Long-Term Follow-Up Guidelines
for Survivors of Childhood, Adolescent,and Young Adult Cancers
Version 3.0 – October 2008

Appendix I
Materials forClinical Applicationof LTFU Guidelines

Copyright 2008 © Children’s Oncology GroupAll rights reserved worldwide

Children’s Oncology Group
Long-Term Follow-Up Guidelines for Survivors of Childhood,
Adolescent, and Young Adult Cancers
Version 3.0 – October 2008

Materials for Clinical Applicationof the COG LTFU Guidelines
Appendix 1 Content
Reference Materials- Abbreviations- Chemotherapy Agents
Summary of Cancer Treatment- Instructions- Summary Form Template - Abbreviated- Summary Form Template - Comprehensive- Summary Form Key
Patient-Specific Guideline Identification Tool
- Instructions- Patient-Specific Guideline Identification Tool
Radiation Reference Guide- Instructions- Dose Calculation Examples- Radiation Fields Defined- Radiation Diagrams By Anatomic Location
 By Guideline Section Number- Relevant Guideline Sections by Radiation Exposure
Health Link Index by Section Number

Appendix 1
Content

Long-Term Follow-Up Guidelines
for Survivors of Childhood, Adolescent,and Young Adult Cancers
Version 3.0 – October 2008

Reference Materials

Copyright 2008 © Children’s Oncology GroupAll rights reserved worldwideAbbreviations
Abbreviation
AAP-CIDP
ABR
AFP
ACS
AHA
ALT
AST
ATM
AVN
BAER
BCNU
BMD
BMI
BRCA1
BRCA2
BUN
Ca
CBC
CCG
CCNU
CD-4
CDC
cGVHD
Cl
CNS
CO2
COG
CSF
CT
CXR
DES
DEXA
DLCO
DOE
EBMT
ECHO
EKG
EIA
FAP
FNA
FSH
GH
GVHD
Gy
HBcAb
HBsAg
HCT
HCV
HDL
HIB
HIV

Definition
American Academy of Pediatrics Committee on Infectious Disease Prevention
Brainstem auditory evoked responses
Alpha fetoprotein
American Cancer Society
American Heart Association
Alanine aminotransferase
Aspartate aminotransferase
Ataxia telangiectasia cancer susceptibility gene located on chromosome 11
Avascular necrosis
Brainstem auditory evoked responses
Carmustine
Bone mineral density
Body mass index
Breast cancer, early onset gene (cancer susceptibility gene located on chromosome 17)
Breast cancer 2, early onset gene (cancer susceptibility gene located on chromosome 13)
Blood urea nitrogen
Calcium
Complete blood countChildren’s Cancer Group
Lomustine
Cluster of differentiation antigen associated with helper T lymphocyte
Centers for Disease Control
Chronic graft versus host disease
Chloride
Central nervous system
Carbon dioxide
Children’s Oncology Group
Cerebral spinal fluid
Computed tomography
Chest radiograph
Diethylstilbestrol
Dual energy x-ray absorptiometry
Diffusion capacity of carbon monoxide
Dyspnea on exertion
European Group for Blood and Marrow Transplant
Echocardiogram
Electrocardiogram
Enzyme immunoassay
Familial adenomatous polyposis
Fine needle aspirate
Follicle stimulating hormone
Growth hormone
Graft versus host disease
Gray
Hepatitis B core antibody
Hepatitis B surface antigen
Hematopoietic cell transplant
Hepatitis C virus
High-density lipoproteins
Haemophilus influenza B
Human immunodeficiency virus

Abbreviations
Page 1

Abbreviations (cont)Abbreviation
HNPCC
HPF
HPV
HRT
Hz
IBD
K
I-131
IQ
IT
IV
IVIG
KUB
LH
MIBG
Mg
MOPP
MRI
MUGA
Na
NCEP
NCHS
NF1
NSAIDs
OAE
OCP
PAP
PCR
PFTs
p53
PO
PO4
PRN
PSA
QCT
QTc
RB1
RBC
RDA
RUQ
SCUBA
SD
SOB
T4
TBI
TPN
TSH
U/A
USPSTF
VOD
VZIGDefinition
Hereditary nonpolyposis colorectal cancer
High power field
Human papilloma virus
Hormonal replacement therapy
Hertz
Inflammatory bowel disease
Potassium
Iodine 131 radioisotope
Intelligence quotient
Intrathecal
Intravenous
Intravenous immunoglobulin
Kidneys, ureters, bladder radiograph
Luteinizing hormone
Iodine-131-meta-iodobenzylguanidine
Magnesium
Mechlorethamine, Oncovin, Procarbazine, Prednisone
Magnetic resonance imaging
Multiple Gated Acquisition scan
SodiumNational Cholesterol Education Program
National Center for Health Statistics
Neurofibromin 1 (neurofibromatosis) cancer susceptibility gene located on chromosome 17
Non-steroidal anti-inflammatory drugs
Otoacustic emissions
Oral contraceptive pills
Papanicoulau
Polymerase chain reaction
Pulmonary function tests
Cancer susceptibility gene located on chromosome 17 associated with familial cancers
By mouth
Phosphate
As needed
Prostate specific antigen
Quantitative computed tomography
Corrected QT interval
Retinoblastoma gene – cancer susceptibility gene located on chromosome 13
Red blood cell
Recommended daily allowance
Right upper quadrant
Self-contained underwater breathing apparatus
Standard deviation
Shortness of breath
Thyroxine
Total body irradiation
Total parenteral nutrition
Thyroid stimulating hormone
Urinalysis
United States Preventive Services Task Force
Veno-occlusive disease
Varicella zoster immunoglobulin

Abbreviations
Page 2

Chemotherapy Agents
Generic Name
Asparaginase

Additional Name(s)Elspar®

Classification
EnzymeErwinia asparaginase
Kidrolase®
L-asparaginase
Oncaspar®
PEG-asparaginase
Bleomycin

Blenoxane®

Anti-tumor antibiotic

BusulfanBusulfex®

Alkylating agent

Busulphan
Myleran®
Carboplatin

CBDCA

Heavy metal

Paraplatin®
Carmustine

BCNU

Alkylating agent

BiCNU®
Chlorambucil

Leukeran®

Alkylating agent

Cisplatin

CDDP

Heavy metal

Cisplatinum
Platinol®
Cyclophosphamide

CPM

Alkylating agent

Cytoxan®
Neosar®
Procytox®
Cytarabine

Ara-C

Antimetabolite

Cytosar®
Cytosar-U®
Cytosine arabinoside
Dacarbazine

DTIC

Non-classical alkylator

DTIC-Dome®
Dactinomycin

Actinomycin-D

Anti-tumor antibiotic

Cosmegen®
Daunorubicin

Cerubidine®

Anthracycline antibiotic

Daunomycin
DaunoXome®
Dexamethasone

Decadron®

Corticosteroid

Doxorubicin

Adriamycin®

Anthracycline antibiotic

Doxil®
Rubex®
Epirubicin

Ellence®

Anthracycline antibiotic

Pharmorubicin PFS®

Chemotherapy Agents
Page 1

Chemotherapy Agents (cont)
Generic Name
Etoposide

Additional Name(s)VePesid®

Classification
Epipodophyllotoxin

VP-16
Idarubicin

Idamycin®

Anthracycline antibiotic

Ifosfamide

Ifex®

Alkylating agent

Lomustine

CeeNU®

Alkylating agent

CCNU
Mechlorethamine

Mustargen®

Alkylating agent

Nitrogen Mustard
Melphalan

Alkeran®

Alkylating agent

Mercaptopurine

6-Mercaptopurine

Antimetabolite

6-MP
Purinethol®
Methotextrate

Amethopterin

Antimetabolite

Folex®
Mexate®
Trexall®
Mitoxantrone

Novantrone®

Anthracycline antibiotic

Prednisone

Deltasone®

Corticosteroid

Methylprednisolone
Prednisolone
Procarbazine

Matulane®

Alkylating agent

Natulan®
Temozolomide

Temodal®

Non-classical alkylator

Temodar®
Teniposide

VM-26

Epipodophyllotoxin

Vumon®
Thioguanine

Lanvis®

Antimetabolite

Tabloid®
6-Thioguanine
6-TG
Thiotepa

Thioplex®

Alkylating agent

Vinblastine

VBL

Plant alkaloid

Velban®
Velbe®
Vincristine

Oncovin®

Plant alkaloid

VCR
Vincasar®
Vincrex®

Chemotherapy Agents
Page 2

Long-Term Follow-Up Guidelines
for Survivors of Childhood, Adolescent,and Young Adult Cancers
Version 3.0 – October 2008

