Facilitating Assessment of Late Effects by Organ System

Contents

Chemotherapy. . . 17 Other Terms . . . 18

This chapter provides charts by organ system that cover the late effects of various cancer treatments.

The healthcare provider for a patient with cardiac symptomatology, for example, can review the cardiac chart to find the common late side effects, causative treatments (chemo, radiation or surgery), signs and symptoms, screening and diagnostic tests and appro- priate intervention and management procedures. If further information is needed, the reader can refer to the chapter that covers the affected organ for a de- tailed discussion of the pathophysiology and clinical manifestations, as well as additional information re- garding detection, screening, management and inter- vention.

The charts, in conjunction with the algorithms in chapter 2, should facilitate planning patient evalua- tions in preparation for accessing more detailed in- formation in the chapters that follow.

Abbreviations used in this section are included in the glossary at the end.

Chemotherapy

ABVD Adriamycin, Bleomycin, Vincristine, Actinomycin-D

Act-D Actinomycin-D Ara-C Cytosine arabinoside

BCNU 1, 3-Bis (2 chloroethyl-1 nitrosourea) BLEO Bleomycin

Bus Busulfan

CCNU 1, -(2-chloroethyl-3-cyclohexyl-1 nitrosourea)

CDDP Cisplatin Carbo Carboplatin

Facilitating Assessment of Late Effects

by Organ System

Cindy L. Schwartz · Wendy L. Hobbie ·

Louis S. Constine

DTIC Dimethyl Triazine Imidazole Carboxamide

Doxo Doxorubicin

Dnm Daunomycin

HN

Nitrogen mustard

HU Hydroxyurea

Ifos Ifosfamide IT Intrathecal MTX Methotrexate PCB, PCZ Procarbazine VCR Vincristine VP-16 Etoposide 5FU 5- Fluorouracil 6MP 6-Mercaptopurine 6TG 6-Thioguanine

Other Terms

Abd Abdominal

ACTH Adrenocorticotropic hormone

ASA Aspirin

B/P Blood pressure BA Barium swallow

BM Bone marrow

BMT Bone marrow transplant BSE Breast self examination BUN Blood urea nitrogen

Ca Calcium

CBC Complete blood count CMV Cytomegalovirus CNS Central nervous system CO

Carbon dioxide Cr Creatinine

CT Computed tomography CXR Chest radiograph DHEA Dehydroepiandrosterone

DLCO Diffusing capacity for carbon monoxide (pulmonary)

ECHO Echocardiogram EEG Electroencephalogram EKG Electrocardiogram FiO

Fractional inspired oxygen FSH Follicle-stimulating hormone FS Fractional shortening GFR Glomerular filtration rate GI Gastrointestinal

GU Genitourinary

GVHD Graft-versus-host disease Gy Grey (measure of radiation)

GH Growth hormone

GnRH Gonadotropin releasing hormone

HD High Dose

H/O History of

H/P axis Hypothalamic-pituitary axis IOP Intra ocular pressure IQ Intelligence quotient IT Intrathecal

IV Intravenous

IVP Intravenous pyelogram LFT Liver function tests LH Luteinizing hormone MCV Mean corpuscle volume

Mg Magnesium

MRI Magnetic resonance imaging NPO Nothing by mouth

PET scan Positron emission tomography PFT Pulmonary function test PO

Phosphate

PRN As needed PTU Propylthiouracil QTc Corrected QT interval RNA Radionuclear angiography R/O Rule out

RT Radiation therapy

SMN Second malignant neoplasm SPECT Single photon emission computed

tomography T

Triiodothyronine T

Thyroxine

Free T

Unbound thyroxine TBI Total body irradiation TMJ Temporomandibular joint TSE Testicular self examination TSH Thyroid-stimulating hormone TRH Thyrotropin-releasing hormone U/A Urinalysis

