Late effects of treatments for childhood Hodgkin lymphoma

Recovering from childhood Hodgkin lymphoma (HL) and adjusting to life after treatment is different for each child. Recovery can depend on 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.

Sometimes the immune systems of children with HL don’t work as they should. Treatments for childhood HL, such as chemotherapy, radiation therapy or removal of the spleen (splenectomy) can also affect the immune system. People who have had their spleen removed may need certain vaccinations to help increase their immunity.

Find out more about infection and immunizations.

Some chemotherapy drugs and radiation therapy to the head or neck can cause oral and dental problems. These problems may include a higher risk for cavities and white or discoloured patches on the teeth. These treatments can also affect the roots of teeth so they are shorter or thinner, or sometimes teeth or roots don’t grow at all. 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 for developing hypothyroidism, hyperthyroidism and thyroid nodules. Hypothyroidism is lower than normal thyroid function. Hyperthyroidism is higher than normal thyroid function. Thyroid nodules are growths on the thyroid that can sometimes cause hyperthyroidism.

Find out more about thyroid problems.

Children treated with radiation therapy for Hodgkin lymphoma may develop problems with their bones and muscles. Radiation therapy to the spine can result in them not getting as tall as expected. Radiation therapy to the chest and neck area can cause narrow shoulders, a narrower neck and a poorly developed chest. Lower doses of involved-nodal radiation therapy (INRT) used along with chemotherapy don’t have a significant effect on bone growth and muscle development.

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, or density, and the bone tissue breaks down. This risk of osteoporosis decreases with risk-adapted treatment and lower doses of steroids.

Find out more about bone and muscle problems.

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

• abnormal heartbeat (called arrhythmia)
• 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)
• inability of the heart to pump blood properly (called congestive heart failure)

Find out more about heart problems.

Lung problems, including pneumonitis and pulmonary fibrosis, can develop after certain treatments for childhood Hodgkin lymphoma. Pneumonitis is inflammation of the lungs. It can develop into pulmonary fibrosis, which is the formation of scar tissue in the lungs.

Pneumonitis is the most common lung problem caused by certain chemotherapy drugs, such as bleomycin (Blenoxane).

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

Find out more about lung problems.

Some chemotherapy drugs and radiation used to treat Hodgkin lymphoma can cause reproductive system problems.

Certain chemotherapy drugs, such as cyclophosphamide (Procytox), can also affect fertility in both boys and girls. Alkylating drugs can affect the ovaries or testicles and cause reproductive problems for children as they get older. These problems include early or delayed puberty in boys and girls. Girls treated with alkylating drugs may have premature menopause as women.

The higher the total dose of chemotherapy, the greater the risk of damage. High doses of chemotherapy used before 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 damage to the ovaries or problems with pregnancy, such as premature delivery.

There are ways to help prevent reproductive system problems. Find out more about male reproductive system problems and female reproductive system problems.

Today children treated for Hodgkin lymphoma 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 are more accurately targeted to the tumour have lowered the risk of developing a second cancer.

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

The risk of developing non-Hodgkin lymphoma may also be higher in children treated for Hodgkin lymphoma. This may be because both Hodgkin lymphoma and its treatments can weaken the immune system.

Children treated for Hodgkin lymphoma also have a higher risk of developing other cancers, such as breast, lung, thyroid and non-melanoma skin cancer. The risks of secondary solid tumours depend on the treatments given, but these tumours are most likely to develop after radiation therapy. The risk may be even greater if both radiation therapy and chemotherapy are given.

The Children’s Oncology Group (COG) follow-up guidelines recommend that children with Hodgkin lymphoma 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 years, whichever is later.

Find out more about second cancers and the Children’s Oncology Group (COG) long-term follow-up guidelines.