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Late effects of treatment for childhood cancer. 1950 – 1960 5 years EFS – 20% >1990 - 70% >2000- 80% - PowerPoint PPT Presentation
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Late effects Late effects of treatment of treatment
for childhood cancerfor childhood cancer
1950 – 1960 5 years EFS – 20%1950 – 1960 5 years EFS – 20% >1990 - 70%>1990 - 70% >2000- 80%>2000- 80% Approximately 1 of every 640 individuals Approximately 1 of every 640 individuals
in US between ages of 20 and in US between ages of 20 and 39 years is 39 years is survivor of childhood cancersurvivor of childhood cancer
10 cancer survivors/100,000 healthy 10 cancer survivors/100,000 healthy children/yearchildren/year
Children Cancer Survivor Children Cancer Survivor Study (CCSS)Study (CCSS)
>20,000 survivors at least 5 years, treated from >20,000 survivors at least 5 years, treated from 1970 to 1986 (CCSS) 1970 to 1986 (CCSS)
- - standarized mortality rate (SMR)standarized mortality rate (SMR) =10,8 =10,8 SMR higher in womenSMR higher in women SMR higher in survivors treated <5years of ageSMR higher in survivors treated <5years of age SMR highest in children treated for: SMR highest in children treated for:
CNS tumors and acute leukemias CNS tumors and acute leukemias
Causes of deathCauses of death
Cancer recurrence/ second neoplasm Cancer recurrence/ second neoplasm SMR =19.4 SMR =19.4
Pulmotoxicity Pulmotoxicity SMR = 9.2 SMR = 9.2
Cardiotoxicity Cardiotoxicity SMR = 8.2 SMR = 8.2
infectionsinfections
Secondary malignancySecondary malignancy
Standarized incidence ratio (SIR) is 6.38 Standarized incidence ratio (SIR) is 6.38 for the largest observed for the largest observed excesses for bone excesses for bone (SIR=19.1) and breast cancer (SIR=16.2) (SIR=19.1) and breast cancer (SIR=16.2) a 10-fold - for a 10-fold - for subsequent CNS cancer and thyroid cancersubsequent CNS cancer and thyroid cancer
The cumulative incidence of SMN 20 years from The cumulative incidence of SMN 20 years from the time of original cancer diagnosis is 3.2% the time of original cancer diagnosis is 3.2% overall and varied by diagnostic subgroups: overall and varied by diagnostic subgroups:
- Hodgkin lymphoma - 7.6% - Hodgkin lymphoma - 7.6% - soft-tissue sarcoma - 4.0%- soft-tissue sarcoma - 4.0% - bone sarcoma - 3.3%- bone sarcoma - 3.3%
Risk factors:Risk factors:
Primary neoplasm (retinoblastoma, HL, STS)Primary neoplasm (retinoblastoma, HL, STS) Younger age at the time of therapyYounger age at the time of therapy Female sexFemale sex RadiotherapyRadiotherapy Chemotherapy Chemotherapy
(alkylating agents, topoizomerase inhibitors) (alkylating agents, topoizomerase inhibitors) Genetic predisposition ( Li-Fraumeni syndrome, Genetic predisposition ( Li-Fraumeni syndrome,
NF t.1, Fanconi anemia, gene polimorphisme)NF t.1, Fanconi anemia, gene polimorphisme) enviromentenviroment
Hodgkin lymphoma >ALL, ANLL, CML, Hodgkin lymphoma >ALL, ANLL, CML, bone tumors, thyroid cancer, breast/ skin bone tumors, thyroid cancer, breast/ skin cancercancer
Retinoblastoma > osteosarcomaRetinoblastoma > osteosarcoma Nephroblastoma (genetic form) Nephroblastoma (genetic form)
>osteochondroma, adenocarcinoma>osteochondroma, adenocarcinoma T-ALL > ANLLT-ALL > ANLL Radiotherapy > osteosarcoma, STS, skin cancerRadiotherapy > osteosarcoma, STS, skin cancer Radiotherapy of neck > thyroid cancerRadiotherapy of neck > thyroid cancer
ManagementManagement
Patient educationPatient education Detailed history, including family historyDetailed history, including family history Careful clinical examinationCareful clinical examination Advice on reduction risk behaviours, Advice on reduction risk behaviours,
especially smoking and especially smoking and sunbathingsunbathing
Circulatory systemCirculatory system