US Ultrasound

UTI Urinary tract infection

UV Ultraviolet light

VA Visual acuity

VF Visual field

WBC White blood count

Table3.1.Evaluation of patients at risk for late effects:thyroid Late effectsCausative treatmentSigns Screening Management ChemotherapyRadiationSurgeryand symptomsand diagnostic testsand intervention Overt hypo->20Gy Partial or HoarsenessFree T4,TSH annuallyThyroxine thyroidism to the neck,completed FatiguePlot on growth chartreplacement (Elevated TSH,cervical spinethyroidectomyWeight gain decreased T4)>7.5Gy TBI Dry skinAnticipatory (total body Cold intoleranceguidance regarding irradiation)Dry brittle hairsymptoms of Alopeciahyper-thyroidism/ Constipationhypothyroidism Lethargy Poor linear growth Menstrual irregularities Pubertal delay Bradycardia Hypotension Compensated Same as Same as AsymptomaticFree T4,TSH annuallyThyroxine to suppress hypothyroidism Overt hypo-Overt hypo-Plot on growth chartgland activity (Elevated TSH,thyroidismthyroidism normal T4) Thyroid nodulesSame as Same as Overt hypo-Free T4,TSH annuallyThyroid scan Overt hypo-thyroidismPhysical examBiopsy/resection thyroidism HyperthyroidismSame as NervousnessFree T4,TSH annuallyRefer to endocrinol- Decreased TSH,Overt hypo-TremorsPhysical examogist for PTU, elevated T4thyroidismHeat intoleranceT3,antithyroglobulinpropranolol,131I Weight lossAntimicrosomalThyroidectomy InsomniaAntibody baselines, Increased appetitethen prn symptoms Diarrhea Moist skin Tachycardia Exophthalmus Goiter

Table3.2.Evaluation of patients at risk for late effects:CNS effects Late effectsCausative treatmentSigns Screening Management ChemotherapyRadiationSurgeryand symptomsand diagnostic testsand intervention Neurocognitive High-dose >18Gy Resection Difficulty with:Neurocognitive Psychoeducation deficitIV MTXof CNS tumorReading,language,testing:assistance IT MTXverbal/non-verbal memory,Psychoeducational arithmetic,receptive Neuropsychologic and expressive language. Decreased speed of mental processing Attention deficit Decreased IQ Behavior problems Poor school attendance Poor hand-eye coordination Leukoencephalo-MTX:IT or IV>18Gy SeizuresCT/MR scan baseline Symptom pathyIT Ara-CNeurologic impairmentand symptomsmanagement: * Compare with Muscle relaxant premorbid statusAnticonvulsants Physical therapy Occupational therapy Focal necrosisMTX:IT or >50Gy Resection HeadachesCT/MR scan baseline,Steroid therapy high-dose IV(especially of tumorNauseaPRN symptomsDebulking BCNU,with >21Gy SeizuresPET or SPECT scanof necrotic tissue CDDPdaily fraction)Papilledema Hemiparesis/ other focal findings Speech,learning, and memory deficits Large-vessel stroke>60Gy HeadacheCT scan/MRIDetermined by specific SeizuresArteriogramNeurologic impairment Hemiparesis Aphasia Focal neurologic findings BlindnessIntraarterialRT (optic Resection Progressive visual lossOphthalmic Visual aids BCNU,nerve chiasm,of tumorevaluation CDDPoccipital lobe)Visual-evoked response OtotoxicityCDDP>50Gy Abnormal speech Audiogram baseline Speech therapy Carboplatin(middle/inner developmentprn symptomsHearing aid ear)Hearing Myelitis>45–50Gy Spinal cord ParesisMRISteroids surgerySpasticityPhysical therapy Altered sensationOccupational therapy Loss of sphincter control

Table3.3.Evaluation of patients at risk for late effects:gastrointestinal Late effectsCausative treatmentSigns Screening Management ChemotherapyRadiationSurgeryand symptomsand diagnostic testsand intervention EnteritisAct-D,doxo,>40Gy Abdominal Abdominal painHeight and weight q yrDietary management enhance surgery DiarrheaStool guaiac q yrRefer to gastro- RT effectenhances Decreased stool bulkCBC with MCV q yrenter-ologist RT effectEmesisTotal protein Weight lossand albumin q 3–5 yr Poor linear growth(Absorption tests, vitamin B12level,and contrast studies) AdhesionsRT enhances LaparotomyAbdominal painAbdominal radiographNPO effectBilious vomitingGastric suction Hyperactive bowel soundsAdhesion lysis Fibrosis:Doxo and >40–50Gy AbdomenDysphagiaHeight and weight q yrRefer to GI Esophagus Act-D Weight lossCBC q yr (stricture)(RT enhancers)Poor linear growth Fibrosis:>40Gy AbdomenAbdominal painHeight and weight q yrEsophageal dilation Small intestinesConstipationCBC q yrAntireflux surgery Diarrhea(BA swallow/ Weight lossendoscopy prn) Obstruction Fibrosis:>40Gy AbdomenAbdominal colicHeight and weight q yrStool softeners Large intestine,Rectal painRectal examHigh-fiber diet colonConstipationStool guaiac q yr MelenaLower GI Weight lossColonoscopy ObstructionSigmoidoscopy

