Late toxicity

♦ Cataracts occur in <20% of patients, incidence increases at 2-6 years, but then appears to plateau.

♦ Hormonal changes—azoospermia and amenorrhoea with consequent sterility are the norm; very occasionally fertility has been maintained leading to normal pregnancies with no increased incidence of abnormalities in the offspring

♦ Hypothyroidism may result from damage to the thyroid alone or in combination with pituitary damage.

♦ In children, there may be impaired production of growth hormone which, added to the effect of early epiphyseal fusion from TBI, results in stunting of growth.

♦ Induction of second malignancy—there is a 5-fold increase in the risk of second malignancies. Brain tumours may be attributed to the TBI and oral and rectal carcinomas have been reported.

♦ Malignancy of the lymphoid system may result from the prolonged immune suppression.

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