AnthracyclinesAnthracyclines (doxorubicin, daunorubicin, (doxorubicin, daunorubicin, idarubicin, epirubicin, mitoxantrone) , idarubicin, epirubicin, mitoxantrone) , cyclophosphamide cyclophosphamide - myocytes damage due to free radicals - myocytes damage due to free radicals generationgeneration
Thoracic Thoracic radiationradiation therapy therapy - affected fine vasculature of the - affected fine vasculature of the heartheart
The risks to the heart are The risks to the heart are related to:related to:
-- Cumulative Cumulative anthracycline dose: anthracycline dose:
>200-300mg/m>200-300mg/m22 >600mg/m >600mg/m22 > 30% > 30% 500- 600mg/m 500- 600mg/m22 > > 11% 11%
- method of administration (bolus) - method of administration (bolus) - younger age (<15years of - younger age (<15years of age) age) - female sex - female sex - trisomy 21 - trisomy 21
and in addition:and in addition:
- hypothyroidism - ovarian - hypothyroidism - ovarian failurefailure
- obesity - renal failure- obesity - renal failure
- hyperlipidemia - pulmonary - hyperlipidemia - pulmonary failurefailure
- pregnancy - cong.heart - pregnancy - cong.heart diseasedisease
- growth hormone therapy- growth hormone therapy
- sex steroid replacement therapy - sex steroid replacement therapy
CardiomyopathyCardiomyopathy
Early: Early: at the time of treatment to 1 at the time of treatment to 1 year after the treatmentyear after the treatment
Late: Late: > 1 year after treatment > 1 year after treatment
Thoracic radiation therapy >15GyThoracic radiation therapy >15Gy
Delayed pericarditisDelayed pericarditis Pancarditis, which includes pericardial and Pancarditis, which includes pericardial and
myocardial fibrosis, with or without endocardial myocardial fibrosis, with or without endocardial fibroelastosisfibroelastosis
MyopathyMyopathy Coronary artery disease (CAD)Coronary artery disease (CAD) Functional valve injuryFunctional valve injury Conduction defectsConduction defects
Signs and symptomsSigns and symptoms
CardiomyopathyCardiomyopathy (after chemotherapy): (after chemotherapy): fatigue, cough,dyspnea on fatigue, cough,dyspnea on exertion, peripheral edema, hypertension, tachypnea/rales, exertion, peripheral edema, hypertension, tachypnea/rales, tachycardia, cardiomegaly, syncope, palpitations, arrhytmiastachycardia, cardiomegaly, syncope, palpitations, arrhytmias
Valvular damage Valvular damage (after radiation therapy >40Gy): (after radiation therapy >40Gy): weakness,cough, dyspnea on exertion, new weakness,cough, dyspnea on exertion, new murmurmurmur
Pericardial damage Pericardial damage ( radiation >35 Gy) : ( radiation >35 Gy) : fatigue, dyspnea on exertion, chest pain, cyanosis, ascites, fatigue, dyspnea on exertion, chest pain, cyanosis, ascites, peripheral edema, hypotension, friction rub, muffled heart sounds, peripheral edema, hypotension, friction rub, muffled heart sounds, venous distension, pulsus paradoxus venous distension, pulsus paradoxus
Coronary artery disease Coronary artery disease (radiation > 30Gy):(radiation > 30Gy): chest pain on exertion, dyspnea, diaphoresis, pallor, arrhytmias chest pain on exertion, dyspnea, diaphoresis, pallor, arrhytmias
DiagnosisDiagnosis
Electrocardiogram (ST-T changes voltage, Electrocardiogram (ST-T changes voltage, decreased voltage)decreased voltage)
Chest x-rayChest x-ray Holter monitoringHolter monitoring Exercise testing baselineExercise testing baseline EchocardiogramEchocardiogram
( lower % EF, shortening fraction <28%, higher ( lower % EF, shortening fraction <28%, higher afterload)afterload)
IndicationsIndications
Abnormal clinical examination & abnormal Abnormal clinical examination & abnormal echocardiogram & planning sport & before echocardiogram & planning sport & before pregnancy :pregnancy :
->cardiologist consultation ->cardiologist consultation
TreatmentTreatment- angiotensin converting enzyme inhibitorsangiotensin converting enzyme inhibitors- cardiac transplantation cardiac transplantation
