Pediatric Hematology-Oncology Resident Rotation Manual The Basics (Important phone numbers and logistics of the ward): Who? What? Where? 1N: 7-8446 Bass Center Day Hospital (BCDH) (outpatient 1N) Resource RN: 721-9542 Procedure RN: 721-9547 BCDH procedure coordinator (Shawna): Voice mail: 497-8502 Ascom phone: 721-9553 Fax: 721-1243 Surgery scheduler: 3-6439 Bass Center Pharmacy Inpatient: 7-8776 Outpatient: 7-8289 Home: 7-8316 Radiology: 7-8376 scheduling Body MRI/CT reading: 42727 Neuro MRI/CT reading: 42728 Nuclear Medicine: 3-6855 ED: 3-4422 PICU: 7-8850

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1N charge RN phone: 721-9557 Fellow phone: 721-9572 Resident phone: 721-9574 Jen Owens phone: 721-9573 Inpt case manager: 721-9476

Child life: 721-8547 Clinical lab: 3-6111 Micro lab: 4-8632

Transfusion Service: 3-6444/ 3-6445

PICC RN: 4-PICC APU: 7-8912

Oncology rounds begin daily at 8:30 am in 1N workroom, except on Fridays, when they start at 9 am after Grand Rounds Jen Owens is the inpatient Oncology NP; she takes care of all the patients who come in for scheduled chemo (ie are not otherwise sick), and rounds on them during the week with the attending on service Purple charts: These are the clinic charts for the oncology patients and Jen Owens or fellow on service usually brings them to the workroom when a patient has been admitted o These are important for many aspects of patient care  Reference of the chemotherapy plan (roadmap) for each patient • Helps to know what chemo/when the patient is next due for, and whether they need to be scheduled for a procedure • Helpful to know timing of last chemo with regard to expectations around when counts should nadir--> recover • Allow the resident to anticipate specific toxic effects from the chemo last given or due while the patient is inpatient

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Note that these purple charts are not part of the LPCH medical record and should never be removed from the Bass Center

Sign Outs: o Every morning the night float resident emails an overnight signout to the residents on service and to [email protected] o On Friday PM, Jen Owens emails a weekend sign out since the residents cover the chemo patients over the weekend; try to get a verbal sign out from Jen before she leaves for the weekend. o When a patient is discharged, the inpatient fellow will send a brief email to the heme/onc staff which includes the general hospital course and follow up plan for the patient. The fellow on service should be scheduling outpatient clinic/lab appointments or coordinating this with the patient’s primary fellow or NP o The subject line of all emails from residents/staff with patient information should read SECURE: ONC signout

Transfusion Medicine: General guidelines • Parameters for transfusion: Hemoglobin (Hgb)50,000 unless patient having a diagnostic lumbar puncture, then general recommendation is for platelet count >100,000 **Hem/Onc/SCT patients should generally receive leukoreduced, irradiated blood products ** • Leukocyte-reduction: o Reduces transmission of cytomegalovirus, alloimmunization to HLA antigens, and the incidence of febrile transfusion reactions. • Irradiation: o γ irradiation prevents transfusion-associated-graft-versus-host-disease in immunocompromised or immunologically immature patients. • Washing: o RBCs may be washed and resuspended in sterile saline to a Hematocrit of 70-80%; this removes about 98% of plasma.  Washing is indicated only in unusual circumstances (so talk to blood bank before ordering)

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Among Heme/Onc/SCT patients, it is generally used to remove plasma proteins in blood components for patients who experience recurrent and severe allergic transfusion reactions.

Red Blood Cells • Indication for transfusion: Hemoglobin < 8 g/dL and symptoms of anemia o Transfusion of 10-15 ml/kg will raise Hb concentration by 2-3 g/dL o Recommended administration is over 2-4 hrs  If Hgb 30 kg  ½ apheresis unit for patients 50,000 **The degree of leukocyte count elevation remains one of the most important predictor of prognosis in ALL** • Neutopenia (100,000. If necessary please transfuse patient with platelets prior to the first LP. o CNS status is defined as:  CNS 1: zero blasts in CSF  CNS 2: 5 WBC + blasts on cytospin but negative by the Steinherz/Bleyer algorithm (ie, presence of blasts determined to be due to traumatic tap, not CNS leukemia)  CNS 3: >5 WBC and +blasts or clinical signs of CNS leukemia (such as cranial nerve palsy)

Other Considerations at the time of admission with new diagnosis of leukemia: • In general, patients with active acute leukemia are “functionally neutropenic,” even if ANC level is >500, as their neutrophils are abnormal in morphology/function o Should be treated with empiric F&N antibiotics (usually Ceftazadime is sufficient) if febrile (or history of fever) at presentation o Obtain peripheral blood culture prior to starting antibiotics • Determine transfusion needs • To make a Bass Center procedure room reservation for BMA +/- LP; o FAX LPCH Scheduling/Precertification Form to Shawna (1-1243) and also leave her a voice message (7-8502) with the same information, she checks this first thing every AM. • Determine vascular access needs: PICC line through vascular access, tunneled Hickman or port via Peds Surgery office. Note that PICC placements can typically NOT be scheduled for Bass Center procedure room, must be done in APU or on 1N. Discuss choice of venous access with fellow/attending on service.

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Intrathecal chemotherapy to be written (if will be given with diagnostic LP), bone marrow paperwork filled out, heme path tech and leukemia CRA made aware (these are generally the responsibilities of the fellow/attending on service)

Prognostic Factors for ALL Background Newly diagnosed ALL patients are treated based on risk stratification. Risk stratification is a classification system derived from clinical and laboratory observations that correlate with outcome. For ALL we use: WBC count and age at diagnosis; the presence of CNS or testicular disease; DNA index/ploidy and presence or absence of recurrent translocations; and minimal residual disease status at the end of induction therapy. The latter is based on flow cytometry studies using antibodies to cluster differentiation (CD) antigens present in leukemia cells. This methodology can detect 1 leukemia cell: in 10,000-100,000 cells from bone marrow or blood. Retrospective studies show that a threshold exists at around 0.1% detectable leukemia cells at day 29 of induction therapy (see below). The next section outlines how these clinical and laboratory findings are used to risk stratify patients. General Information BONE MARROW STATUS: M1: < 5% lymphoblasts = Complete Remission if normal blood counts, and no blasts in blood. M2: 5 - 25% lymphoblasts M3: > 25% lymphoblasts. BONE MARROW Minimal Residual Disease (MRD) STATUS (Day 29 Induction) Positive: ≥ 0.1% detectable leukemia cells (higher risk or relapse) Negative: < 0.1% detectable leukemia cells (lower risk of relapse).

High-risk (HR) features (to be treated on AALL0232/current open HR protocol) NCI/Rome-risk criteria: • Age ≥10 years at diagnosis o Infants less than or equal to 1 year of age will be treated on infant leukemia protocol (current open protocol AALL0631) • Initial WBC ≥50,000 Other high risk features: • T-cell ALL (treated on AALL0434) • Testicular involvement (treated on HR protocol) • Steroid pretreatment (may be treated on SR or HR protocol-see eligibility criteria)

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Standard-risk (SR) features (to be treated on different arms of AALL0331) NCI/Rome risk criteria: • Age >1 and < 10 years at diagnosis • Initial WBC 600 mg/m2 Cytarabine >500 mg/m2 Daunorubicin/Doxorubicin >30 mg/m2 Methotrexate >1000 mg/m2

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