Summary ofCancer Treatment

Copyright 2008 © Children’s Oncology GroupAll rights reserved worldwide

Summary of Cancer Treatment - Instructions
Importance of a Comprehensive Cancer Treatment Summary
The Children’s Oncology Group Long-Term Follow-Up Guidelines for Survivors ofChildhood, Adolescent, and Young Adult Cancers are based on therapeutic exposures
received during cancer treatment. Availability of a comprehensive treatment summary,
including all therapeutic agents received by the survivor, is presumed. Patients who do
not have a comprehensive treatment summary should be instructed to obtain one fromthe institution(s) where they received their treatment. Ideally, the comprehensive
treatment summary should include the following information:
 Demographics (name, sex, date of birth, contact information)
 Diagnosis, including site/stage, date, and relapse(s) if any
 Pertinent secondary diagnoses (e.g., second malignancy, Down syndrome) Treatment protocol information, if applicable All chemotherapy agents received during treatment (including route ofadministration for all agents, cumulative doses for alkylators, bleomycin, andanthracyclines, and designation of “high dose” versus “standard dose” formethotrexate and cytarabine). Cumulative doses for all other agents should be
provided if available. Note: “High dose” methotrexate/cytarabine is defined as
any single dose >1000 mg/m2. “Standard dose” methotrexate/cytarabine isdefined as all single doses <1000 mg/m2. See section 28 of Guidelines foranthracycline isotoxic dose-equivalent conversion. For doses in mg/kg, multiply
by 30 to obtain equivalent dosing in mg/m2 (example: 2 mg/kg = 60 mg/m2).
 Radiation therapy summary, including field(s), laterality (if applicable), start/stop
dates, number of fractions, dose per fraction, boost dose/location (if applicable),
total dose (in Gy), and radiation type. Note: To convert cGy or rads to Gy, divide
dose by 100 (example: 2400 cGy = 2400 rads = 24 Gy); for definition of radiation
fields, see page 6 of the Radiation Reference Guide (Appendix 1)
 Hematopoietic cell transplant(s), including type(s), date(s), conditioning
regimen(s), and GVHD prophylaxis and/or treatment
 Surgical procedures, including date, site, and laterality if applicable Other therapeutic modalities (e.g., biologicals, systemic radiation)
 Significant complications/late effects with dates of onset/resolution
 Adverse drug reactions/allergies
Minimum Information Necessary to Generate Patient-Specific Guidelines:
In order to generate accurate exposure-based follow-up recommendations from theseguidelines, the following information regarding the survivor’s diagnosis and treatment isrequired, at minimum:Survivor’s sex

Survivor’s date of birthDate of cancer diagnosisDate cancer therapy was completed
Summary Form Instructions
Page 1Names of all chemotherapy agents received. Note: For a list of chemotherapy
agents addressed by these guidelines (sections 6-37), see the “Chemotherapy”
portion of the Patient-Specific Guideline Identification Tool in Appendix 1. For
generic and brand names of chemotherapy agents, see Chemotherapy Agents inAppendix I.
Cumulative dose of all anthracycline chemotherapy received (i.e., doxorubicin,
daunorubicin, idarubicin, mitoxantrone and epirubicin), and age at firstanthracycline dose (if unknown, age at first anthracycline dose is presumed to be
age at diagnosis). Note: For anthracycline isotoxic dose-equivalent conversion,see Section 28 of Guidelines. For doses in mg/kg, multiply by 30 to obtainequivalent dosing in mg/m2 (example: 2 mg/kg = 60 mg/m2).



For carboplatin: Whether any dose was myeloablative (i.e., given as conditioningfor HCT).



For cytarabine and methotrexate:Route of administration (i.e., IV, IM, SQ, PO, IT, IO)

If IV: Designation of “high dose” (any single dose >1000 mg/m2) versus“standard dose” (all single doses <1000 mg/m2)
All radiation field(s) and total radiation dose (in Gy) to each field. For chest,
thoracic spine, and abdominal radiation, include age at first dose; if unknown,
age at first dose is presumed to be age at diagnosis. Note: Total radiation doseto each field should include boost dose, if given. To convert cGy or rads to Gy,
divide dose by 100 (example: 2400 cGy = 2400 rads = 24 Gy). For list ofradiation fields addressed by these guidelines (Sections 38-91), see “Radiation”
portion of the Patient-Specific Guideline Identification Tool in Appendix 1; fordefinition of radiation fields, see page 6 of the Radiation Reference Guide(Appendix 1)
Whether or not the survivor underwent a hematopoietic cell transplant (HCT),
and if so, whether or not the survivor developed chronic graft-versus-hostdisease (cGVHD).








Names of all relevant surgical procedures. Note: For list of surgical procedures
addressed by these guidelines (Sections 107-132), see “Surgery” portion of thePatient-Specific Guideline Identification Tool in Appendix 1.

Names of all other therapeutic modalities. Note: For list of other therapeuticmodalities addressed by these guidelines (Sections 133-36), see “Other
Therapeutic Modality” portion of the Patient-Specific Guideline Identification Tool
in Appendix 1.

Templates for Summary of Cancer Treatment
Two templates for summarizing cancer treatment are included in Appendix I (and alsoavailable in electronic format at www.survivorshipguidelines.org). These templates wereoriginally developed by the COG Nursing Clinical Practice Subcommittee under theleadership of Lisa Bashore, MS, RN, CPNP, CPON® and Lori Boucher, RN, CRA. The
templates were subsequently pilot tested and revised, then further refined based on
feedback from the Late Effects Committee and a working group from the National
Cancer Institute. The abbreviated form contains all data elements currently necessary
Summary Form Instructions
Page 2

for generation of patient-specific recommendations from the COG LTFU Guidelines, andmeets the minimum data requirements for initial use of the “Passport for Care” webbased guideline interface. However, the COG Long-Term Follow-Up Guidelines Core
Committee recognizes that as new evidence becomes available and these guidelines
are updated, additional details regarding the childhood cancer survivor’s therapeutic
exposures may be required in order to generate comprehensive recommendations.
Therefore, we strongly advise that a comprehensive treatment summary be prepared foreach childhood cancer survivor when feasible, including a record of all therapeutic
exposures with applicable dates, details of administration, and cumulative doses of allagents, including those not currently addressed by these guidelines.
In addition to the treatment summary templates, a “key” for completing thecomprehensive version of the treatment summary is also included in Appendix I. This“key” correlates to the drop-down menus that will be available in the web-based“Passport for Care” guideline interface.

