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Acute Lymphoblastic Leukemia

 

 

 

Late Effects

Summary of Late Effects of chemotherapy in the treatment of ALL:

Therapy Late Toxicity
Steroids

Avascular necrosis

  • Especially affects hip joints

 
Intensive chemotherapy Increased risk of early osteoporosis
Adriamycin

Cardiomyopathy

 
Methotrexate (MTX)

Leukoencephalopathy:

  • Can result in mild learning disability or more serious neurocognitive problems

 

 

Summary of Late Effects from supportive care in the treatment of ALL:

Supportive care Late Toxicity
Blood transfusion
  • Any patient treated prior to 1992 in North America for leukemia who received a blood transfusion is at risk for hepatitis C and should be screened for viral hepatitis.

 

Late Effects of Radiation Therapy (RT):

  • Occur 90 days to many years after RT 

Late Effects depend very much on:

  • Age of the child at therapy:
    • The younger the child, the more pronounced the toxicity is likely to be
  • Dose of RT:
    • Higher dose associated with increased toxicity
    • Dose of RT used in ALL is generally low
  • RT treatment field extent:
    • Low dose whole brain RT given in RT. Craniospinal RT used for CSF positive disease and spinal RT dose is generally much lower than the cranial dose
  • Concurrent chemotherapy (MTX) increases toxicity.

 

Summary of Late Effects of RT in the treatment of ALL:

Therapy Late Toxicity

Cranial RT

Neurocognitive problems:

  • Leukoencephalopathy can occur in these patients
  • Methotrexate (MTX) can also cause this problem
  • Poor short term memory
  • Difficulty with executive function

 

Depression:

  • Usually related to neurocognitive dysfunction

 

Thyroid damage can often occur as a late effect from scattered RT:

 

Pituitary and hypothalamic dysfunction:

 

Increased risk for cerebrovascular events (strokes):

  • RT effect on cerebral vasculature

 

Increased risk of second neoplasms:

 

Cataracts:

  • Lens of the eye very sensitive to RT

 
  • Mild hypoplasia of occipital region after cranial RT in very young children

 

Craniospinal

RT (spinal portion of RT field)

Thyroid damage can occur after cranial RT alone, but is more common after spinal RT due to the "exit"dose:

 

Damage to bone marrow reserve:

  • After craniospinal RT, it may be very difficult to tolerate further intensive chemotherapy
  • Bone marrow reserve is permanently damaged

Infertility:

  • Exit dose from lower end of spinal field may damage ovaries or testicles (this is unusual in the setting of low dose craniospinal RT for leukemia)
Testicular RT

Infertility:

  • Certain to occur after direct testicular RT

Hypogonadism:

  • Very common
  • Treated with testosterone hormone replacement therapy

Testicular hypoplasia:

  • May require testicular prosthesis

Second malignant neoplasm:

  • Self examination of testes recommended in long term survivors after testicular RT

 

ALL patients are sometimes treated with Bone Marrow Transplant. This often includes low dose whole body RT (Total Body Irradiation or TBI). 

There are many long term health risks after BMT and TBI.  Please follow these links:

 

Link:  Ongoing COG study AALL 06N1

Designed to study brain function in young patients treated with methotrexate for ALL.

 

 

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