Long-term follow-up and late effects of childhood cancer: Case

Clinical long case of a twenty-two-year-old woman presenting to the survivorship clinic fifteen years after the treatment of a childhood Hodgkin lymphoma with a cumulative anthracycline dose and chest radiation, covering the treatment-summary-driven and risk-stratified surveillance, the anthracycline cardiomyopathy, the radiation-associated breast cancer surveillance, the endocrine and the fertility late effects, and the structured transition to the adult late-effects service.

paediatric oncology survivorship long case5 min readVerification in progress

Prompt

A twenty-two-year-old woman is reviewed in the survivorship clinic fifteen years after she was treated for a stage two Hodgkin lymphoma at the age of seven with six cycles of chemotherapy including a cumulative doxorubicin-equivalent dose of three hundred milligrams per square metre and involved-field chest radiation of thirty gray. She reports six months of increasing exercise intolerance, with dyspnoea on climbing one flight of stairs and occasional palpitations. She also asks whether she will be able to have children. The examination shows a quiet heart with a third heart sound at the apex, a normal thyroid and no palpable breast mass. The examiner asks how you frame the problem, how you build the surveillance, how you manage the late effects, and how you counsel and transition her.

Framing the case

This twenty-two-year-old woman is a childhood cancer survivor at the age of fifteen years post-treatment, and her presentation brings together the three highest-yield late effects of the childhood cancer therapy. The cumulative anthracycline dose of three hundred milligrams per square metre places her in the high-risk group for the cardiomyopathy, because it exceeds the two hundred and fifty milligrams per square metre threshold, and her exercise intolerance with the third heart sound is the clinical declaration of the cardiac late effect. The chest radiation of thirty gray places her in the high-risk group for the breast cancer, because it exceeds the twenty gray threshold. The treatment exposures and the symptoms together frame the case as the risk-stratified survivorship assessment, and the first priority is the urgent cardiac assessment. ^[1]^[5]

The immediate assessment and the cardiac investigation

The assessment begins with the treatment summary, which documents the diagnosis, the cumulative anthracycline dose, the chest radiation dose and the other exposures. The summary is mapped onto the Children's Oncology Group guidelines to generate the surveillance plan. The urgent echocardiogram is the key test, because the exercise intolerance with the third heart sound in a survivor with the high anthracycline dose is the anthracycline cardiomyopathy until proven otherwise. The echocardiogram measures the left ventricular ejection fraction and the shortening fraction, and the electrocardiogram looks for the arrhythmia. The troponin and the natriuretic peptide are the adjuncts, and the cardiac magnetic resonance imaging is considered if the echocardiogram is discordant. The cardio-oncology team is involved early. ^[5]

References6Show

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[2]DeVine A, Landier W, Hudson MM The Children's Oncology Group Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers: A Review JAMA Oncol, 2025.PMID 39976936
[5]Leerink JM, de Baat EC, Feijen EAM Cardiac Disease in Childhood Cancer Survivors: Risk Prediction, Prevention, and Surveillance: JACC CardioOncology State-of-the-Art Review JACC CardioOncol, 2020.PMID 34396245
[3]Chemaitilly W, Cohen LE, Mostoufi-Moab S Endocrine Late Effects in Childhood Cancer Survivors J Clin Oncol, 2018.PMID 29874130
[9]Armstrong GT, Liu W, Leisenring W Occurrence of multiple subsequent neoplasms in long-term survivors of childhood cancer: a report from the childhood cancer survivor study J Clin Oncol, 2011.PMID 21709189
[11]Fardell JE, Wakefield CE, Signorelli C Transition of childhood cancer survivors to adult care: The survivor perspective Pediatr Blood Cancer, 2017.PMID 28436208