Summary Form Instructions
Page 3

SUMMARY OF CANCER TREATMENT(Abbreviated)
DEMOGRAPHICS
Name:

Sex:

Date of Birth:

CANCER DIAGNOSIS
Diagnosis:

Date of Diagnosis:

CHEMOTHERAPY:

Yes

No

Drug Name†

Date Therapy Completed:

If yes, complete chart below
Additional Information†

2

Anthracyclines: Include cumulative dose in mg/m and age at first dose (see section 28 of Guidelines for isotoxic dose conversion);
Carboplatin: Indicate if dose was myeloablative; Methotrexate and Cytarabine: Indicate route of administration (i.e., IV, IM, SQ, PO, IT, IO);
2
2
IV Methotrexate and Cytarabine: Indicate if “high dose” (any single dose >1000 mg/m ) or “standard dose” (all single doses <1000 mg/m )Note: Cumulative doses, if known, should be recorded for all agents, particularly for alkylators and bleomycin.

RADIATION

YesNo

If yes, complete chart below

Site/Field*

Total Dose** (Gy)**** For chest, thoracic spine, and upper abdominal radiation, include age at first dose ** Total dose to each field should include boost dose, if given*** Note: To convert cGy or rads to Gy, divide dose by 100 (example: 2400 cGy = 2400 rads = 24 Gy)

HEMATOPOIETIC CELL TRANSPLANT

Yes

No

If yes, answer question below

Yes

Was this patient ever diagnosed with chronic graft-versus-host disease (cGVHD)?

SURGERY

Yes

No

Procedure

If yes, complete chart below
Site (if applicable)

OTHER THERAPEUTIC MODALITIES

Yes

No

Laterality (if applicable)

If yes, answer questions below

Did this patient receive radioiodine therapy (I-131 thyroid ablation)?

Yes

No

Did this patient receive systemic MIBG (in therapeutic doses)?

Yes

No

Did this patient receive bioimmunotherapy?

Yes

No

Summary prepared by:No

Date prepared:

Summary Form - AbbreviatedSUMMARY OF CANCER TREATMENT(Comprehensive)
DEMOGRAPHICS
Name: (last, first, middle)

Sex: (M/F)

Date of Birth:

COG Reg #:Address: (number, street, city, state/province, postal code, country)
Phone:

SS#

Race/Ethnicity: (see list #1)

Alternate contact:

Relationship:

Phone:CANCER DIAGNOSIS
Diagnosis: (see list #2)
Date of Diagnosis:

Age at Diagnosis:

Date Therapy Completed:

Sites involved/stage/diagnostic details:

Laterality: (Right/Left/NA)

Hereditary/congenital history: (see list #3)
Pertinent past medical history:
Treatment Center:

Medical Record #:MD/APN Contact Information:

RELAPSE(S)
Date:

Yes

Site(s):No If yes, provide information below
Laterality: (Right/Left/NA)
Date Therapy Completed:

SUBSEQUENT MALIGNANT NEOPLASM(S)
Date:Stage/Site(s):No

If yes, provide information below

Date Therapy Completed:

CANCER TREATMENT SUMMARYPROTOCOL(S)
Yes
No
Acronym/Number

Title/Description

CHEMOTHERAPY

Yes

No

Drug Name(see list # 5)†

Yes

Type: (see list #4)

If yes, provide information below
Initiated

If yes, complete chart below
Route(see list #6)

Completed

On-Study

Additional Information†(see list #7)

2

Anthracyclines: Include cumulative dose in mg/m and age at first dose (see section 28 of Guidelines for isotoxic dose conversion);
2
Carboplatin: Indicate if dose was myeloablative; IV Methotrexate and Cytarabine: Indicate if “high dose” (any single dose >1000 mg/m )2
or “standard dose” (all single doses <1000 mg/m );Note: Cumulative doses, if known, should be recorded for all agents, particularly for alkylators and bleomycin.

Summary Form - Comprehensive
Page 1(
RADIATION
Site/Field

Yes
Laterality

No
Start
Date

)

If yes, complete chart below

Stop
Date

Fractions

Dose perFraction(Gy)*

InitialDose(Gy)*

Boost Site(see list #8)

Boost
Dose
(Gy)*

Total Dose(including
boost)(Gy)*(see list #9)

Radiation oncologist:Type(see list #10)

Institution:*Note: To convert cGy or rads to Gy, divide dose by 100 (example: 2400 cGy = 2400 rads = 24 Gy)

HEMATOPOIETIC CELL TRANSPLANT
Type(see list #11)

Yes

Tandem?

Yes

SourceNo

No If yes, complete chart below
Conditioning Regimen
Institution/Treating MD

Date of
Infusion(see list #12)(see list #13)

GVHD prophylaxis/treatment (For transplant patients only)

Yes

Type

No

First DoseIf yes, complete chart below
Last Dose(see list #14)

Was this patient ever diagnosed with chronic graft-versus-host disease (cGVHD)?

SURGERY

Yes

Date

No
ProcedureYesNo

If yes, complete chart below
Site (if applicable)
Laterality (if applicable)

Surgeon/Institution(see list #15)

OTHER THERAPEUTIC MODALITIES

Yes

No

TherapyRoute(see list # 16)(see list #6)

COMPLICATIONS/LATE EFFECTS
Problem

Yes

No

Date onset(see list #17)

Adverse Drug Reactions/Allergies
Drug

Yes

Additional Information/Comments

Yes

Summary prepared by: (name/title/institution)
Summary updated by: (name/title/institution)(see list #7)

If yes, complete chart below
Date resolved
Status(Active/Resolved)(Active/Resolved)(Active/Resolved)(Active/Resolved)(Active/Resolved)

No

ReactionNo

If yes, complete chart below
Cumulative Dose (if known)

If yes, complete chart below
Date
Status(Active/Resolved)(Active/Resolved)
If yes, provide information below

Date prepared:
Date updated:

Summary Form - Comprehensive
Page 2

Key for Completing
Summary of Cancer Treatment(Comprehensive Version)#1: Race/Ethnicity
AsianBlack/African American
Caucasian (non-Hispanic/non-Latino)
Hispanic or Latino
Native American/Alaskan Native
Native Hawaiian/Pacific IslanderMulti-racial/multi-ethnic
Other (specify):#2: Cancer Diagnosis
Central Nervous System Tumor
Astrocytoma
Cerebellar astrocytoma
Supratentorial astrocytoma
Brainstem glioma
Choroid plexus neoplasm
Craniopharyngioma
Ependymoma
Germ cell tumor, intracranial
Optic glioma
Pineal tumor
PNET
Cerebellar (medulloblastoma)
Supratentorial PNET
Spinal cord tumor, intramedullary
CNS tumor, other, specify:___________________
Endocrine tumor
Adrenal tumor (non-neuroblastoma)
Thyroid tumor
Parathyroid tumor
Gastroenteropancreatic tumor
Multiple endocrine neoplasia syndrome
Endocrine tumor, other, specify:___________________
Germ cell tumor (extracranial)
Seminoma
Germinoma
Dysgerminoma
Non-seminomas
Yolk sac tumor
Embryonal carcinoma
Choriocarcinoma
Teratoma
MatureImmatureWith malignant transformation
Germ cell tumor, other, specify:_____________