Table3.4.Evaluation of patients at risk for late effects:hepatic Late effectsCausative treatmentSigns Screening Management ChemotherapyRadiationSurgeryand symptomsand diagnostic testsand intervention Hepatic MTX>30Gy Major ItchingLFTs q yrHepatitis screen Fibrosis/cirrhosisAct-DresectionJaundice(Hepatitis C screen)(hepatitis A,B,C,CMV) 6MPSpider nevi(Liver biopsy)Diuretics 6TGBruising(Endoscopy)Refer to hepatologist Portal hypertension: Esophageal varices Hemorrhoids Hematemesis Encephalopathy Table3.5.Evaluation of patients at risk for late effects:genitourinary Late effectsCausative treatmentSigns Screening Management ChemotherapyRadiationSurgeryand symptomsand diagnostic testsand intervention Glomerular CDDP>20Gy orAsymptomatic or Fatigue,Creatinine,BUN q yr.Low-protein diet dysfunctionCarboplatin>15Gy Poor linear growth,Creatinine clearance Dialysis Ifoswith chemoAnemia,baseline and q 3 yrsRenal transplant OliguriaAnnual: Blood pressure Height,weight Hemoglobin Urinalysis Hypoplastic 20–30Gy orFatigueSame as GlomerularSame as Glomerular kidney/renal 10–15Gy Poor linear growthdysfunctiondysfunction arterio-sclerosiswith chemoHypertension Headache Edema Albuminuria Urinary casts Tubular CDDPSeizures (↓ Mg)Mg,Ca,PO4,Cr,BUN,Mg supplement dysfunctionCarboplatinWeakness (↓ Po4)Hg annually,Po4supplement IfosGlycosuriaBP/urinalysis q year Poor linear growth24 hour urine for Ca, Po4prn abnormalities

Table3.5.Continued Late effectsCausative treatmentSigns Screening Management ChemotherapyRadiationSurgeryand symptomsand diagnostic testsand intervention Nephrotic 20–30Gy ProteinuriaSerum protein,albumin,Low-salt diet syndromeEdemaCr,BUN,q yearDiuretics Urinalysis q yr Blood pressure q yr (24 hr urine for protein and Cr) Bladder:CPM>30Gy UrgencyUrinalysis q yrExercises to Fibrosis or Ifosprepubertalincrease bladder HypoplasiaSurgical referral>50Gy FrequencyCystoscopy,IVP/US;capacity (reduced postpubertalDysuriavolumetrics bladder capacity)Incontinence (nocturia) Pelvic hypoplasia Hemorrhagic CPM>35Gy Hematuria,orUrinalysis q yrRefer to urologist and non-hemor-IfosLower doses Frequency,Cystoscopy if hematuria Maintain Hg rhagic cystitisenhance Urgency,on 2 examsAntispasmodics chemotherapy Dysuria,Hg q yearCounsel regarding effectBladder tendernessrisk of bladder cancer Prostate40–60Gy Decreased volume Prostate Examination Counsel regarding: (lower doses of seminal fluidAnnually of prostate gland.possible infertility due inhibit Hypoplastic or Semen analysis x 1at to inadequate seminal development;atrophied prostatematurity.fluid higher doses UltrasoundMonitor prostate cause atrophy)(exam and prostate- specific antigen) Vagina:(Act-D),4–60Gy Painful intercoursePelvic exam (possibly Dilations Fibrosis/doxo enhance (lower doses Vaginal bleedingunder anesthesia),Reconstructive diminished RT effect)inhibit Small vaginal vaultbaseline during puberty surgery growthdevelopment;and then prn for symptomsPotential need higher doses for cesarean section cause atrophy) Uterus:>20Gy Spontaneous abortionPelvic examination,Counsel regarding Fibrosis/(prepubertal)Low birth-weight infantsprn for symptoms pregnancy Decreased >40–50Gy or if planning pregnancyRefer to Gynecologist growth(postpubertal)if considering pregnancy

