimerism in clinical practice? Do you obta...
Presuming strong indication for ASA - eg history of NSTEMI
Should we stop checking factor VIII levels as part of thrombosis workup?
How do you interpret elevations in antiphospholipid antibodies that are lower than Sapporo criteria?
(e.g. beta 2 glycoprotein IgM > 20 but <40)
In patients who continue to have insomnia despite diphenhydramine, benzos, and trazodone, are there other evidence based treatments that are helpful?
e.g. K, Fya, s, etc
Do you routinely check IgG levels during therapy, if not indicated by a study protocol?
If so, what regimen do you utilize?
How would the approach differ if the patient had a significant bleeding phenotype vs only minor bruising and mucosal bleeding?
If serum markers were normal, how strongly do you consider 1 cycle of BEP for embryonal predominant pathology?
This type of etoposide sparing therapy has been previously described in a case series at https://pubmed.ncbi.nlm.nih.gov/32725881/
Last rituximab 6 months ago
VIP can be considered, but given complex psychosocial issues and limited community cancer treatment resources, this question is being asked.
How do you sequence/integrate radiotherapy relative to high risk chemotherapy?
When would you consider cranial/craniospinal radiotherapy?
What is the impact among patients and providers?
Has your documentation been adjusted now that patients can readily review?
If so, how long after diagnosis do you do so?
NCCN guidelines state check at baseline and then as clinically indicated. Some other sources state, can check prior to each cycle of BEP?
What ...
Are there situations in which a Deauville 3 would cause you to escalate therapy?
Assuming it has previously been treated with excision and steroid injections? Is it reasonable to treat a bothersome keloid in a pediatric patient aft...
This is particularly relevant for patients with extensive delays due to wound healing issues.
Does the degree of resectability affect your management?
Does treatment with B-cell depletion and/or negative anti-spike antibody status despite COVID mRNA vaccination influence your decision?
FVL heterozygotes are often treated similarly to the general population. Aside from avoiding other VTE risk factors, are there situations where prophy...
Are there particular clinical scenarios that would affect your decision?
The patient already received PLADO+sorafenib, Y90, and Atezolizumab/Bevacizumab complicated by recurrent episodes of bleeding from esophageal varices....
e.g. DITP from eptifibatide after a cardiac intervention
If not, how should you select those cases that should be referred?
IVIG, TPO, or other agents?
Given persistent embryonal histology on RPLND, do you favor observation or TIP/VIP? What do you use to guide your decision?
When/how often do you order imaging?
How does your treatment approach vary depending on the underlying predisposition?
Given the POLARIX study data presented at ASH 2021, will this replace R-CHOP as the standard of care therapy in your practice? If not, how will y...
Are there specific vaccines you recommend repeating, or do you recommend a catch-up schedule?
Is there a role for more advanced delivery techniques
Would you offer indefinite anticoagulation if the event is unprovoked and the patient has low bleeding risk?
Individuals often cite ARST0332 to justify radiation omission in high grade R0 resections, but R0 was defined as > 5 mm margins.
If a staging RPLND is NOT performed, is there a role for prophylactically irradiating the lymph nodes, even in the setting of a negative PET/CT at dia...
Also is there value in using voxelotor for the purpose of reducing hemolysis, and if so what parameters do you use to determine when to initiate voxel...
If so, what dose and fractionation would you recommend?
What dose/fractionation regimen is most appropriate?
-i.e. 12 Gy in 4 fractions, but would you modify that approach in a young patient?
What i...
Is there a particular sequence you would adjust contributing antirejection or antimicrobial medications? Is the use of G-CSF appropriate and at what c...
How does belumosudil now fit in your approach to steroid refractory chronic graft-versus-host disease?
Would extent of surgical resection matter?
Do these patients need CSI (like Pineoblastoma), just local radiation, or something in-between (say whole ...
Hydroxyurea is demonstrated to reduce complications and improve long-term outcomes in severe genotypes HbSS and sickle beta0 thalassemia. What clinica...
Are there other supportive care interventions that would otherwise be covered by hospice?
What if the patient is triple-positive or has continued seropositivity on repeat lab testing? What is the appropriate interval of monitoring and does ...
Provoked or unprovoked VTE: Do you use D-Dimer (or even repeat imaging to reassess residual clot) in any capacity to guide anticoagulation duration? E...
Is an LP only recommended in the setting of particular subtypes of lymphoma or symptoms of CNS disease?
Have you used anticoagulants other than coumadin? Or is that the only appropriate agent given monitoring is based on PT/INR?
If yes, by what mechanism?
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...
Especially with the current drug shortage of nelarabine.
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...
How do you incorporate PD-L1 blockade?
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...
Would this change with someone who has a history of thrombosis (e.g. DVT/PE, MI, CVA)?
Would this change with someone who is more fit vs more frail?
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?
In follow up to @Jacqueline Casillas presentation at ASCO 2021 regarding models of survivorship care delivery for AYA patients.
Patient received Pazopanib upfront with Ifos/Dox. Pulmonary metastatectomy is not an option as there are multiple mets.
If given both options, which donor would one prefer: haploidentical related donor or 7/8 mismatched unrelated donor using post transplant cyclophospha...