Respitatory systemRespitatory system
Radiation therapy Radiation therapy >15 Gy >15 Gy (whole lungs, mediastinal, mantle, (whole lungs, mediastinal, mantle, TBI):TBI):
Pneumonitis acute (>40 Gy alone Pneumonitis acute (>40 Gy alone - or lower dose + dactynomycin/ - or lower dose + dactynomycin/ anthracyclines ) anthracyclines ) signs: fever, congestion, cough, dyspneasigns: fever, congestion, cough, dyspnea
12 – 14 Gy – reduced total lung capacity and vital 12 – 14 Gy – reduced total lung capacity and vital capacity to about 70%capacity to about 70%
Pulmonary Pulmonary fibrotic disease fibrotic disease with permanent with permanent restrictive diseaserestrictive disease
Chemotherapy:Chemotherapy:- Bleomycine >200mg/mBleomycine >200mg/m22
- busulphanbusulphan- Lomustine, carmustine, cyclophosphamideLomustine, carmustine, cyclophosphamide
Signs and symptomsSigns and symptoms
Fatigue Fatigue CoughCough dyspnea on exertiondyspnea on exertion reduced exercise tolerancereduced exercise tolerance OrthopneaOrthopnea CyanosisCyanosis finger clubbingfinger clubbing RaleRale cor pulmonarecor pulmonare
Screening and diagnostic testsScreening and diagnostic tests
Baseline chest x-rayBaseline chest x-ray O2 saturationO2 saturation Pulmonary function test Pulmonary function test
Management and interventionManagement and intervention
Advice against smokingAdvice against smoking Pneumococcal immunisation Pneumococcal immunisation Annual influenze immunisation in patients with Annual influenze immunisation in patients with
etablished lung diseaseetablished lung disease
Urinary systemUrinary system
Renal failure due to:Renal failure due to: Disease: nephroblastoma, NHL, leukemia >Disease: nephroblastoma, NHL, leukemia >
> renal infiltration> renal infiltration
> blood vessels compression> blood vessels compression
> hypertension> hypertension
Chemotherapy:Chemotherapy:
Cisplatin ,carboplatinCisplatin ,carboplatin -> glomerular dysfunction -> glomerular dysfunction
- Asymptomatic or fatigue, anemia, oliguria- Asymptomatic or fatigue, anemia, oliguria cisplatin, carbo, ifosfamidecisplatin, carbo, ifosfamide -> tubular dysfunction -> tubular dysfunction
- seizures (- seizures (low Magnesiumlow Magnesium!), weakness (low PO4), !), weakness (low PO4), glikozuria, poor linear growthglikozuria, poor linear growth
ifosfamideifosfamide -> glomerular and tubular toxicity with -> glomerular and tubular toxicity with renal acidosis and Fanconi’s syndromerenal acidosis and Fanconi’s syndrome
cyclophosphamide, ifosfamidcyclophosphamide, ifosfamid ->hemorrhagic ->hemorrhagic cystitiscystitis
- Hematuria, dysuria- Hematuria, dysuria
RadiotherapyRadiotherapy
Doses > 25 Gy to both kidneys > renal failure at delayed Doses > 25 Gy to both kidneys > renal failure at delayed intervals of more than 6 monthsintervals of more than 6 months
Radiation 20 – 30 Gy or 10- 15 Gy with chemotherapy > Radiation 20 – 30 Gy or 10- 15 Gy with chemotherapy > - hypoplastic kidney/ renal - hypoplastic kidney/ renal arteriosclerosis: *fatigue, poor arteriosclerosis: *fatigue, poor linear growth, hypertension, headache, edema, linear growth, hypertension, headache, edema, albuminuria albuminuria - nephrotic syndrome - nephrotic syndrome * proteinuria, edema * proteinuria, edema - bladder: fibrosis or hypoplasia (reduced - bladder: fibrosis or hypoplasia (reduced bladder capacity) bladder capacity) *urgency, frequency, incontinence (nocturia), pelvic *urgency, frequency, incontinence (nocturia), pelvic hypoplasia hypoplasia - bladder tenderness - bladder tenderness *urinary tract infections, renal calculi *urinary tract infections, renal calculi
Management and interventionManagement and intervention
In dependence of late effect:In dependence of late effect: Glomerular dysfunction, hypoplastic kidney Glomerular dysfunction, hypoplastic kidney
