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BACKGROUND Pleraxifor for peripheral blood stem cell (PBSC) mobilization in children with malignancies is often given following failure of standard mobilization (SM) rather than as a primary mobilizing agent. STUDY DESIGN AND METHODS In this retrospective multicenter study, we report the safety of plerixafor-based PBSC mobilization in children with malignancies and compare outcomes between patients who received plerixafor upfront with SM (Group A) with those who received plerixafor following failure of SM (Group B). In the latter pleraxifor was given either following a low peripheral blood (PB) CD34 (

Establishing the diagnosis of classical Hodgkin lymphoma (cHL) in a timely fashion can be a challenge, as there are no pathognomonic signs or symptoms. The percutaneous needle biopsy (CNB) of the tumor gained increased popularity due to its minimal invasiveness and expeditious recovery from procedure. The diagnostic accuracy of CNB depends upon patient size, mass accessibility, and feasibility to obtain diagnostic tissue assuming that the tumor is histologically homogenous. We report on a patient with cHL who underwent multiple CNB from different sites before the diagnosis was established. Yet, only the incisional biopsy of the most metabolically-active tumor site resulted in diagnostic success. It is imperative to thoroughly consider both the biopsy method and the biopsy site for establishing correct diagnosis.

Allogeneic hematopoietic cell transplantation (HCT) remains the definite cure for many pediatric hematologic diseases but causes profound deconditioning, which impairs daily physical functioning and may lead to further health complications. The Transplant Energize Me Patient Outcome (TEMPO) project is a standard-of-care, quality improvement (QI) project whose primary objective is to maintain physical functional mobility and strength throughout admission for pediatric allogeneic HCT patients. Specifically, TEMPO incorporates individualized and developmentally appropriate exercises and activities that are administered by a multidisciplinary team, who objectively measure and record a patient's physical stamina at predetermined frequencies. Discipline-specific metrics at admission, at weekly intervals, at discharge, and at 100 days after graft infusion (D100) are recorded in templated flowsheets in the electronic medical record. As a secondary objective, resource utilization as measured by length of stay, duration of parenteral feeds and narcotics, readmission by D100, and infections was compared between TEMPO and historical control (pre-TEMPO) allogeneic HCT patients. TEMPO participation maintained physical endurance and functional strength throughout hospitalization, an effect that was significantly sustained or improved at D100. Resource utilization did not significantly differ between patient cohorts. Taken together, the TEMPO QI Project maintains physical functional mobility, strength, and endurance, thereby decreasing physical deconditioning in pediatric allogeneic HCT patients, an effect that is objectively sustained at D100.

Hepatic VOD is a potentially fatal complication during stem cell transplantation and is rarely seen in the non-transplant setting. We report the case of a five-year-old boy who presented with visual complaints during delayed intensification phase of treatment for ALL. He was found to have bilateral retinal hemorrhages associated with profound thrombocytopenia due to chemotherapy. VOD was diagnosed based on EBMT criteria and was managed with supportive care. Despite resolution of VOD, his vision progressively deteriorated and resulted in blindness. This case highlights the significance of close monitoring of ALL patients in delayed intensification when they are at risk for developing VOD, the importance of refractory thrombocytopenia as a diagnostic feature and the potential for VOD to manifest with intraocular bleeding.

Preexisting endothelial dysfunction and vascular injury sustained during allogeneic hematopoietic cell transplantation (HCT) increases risk for endothelial injury-related complications such as posterior reversible encephalopathy syndrome (PRES) and transplant-associated thrombotic microangiopathy (TA-TMA) in patients with sickle cell disease (SCD). We report two patients with SCD who developed PRES following allogeneic HCT. In both patients, PRES-related symptoms resolved only after a diagnosis of TA-TMA was established and eculizumab therapy was initiated. Renal manifestations at diagnosis included non-nephrotic range proteinuria and hypertension. This report highlights the importance of screening PRES-affected SCD HCT recipients for TA-TMA as usual treatment strategies may be inadequate.

