Late effects of treatments for childhood non-Hodgkin lymphoma

Recovering from childhood non-Hodgkin lymphoma (NHL) and adjusting to life after treatment is different for each child. Recovery can depend on the type of NHL, the stage and risk group, the type and dose of treatment, the child’s age at time of treatment and many other factors. The end of cancer treatment may bring mixed emotions. Even though treatment has ended, there may be other issues to deal with, such as coping with long-term side effects.

Your child’s healthcare team will watch for late side effects and can help prepare you for what to expect. They can also suggest ways to help your child.

Learning problems can develop in children treated with high-dose chemotherapy, intrathecal chemotherapy with methotrexate or cytarabine (Cytosar) or radiation therapy to the brain. Generally, learning difficulties are mild and do not cause any major disability. Children who are under the age of 5 during treatment may be at higher risk for learning problems.

Find out more about cognitive problems.

Some chemotherapy drugs and radiation therapy to the head or neck can cause oral and dental problems. These problems may include increased risk for cavities, white or discoloured patches on the teeth, shortening or thinning of the roots of the teeth or absence of teeth or roots. Oral and dental problems can develop many years after treatment is finished.

Find out more about dental problems.

Children who receive radiation therapy to the neck area have a higher risk of developing hypothyroidism, hyperthyroidism and thyroid nodules. Hypothyroidism is lowered thyroid function. Hyperthyroidism is increased thyroid function. Thyroid nodules are growths on the thyroid that can sometimes cause hyperthyroidism.

Find out more about thyroid problems.

Radiation therapy to the chest can have late effects on the heart. Certain chemotherapy drugs used to treat NHL, such as doxorubicin (Adriamycin), can also affect the heart. Heart problems can include:

• inflammation or scarring of the protective covering of the heart (called pericarditis)
• hardening or narrowing of the heart arteries (called coronary artery disease)
• scarring or weakening of the heart muscle (called cardiomyopathy)
• abnormal heartbeat (called arrhythmia)
• inability of the heart to pump blood properly (called congestive heart failure)

Find out more about heart problems.

Pneumonitis is the most common lung problem that can develop after treatment with certain chemotherapy drugs, such as doxorubicin. Pneumonitis is inflammation of the lungs. It can develop into pulmonary fibrosis, which is the formation of scar tissue in the lungs.

Radiation therapy to the chest can also cause pneumonitis and pulmonary fibrosis.

Find out more about lung problems.

Certain chemotherapy drugs, such as vincristine (Oncovin), can cause liver problems. The liver may become enlarged (called hepatomegaly). If the liver damage gets worse, the liver may become hard (called fibrosis) and scarred (called cirrhosis).

Find out more about liver problems.

Children treated with radiation therapy for NHL have a higher risk of developing problems with their bones and muscles. Radiation therapy to the spine can result in a shorter overall height. Radiation therapy to the chest and neck area can cause narrow shoulders, a narrow neck and a poorly developed chest.

Treatment with steroids, such as prednisone or dexamethasone (Decadron, Dexasone), can also increase the risk of problems such as osteoporosis. Osteoporosis is a condition in which bones lose mass (density) and the bone tissue breaks down.

Find out more about bone and muscle problems.

Weakness and sensation changes related to chemotherapy drugs such as vincristine and vinblastine may improve over time, but some children have more permanent changes. Follow-up with physiotherapy is recommended.

Some chemotherapy drugs used to treat NHL can cause reproductive system problems. These problems include early or delayed puberty in boys and girls. Children treated for NHL may be infertile when they are adults. Girls treated with alkylating agents may have premature menopause as women. The higher the total dose of chemotherapy, the greater the risk of damage. High doses of chemotherapy used in preparation for a stem cell transplant increase the risk of reproductive system problems.

Girls who receive radiation therapy to the pelvis may also have fertility problems later in life. These problems may include the ovaries not working properly or problems with pregnancy, such as premature delivery.

Find out more about male reproductive system problems and female reproductive system problems.

NHL survivors have a higher risk of developing a second cancer. This risk may be due to treatments, such as chemotherapy or radiation therapy. Children treated for cancer today have a lower risk of developing a second cancer than they did in the past. New chemotherapy combinations, lower doses of chemotherapy and lower doses of radiation that more accurately target the tumour have lowered the risk of a second cancer.

Chemotherapy with alkylating agents and etoposide (Vepesid, VP-16) can raise the risk of developing acute myelogenous leukemia (AML) or a myelodysplastic syndrome (MDS). Secondary leukemia is most commonly diagnosed 5 to 10 years after treatment.

The risk of developing NHL again may also be higher in children treated for NHL. This may be because both the disease and its treatments can weaken the immune system.

Children treated for NHL also have a higher risk of developing solid tumours, such as cancers of the breast or thyroid. The risks of secondary solid tumours vary depending on the treatment given. They are mostly related to radiation therapy, and the risk may be higher if chemotherapy is given with radiation therapy.

The Children’s Oncology Group (COG) follow-up guidelines recommend that children with NHL have early screening for secondary cancer as part of their supportive care. For example, the COG recommends that girls who received radiation to the chest have mammograms 8 years after their treatment or by the age of 25, whichever is later.

Find out more about second cancers.