- low-protein diet, dialysis, renal - low-protein diet, dialysis, renal transplanttransplant
Tubular dysfunction Tubular dysfunction - Mg supplement, PO4 supplement - Mg supplement, PO4 supplement
Nephrotic syndrome Nephrotic syndrome - low salt diet, diuretics - low salt diet, diuretics
Gastrointestinal tractGastrointestinal tract
Enteritis due to:Enteritis due to: Chemotherapy (actinomycin D, doxorubicin)Chemotherapy (actinomycin D, doxorubicin) Radiation >40GyRadiation >40Gy Surgery (abdominal surgery enchance RT effect) Surgery (abdominal surgery enchance RT effect)
- abdominal pain - abdominal pain - diarrhea, - diarrhea, decreased stool bulk decreased stool bulk - emesis - emesis - weigth loss, poor linear growth - weigth loss, poor linear growth
Adhesions due to:Adhesions due to:
Radiation Radiation Surgery Surgery
-abdominal pain -abdominal pain - bilious vomiting - bilious vomiting - - hyperactive bowel sounds hyperactive bowel sounds Indications: Indications:
* abdominal radiograph* abdominal radiograph
* adhesion lysis* adhesion lysis
Fibrosis esophagus (stricture) due to:Fibrosis esophagus (stricture) due to: Chemotherapy (actinomycine D, doxorubicine) Chemotherapy (actinomycine D, doxorubicine)
Radiation >50 –50 GyRadiation >50 –50 Gy Abdominal surgery Abdominal surgery
- weight loss - weight loss - dysphagia - dysphagia
- poor linear growth- poor linear growthIndications:Indications:* esophagus dilatation* esophagus dilatation* Antireflux therapy* Antireflux therapy
Fibrosis small intestine due to:Fibrosis small intestine due to: Radiation > 40 GyRadiation > 40 Gy Abdominal surgery Abdominal surgery
- diarrhea - diarrhea - weight loss - weight loss
- obstruction- obstruction - abdominal pain - abdominal pain
- constipation - constipationIndications:Indications:*high –fiber diet*high –fiber diet*decompression, resection, balloon dilatation*decompression, resection, balloon dilatation
Large intestine/ colon fibrosis due to:Large intestine/ colon fibrosis due to: Radiation >40 GyRadiation >40 Gy Abdominal surgery Abdominal surgery
Signs: Signs: - abdominal colic - abdominal colic
- rectal pain - rectal pain - constipation- constipation - melena- melena - weight loss- weight loss - obstruction- obstruction Indications:Indications:* stool softeners, high-fiber diet* stool softeners, high-fiber diet
Hepatic late effectsHepatic late effects
Fibrosis/ cirrhosis due to:Fibrosis/ cirrhosis due to: Chemotherapy ( mtx, act D, 6-MP, 6-TG)Chemotherapy ( mtx, act D, 6-MP, 6-TG) Radiation >30 GyRadiation >30 Gy SurgerySurgery Hepatitis B/C infectionHepatitis B/C infection
Endocrine systemEndocrine system
Thyroid late effectsThyroid late effects Overt hypothyroidismOvert hypothyroidism - radiation >20 Gy to the neck, cervical spine- radiation >20 Gy to the neck, cervical spine - TBI- TBI - partial or total thyroidectomy- partial or total thyroidectomySymptoms: Symptoms:
hoarseness, fatigue, weight gain, cold hoarseness, fatigue, weight gain, cold intolerance, dry brittle hairs, alopecia, intolerance, dry brittle hairs, alopecia, constipation, lethargy, pubertal delay, constipation, lethargy, pubertal delay, bradycardia, hypotensionbradycardia, hypotension
Diagnosis: T4, TSHDiagnosis: T4, TSH
Compensated hypothyroidismCompensated hypothyroidism- asymptomatic- asymptomatic Hyperthyroidism –Hyperthyroidism –nervousness, tremor, heat nervousness, tremor, heat
intolerance, weight loss,increased apppetite, intolerance, weight loss,increased apppetite, insomnia, diarrhea, moist skin, goiterinsomnia, diarrhea, moist skin, goiter
Thyroid nodulesThyroid nodules – any dose radiation – any dose radiation
hoarseness, fatigue, dry skin, cold intolerance, hoarseness, fatigue, dry skin, cold intolerance, dry brittle hair, alopecia, constipation, lethargy, dry brittle hair, alopecia, constipation, lethargy, poor linear growthpoor linear growth
Biopsy!Biopsy!
