Childhood cancer survivors can be at risk for developing the following musculoskeletal late effects:
·
Osteonecrosis
·
Decreased Bone Mineral Density (BMD)
·
Musculoskeletal Growth Problems
o
Hypoplasia
o
Fibrosis
o
Reduced or uneven growth
o
Shortened trunk height
o
Limb length discrepancy
o
Joint Contractures
·
Craniofacial Abnormalities
o
Osteoradionecrosis
o
Temporomandibular joint dysfunction
·
Scoliosis/Kyphosis
·
Radiation Induced Fracture
·
Amputation or Limb-Sparing Related
Complications
|
If your patient does not have a Survivor Health Plan (SHP), please refer him/her to the appropriate survivor clinic.
Important factors in determining risk for musculoskeletal late effects:
-
Age at treatment
-
Corticosteroids
-
Type and total dose of radiation
-
Epiphysis in radiation treatment field
-
Sickle cell disease
-
Poor healing after surgery
-
Endocrine dysfunction
-
Ethnicity
-
Obesity
-
Diabetes
-
Smoking
-
Alcohol use
-
Carbonated beverages
-
Body Mass Index (BMI)
-
Inadequate intake of Calcium and Vitamin D
|
Chemotherapy
Table
1
|
Osteonecrosis
|
Decreased BMD
|
Musculoskeletal Growth Problems
|
Craniofacial abnormalities
|
Scoliosis
Kyphosis
|
Radiation Induced Fracture
|
Amputation or Limb Sparing Related Complications
|
Alkylating Agents
Carmustine
BCNU
Busulfan
Lomustine
CCNU
Chlorambucil Cyclophosphamide
Cytoxan
Ifosphamide
Mechlorethamine
Melphalan
Procarbazine
Thiotepa
Dacarbazine
DTIC
Temozolomide
|
|
|
|
|
|
|
|
Heavy Metals
Carboplatin
Cisplatin
|
|
|
|
|
|
|
|
Antimetabolites
Cytarabine
Ara-C
Mercaptopurine
6MP
Thioguanine
6TG
Methotrexate
|
|
X
Methotrexate Only
|
|
|
|
|
|
Anthracycline antibiotics
Daunorubicin
Doxorubicin
Adriamycin
Epirubicin
Idarubicin
Mitoxantrone
|
|
|
|
|
|
|
|
Chemotherapy
Table
2
|
Osteonecrosis
|
Decreased BMD
|
Musculoskeletal Growth Problems
|
Craniofacial abnormalities
|
Scoliosis
Kyphosis
|
Radiation Induced Fracture
|
Amputation or Limb Sparing Related Complications
|
Anti-tumor antibiotics
Bleomycin
Dactinomycin
|
|
|
|
|
|
|
|
Corticosteroids
Dexamethasone
Decadron
Prednisone
|
X
|
X
|
|
|
|
|
|
Enzymes
Asparaginase
|
|
|
|
|
|
|
|
Plant alkaloids
Vincristine
Vinblastine
|
|
|
|
|
|
|
|
Epipodophyllotoxins
Etoposide
VP16
Teniposide
VM26
|
|
|
|
|
|
|
|
Radiation
|
Osteonecrosis
|
Decreased BMD
|
Musculoskeletal Growth Problems
|
Craniofacial abnormalities
|
Scoliosis
Kyphosis
|
Radiation Induced Fracture
|
Amputation or Limb Sparing Related Complications
|
All Radiation
|
|
|
|
|
|
|
|
TBI
|
|
|
X
|
|
|
|
|
Head/Brain
|
|
|
|
X
Cranio-facial abnormalities
>40 GY
Osteoradionecrosis
|
|
|
|
Neck
|
|
|
X
|
|
|
>40 Gy
Include TBI in total dose
calculation
|
|
Thorax
|
|
|
X
|
|
X
|
> 40 Gy
Include TBI in total dose
calculation
|
|
Abdomen
|
|
|
X
|
|
X
|
> 40 Gy
Include TBI in total dose
calculation
|
|
Pelvis
|
|
|
X
|
|
X
|
> 40 Gy
Include TBI in total dose
calculation
|
|
Extremity
|
|
|
X
|
|
|
> 40 Gy
Include TBI in total dose
calculation
|
|
Hematopoeitic Stem Cell Transplant
|
Osteonecrosis
|
Decreased BMD
|
Musculoskeletal Growth Problems
|
Craniofacial abnormalities
|
Scoliosis
Kyphosis
|
Radiation Induced Fracture
|
Amputation or Limb Sparing Related
Complications
|
Hematopoeitic Stem
Cell Transplant
|
X
|
X
|
|
|
|
|
|
Hematopoeitic Stem
Cell Transplant with any History of Chronic GVHD
|
|
|
X
|
|
|
|
|
Surgery
|
Osteonecrosis
|
Decreased BMD
|
Musculoskeletal Growth
Problems
|
Craniofacial abnormalities
|
Scoliosis
Kyphosis
|
Radiation Induced Fracture
|
Amputation or Limb Sparing
Related Complications
|
Amputation
|
|
|
|
|
|
|
X
|
Limb Sparing Procedure
|
|
|
|
|
|
|
X
|
Neurosurgery – Spine
|
|
|
|
|
X
|
|
|
Thoracic Surgery
|
|
|
|
|
|
|
|
|