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...
Is there a role for empiric antibiotics if there is history of opportunistic infection?
With a strong family history
Both the patient's nasopharyngeal swab and stem cells themselves resulted COVID positive post-harvesting.
Are there any effective non-pharm or pharm interventions?
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....
Do you follow the 2019 EULAR Guidelines that SLE patients with asymptomatic, positive aPL should be on low-dose ASA?
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 ...
Would you consider this type of patient as having polycythemia?
How long after eculizumab infusion would you wait before giving blood transfusions?
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 ...
What is the potential differential diagnoses for low iron saturation?
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 ...
What is the role of methylene blue prophylaxis?
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(...
At what frequency and for how long should echos be monitored?
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...
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...
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.
Have the RAPID or CALGB 5064 studies changed your treatment approach?
What volume and dose would you use?
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?
Given the high cost of eculizumab, are there patient characteristics that inform which patients, if any, should be on indefinite therapy versus a time...
How do you manage an uncomplicated DHTFR versus a hyperhemolysis?
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.
FOXO1 translocation positive
Presented at ASH: FLIGHT trial
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.
If so, what additional testing do you send?
When the original tumor extent is substantial (displaces normal abdominopelvic organs), but responds well to therapy (i.e. as of week 12) - How would ...
What if the patient had also received HIPEC prior?
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 ...
Patient treated per AAML0531
Particular patient is s/p 2 HSCTs
Do you re-test patients who test positive for COVID-19 during or prior to starting cancer treatment?
There are mixed recommendations about re-testing vs simply waiting for a quarantine period prior to resuming therapy.
Late relapse is > 36 months from diagnosis.
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...
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...
What if this was "triple-negative" antiphospholipid syndrome?
The new mass was noted on imaging after primary tumor resection and 3 cycles of BEP chemotherapy.
Patient's leukemia has both T and Myeloid lineages
-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...
What are the data supporting this?
Or do you use prophylactic defibrotide?
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?
If you do what dose and fractionation do you recommend?
Utility of maintenance chemotherapy per ACNS0831 in patients with anaplastic ependymoma
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...
Is it higher than the average person?
Parameningeal disease with distant metastatic deposits to lymph nodes and lungs, fusion negative. What are the considerations for cyclophosphamide dos...
Presented with mass projecting into right/left anterior ethmoid complex
The patient previously received the P6 regimen.
Should the goal always be to proceed to a second transplant?
CT scans show omental and pelvic disease.
Would you consider “bridging” therapy with something like an HMA?
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...
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...
Do you find that one method is more sensitive than the other?
Does acute leukemia sub-type affect your decision?
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, ...
What are there most evidence-based options?
E.g. a patient with progression of their primary cancer but still is testing COVID19+ over a month after infection?
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...
Are you placing more weight on patient risk factors such as age >65 or co-morbidities?
If so, what dose would you recommend?
Discuss the role of mAb in DIPG.
What advice do you give regarding dietary practices, feeding tubes / parenteral nutrition, and pharmacotherapy specifically for cachexia?
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...
Should treatment be based on current histology (rhabdomyosarcoma) or origin (germ cell)?
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?
GI work up negative. NGS cancer type and isochromosome 12p ordered and pending. Pathology at RPLND was negative for cancer.
There are conflicting reports of increased incidence of bleomycin-induced lung toxicity with G-CSF.
Obviously, patient and caregiver preferences are paramount. But, what factors do you consider? Does expanded hospice (e.g., Medicare Care Choices) inf...
Following local therapy, what is your choice of systemic therapy?
Acknowledging that there is no time for good trials yet in this setting
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?
Would you offer repeat CSI or favor chemotherapy?
How do you assess risk of tumor lysis syndrome, and is hydration sufficient or should hypouricemic agents be used as well?
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...
With the recent publication of multi-institutional trial data, should this now become standard of care?
Is there a role for adjuvant radiation? Other chemotherapy options?
In a patient s/p orchiectomy and with pelvic lymphadenopathy, would you consider lymph node biopsy to confirm involvement by non-seminomatous germ cel...
Would the translocation status influence your decision? Are there specific subsites where elective radiotherapy likely offers a higher therapeutic rat...
Is there a role for immunotherapy outside of trial setting?
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...
Comments regarding risk of Moyamoya
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...
Is it recommended in every pediatric patient? Are there any guidelines for organ-specific surveillance after XRT for children based on age, dose...
What fields would you use for adjuvant RT? SBRT vs. whole brain?
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...
Would the risk of secondary malignancy affect the decision?
Assuming CSF is negative for neoplastic cells would you:
Re-irradiate gross disease only?
Re-irradiate posterior fossa only?
Re-irradiate the entir...
Given the non-specific nature of AFP and its elevation in various benign conditions, is there an AFP cutoff level or change over time for which you wo...
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 ...
Can you use SBRT for boost?
Is any amount of teratoma or PNET an indication for surgery?
What is the risk of joint issues if you treat the epitrochlear nodes?
What dose do you recommend?
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...
What if there is a CR to chemo?
Are the results of AHOD0031 practice changing?
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.
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