Neuroendocrine late effectsNeuroendocrine late effects
GH deficiencyGH deficiency
- Radiation >24 Gy- Radiation >24 Gy
- Surgery (tumor in region of H-P axis)- Surgery (tumor in region of H-P axis)
Adrenocorticotropic hormone deficiencyAdrenocorticotropic hormone deficiency
- Radiation >40 Gy/ surgery- Radiation >40 Gy/ surgery
Thyrotropin-releasing hormone deficiencyThyrotropin-releasing hormone deficiency
- Radiation > 40 Gy- Radiation > 40 Gy
Precocious pubertyPrecocious puberty
- Radiation >20 Gy- Radiation >20 Gy
Gonadotropin deficiencyGonadotropin deficiency - Radiation >40 Gy/ surgery- Radiation >40 Gy/ surgeryHyperprolactinemiaHyperprolactinemia - Radiation >40 Gy/surgery- Radiation >40 Gy/surgery
Metabolic syndromeMetabolic syndrome: : (insulin resistance, hyperglycemia, (insulin resistance, hyperglycemia, hyperinsulinemia, hypertension, hyperlipidemia, hyperinsulinemia, hypertension, hyperlipidemia, obesity):obesity):
- steroids- steroids - radiation ? >18 Gy- radiation ? >18 Gy
Musculoskeletal systemMusculoskeletal system
Radiation therapy> 20 Gy : Radiation therapy> 20 Gy : > soft tissue hypoplasia> soft tissue hypoplasia > > assymmetry of muscle mass when compared with assymmetry of muscle mass when compared with untreated area,decreased range of motion, stiffness untreated area,decreased range of motion, stiffness and pain in affected area and pain in affected area > spinal abnormalities : > spinal abnormalities : scoliosis, kyfosis, lordosis, decreased sitting height scoliosis, kyfosis, lordosis, decreased sitting height > back > back pain, hip pain, uneven shoulder height, rib humps or pain, hip pain, uneven shoulder height, rib humps or flares, deviation from vertical curve, gait flares, deviation from vertical curve, gait abnormalitiesabnormalities
diminution of bone growthdiminution of bone growth
> lenght discrepancy: > lenght discrepancy: lower back pain, limp,hip pain, lower back pain, limp,hip pain, discrepancy in muscle mass and length when discrepancy in muscle mass and length when compared with untreated extremity, scoliosiscompared with untreated extremity, scoliosis
> pathological fracture> pathological fracture
>osteonecrosis (steroids, radiation >40Gy): >osteonecrosis (steroids, radiation >40Gy): pain in affected joint, limp pain in affected joint, limp
>osteopenia/ osteoporosis (steroids,radiation >osteopenia/ osteoporosis (steroids,radiation >18 Gy)>18 Gy)
ObesityObesity
Risk factors:Risk factors: Female survivorsFemale survivors ALLALL CNS radiationCNS radiation SteroidsSteroids Cranial irradiationCranial irradiation Genetic predispositionGenetic predisposition Polimorphism in the leptin receptor gene Polimorphism in the leptin receptor gene Brain tumors (hypothalamic dysfunction)Brain tumors (hypothalamic dysfunction)
Reproductive systemReproductive system
Male gonadal functionMale gonadal function::Germ cell damage (oligospermia/azoospermiaGerm cell damage (oligospermia/azoospermia)) Chemotherapy: cyclophosphamide, lomustine, Chemotherapy: cyclophosphamide, lomustine,
carmustine, procarbazine, ifosfamide, busulfan, carmustine, procarbazine, ifosfamide, busulfan, melphalan,dacarbazinemelphalan,dacarbazine
Radiation >1 GyRadiation >1 Gy Surgery (orchiectomy or surgical manipulation)Surgery (orchiectomy or surgical manipulation)
* * SymptomsSymptoms: testicular atrophy: testicular atrophy