Key – Summary Form
Page 1#2: Cancer Diagnosis (continued)
Langerhans cell histiocytosis
Leukemia
Acute lymphoblastic leukemia
Acute myeloid leukemia
Chronic myeloid leukemia
Myelodysplastic syndrome
Myeloproliferative disorder
Leukemia, other, specify:_________
Liver tumor
Hepatoblastoma
Hepatocellular carcinoma
Liver tumor, other, specify: _________
Lymphoma
Hodgkin lymphoma
Non-Hodgkin lymphoma
Lymphoblastic lymphoma
Burkitt’s lymphoma
Large cell lymphoma
Anaplastic large cell lymphoma
Diffuse large B-cell lymphoma
Lymphoma, other, specify:________
Nasopharyngeal carcinoma
Neuroblastoma
Ganglioneuroblastoma
Renal tumor
Wilms tumor
Clear cell sarcoma
Renal cell carcinoma
Renal tumor, other:Retinoblastoma
SarcomaEwing’s sarcoma/peripheral PNET
Osteogenic sarcoma
Rhabdomyosarcoma
Soft tissue sarcoma (nonrhabdomyosarcomatous)
Alveolar soft part sarcoma
Fibrosarcoma
Leiomyosarcoma
Liposarcoma
Malignant fibrous histiocytoma
Malignant peripheral nerve sheath tumor
Neurofibrosarcoma
Synovial sarcoma
Undifferentiated sarcoma
Sarcoma, other, specify: ____________
Skin cancer
Basal cell carcinoma
Malignant melanoma
Squamous cell carcinoma
Skin cancer, other, specify:____________
Malignancy, other, specify:
Diagnosis, other, specify:
Key – Summary Form
Page 2

#3: Hereditary/Congenital History
Congenital heart disease
Congenital disease, other, specify:
Hemihypertrophy
Neurofibromatosis, specify: Type I, Type II
Down syndrome
Syndrome, other, specify:
Hereditary condition, other, specify:
None
Unknown#4: Subsequent Malignancy Diagnosis
Bladder cancer
Breast cancer
Central nervous system tumor
Malignant, specify type and location:
Meningioma, specify location:
Other CNS tumor, specify type:
Cervical cancer
Gastrointestinal cancer
Esophageal cancer
Stomach cancer
Colorectal cancer
Hepatocellular carcinoma
Pancreatic cancer
Other GI cancer, specify:
Leukemia
Acute lymphoblastic leukemia
Acute myeloid leukemia
Chronic myeloid leukemia
Myelodysplastic syndrome
Myeloproliferative disorder
Leukemia, other, specify:
Lung cancer
Lymphoma
Hodgkin lymphoma
Non-Hodgkin lymphoma
Lymphoblastic lymphoma
Burkitt’s lymphoma
Large cell lymphoma
Post-transplant lymphoproliferative disorder (PTLD)
Lymphoma, other, specify:
Peripheral nerve sheath tumor/Schwannoma/Acoustic neuroma
Renal cancer
Renal cell carcinoma
Clear cell sarcoma
Other renal cancer, specify:_________
SarcomaEwing’s sarcoma/peripheral PNET
Osteogenic sarcoma
Rhabdomyosarcoma
Soft tissue sarcoma (nonrhabdomyosarcomatous)
Undifferentiated sarcoma
Other sarcoma, specify:
Key – Summary Form
Page 3#4: Subsequent Malignancy Diagnosis (continued)
Skin cancer
Basal cell carcinoma
Malignant melanoma
Squamous cell carcinoma
Thyroid cancer
Other malignancy, specify:
None
Unknown#5: Chemotherapy
Asparaginase
Bleomycin
Busulfan
Carboplatin
Myeloablative dose?
Yes
No
Carmustine (BCNU)
Chlorambucil
Cisplatin
Cladribine
Clofarabine
Cyclophosphamide
Cytarabine
If IV: Any single dose >1000 mg/m2?
Dacarbazine (DTIC)
Dactinomycin
Daunorubicin
Dexamethasone
Docetaxel
Doxorubicin
Epirubicin
Etoposide (VP-16)
Fludarabine
Fluorouracil
Gemcitabine
Hydrocortisone
Hydroxyurea
Idarubicin
Ifosfamide
Imatinib Mesylate
Irinotecan
Lomustine (CCNU)
Mechlorethamine
Melphalan
Mercaptopurine
Methotrexate
If IV: Any single dose >1000 mg/m2?
Mitoxantrone
Oxaliplatin
Paclitaxel
Prednisone

Yes

No

Yes

No

Key – Summary Form
Page 4#5: Chemotherapy (continued)
Procarbazine
Temozolomide
Teniposide (VM-26)
Thioguanine (6-TG)
Thiotepa
Topotecan
Trimetrexate
Vinorelbine
Vinblastine
Vincristine
Other, specify:
None
Unknown#6: Route
PO
IM
IV
SQ
IT
IO
Other, specify:
Unknown#7: Cumulative Dose (Note: this is a required field for anthracyclines and optional but suggested for all others)
mg/m2
units/m2
mg/kg (Note: computer will multiply mg by 30 and display as mg/m2)
Not available
Not applicable
Other, specify:
Unknown#8: Radiation Site/Field
Head/brain
CranialOrbital/eye, specify: Right, left, bilateral
Ear/infratemporal, specify: Right, left, bilateral
Nasopharyngeal
Oropharyngeal
Waldeyer’s Ring
Other head/brain radiation, specify:________
Neck
Cervical (neck), specify: Right, left, bilateral
Supraclavicular, specify: Right, left, bilateral
Spine
Spine - cervical
Spine - thoracic
Spine - lumbar
Spine - sacral
Spine - whole
Key – Summary Form
Page 5

#8: Radiation Site/Field (continued)
Axilla, specify: Right, left, bilateralThoraxChest (thorax)
Whole lung, specify: Right, left, bilateralMediastinal
Chest, other, specify:_________
Abdomen
Hepatic
Renal, specify: Right, left, bilateral
Upper quadrant, specify: Right, left, bilateral
Spleen, specify: partial, entire
Paraaortic
Flank/hemiabdomen, specify: Right, left; specify: Extended below iliac crest: Yes/No
PelvisPelvicVaginalProstate
Bladder
Iliac
Inguinal
FemoralTesticular, specify: Right, left, bilateral
Extremity
Upper, specify: Right, left, bilateral; specify: proximal, distal, entire
Lower, specify: Right, left, bilateral; specify: proximal, distal, entire
Total Body Irradiation (TBI)
Combination Fields:
MantleMini-Mantle
Extended Mantle
Inverted Y
Whole abdomen
Total lymphoid irradiation (TLI)
Subtotal lymphoid irradiation (STLI)Other, specify:
None
Unknown
Add comment:#9: Radiation Boost
Tumor bed, specify location:
Other location, specify:
None
Unknown
Add comment:

Key – Summary Form
Page 6

#10: Radiation Type
Brachytherapy
Conformal
External beam (conventional)
IMRT
Stereotactic
Other, specify:
None
Unknown#11: Hematopoietic Cell Transplant - Type
Autologous
Matched related
Mismatched related
Haploidentical related
Syngeneic
Matched unrelated
Other, specify:
Unknown#12: Hematopoietic Cell Transplant - Source
Bone marrow
Peripheral blood stem cells
Cord blood
Other, specify:
Unknown#13: Hematopoietic Cell Transplant - Conditioning Regimen
ATG
Busulfan
Carmustine (BCNU)
Cyclophosphamide
Etoposide
Fludarabine
MelphalanThiotepa
TBI
Other, specify:
Unknown#14: GVHD Prophylaxis/Treatment
ATG
Cyclosporine
Methotrexate
MMF (mycophenolate mofetil)
Prednisone
PUVA
Sirolimus
Tacrolimus
Other, specify:
None
Unknown

Key – Summary Form
Page 7

#15: Surgery
Amputation, specify: Right, left, bilateral; specify site:
Central venous catheter
Cystectomy
Enucleation specify: Right, left, bilateral
Hysterectomy
Laparotomy
Limb sparing procedure, specify: Right, left, bilateral; specify site:
Nephrectomy, specify: Right, left, bilateral
Neurosurgery - brain
Neurosurgery – spinal cord
Oophoropexy
Oophorectomy, specify: Right, left, bilateral
Orchiectomy, specify: Right, left, bilateral
Pelvic surgery
Pulmonary lobectomy, specify site:
Pulmonary wedge resection, specify site:
Pulmonary metastasectomy, specify site:
Splenectomy
Thyroidectomy
Other, specify:
None
Unknown
Add comment:#16: Other Therapeutic Modalities
Systemic Radiation
Radioiodine therapy (I-131 thyroid ablation)
Systemic MIBG (in therapeutic doses)
Other, specify:
Bioimmunotherapy
Hematopoietic growth factors:
G-CSF
Erythropoietin
Thrombopoietin
Interferon:
Alpha interferon
Gamma interferon
Interleukin:
IL-2
IL-11
Other, specify:
Monoclonal antibody, specify type:
Retinoic acid, specify type:
Other, specify:
Other therapeutic modality, specify:
None
Unknown

