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    Late Effects of Treatment for Childhood Cancer (PDQ®): Treatment - Health Professional Information [NCI] - Late Effects of the Digestive System

    Table 4. Oral/Dental Late Effects

    Predisposing Therapy Oral/Dental Effects Health Screening/Interventions
    CT = computed tomography; GVHD = graft-versus-host disease; MRI = magnetic resonance imaging.
    Any chemotherapy; radiation impacting oral cavity Dental developmental abnormalities; tooth/root agenesis; microdontia; root thinning/shortening; enamel dysplasia Dental evaluation and cleaning every 6 months
    Regular dental care including fluoride applications
    Consultation with orthodontist experienced in management of irradiated childhood cancer survivors
    Baseline panorex before dental procedures to evaluate root development
    Radiation impacting oral cavity Malocclusion; temporomandibular joint dysfunction Dental evaluation and cleaning every 6 months
    Regular dental care including fluoride applications
    Consultation with orthodontist experienced in management of irradiated childhood cancer survivors
    Baseline panorex before dental procedures to evaluate root development
    Radiation impacting oral cavity; hematopoietic cell transplantation with history of chronic GVHD Xerostomia/salivary gland dysfunction; periodontal disease; dental caries; oral cancer (squamous cell carcinoma) Dental evaluation and cleaning every 6 months
    Supportive care with saliva substitutes, moistening agents, and sialogogues (pilocarpine)
    Regular dental care including fluoride applications
    Radiation impacting oral cavity (≥40 Gy) Osteoradionecrosis History: impaired or delayed healing after dental work
    Exam: persistent jaw pain, swelling or trismus
    Imaging studies (x-ray, CT scan and/or MRI) may assist in making diagnosis
    Surgical biopsy may be needed to confirm diagnosis
    Consider hyperbaric oxygen treatments

    Digestive Tract

    Radiation and specific chemotherapeutic agents may produce gastrointestinal (GI) or hepatic toxicity that is acute and transient in the majority of patients, but rarely may be delayed and persistent. Late radiation injury to the digestive tract is attributable to vascular injury. Necrosis, ulceration, stenosis, or perforation can occur and are characterized by malabsorption, pain, and recurrent episodes of bowel obstruction, as well as perforation and infection.[19,20,21] In general, fractionated doses of 20 Gy to 30 Gy can be delivered to the small bowel without significant long-term morbidity. Doses greater than 40 Gy cause bowel obstruction or chronic enterocolitis.[22] Sensitizing chemotherapeutic agents such as dactinomycin or anthracyclines can increase this risk.

    A limited number of reports describe GI complications in pediatric patients with genitourinary solid tumors treated with radiation.[23,24,25,26,27] One study comprehensively evaluated intestinal symptoms in 44 children with cancer who underwent whole-abdominal (10 Gy to 40 Gy) and involved-field (25 Gy to 40 Gy) radiation and received additional interventions predisposing them to GI tract complications including abdominal laparotomy in 43 (98%) and chemotherapy in 25 (57%) patients.[23] Late small bowel obstruction was observed in 36% of patients surviving 19 months to 7 years, which was uniformly preceded by small bowel toxicity during therapy. Reports from the Intergroup Rhabdomyosarcoma Study evaluating GI toxicity in long-term survivors of genitourinary rhabdomyosarcoma infrequently observed abnormalities of the irradiated bowel.[24,25,27] Radiation-related complications occurred in approximately 10% of long-term survivors of paratesticular and bladder/prostate rhabdomyosarcoma and included intraperitoneal adhesions with bowel obstruction, chronic diarrhea, and stricture or enteric fistula formation.[24,27] Children irradiated at lower doses for Wilms tumor also uncommonly develop chronic GI toxicity. Several studies have reported cases of small bowel obstruction after abdominal surgery, but the role of radiation appears to be less important as operative findings of enteritis have not consistently been observed.[26,28] Among 5-year childhood cancer survivors participating in the Childhood Cancer Survivor Study (CCSS), the cumulative incidence of self-reported GI conditions was 37.6% at 20 years (25.8% for upper GI complications and 15.5% for lower GI complications) from cancer diagnosis, representing an almost twofold excess risk of upper GI (relative risk [RR], 1.8; 95% confidence interval [CI], 1.6-2.0) and lower GI (RR, 1.9; 95% CI, 1.7-2.2) complications compared with sibling controls. Factors predicting higher risk of specific GI complications include older age at diagnosis, intensified therapy (anthracyclines for upper GI complications and alkylating agents for lower GI complications), abdominal radiation, and abdominal surgery.[29]

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