* * Diagnosis: Diagnosis: FSH, inhibin B, spermiogramFSH, inhibin B, spermiogram
* * Management: Management: sperm banking prior to treatmentsperm banking prior to treatment
Leydig cell damage:Leydig cell damage: Chemotherapy: cyclophosphamide, etoposideChemotherapy: cyclophosphamide, etoposide Radiation> 12 Gy to the testes or scattered from Radiation> 12 Gy to the testes or scattered from
pelvispelvis Surgery: orchiectomySurgery: orchiectomy**SymptomsSymptoms: delayed/arrested/absent pubertal : delayed/arrested/absent pubertal
development, lack of penile and testicular development, lack of penile and testicular enlargement, voice change, body odor and acne, enlargement, voice change, body odor and acne, testicular atrophytesticular atrophy
* * DiagnosisDiagnosis: LH, testosterone: LH, testosterone* * ManagementManagement: testosterone replacement regarding : testosterone replacement regarding
testosterone deficiencytestosterone deficiency
Female gonadal late effectsFemale gonadal late effects
Ovarian failure:Ovarian failure: Chemotherapy (cyclophosphamide,procarbazine, Chemotherapy (cyclophosphamide,procarbazine,
busulfan,melphalan, dacarbazine, carmustine, busulfan,melphalan, dacarbazine, carmustine, ifosfamide)ifosfamide)
Radiation >4 GyRadiation >4 Gy Surgery: oophorectomy or oophoropexySurgery: oophorectomy or oophoropexy **Symptoms: Symptoms: delayed/arrested pubertal development delayed/arrested pubertal development
(breasts, female habitus, menses, estrogen (breasts, female habitus, menses, estrogen deficiency, infertility), osteoporosis, atherosclerosisdeficiency, infertility), osteoporosis, atherosclerosis
*Diagnosis*Diagnosis: LH,FSH, inhibin B, anti-mullerian hormone: LH,FSH, inhibin B, anti-mullerian hormone **ManagementManagement: hormone replacement: hormone replacement
Vagina: Vagina: fibrosis/diminished growthfibrosis/diminished growth Chemo: act D, doxo – enhance radiation therapy Chemo: act D, doxo – enhance radiation therapy
effecteffect Radiation >40GyRadiation >40Gy
Uterus:Uterus: Radiation >20 Gy (prepubertal), >40 Gy Radiation >20 Gy (prepubertal), >40 Gy
(pubertal)(pubertal)
*Symptoms: *Symptoms: spontaneous abortions, low birth-spontaneous abortions, low birth-weight infants, small uterusweight infants, small uterus
**Diagnosis: Diagnosis: usgusg
Growth impairmentGrowth impairment
Brain tumors (craniopharyngioma)Brain tumors (craniopharyngioma) Cranial radiotherapy > GH deficiency (>24 Gy) Cranial radiotherapy > GH deficiency (>24 Gy)
LH/ FSH/ ACTH/ TSH deficiency LH/ FSH/ ACTH/ TSH deficiency (>40 Gy)(>40 Gy)
Spinal irradiation > spinal growth is affected > Spinal irradiation > spinal growth is affected > skeletal disproportionskeletal disproportion
Radiation directed on the gonadsRadiation directed on the gonads TBITBI Precocious puberty after cranial irradiationPrecocious puberty after cranial irradiation Chemotherapy, steroidsChemotherapy, steroids
Monitoring for growth problemsMonitoring for growth problems
Regular height measurementRegular height measurement Endocrinologist consultationEndocrinologist consultation
Treatment with growth hormoneTreatment with growth hormone- CraniopharyngiomaCraniopharyngioma- After cranial iradiation (acute leukemia) After cranial iradiation (acute leukemia)
– possibility of cancer – possibility of cancer recurrence???recurrence???
