Long Term Effects of Radiation

Eyes

Effects: depending on the treatment volume and dose required, radiation therapy may result in injury to the lens, lacrimal apparatus, retina, or optic nerve, cataracts

Physical findings: abnormal intraocular pressure, cataract, presence of tears, fundoscopic examination

Recommendations: ophthalmologic examination; assess for cataracts, xerophthalmia; slit lamp examination, fluorescein retinal angiography, electroretinogram, visual field evaluation, fitting for corrective lenses as needed

Ears/Hearing

Effects: tinnitus, hearing loss; failure to follow instructions, poor school performance; decreased hearing acuity ("People don’t talk loud enough"); middle and high-frequency range hearing thresholds are worse among children treated with combined therapy than among those receiving radiation therapy alone or cisplatin with no radiation

Physical findings: presence of fluid or pus behind tympanic membrane; Rhinne and Weber tests

Recommendations: pure tone audiometry, brainstem auditory evoked response

Teeth 

Effects: disturbances in dentine and enamel; root stunting, microdontia, hypodontia, taurodontia (enlarged pulp chamber), over–retention of primary teeth, osteoradionecrosis (these may not be expressed for months or years); increased risk for infection and caries; xerostomia (dry mouth)

Physical findings: caries present, gum recession, pitting of enamel, hypoplastic teeth

Recommendations: routine dental examination, panorex evaluation, fluoride applications, oral hygiene education; evaluate viability of teeth and degree of gum recession

Salivary Glands

Effects: dry mouth, bad breath, susceptibility to caries

Physical findings: dry mouth, possibly caries, gum recession

Recommendations: assess saliva production if decreased, institute early and regular dental surveillance and therapy

Head and Neck

Effects: maxillofacial abnormalities and maldevelopment, hormonal deficiencies (see below),cognitive disabilities, thyroid neoplasia

Physical findings: changes consistent with above radiation effects

Recommendations: institute early and regular surveillance and therapy as needed

Bone

Effects:

Spine – decrease in vertebral height; narrowing and asymmetry of vertebral body resulting in the reduction in spinal growth; scoliosis is a late effect, (example – patient with Wilm’s tumor); short stature; back pain

Long bones - hypoplasia, widening and fraying of the metaphyseal plate, sclerosis, and abnormal trabeculation; possible functional limitation, shortening of the extremity, osteonecrosis, increased susceptibility to fracture, and poor healing; avascular necrosis of the femoral neck and slipped capital femoral epiphysis after pelvic radiation

Recommendations: focused physical examination, appropriate orthopedic or reconstructive intervention and physical therapy as needed

Heart 

Effects: may vary depending on radiation dose, age and combination with cardiotoxic chemotherapy and may include: pericarditis, pericardial effusion, myocardial fibrosis, ischemic heart disease, decreased size of left ventricular cavity secondary to restrictive left ventricular cardiomyopathy, valvular damage

Physical findings: may include jugular venous distention; blood pressure; pulses paradoxus; heart rhythm and rate; murmur; pericardial friction rub; peripheral edema

Recommendations: focused history and physical examination and evaluation (may include echo/stress testing), therapeutic intervention as needed

Peripheral Arteries 

Effects: claudication, premature plaque formation

Physical findings: decreased or absent peripheral pulse, decreased local skin temperature, skin ulcers, hypertension, flow bruits

Recommendations: doppler ultrasound flow evaluation; additional tests, such as angiogram, depending on the clinical situation

Lungs/Pulmonary System

Effects: may damage the elastic properties of the lung volume, decreasing compliance and diffusing capacity or lung volume; may increase risk of lung malignancies

Physical findings: restrictive lung disease

Recommendations: pulmonary function testing at regular intervals if suspicious symptoms are elicited. Chest radiograph and counseling about increased risk of lung cancer, tobacco avoidance or cessation

Breast 

Effects: increased risk of subsequent breast cancer

Recommendations: breast exam, mammography beginning age 25-30

Liver

Effects: may cause acute or chronic damage, including chronic hepatic fibrosis; potential to develop long term sequelae is enhanced if radiation is administered in combination with dactinomycin or doxorubicin and if juxtaposed to hepatic resection

Physical findings: spider nevi, jaundice, distention of superficial thoracic veins, hepatomegaly, splenomegaly

Recommendations: liver function evaluation and focused history and physical examination

Gastrointestinal Tract

Effects: may result in fibrosis, stricture, obstruction, ulceration, malabsorption syndromes;  radiomimetic chemotherapy or surgery may compound toxicity

Physical findings: hyperactive bowel sounds, rectal atrophy or stricture, evidence of malabsorption or weight loss

Recommendations: elicit history for late sequelae such as malabsorption , adhesive/obstructive complications; Liver function test; stool examination for occult blood, upper GI series, barium enema, compliance with American Cancer Society recommendations

Genitourinary/Renal System

Effects: may include renal dysfunction including renal failure; combinations with radiomimetic chemotherapeutic agents such as Actinomycin D and Adriamycin may exacerbate toxicity

Recommendations: monitor renal function and urine sediment; additional biochemical or radiologic evaluation as needed

Bladder

Effects: may include hematuria, pyuria, dysuria, increased frequency of voiding, urinary incontinence, chronic cystitis; bladder fibrosis, contractures

Physical findings: bladder distention

Recommendations: urinalysis with microscopic examination, urine for cytology (every 3-5 years, cystometric evaluation and voiding cystourethrography in patients with hematuria or urinary frequency; additional evaluation as needed

Gonads 

Effects: both genders have increased risk for sterility and decreased sex steroid production; radiation after puberty increases risk of gonadal dysfunction

Physical findings: abnormal development of secondary sexual characteristics

Recommendations: focused history of sexual and reproductive function, physical examination for age appropriate sexual maturation, reproductive hormone measurements

Nervous System 

Effects: progressive impairment of cognitive, motor or sensory function may occur; radiation that includes the hypothalamic or pituitary areas frequently results in impaired pituitary function including abnormal growth and development

Recommendations: surveillance of neurologic and cognitive function; evaluation of pituitary function and appropriate hormone replacement as needed

Endocrine System

Cancer Therapy: radiation involving the hypothalamic-pituitary gland

Effects: isolated growth hormone deficiency is the most frequent sequela; additional hypothalamic and pituitary deficiencies may occur

Physical findings: growth and pubertal delay or failure, thyroid or adrenal insufficiency, hypothalamic obesity

Recommendations: careful assessment of growth and development, nutritional counseling and therapy as needed

Cancer Therapy: radiation to neck, mediastinum that includes the thyroid gland

Effects: increased risk for hypothyroidism (progressively over many years); increased risk of thyroid nodules and thyroid cancer

Physical findings: signs of hypothyroidism or thyroid and neck masses

Recommendations: regular surveillance of thyroid function and physical examination of the neck; additional evaluation if abnormalities are detected; use of routine radiologic evaluation is controversial

Skin

Effects: hyperpigmentation, atrophy and dermatologic malignancies

Recommendations: regular physical examination