Table3.5.Continued Late effectsCausative treatmentSigns Screening Management ChemotherapyRadiationSurgeryand symptomsand diagnostic testsand intervention Ureter:>50–60Gy Frequent UTIsUrinalysis q yrUTI prophylaxis FibrosisPelvic hypoplasiaUrethrogram Hydronephrosis Urethra:>50Gy GUFrequent UTIsUrinalysis q yrUTI prophylaxis StricturesDysuriaVoiding cystogramSurgical intervention Stream abnormalities Table3.6.Evaluation of patients at risk for late effects:head and neck Late effectsCausative treatmentSigns Screening Management ChemotherapyRadiationSurgeryand symptomsand diagnostic testsand intervention Xerostomia Doxorubicin,>30Gy Decreased salivary flowDental examinationEncourage meticulous (decreased Actinomycin D and >50% Dry mouthSalivary flow studiesoral hygiene salivary gland enhance RT gland must Altered taste perceptionAttention to early caries,Saliva substitute function)effectbe radiatedDental decayperiodontal diseaseProphylactic fluoride Candida (thrush)Dietary counseling regarding avoiding fermentable carbohydrates Nystatin for oral candidiasis Pilocarpine Intranasal >40Gy Chronic rhinosinusitisInspection of mucosaDecongestants scarringNasal dischargeNasopharyngoscopyDrainage procedures Postnasal dripAntibiotics prn Facial pain Headache Epilation (scalp)>15–20Gy Thinning of hairExaminationWigs AlopeciaCompensatory hair styling Eyelash>30Gy Eyebrow>50Gy Fibrosis>40Gy PainExaminationPrevention of infection Constriction(especially after trauma) Facial asymmetry“Stretching”exercises of TMJ Limitation of jaw motion (TMJ fibrosis)

Table3.6.Continued Late effectsCausative treatmentSigns Screening Management ChemotherapyRadiationSurgeryand symptomsand diagnostic testsand intervention Osteo-necrosis>50–60Gy Tooth Ulcers/necrosisExaminationProsthetic devices (or interstitial extractionSurgical repair radiation) Abnormal >30Gy Facial asymmetryExaminationProsthetic devices facial growthHypoplastic development Surgical repair of orbit,maxilla,mandible Craniofacial SurgeryExaminationSurgical repair deformity Abnormal tooth (VCR,Act-D,≥10Gy Enamel appears paleDental exam q6 months Careful evaluation prior and root CPM,6MP,Teeth appear small,with attention to early to tooth extraction, developmentPCZ,HN2)unevencaries,periodontal disease,endodontics,and ortho- Malocclusionand gingivitis.Panorex/dontics Fluoride bite-wing radiographs Antibiotics prn risk baseline (age 5–6)of infection (e.g.,trauma) Chronic otitis≥40–50Gy Dryness and thickening Otoscopic examAntibiotic therapy of canal and tympanic AudiometryDecongestants membraneMyringotomy Conductive hearing lossPE tubes Perforation of TMPreferential seating in school Amplification Sensorineural Cisplatin≥35–40Gy High frequency hearing Conventional pure tone Preferential seating hearing lossCranial RT loss (bilateral)audiogram baseline in school enhances the Tinnitusand then q 2–3 yrAmplification platinum effectVertigoBilateral,symmetrical, irreversible Decreased ≥30–40Gy Hard and encrusted Examination of canalPeriodic cleaning of ear canal production cerumen in canalCerumen-loosening agents of cerumenHearing impairmentOtic drops for otitis externa Otitis externaKeep ear dry: Ear plugs Drying solution Chondritis≥50Gy Cauliflower earInspection of auricleAntibiotics Surgical repair (Reconstruction may be hampered by poor blood supply) Chondrone-crosis≥60Gy