Key – Summary Form
Page 8

#17: Complications/Late Effects (by system)
Psychosocial
Behavioral problems/behavioral change
Educational problems
Fatigue
Limitations in healthcare access and/or insurance
Psychosocial disability due to pain
Anxiety
Depression
Post-traumatic stress
Psychosocial disability due to pain
Social withdrawal
Risky behaviors
Tobacco use
Alcohol abuse
Substance abuse
Other, specify:
Psychosocial maladjustment
Impaired quality of life
Psychosocial complication, other, specify:
OcularCataract
Enophthalmos
Orbital hypoplasia
Glaucoma
Keratitis
Xerophthalmia (keratoconjunctivitis sicca)
Lacrimal duct atrophy
Optic chiasm neuropathy
Retinopathy
Telangiectasia
Maculopathy
Papillopathy
Chronic painful eye
Visual impairment (uncorrectable)
Ocular nerve palsy
Gaze paresis
Nystagmus
Papilledema
Optic atrophy
Ocular complication, other, specify:
Auditory
Eustachian tube dysfunction
Hearing loss (requires hearing aids?
Yes
No)
Specify type: Sensorineural hearing loss; Conductive hearing loss
Otosclerosis
Tinnitus
Tympanosclerosis
VertigoAuditory complication, other, specify:
DentalDental abnormalities
Enamel dysplasia
Root thinning/shortening
Tooth/root agenesis
Key – Summary Form
Page 9#17: Complications/Late Effects (by system, continued)
Microdontia
Periodontal disease
Tooth decay
Malocclusion
Xerostomia (salivary gland dysfunction)
Osteoradionecrosis
Temporomandibular joint dysfunction
Dental complication, other, specify:
Cardiovascular
Arrhythmia
Atherosclerotic heart disease
Cardiomyopathy
Congestive heart failure
Myocardial infarction
Pericardial fibrosis
Pericarditis
Subclinical left ventricular dysfunction
Valvular disease
Carotid artery disease
Subclavian artery disease
Thrombosis/vascular insufficiency (related to central line)
Vasospastic attacks (Raynaud’s phenomenon)
Cardiovascular complication, other, specify:
PulmonaryBronchiolitis obliteransInterstitial pneumonitis
Pulmonary fibrosis
Pulmonary dysfunction
Acute respiratory distress syndrome (ARDS)
Obstructive lung disease
Restrictive lung disease
Chronic bronchitis
Bronchiectasis
Pulmonary complication, other, specify:
Gastrointestinal/Hepatic
Abdominal adhesions
Bowel obstruction
Bowel strictures
Fecal incontinence
Cholelithiasis
Cholecystitis
Chronic enterocolitis
Esophageal stricture
FistulaMalabsorption
Nutritional deficiency
Vitamin B12, folate or carotene deficiency
Cirrhosis
Hepatic fibrosis
Hepatic dysfunction
Chronic hepatitis (non-infectious)
Iron overload
Venocclusive disease (VOD) of the liver
Gastrointestinal/hepatic complication, other, specify:
Key – Summary Form
Page 10

#17: Complications/Late Effects (by system, continued)
Endocrine/Metabolic
Hypothyroidism
Primary hypothyroidism (thyroid gland failure)
Secondary (central) hypothyroidism (TR/TSH deficiency)
Hyperthyroidism
Thyroid nodule
Precocious puberty
Gonadal dysfunction/failure
Gonadotropin deficiency (LH/FSH deficiency) [central gonadal failure]
Gonadal dysfunction – testicular: See Reproductive (male)
Gonadal dysfunction – ovarian: See Reproductive (female)
Metabolic syndrome
Overweight (Age 2-20 yrs: BMI for age >85 - <95%ile; Age >20 yrs: BMI 25 to 29.9)
Obesity (Age 2-20 yrs: BMI for age >95%ile; Age >20 yrs, BMI >30)
Underweight (FTT)
Insulin resistance
Impaired glucose tolerance
Diabetes mellitus
Type I
Type II
Gestational
Dyslipidemia
Adrenal insufficiency
Primary adrenal insufficiency (adrenal gland failure)
Secondary (central) adrenal insufficiency (ACTH deficiency)
Hyperprolactinemia
Growth deceleration
Growth hormone deficiency
Short stature (<5th percentile)
Endocrine/metabolic complication, other, specify:
Musculoskeletal
Amputation, specify type and site:
Osteonecrosis (avascular necrosis – AVN), specify site:
Craniofacial abnormalities
Impaired cosmesis
Contractures
Functional and activity limitation, specify:
Hypoplasia, specify site:
Kyphosis
Limb length discrepancy
Limb salvage, specify type and site:
Phantom pain
Prosthesis, malfunction (poor fit, loosening, non-union, fracture)
Prosthesis, revision required due to growth
Reduced bone mineral density
Residual limb integrity problems
Fracture (radiation-induced)
Increased energy expenditure (related to amputation/limb salvage)
Fibrosis (musculoskeletal)
Scoliosis
Short stature
Shortened trunk height
Reduced/uneven growth
Musculoskeletal complication, other, specify:
Key – Summary Form
Page 11

#17: Complications/Late Effects (by system, continued)
Central Nervous System (CNS)
Clinical leukoencephalopathy
With imaging abnormalities
Without imaging abnormalities
Learning disorder/disability
MathReading
Other, specify:
Motor deficit
Neurocognitive deficit, specify:
Diminished IQ
Executive function (planning/organization)
Sustained attention
MemoryProcessing speed
Visual-motor integration
MoyamoyaAtaxiaMovement disorder
Neurogenic bladder
Neurogenic bowel
Paralysis
Occlusive cerebral vasculopathy
Seizures
StrokeCNS complication, other, specify:
Peripheral Nervous System (PNS)
Peripheral sensory neuropathy
Peripheral motor neuropathy
PNS complication, other, specify:
Urinary
Hydronephrosis, specify: Right, left, bilateralHypertension
MononephricRenal insufficiency
Renal glomerular disorder
Hyperfiltration
Renal tubular disorder
Hypophosphatemic rickets
Renal Fanconi syndrome
Renal tubular acidosis
Vesicoureteral reflux
Bladder fibrosis
Urinary incontinence
Reservoir calculi
Dysfunctional voiding
Hemorrhagic cystitis
Proteinuria
Chronic UTI
Neobladder perforation
Urinary tract obstruction (due to retroperitoneal fibrosis)
Stricture, urinary tract, specify:
Urinary complication, other, specify:
Key – Summary Form
Page 12