- - - second cancers?second cancers?
CNS late effectsCNS late effects
Neurocognitive deficitsNeurocognitive deficits (after radiation >18Gy, HD MTX) (after radiation >18Gy, HD MTX) -difficulty with: -difficulty with: reading, language, memory, attention, decreased IQ, reading, language, memory, attention, decreased IQ, poor school attendance, poor hand-eye coordinationpoor school attendance, poor hand-eye coordination
Leuko-encephalopathyLeuko-encephalopathy (MTX, Ara-C, radiation >18 Gy) -seizures, (MTX, Ara-C, radiation >18 Gy) -seizures, neurologic impairmentneurologic impairment
Focal necrosisFocal necrosis (MTX,cisplatin, carmustine, radiation >50 Gy) (MTX,cisplatin, carmustine, radiation >50 Gy) -headaches, seizures, papilledema, -headaches, seizures, papilledema, hemiparesis, speech/learning/memory deficitshemiparesis, speech/learning/memory deficits
Large vessel strokeLarge vessel stroke (radiation >50 Gy) (radiation >50 Gy) -headache, seizures, hemiparesis, -headache, seizures, hemiparesis, aphasia, focal neurologic findingsaphasia, focal neurologic findings
Vision lossVision loss (cisplatin, radiation >50 Gy, surgery) (cisplatin, radiation >50 Gy, surgery) -progressive visual loss -progressive visual loss
OtotoxicityOtotoxicity (cisplatin, carboplatin, radiation >35 (cisplatin, carboplatin, radiation >35 Gy, surgery) Gy, surgery) - abnormal speech development, - abnormal speech development, hearninghearning
Myelitis Myelitis (radiation >45 Gy, surgery) (radiation >45 Gy, surgery) -paresis, spasticity, altered -paresis, spasticity, altered sensation, loss of sphincter controlsensation, loss of sphincter control
Ear late effectsEar late effects
Chronic otitis (radiation >35 Gy)Chronic otitis (radiation >35 Gy) Sensorineural hearing loss (cisplatin, carboplatin, Sensorineural hearing loss (cisplatin, carboplatin,
radiation >40 Gy) radiation >40 Gy) Decreased production of cerumen (radiation >30 Decreased production of cerumen (radiation >30
Gy)Gy) Chondritis ( radiation 50 Gy)Chondritis ( radiation 50 Gy) Chondronecrosis (radiation 60 Gy)Chondronecrosis (radiation 60 Gy)
Eye late effectsEye late effects
Radiation >50 Gy:Radiation >50 Gy: Decreased tear production Decreased tear production Lacrimal duct fibrosisLacrimal duct fibrosis Ulceration of eyelidsUlceration of eyelids Conjunctiva: necrosis, scarring Conjunctiva: necrosis, scarring Thinning of acleraThinning of aclera Cornea ulcerationCornea ulceration NeovascularizationNeovascularization keratinizationkeratinization
CataractCataract Secondary glaucomaSecondary glaucoma Iris neovascularizationIris neovascularization Retina: Retina:
infarction, exudates, hemorrhage, infarction, exudates, hemorrhage, teleangiectasia, neovascularization, macular teleangiectasia, neovascularization, macular edema, optic neuropathyedema, optic neuropathy
Dental late effectsDental late effects
Xerostomia (decreased salivary gland function) Xerostomia (decreased salivary gland function) due to radiation >40 gydue to radiation >40 gy
Abnormal tooth and root development due to Abnormal tooth and root development due to radiation >10 Gy and chemotherapy radiation >10 Gy and chemotherapy
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