Table3.7.Evaluation of patients at risk for late effects:integumentary/breast Late effectsCausative treatmentSigns Screening Management ChemotherapyRadiationSurgeryand symptomsand diagnostic testsand intervention Alopecia>40Gy Hair loss involving ExaminationWig management the scalp,eyelashes, or eyebrows Hyper-Bleo,Bus,>30Gy Hyperpigmentation Examine skin Cosmetic intervention only PigmentationDTIC Skin Increased benign RTIncreased numbers Skin examination annually.Refer to dermatologist or malignant of pigmented nevi Photograph involved for close follow-up of melanocytic neviin the field of radiationareas to follow accuratelymultiple or suspicious lesions. Biopsy of suspicious lesions Basal cell RTLesionSkin examination annually.Excisional biopsy carcinoma Hypoplasia (Effect enhanced >20Gy Decreased elasticityAnnual examination Avoid sun exposure of soft tissueby:Act-D Doxo)(developing Decreased tissue volumeof skin elasticity Use sunscreen child)Local inability to sweatand volumein treated area DrynessMoisturizers Telangiec-tasiaAs above>40Gy Enhances Skin appears tight Annual examination Avoid sun exposure risk,compro-with woody textureof skinin treated areas. mises blood Spidery pattern Avoid trauma supplyof small blood vessels Skin fibrosis/As above>40Gy Enhances risk,ContracturesAnnual skin examMust be in the care necrosiscompromises Discoloration of tissueExamination of a dermatologist – blood supplyfor tissue breakdownmay require surgery Hypoplasia >10Gy Reduced breast tissueAnnual breast Teach BSE of breast tissuePubertal Failure to lactate examinationAnticipatory guidance re: breast very in treated breastMammography at age Breast nodules sensitive25 yrs or 8 years post-XRT Impaired lactation baseline,then q 1–2 years (annually after age 40)

Table3.8.Evaluation of patients at risk for late effects:musculoskeletal Late effectsCausative treatmentSigns Screening Management ChemotherapyRadiationSurgeryand symptomsand diagnostic testsand intervention Muscular >20Gy Muscle loss Asymmetry of muscle Careful comparison Prevention: hypoplasia(growing child)or resectionmass when compared and measurement Exercise program: Younger with untreated areaof irradiated and Range of motion children Decreased range unirradiated areasMuscle strengthening more sensitiveof motionRange of motion Stiffness and pain in affected area (uncommon) Spinal For young Lami-Spinal CurvatureStanding by stadiometer.Refer to orthopedist abnormalitieschildren,RT to nectomyBack painDuring puberty examine if any curvature is noted, Scoliosishemi-abdomen Hip painspine q 6 months until especially during a period Kyphosisor spine Uneven shoulder heightgrowth is completedof rapid growth Lordosis(especially Rib humps or flaresSpinal films baseline Decreased hemi-vertebral)Gait abnormalitiesduring puberty, sitting height10Gy then prn curvature (minimal effect)(COBB technique >20Gy to measure curvature) (clinically notable defect) Length >20Gy Lower back painAnnual measurement Contralateral discrepancyLimpof treated and untreated epiphysiodesis Hip painlimb (completely undressed Limb-shortening Discrepancy in patient to assure accurate procedures muscle mass and length measurements) when compared Radiograph baseline with untreated to assess remaining extremityepiphyseal growth ScoliosisRadiographs annually during periods of rapid growth Pathological >40Gy BiopsyPainBaseline radiograph Consider limitation of fractureEdemaof treated area to assess activities (e.g.,contact Ecchymosisbone integrity,then prn sports) symptomsSurgical repair of fracture;may require internal fixation