#17: Complications/Late Effects (by system, continued)
Reproductive - Female
Breast tissue hypoplasia
Uterine vascular insufficiency
Adverse pregnancy outcome
Pregnancy complications
Delivery complications
Fetal malposition
Low birthweight infant
Spontaneous abortion
Premature labor
Neonatal death
Gonadal dysfunction - ovarian
Primary ovarian failure
Delayed/arrested pubertyPremature menopause
Infertility
Inability to conceive (despite normal ovarian function)
Dyspareunia
Symptomatic ovarian cysts
Pelvic adhesions
Sexual dysfunction
Vaginal stenosis/fibrosis
Reproductive - Male
Gonadal dysfunction - testicularGerm cell failure
Azoospermia
Oligospermia
Infertility
Leydig cell failure
Hypogonadism (testosterone deficiency)
Delayed/arrested puberty
Sexual dysfunction - male
Erectile dysfunction
Anejaculation
Retrograde ejaculation
Hydrocele
Dermatologic
Alopecia (permanent)
Dysplastic nevi
Altered skin pigmentation
Skin fibrosis
Nail dysplasia
Scleroderma
Telangiectasia
Vitiligo
ImmuneAsplenia
Functional asplenia
Surgical asplenia
History of life-threatening infection related to asplenia
Chronic sinusitis
Chronic graft versus host disease (GVHD)
Chronic Hepatitis B
Chronic Hepatitis C
Key – Summary Form
Page 13

#17: Complications/Late Effects (by system, continued)
Chronic infection, specify:
Human immunodeficiency virus (HIV) infection
Hypogammaglobulinemia
Secretory IgA deficiency
Pain, chronic
Musculoskeletal
Neuropathic
Other, specify:
Other, specify
No late effects identified
Unknown

Key – Summary Form
Page 14

Long-Term Follow-Up Guidelines
for Survivors of Childhood, Adolescent,and Young Adult Cancers
Version 3.0 – October 2008

Patient-Specific
Guideline
Identification Tool

Copyright 2008 © Children’s Oncology GroupAll rights reserved worldwide

Instructions for Using thePatient-Specific Guideline Identification Tool
To determine Long-Term Follow-Up Guideline sections relevant to an individual patient:
1. Place a checkmark in the “Mark if Patient Received” or “Mark All that Apply” column
for each chemotherapy agent, radiation field, surgery, or other therapeutic modalitythat the patient received.
2. Place a checkmark in the “Mark as Indicated” column for all cancer screening
guidelines that are applicable to this patient based on age, gender, and indicatedconditions.
3. Compile a list of all section numbers generated during steps 1 and 2. Include thefollowing sections as applicable:- Sections 1-2
Applicable to all patients- Section 3
Patients diagnosed before 1972
- Section 4
Patients diagnosed before 1993
- Section 5
Patients diagnosed between 1977 and 1985
- Section 6
All patients who received chemotherapy- Sections 92-97
All patients who underwent hematopoietic cell transplant- Sections 98-106
Patients with history of chronic graft-vs-host (cGVHD) disease**Section 103 is for patients with active cGVHD only
*Section 105 is for females only
- Section 146
Applicable to all patients
You now have a list of all guideline sections potentially applicable to this patient.
4. For patients who received radiation for which a minimum dose specification isindicated, follow the instructions for “Determining Applicability of Radiation Sectionsfor Specific Patients Based on Exposure” (see page 47 of Guidelines or page 2 ofRadiation Reference Guide). Delete from your list those radiation section(s) for
which this patient did not receive the minimum radiation exposure at which thesection(s) become applicable.
5. You now have a finalized list of all guideline sections applicable to this patient.

Patient Specific Tool
Instructions

Patient-Specific Guideline Identification Tool
(Applicable Guideline Sections indicated in Bold/Red; M=Male; F=Female)
Name:

Sex: M/F

Date of Birth:

Cancer Diagnosis: _________________

Date of Diagnosis: ________End Therapy Date: _____________X Sections 1 & 2 applicable to all patients

CHEMOTHERAPY:Yes

No If yes:

Prior to 1972:

Section 3

Prior to 1993:

Section 4

1977 - 1985:

Section 5

LTFU guidelines are applicable to patients who are>2 years following completion of cancer therapy

X Section 6 and applicable guidelines for specific chemotherapy agents below

Chemotherapy Agent(mark if patient received)

Applicable guideline sections

Asparaginase

Section 34

Bleomycin

Section 29

BusulfanSections 7M/F, 8, 9, 10

Carboplatin – all doses

Sections 7M/F, 8, 15, 16, 17– myeloablative dose

See also: Section 14

Note: Myeloablative dose = conditioning for HCT

Carmustine

Sections 7M/F, 8, 9

Chlorambucil

Sections 7M/F, 8

Cisplatin

Sections 7M/F, 8, 14, 15, 16, 17

Cyclophosphamide

Sections 7M/F, 8, 11, 12

Cytarabine: SQ, IT, IO, low-dose IV

Section 20

Note: Low-dose IV = all single doses < 1000 mg/m2

Cytarabine: High-dose IV

Sections 18, 19

Note: High-dose IV = any single dose >1000 mg/m2

Dacarbazine

Sections 7M/F, 8

Dactinomycin

Section 30

Daunorubicin*

Sections 27, 28M/F

Cumulative dose: ______mg/m2

Cumulative dose x 0.833 = _______ mg/m2 = doxorubicin isotoxic dose

Age at first dose: ______
Dexamethasone

Sections 31, 32, 33

Doxorubicin*

Sections 27, 28M/F

Cumulative dose: ______mg/m2
Age at first dose: ______

Cumulative dose x 1 = _______ mg/m2 = doxorubicin isotoxic dose

Epirubicin*

Sections 27, 28M/F

Cumulative dose: ______mg/m2
Age at first dose: ______

Cumulative dose x 0.67 = _______ mg/m2 = doxorubicin isotoxic dose

Etoposide (VP-16)

Section 37

Idarubicin*

Sections 27, 28M/F

Cumulative dose: ______mg/m2

Cumulative dose x 5 =_______ mg/m2= doxorubicin isotoxic dose

Age at first dose: ______
Ifosfamide

Sections 7M/F, 8, 11, 13

Lomustine

Sections 7M/F, 8, 9

Mechlorethamine

Sections 7M/F, 8Melphalan

Sections 7M/F, 8

Mercaptopurine (6-MP)

Section 21*Use formulas below to convert to doxorubicin isotoxic equivalents prior to calculating total cumulative anthracycline dose:
Doxorubicin – multiply total dose x 1

Daunorubicin – multiply total dose x 0.833

Idarubicin - multiply total dose x 5

Epirubicin - multiply total dose x 0.67

Mitoxantrone - multiply total dose x 4

Note: There is a paucity of literature to support isotoxic dose conversion; however, the above conversion factors may be used for conveniencein order to gauge screening frequency. Clinical judgment should ultimately be used to determine indicated screening for individual patients.
PST REV 10-08

Page 1 of 7

Chemotherapy Agent (cont)(mark if patient received)

Applicable guideline sections

Methotrexate: PO, IM, low and high-dose IV

Sections 22, 23, 24

Methotrexate: High-dose IV, IT, IO

Sections 25, 26

Mitoxantrone* (see footnote on previous page)

Sections 27, 28M/F

Cumulative dose: ______mg/m2
Age at first dose: _________

Note: High-dose IV = any single dose >1000 mg/m2

Cumulative dose x 4 =Prednisone

Sections 31, 32, 33

Procarbazine

Sections 7M/F, 8

Temozolomide

Sections 7M/F, 8

Teniposide (VM-26)

Section 37

Thioguanine (6-TG)

Section 21

Thiotepa

Sections 7M/F, 8

Vinblastine

Sections 35, 36

Vincristine

Sections 35, 36_______ mg/m2 = doxorubicin isotoxic dose2

Total anthracycline cumulative dose (doxorubicin isotoxic equivalent) = _________ mg/m
(Instructions: Add all anthracycline doses from boxes in above table to obtain total cumulative dose)
2
Note: For doses in mg/kg, multiply by 30 to obtain equivalent dosing in mg/m

RADIATION:

§

Yes

§

No If yes, include applicable guidelines based on exposure to specific radiation field(s) (see instructions )INSTRUCTIONS FOR RADIATION SECTIONS:DETERMINING APPLICABILITY OF GUIDELINE SECTION BASED ON MINIMUM RADIATION DOSE SPECIFICATIONS:
Sections with minimum dose specifications are applicable to a patient only if:
1. Patient received radiation to any field(s) relevant to the particular guideline section at > the specified minimum dose

†

OR
†

‡

2. Patient received a combination of radiation to any relevant field(s) plus relevant spinal radiation and/or TBI, the sum of§which is > the specified minimum dose†

Total dose to each field should include boost dose, if given. If patient received radiation to more than one field relevant to aparticular guideline section during a single planned course of radiation treatment (excluding spinal radiation and TBI), the fieldthat received the largest radiation dose should be used in making the determination as to the applicability of the indicatedguideline section(s). Exception: If patient received radiation to the same field at different times (e.g., at time of diagnosis AND at
relapse), these doses should be added together when considering the applicability of the indicated guideline section.
‡

Use the largest dose of radiation delivered to the spinal field(s) specified in the guideline section§

Whole lung radiation, if given, should be included in minimum dose calculations for Sections 65, 66, 67, 68, 73, and 91.