Infantile meningioma is exceedingly rare, frequently larger and of higher-grade histology than older patients. We describe a case of papillary meningioma with rhabdoid features in a 6-month-old, previously healthy infant. During evaluation for accidental head trauma the patient was found to have a large heterogeneous mass in the right temporal parietal region with midline shift and uncal herniation on cranial Computed Tomography (CT).Magnetic resonance imaging (MRI) of the brain revealed a large extra axial middle cranial fossa lesion with involvement of sphenoid and extraconal space of right orbit. There was no metastatic disease on MRI spine, CT chest, abdomen and CSF studies. A diagnostic cerebral angiogram showed a hyperplastic right middle meningeal artery (MMA) supplying the tumor. Skull base near total resection of tumor was performed after embolization of the right MMA pedicle artery and right ophthalmic artery recurrent branch. Pathology was consistent with papillary meningioma with focal rhabdoid features. Comprehensive genomic profile was positive for Neurofibromatosis (NF) type II. MRI obtained 4 weeks after initial resection revealed local progression. Gross total resection(GTR) of residual tumor was performed. In view of rapid progression, chemotherapy was initiated 12 weeks from diagnosis, as per Dana Farber Protocol 02-294 for ATRT (Atypical Teratoid Rhabdoid Tumor). Therapy related complications included – febrile neutropenia, Candida rugosa fungemia, loss of vision in right eye and right ear sensorineural hearing loss. The patient continues to be in remission 1 year after completion of his therapy. There are no established guidelines for the management of pediatric rhabdoid meningiomas. Multiagent chemotherapy as per DFCI ATRT 02-294 along with GTR should be considered as a potential treatment option for papillary rhabdoid meningioma. Radiation therapy should be excluded in younger patients due to risk of neuro-cognitive sequelae. Patients with meningioma associated with NF II need to have lifelong follow up.

Pre-existing endothelial dysfunction and vascular injury sustained during allogeneic hematopoietic stem cell transplantation (HCT) increases risk for endothelial injury-related complications like posterior reversible encephalopathy (PRES) and transplant-associated thrombotic microangiopathy (TA-TMA) in patients with sickle cell disease (SCD). Herein, we report two SCD HCT recipients in whom PRES-related symptoms resolved only after eculizumab therapy was initiated for underlying TA-TMA. Case 1 25-year-old male with SCD developed PRES-related seizures and headaches on Day+30 following matched sibling donor bone marrow transplant (BMT) and reduced-intensity conditioning (RIC) with fludarabine/melphalan/alemtuzumab and graft-versus-host disease (GvHD) prophylaxis with tacrolimus and methotrexate (MTX). Symptoms initially resolved after discontinuing tacrolimus. However, on Day+60, he presented with hypertension (HTN), status epilepticus, and right intracranial hemorrhage. Despite adequate HTN control and maximal anti-epileptic therapy, his symptoms persisted. Two weeks later, laboratory testing confirmed TA-TMA. Both PRES and TA-TMA symptoms and signs resolved after five weeks of eculizumab therapy (Figure 1). Case 2 Eight-year-old female with SCD underwent 10/10 matched unrelated BMT following RIC with fludarabine/melphalan/thiotepa/alemtuzumab and MTX/tacrolimus/abatacept for GvHD prophylaxis. She developed altered mental status, seizures, and HTN and Day+74 MRI brain confirmed PRES. Her symptoms also persisted despite tacrolimus cessation and effective HTN control. One week later, laboratory testing confirmed TA-TMA. Complete resolution of neurological symptoms occurred after three weeks of eculizumab therapy. (Figure 2). Conclusion Our cases highlight maintaining a high level of clinical suspicion for TA-TMA in SCD patients presenting with PRES post-HCT and consideration for eculizumab therapy in such patients.