Table3.8.Continued Late effectsCausative treatmentSigns Screening Management ChemotherapyRadiationSurgeryand symptomsand diagnostic testsand intervention Osteo-necrosisSteroids>40–50Gy Pain in affected jointRadiograph,CT scan prn Symptomatic care (more common LimpsymptomsJoint replacement in adults) Osteo-RTPainless lump/Radiograph baseline Resection for cosmetic cartilaginous mass noted in the and prn growth of lesionFunctional reasons exostosesfield of radiationCounsel regarding 10% incidence of malignant degeneration Slipped capito-High-dose >25Gy (at Pain in affected hipRadiograph baselines Refer to orthopedist femoral epiphysissteroidsyoung ageLimpto assess integrity for surgical intervention Abnormal gaitof the treated joint(s), then prn symptoms Table3.9.Evaluation of patients at risk for late effects:ophthalmology Late effectsCausative treatmentSigns Screening Management ChemotherapyRadiationSurgeryand symptomsand diagnostic testsand intervention Lacrimal glands:5FU>40Gy Dry,irritated red eyeEye exam/slit lamp examTear replacement Decreased tear Foreign-body sensationFluorescein stainingOcclude lacrimal puncta production Lacrimal duct:5FU>50Gy TearingOphthalmic examDilation of duct Fibrosis Eyelids:50Gy BlepharitisEye examTopical/oral steroids UlcerationBleeding/crusted lesionSkin balm Previous infectionsTeach: Lid hygiene Radiosensitizing drugs Telangiectasia50Gy Enlarged,tortuous Slit lampUV protection blood vesselsAvoid trauma, Pigmentary changesHarsh soaps and lotions Conjunctiva:>45Gy PainEye ExamSteroids/antibiotic drops NecrosisRadioactive Dry,irritated eyeSlit lamp plaque therapyForeign-body sensationFluorescein stain Sclera:>50Gy May be asymptomaticEye ExamAntibiotic drops ThinningGrey,charred,blue scleraSlit lamp examAvoid trauma Protective glasses

Table3.9.Continued Late effectsCausative treatmentSigns Screening Management ChemotherapyRadiationSurgeryand symptomsand diagnostic testsand intervention Cornea:>45Gy PainEye ExamAntibiotics UlcerationForeign-body sensationSlit lampSoft bandages KeratinizationDecreased VAFluorescein stainingSoft contact lens PhotosensitivitySurgery Ophthalmology Lens:Steroids>6Gy Decreased visual acuityDirect ophthalmoscopic Prevention by shielding Cataract(incidence (single dose Opaque lensexamduring treatment varies with or >10Gy Decreased red reflexSurgical removal dose)fractionated)Slit lampEducate regarding UV Opaque lensprotection Iris: Neovascularization>50Gy May be asymptomaticEye ExamSteroid drops New blood vessels Slit lamp in iris (rubeosis) Blood in anterior chamber Secondary Eye pain,headache,Measure ocular pressureBeta blocker drops glaucomanausea/vomiting,Atropine decreased peripheral Diamox vision,increased IOP Atrophy>50Gy Decreased iris stroma Slip lamp/penlight examPhotocoagulation at pupillary margin Retina: Infarction>50Gy Blanched white Visual acuitySteroids cotton spotsVisual fieldPhotocoagulation Decreased visual acuityEducation regarding Decreased visual fieldavoiding ASA and Blurred vision (central bleeding precautions or peripheral) Hemorrhage>50Gy Telangiectasia>50Gy Neovascularization>50Gy Mascula edema>50Gy Blister of fluid in the mascula Optic neuropathy>50Gy Tumor Pale optic discVisual evaluationVisual aids resectionAbnormal pupillary responses

Table3.10.Evaluation of patients at risk for late effects:ovarian Late effectsCausative treatmentSigns Screening Management ChemotherapyRadiationSurgeryand symptomsand diagnostic testsand intervention Ovarian failureCPM,PCB,4–12Gy Oophorectomy Delayed/arrested/absent Tanner stage,LH,FSH,Hormone replacement bus,BCNU,Tolerance or pubertal developmentestradiol at:therapy CCNU,Ifosdecreases oophoropexyChanges in duration,1) Age 12 yrsAnticipatory guidance with frequency,and character 2) Failure of pubertal regarding symptoms increasing of menses (cramping)developmentof estrogen deficiency ageEstrogen deficiency:3) Baseline when and early menopause Hot flashesfully matureAlternate strategies Vaginal dryness4) PRN symptomsfor parenting Dyspareunia Low libido Infertility Table3.11.Evaluation of patients at risk for late effects:peripheral system effects Late effectsCausative treatmentSigns Screening Management ChemotherapyRadiationSurgeryand symptomsand diagnostic testsand intervention Peripheral VP-16,60Gy WeaknessAnnual neurologic Protecting affected neuropathyVCRLack of coordinationexaminationarea from excess heat CDDPTinglingor cold exposure NumbnessPhysical therapy Occupational therapy