See Appendix I – “Radiation Reference Guide” – for examples.
SELECTING APPLICABLE GUIDELINE RADIATION SECTIONS BASED ON RADIATION EXPOSURE:-

Select all sections listed under “any dose” for each applicable radiation exposure-

Refer to the “Radiation Reference Guide” in Appendix I to determine which, if any, of the sections with minimum dose
specifications are applicable to each particular patient based on their exposures-

For examples of radiation dose calculations, see pages 3 – 5 of the “Radiation Reference Guide”

PST REV 10-08

Page 2 of 7

§Radiation by field (mark all that apply)

Applicable guideline sections

ALL RADIATION FIELDS:
All radiation fields including TBI

Any dose

Sections 38, 39

All radiation fields except TBI

Any dose

Sections 40, 41

Any dose

Sections 38, 39, 42, 43, 44, 49, 50, 56, 60, 62, 63, 64, 68F , 69F, 70, 71M/F, 78 ,79, 83F, 84F, 86M, 88 ‡Screening may be indicated; refer to Info Link in this section

TOTAL BODY IRRADIATION (TBI):
Total body irradiation (TBI)‡‡

HEAD/BRAIN:
CranialAny dose

Sections 42, 43, 44, 46, 47, 48, 49, 50, 51M/F, 56, 59, 60, 62, 63, 64[Any field involving the
cranium/head, brain, and/or
face]

Minimum dose
specifications
apply

See Pages 11-13 of the Radiation Reference Guide to determine theapplicability of the following sections for this patient:
Sections 45, 52M/F, 53, 54 M/F, 55, 57, 58, 61, 65, 66

Orbital/Eye

Any dose

Sections 42, 46, 47, 48, 49, 50, 51M/F, 56

Minimum dose
specifications
apply

See Page 11 of the Radiation Reference Guide to determine theapplicability of the following sections for this patient:
Sections 45, 52M/F, 53, 54M/F, 55, 57

Any dose

Sections 42, 43, 44, 46, 47, 48, 49, 50, 51M/F

Minimum dose
specifications
apply

See Page 11 of the Radiation Reference Guide to determine theapplicability of the following sections for this patient:
Sections 45, 52M/F, 53, 54M/F, 55, 58

Any dose

Sections 42, 46, 47, 48, 49, 50, 51M/F, 59, 60, 62, 63, 64

Minimum dose
specifications
apply

See Pages 11-13 of the Radiation Reference Guide to determine theapplicability of the following sections for this patient:
Sections 45, 52M/F, 53, 54M/F, 55, 58, 61, 65, 66

Any dose

Sections 59, 60, 62, 63, 64

Minimum dose
specifications
apply

See Page 12-13 of the Radiation Reference Guide to determine theapplicability of the following sections for this patient:
Sections 61, 65, 66

Waldeyer’s Ring

Any dose

Sections 42, 46, 47, 48, 49, 50, 51M/F, 59, 60, 62, 63, 64(Nasopharyngeal +Oropharyngeal)

Minimum dose
specifications
apply

See Page 11-13 of the Radiation Reference Guide to determine theapplicability of the following sections for this patient:
Sections 45, 52M/F, 53, 54M/F, 55, 58, 61, 65, 66

Spine (cervical)

Any dose

Sections 59, 60, 62, 63, 64, 88[Including some or all of thecervical spine (C1 – C7)]

Minimum dose
specifications
apply

See Pages 12-13, 18, 25 of the Radiation Reference Guide to determine theapplicability of the following sections for this patient:

Ear/Infratemporal

Nasopharyngeal

Oropharyngeal

SPINE:

Sections 61, 65, 66, 67, 73, 91

Spine (thoracic)

Any dose

Sections 71M/F, 88, 89, 90

Age at time of XRT: ______[Including some or all of thethoracic spine (T1 – T12)]

Minimum dose
specifications
apply

See Pages 16, 18, 20, 25-26 of the Radiation Reference Guide to determine
the applicability of the following sections for this patient:

Spine (lumbar)

Any dose

Sections 83F, 84F, 88[Including some or all of thelumbar spine (L1 – L5)]

Minimum dose
specifications
apply

See Pages 20, 23, 25 of the Radiation Reference Guide to determine theapplicability of the following sections for this patient:

Spine (sacral)[Including some or all of thesacral spine (S1 – S5)]

Any dose

Sections 82, 83F, 84F, 88

Minimum dose
specifications
apply

See Pages 20, 22-23, 25 of the Radiation Reference Guide to determine theapplicability of the following sections for this patient:
Sections 76, 77, 78, 80, 81, 91

Spine (whole)[Includes cervical, thoracic,
lumbar and sacral spine]

Sections 73, 76, 77, 78, 91

Sections 76, 77, 78, 91

Any dose

Sections 59, 60, 62, 63, 64, 71M/F, 82, 83F, 84F, 88, 89, 90

Minimum dose
specifications
apply

See Pages 12-13, 16, 18, 20, 22-23, 25-26 of the Radiation Reference Guide
to determine the applicability of the following sections for this patient:
Sections 61, 65, 66, 67, 73, 76, 77, 78, 80, 81, 91§

See instructions on page 2

PST REV 10-08

Page 3 of 7

§Radiation by field (mark all that apply)

Applicable guideline sections

NECK:
Cervical (neck)Any dose

Sections 59, 60, 62, 63, 64, 88

Supraclavicular

Minimum dose
specifications
apply

See Pages 12-13, 18, 25 of the Radiation Reference Guide to determine theapplicability of the following sections for this patient:

Mini-Mantle

Any dose

Sections 59, 60, 62, 63, 64, 69F, 70, 88[Includes cervical (neck),supraclavicular, axillary]

See Pages 12-15, 18, 25 of the Radiation Reference Guide to determine theapplicability of the following sections for this patient:Excludes mediastinal and lung

Minimum dose
specifications
apply

MantleAny dose

Sections 59, 60, 62, 63, 64, 69F, 70, 71M/F, 88, 89, 90[Includes bilateral cervical(neck), supraclavicular,
mediastinal, hilar, axillary)

Minimum dose
specifications
apply

See Pages 12-16, 18, 25-26 of the Radiation Reference Guide to determine
the applicability of the following sections for this patient:

Extended Mantle

Any dose

Sections 59, 60, 62, 63, 64, 69F, 70, 71M/F, 79, 88, 89, 90[Includes mantle + paraaortic]

Minimum dose
specifications
apply

See Pages 12-16, 18-21, 25-26 of the Radiation Reference Guide to
determine the applicability of the following sections for this patient:

Subtotal Lymphoid (STLI)

