Late Effect (1st of 14)
Neurocognitive deficits (lowered IQ), including possible functional deficits (e.g., slower processing speed, sequencing, memory), low attention span, difficulties with reading, math, planning, and organization, and social difficulties
Your risk is greater if:
- You were young when you were treated. The risk is greater for those who were treated under the age of 6 years.
- You are female.
- You had a primary CNS tumor or all/most of your brain was in the radiation field.
- You had relapsed ALL.
- You had intrathecal chemotherapy.
- Radiation was combined with dexamethasone, high-dose cytarabine, or high-dose methotrexate.
- You have a pre-existing history of learning problems or a family history of learning problems.
Recommended Evaluation
- Assessment of educational or vocational progress at the end of treatment and yearly
- Neuropsychological screening at the end of treatment and every 1-2 years thereafter
Management
You may benefit from any or all of the following:
- Neuroimaging (e.g., MRI, CT)
- Special assistance in school including possible placement in special education classes
- Psychotropic medication (stimulant)
Late Effect (2nd of 14)
Poor balance
Partial paralysis
Seizures
Your risk is greater if:
- You were young when you were treated. The risk is higher if you were less than 2 years.
- You had a higher dose of radiation, especially if the total dose was greater than 55 Gy or the fraction dose was greater than 2 Gy.
- You also received high-dose methotrexate or intrathecal methotrexate or cytarabine (delivered directly into the spinal canal).
- You had a prior diagnosis of hydrocephalous requiring a shunt.
- You had "posterior fossa syndrome."
Recommended Evaluations
- Clinical evaluation yearly
- Special imaging studies such as MRI, CT, MRI with MR angiography as indicated
Management
- You may benefit from physical, occupational, or speech therapy.
- You may need to see a neurologist.
- If you have seizures, you will be treated with medications.
Late Effect (3rd of 14)
Stroke
Your risk is greater if:
- You have neurofibromatosis (NFI).
- You received a dose greater than 40 Gy.
Recommended Evaluations
- Clinical evaluation yearly
- Special imaging studies such as an MRI with MR angiography as indicated
Management
- You will be referred to a pediatric or adult neurologist.
Late Effect (4th of 14)
Brain tumor (high-grade astrocytoma, meningioma, sarcoma)
Your risk is greater if:
- You were young when you were treated, especially if you were less than 6 years.
- You had central nervous system (CNS) leukemia when you were diagnosed.
- You have neurofibromatosis (NFI).
- You have Ataxia elangiectasia (hereditary disorder with many manifestations).
- You received a higher dose of radiation.
Recommended Evaluation
- History and physical exam yearly
- Special imaging such as an MRI or CT based on symptoms
Management
- You may need a neurosurgical consultation for diagnosis and possible surgery.
- You will need a neuro-oncology consultation for medical management.
Late Effect (5th of 14)
Growth hormone deficiency
Your risk is greater if:
- You had a higher radiation dose, especially if the dose to the pituitary gland was over 18 Gy.
Recommended Evaluation
- You should have an evaluation every 6 months until your growth is completed.
- Your height, weight, and body mass should be monitored with regular physical exams.
- You will need to see a growth specialist (a pediatric endocrinologist) if you are growing poorly.
Management
- You should see an endocrinologist for further evaluation and possible treatment.
Late Effect (6th of 14)
Early onset of puberty
Your risk is greater if:
- You are female.
- You were less than 6 years of age when you were treated and you are now less than 10 years of age
Recommended Evaluation
- A complete physical exam every 6 months until you are 12-13 years of age
Management
- If there are signs of early puberty (breast development in a girl less than 8 years, sexual hair in a boy less than 9 years) you will need to see a pediatric endocrinologist.
- Drug treatments are available to temporarily stop early puberty, if indicated.
Late Effect (7th of 14)
Other pituitary hormone deficiencies (such as the hormones that regulate the thyroid [TSH], the adrenal glands [ACTH], and the testicles/ovaries [LH and FSH])
Your risk is greater if:
- Your treatment dose was high, especially if the dose to the pituitary gland was over 30 Gy.
Recommended Evaluation
- Special hormone tests should be performed yearly by an endocrinologist (a hormone specialist).
Management
- Hormone replacement therapy is available if you develop one of these hormone problems
Late Effect (8th of 14)
Obesity
Your risk is greater if:
- You were young at diagnosis, especially if you are female and were less than 4 years old.
- You had a high dose to the head (brain), especially greater than 20 Gy.
- You have growth hormone deficiency.
- You cannot or do not exercise.
Recommended Evaluation
- A complete physical exam yearly
- Fasting bloods for fat levels such as cholesterol every five years
- Fasting blood for insulin and sugar levels to look for signs of diabetes as indicated
Management
- Weight reducing diets; consider nutritional counseling
- Regular exercise (30-45 minutes) 3-5 times per week
Late Effect (9th of 14)
Chronic sinusitis
Your risk is greater if:
- You had higher cumulative dose to sinuses.
- You have hayfever or other types of allergies.
- You have reduced immunity (your immunoglobulin levels are low).
Recommended Evaluation
- History and physical exam yearly
- CT of sinuses as indicated
Management
- You may need an otolaryngology (eye, ear, nose, and throat specialist) consultation.
Late Effect (10th of 14)
Dry mouth (salivary gland dysfunction)
Your risk is greater if:
- You had head and neck radiation including the parotid gland, especially if it was greater than 30 Gy.
Recommended Evaluation
- History and physical exam yearly
Management
- You may benefit from saliva substitutes.
- You should have regular dental care including fluoride applications.
Late Effect (11th of 14)
Dental problems (small teeth, enamel dysplasia, periodontal disease, tooth decay, malocclusion [poor bite], dysfunction of the jaw bone joint)
Your risk is greater if:
- You were young when you were treated, especially if you were younger than 5 years.
- You had a higher radiation dose, especially 30 Gy or more, but dental problems are possible in children who had only 10 Gy.
Recommended Evaluation
- Dental exam and cleaning every 6 months
Management
- Have regular dental care including fluoride applications.
Late Effect (12th of 14)
Craniofacial abnormalities
Your risk is greater if:
- You were at a younger age at treatment, especially age 5 or younger.
- You received a higher dose of radiation.
Recommended Evaluation
- You should have a psychosocial assessment as indicated to help with coping.
Management
- Most patients with this type of side effect will benefit from counseling.
Late Effect (13th of 14)
Cataracts
Your risk is greater if:
- You had a higher dose of radiation, especially over 10 Gy.
- You also were treated with steroids.
- You also were treated with busulfan.
Recommended Evaluation
Management
- You should have an ophthalmology consultation if indicated.
Late Effect (14th of 14)
Ringing in the ears (tinnitus)
Your risk is greater if you:
- Were at a younger age during treatment.
- Had a central nervous system (CNS) tumor.
- Have had a shunt.
- Had a higher radiation dose, especially over 30-40 Gy.
- Were also treated with cisplatin and/or certain antibiotics, e.g., Gentamicin.
Recommended Evaluation
- History and physical exam yearly
- Hearing test (audiogram) yearly after treatment for at least five years, then every five years
Management
- Minimize your exposure to loud noise, e.g., listening to loud music.
- You may need an audiology consultation for hearing loss and hearing aids.
- You may need an otolaryngology consultation for chronic infection or ear wax.
