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Late Effects







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Late Effects


Radiotherapy (RT) Late Effects:

Late effects occur 90 days to many years after therapy. All cancer treatment is associated with adverse effects. RT treatment for neuroblastoma (NBL) is associated with long-term health risks and problems.

Late Effects associated abdominal RT (to adrenal bed):

Organ at risk Toxicity


Growth abnormalities and hypoplasia:

  • Scoliosis and mild asymmetry of all musculoskeletal structures in the RT field can occur due to reduced growth of bone and paravertebral muscles
  • Scoliosis is more likely for survivors of neuroblastoma than Wilms tumor
  • NBL tumors are more likely to cross the midline than Wilms and impinge on the opposite kidney. Patients often received RT with 3D conformal fields and sparing renal tissue takes precedence over irradiating the vertebral bodies uniformly.  The dose of RT is also generally higher for NBL than Wilms and therefore skeletal asymmetry is more likely in NBL.
  • There is likely to be a decrease in sitting height and modest decrease in standing height after abdominal RT
  • These effects are more pronounced the younger the patient is at the time of RT

Increased risk of osteoporosis (especially involving the spine) and degenerative disease:

  • Patients should avoid lifting heavy weights
  • Bone density should be checked roughly 10 years before one would normally worry about osteoporosis
  • Important to maintain bone density (Vit D, dairy servings in diet and exercise)



There is a small long term risk of veno-occlusive disease which consists of the clinical triad:

  • hepatomegaly
  • ascites
  • icterus


Patients may have undergone nephrectomy when their primary NBL tumor was resected and therefore have less renal reserve.


Large primary abdominal NBL tumors that cross the midline may extend very close to the contralateral kidney.  RT to the tumor bed is likely to be associated with a significantly increased risk of chronic renal failure


If included in the RT treatment volume, stenosis of the contralateral renal artery may produce hypertension.


It is very important to check NBL survivor's blood pressure on a regular basis




Primary gonadal failure is rare in survivors of NBL as whole abdominal RT is rarely if ever indicated.


Pelvic RT for a primary NBL arising in that region would be associated with a risk of gonadal failure


Pregnancy Outcome

It would be anticipated that female patients who have abdominal RT for NBL - as with patients who received flank RT for Wilms are at increased risk for premature and low birth weight babies.


Secondary Neoplasms

  • RT is associated with an increase risk of secondary malignancies
  • Probably in the range of 3 - 5% long-term increased risk


Late Effects associated with RT for paraspinal NBL:

Musculo-skeletal Growth

Scoliosis and asymmetry of all musculoskeletal structures in the RT field are likely to occur due to:

  • Spinal deformity secondary to primary NBL tumor
  • Surgically induced spinal asymmetry
  • Reduced growth of bone and paravertebral muscles secondary to RT


There will be a decrease in sitting height and modest decrease in standing height after flank or abdominal RT depending on the age of the child at the time of therapy


If the child is very young, after RT to the thoracic spine there may be a mild restrictive problem due to reduced growth of the chest wall and ribs.


RT to the thoracic spine may be associated with:

  • A mild restrictive problem due to reduced growth of the spine, adjacent chest wall and ribs.
  • Extensive primary NBL therapy may be associated with a risk of pneumonitis and subsequent lung fibrosis




Cervical spine RT is likely to be associated with a risk of hypothyroidism, thyroid nodules and papillary carcinoma of the thyroid.

Secondary Neoplasms

  • Increased risk of secondary neoplasms
  • Survivors should be discouraged from smoking.  A previous history of chest RT as a child gives a very high risk of lung cancer in survivors that smoke.
  • Women who had chest RT as children are at increased risk for the development of breast cancer and require early screening.


Surgery Late Effects:

NBL patients often undergo a unilateral nephrectomy when their primary adrenal tumor is resected.  Therefore they have many of the same long-term health concerns as patients who are Wilms tumor survivors.  The remaining kidney generally adjusts its function and size: “compensatory hypertrophy of the kidney".

Proteinuria and hypertension may occur in the long term after a combination of nephrectomy, chemotherapy and significant radiotherapy.

In long term follow up, it is important to check:

  1. Blood pressure (a solitary kidney is associated with an increased risk of hypertension)
  2. Renal function using routine blood tests and urinalysis

It is also important to warn about the prompt treatment of urinary tract infections (there is no increased risk, but infection could potentially damage remaining renal tissue). Antibiotics associated with a risk of renal damage (such as aminoglycosides) should be avoided.

Patients who have had a nephrectomy may wish to avoid activities that might damage the remaining kidney and it would be reasonable to avoid contact sports.

COG Survivorship guidelines: Keeping your single kidney healthy


Chemotherapy Late Effects:

Drug Late Effects
Cisplatin & Carboplatin
  • Secondary AML (short latency period)
  • Significant cardiac toxicity is very rare in neuroblastoma survivors

COG survivorship guidelines: Kidney health after childhood cancer





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