Table3.12.Evaluation of patients at risk for late effects:pulmonary Late effectsCausative treatmentSigns Screening Management ChemotherapyRadiationSurgeryand symptomsand diagnostic testsand intervention Pulmonary Bleo,CCNU,Pulmonary FatigueCXR,O2saturation,If symptomatic, fibrosisBCNU,(CPM),RT >10Gy CoughPFT with DLCO,refer to pulmonologist (MTX),(Vinca Risk increases Dyspnea on exertionbaseline then q 3–5 yrs prnPrevention: alkaloids)with doses,Reduced exercise Avoidance of smoking larger volume toleranceAvoidance of infections: irradiated,OrthopneaInfluenza vaccine and younger CyanosisPneumovax ageFinger clubbingAfter bleomycin: RalesAvoid Fi02>30% Cor pulmonale(e.g.during surgery)

Table3.13.Evaluation of patients at risk for late effects:testicular Late effectsCausative treatmentSigns Screening Management ChemotherapyRadiationSurgeryand symptomsand diagnostic testsand intervention Germ cell CPM,HN2>1–6Gy Orchiectomy Testicular atrophy Tanner stageInstruct: damage:CCNU/BCNU to the testes or surgical (softer,smaller)Inquire regarding Testicular self-examination Oligospermia/PCB,Ifos(direct manipulationFailure to impregnateprevious sperm bankingAnticipatory guidance re: azoospermiaor scatter)Assess testicular size Infertility counseling: and consistency.Alternate strategies LH,FSH,testosterone:for fathering 1) For failure of pubertal development 2) Baseline when sexually mature 3) For failure to impregnate (repeat q 3yr for possible recovery) Spermoto-analysis at maturity or for failure to impregnate (repeat q 3–5 years prn to assess recovery) Leydig cell CPM>24Gy OrchiectomyTesticular atrophy LH and testosterone at:Testosterone replacement damage:to the testes or surgical (softer,smaller) (direct or manipulation scattered from pelvis) Testosterone VP-16Delayed/arrested/Age 13 yrsAnticipatory guidance deficiencyIfos,CCNU,absent pubertal Failure of pubertal regarding testosterone BCNU,HN2development:developmentdeficiency Pubic and axillary hair Baseline,if sexually mature (female hair pattern)Changes in libido Lack of penile and or sexual performance testicular enlargement, Voice change or Body odor and acne

Table3.14.Evaluation of patients at risk for late effects:cardiac Late effectsCausative treatmentSigns Screening Management ChemotherapyRadiationSurgeryand symptomsand diagnostic testsand intervention CardiomyopathyAnthracycline>30Gy FatigueEKG,ECHO/RNA Diuretics (Ventricular >300mg/m2>20Gy and Coughand CXR baselines,Digoxin dysfunction)>200mg/m2AnthracyclinesDyspnea on exertionq 1–5 yr (depending Afterload reducers and RT to Peripheral edemaon risk factors)Antiarrhythmics mediastinumHypertensionCardiac transplant High-dose CTXTachypnea/ralesEducation: (BMT)Tachycardiarisks of smoking, Cardiomegaly (S3/S4)pregnancy, Hepatomegalyanesthesia, alcohol, drug use, Isometric exercise Valvular damage >30Gy WeaknessECHO and CXR (baseline),Penicillin prophylaxis (Mitral/tricuspid Coughq 3–5 yr and prn symptomsfor surgery/dental aortic)Dyspnea on exertionprocedures New murmur Pulsating liver Pericardial >30Gy FatigueEKG (ST–T changes,Pericardial stripping damageDyspnea on exertiondecreased voltage),ECHO, Chest painCXR baseline,q 3–5 yr Cyanosis Ascites Peripheral edema Hypotension Friction rub Muffled heart sounds Venous distention Pulsus paradoxicus Coronary artery >30Gy Chest pain on exertion EKG q 3 yrsDiuretics disease(radiates to arm/neck)Stress test (consider Cardiac medications Dyspneadobutamine stress Low-sodium,low-fat diet Diaphoresisechocardiography) baseline,Conditioning regimens Pallorq 3–5 yr or prn symptoms Hypotension Arrhythmias

Table3.14.Continued Late effectsCausative treatmentSigns Screening Management ChemotherapyRadiationSurgeryand symptomsand diagnostic testsand intervention Conduction Anthracycline>30Gy SyncopeEKG abnormality>300mg/m2PalpitationsHolter monitor after high >200mg/m2Arrhythmiascumulative anthracycline and RT to dose (>300mg/m2) mediastinumor symptoms