Late Effects of Treatment for Childhood Cancer (PDQ®): Treatment - Health Professional Information [NCI] - Late Effects of the Digestive System
Table 6. Hepatobiliary Late Effects
|Predisposing Therapy||Hepatic Effects||Health Screening/Interventions|
|ALT = alanine aminotransferase; AST = aspartate aminotransferase; HSCT = hematopoietic stem cell transplantation.|
|Methotrexate; mercaptopurine/thioguanine; HSCT||Hepatic dysfunction||Lab: ALT, AST, bilirubin levels|
|Ferritin in those treated with HSCT|
|Mercaptopurine/thioguanine; HSCT||Veno-occlusive disease/sinusoidal obstructive syndrome||Exam: scleral icterus, jaundice, ascites, hepatomegaly, splenomegaly|
|Lab: ALT, AST, bilirubin, platelet levels|
|Ferritin in those treated with HSCT|
|Radiation impacting liver/biliary tract; HSCT||Hepatic fibrosis/cirrhosis||Exam: jaundice, spider angiomas, palmar erythema, xanthomata hepatomegaly, splenomegaly|
|Lab: ALT, AST, bilirubin levels|
|Ferritin in those treated with HSCT|
|Prothrombin time for evaluation of hepatic synthetic function in patients with abnormal liver screening tests|
|Screen for viral hepatitis in patients with persistently abnormal liver function or any patient transfused prior to 1993|
|Gastroenterology/hepatology consultation in patients with persistent liver dysfunction|
|Hepatitis A and B immunizations in patients lacking immunity|
|Consider phlebotomy and chelation therapy for iron overload|
|Radiation impacting liver/biliary tract||Cholelithiasis||History: colicky abdominal pain related to fatty food intake, excessive flatulence|
|Exam: right upper quadrant or epigastric tenderness (acute episode)|
|Consider gallbladder ultrasound in patients with chronic abdominal pain|
The pancreas has been thought to be relatively radioresistant because of a paucity of information about late pancreatic-related effects. However, children and young adults treated with total-body or abdominal radiation are known to have an increased risk of insulin resistance and diabetes mellitus.
A retrospective cohort study, based on self-reports of 2,520 five-year survivors of childhood cancer treated in France and the United Kingdom, investigated the relationship between radiation dose to the pancreas and risk of a subsequent diabetes diagnosis. Sixty-five cases of diabetes were validated; the risk increased with radiation to the tail of the pancreas, where the islets of Langerhans are concentrated. Risk increased up to 20 to 29 Gy and then plateaued. The estimated RR at 1 Gy was 1.61. Radiation dose to other parts of the pancreas did not have a significant effect. Compared with patients who did not receive radiation, the RR of diabetes was 11.5 in patients who received more than 10 Gy to the pancreas. Children younger than 2 years at the time of radiation were more sensitive than older patients (RR at 1 Gy was 2.1 for the young age group vs. 1.4 for older patients). For the 511 patients who received more than 10 Gy, the cumulative incidence of diabetes was 16%.
Refer to the Children's Oncology Group Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers for digestive system late effects information including risk factors, evaluation, and health counseling.
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