Any dose

Sections 59, 60, 62, 63, 64, 69F, 70, 71M/F, 79, 88, 89, 90[Includes mantle + paraaortic +spleen]See Pages 12-21, 25-26 of the Radiation Reference Guide to determine theapplicability of the following sections for this patient:Age at time of XRT: ______

Minimum dose
specifications
apply

Total Lymphoid (TLI)

Any dose

Sections 59, 60, 62, 63, 64, 69F, 70, 71M/F, 79, 82, 83F, 84F, 85F,
86M, 88, 89, 90

Minimum dose
specifications
apply

See Pages 12-26 of the Radiation Reference Guide to determine theapplicability of the following sections for this patient:

AxillaAny dose

Sections 69F, 70, 88

Age at time of XRT: ______

Minimum dose
specifications
apply

See Pages 14-15, 25 of the Radiation Reference Guide to determine theapplicability of the following sections for this patient:

Mini-Mantle

See “Neck”

See “Neck” (above)

MantleSee “Neck”

See “Neck” (above)

Extended Mantle

See “Neck”

See “Neck” (above)

Subtotal Lymphoid (STLI)

See “Neck”

See “Neck” (above)

Total Lymphoid (TLI)

See “Neck”

See “Neck” (above)

Chest (thorax):

Any dose

Sections 62, 63, 64, 69F, 70, 71M/F, 88, 89, 90

Age at time of XRT: ______

Minimum dose
specifications
apply

See Pages 13-16, 18, 25-26 of the Radiation Reference Guide to determine
the applicability of the following sections for this patient:

Any dose

Sections 62, 63, 64, 69F, 70, 71M/F, 88, 89, 90

Sections 61, 65, 66, 67, 73, 91

Sections 61, 65, 66, 67, 68F, 73, 91

Sections 61, 65, 66, 67, 68F, 73, 91

Age at time of XRT: ______

Age at time of XRT: ______[Includes mantle + inverted Y +spleen]Age at time of XRT: ______

Sections 61, 65, 66, 67, 68F, 73, 74, 75, 76, 77, 78, 91

Sections 61, 65, 66, 67, 68F, 72, 73, 74, 75, 76, 77, 78, 91

Sections 61, 65, 66, 67, 68F, 72, 73, 74, 75, 76, 77, 78, 80, 81, 87M, 91

AXILLA:

Sections 68F, 91

THORAX:[May include any of thefollowing: mediastinal, hilar,
whole lung, chest wall]
Whole lungSections 65, 66, 67, 68F, 73, 91§

See instructions on page 2

PST REV 10-08

Page 4 of 7

§Radiation by field (mark all that apply)

Applicable guideline sections

THORAX (cont):
Mediastinal

Any dose

Sections 62, 63, 64, 69F, 70, 71M/F, 88, 89, 90

Age at time of XRT: ______[Includes mediastinum plus
bilateral hilar]

Minimum dose
specifications
apply

See Pages 13-16, 18, 25-26 of the Radiation Reference Guide to determine
the applicability of the following sections for this patient:
Sections 65, 66, 67, 68F, 73, 91

Mini-Mantle

See “Neck”

See “Neck” (page 4)

MantleSee “Neck”

See “Neck” (page 4)

Extended Mantle

See “Neck”

See “Neck” (page 4)

Subtotal Lymphoid (STLI)

See “Neck”

See “Neck” (page 4)

Total Lymphoid (TLI)

See “Neck”

See “Neck” (page 4)

Any abdominal field*

Any dose

Sections 71M/F, 79, 88, 89, 90

Age at time of XRT: ______

Minimum dose
specifications
apply

See Pages 16-21, 25-26 of the Radiation Reference Guide to determine theapplicability of the following sections for this patient:

Extended mantle

See “Neck”

See “Neck” (page 4)

Subtotal Lymphoid (STLI)

See “Neck”

See “Neck” (page 4)

Total Lymphoid (TLI)

See “Neck”

See “Neck” (page 4)

Inverted Y[Includes paraaortic andpelvic + spleen]

Any dose

Sections 71 M/F, 79, 82, 83F, 84F, 85F, 86M, 88, 89, 90

Minimum dose
specifications
apply

See Pages 16-26 of the Radiation Reference Guide to determine theapplicability of the following sections for this patient:
Sections 72 (if spleen in field), 73, 74, 75, 76, 77, 78, 80, 81, 87M, 91

Whole abdomen

Any dose

Sections 71M/F, 79, 82, 83F, 84F, 85F, 86M, 88, 89, 90

Age at time of XRT: ______

Minimum dose
specifications
apply

See Pages 16-26 of the Radiation Reference Guide to determine theapplicability of the following sections for this patient:

ABDOMEN:*Includes: Hepatic, renal,
upper quadrant (right, left),spleen (partial, entire), paraaortic,
flank/hemiabdomen (right, left)[Includes all abdominal andpelvic fields]

Sections 72 (if spleen in field*), 73, 74, 75, 76, 77, 78, 91*includes left upper quadrant, entire spleen, left flank/hemiabdomen, andparaaortic if spleen in field

Sections 72, 73, 74, 75, 76, 77, 78, 80, 81, 87M, 91

PELVIS:Any pelvic field**Any dose**Iliac crest to 3 cm below ischium.
Includes: Pelvic, vaginal,
prostate, bladder, iliac, inguinal,
femoral; Flank/hemiabdomen
included only if field extended
below iliac crest

Sections 82 (except femoral), 83F (except iliac/inguinal/femoral),
84F (except inguinal/femoral), 85F (except inguinal/femoral), 86M, 88

Minimum dose
specifications
apply

See Pages 20, 22 (except femoral), 23 (except prostate/inguinal/femoral),
24 (except vaginal), and 25 of the Radiation Reference Guide to determine
the applicability of the following sections for this patient:

Inverted Y

See “Abdomen”

See “Abdomen” (above)

Whole abdomen

See “Abdomen”

See “Abdomen” (above)

Total Lymphoid (TLI)

See “Neck”

See “Neck” (page 4)

Any dose

Section 86M

Minimum dose
specifications
apply

See Page 24 of the Radiation Reference Guide to determine theapplicability of the following section for this patient:

Any dose

Section 88

Minimum dose
specifications
apply

See Page 25 of the Radiation Reference Guide to determine theapplicability of the following section for this patient:

Sections 76, 77, 78, 80 (except femoral), 81 (except femoral), 87M, 91

TESTICULAR:
Testicular

Section 87M

EXTREMITIES:Extremity (Upper, Lower)

Section 91§

See instructions on page 2

PST REV 10-08

Page 5 of 7

HEMATOPOIETIC CELL TRANSPLANT:Yes

No If yes:

X Sections 92, 93M/F, 94-97

If yes, does patient have any history of chronic graft-versus-host disease (cGVHD)?

SURGERY:

Yes

No

Yes

No If yes: X Sections 98-106**103 – active cGVHD only
105F – females only

If yes, include applicable guideline sections below:

Surgical procedure (mark if patient received)

Applicable guideline sections

Amputation

Section 107

Central venous catheter

Section 108

Cystectomy

Sections 109, 126, 127, 128M/F, 129M

Enucleation

Section 110

Hysterectomy

Section 111F (see also oophorectomy, if applicable, section 123F or 124F)

Laparotomy

Section 112

Limb sparing procedure

Section 113

Nephrectomy

Section 114M/F

Neurosurgery - brain

Sections 115, 116, 117, 118

Neurosurgery - spinal cord

Sections 119, 120, 121M/F

Oophoropexy

Section 122F

Oophorectomy - unilateral

Section 123F

Oophorectomy - bilateral

Section 124F

Orchiectomy

Section 125M

Pelvic surgery

Sections 126, 127, 128M/F, 129M

Pulmonary lobectomy, metastasectomy
and/or wedge resection

Section 130

Splenectomy

Section 131

Thyroidectomy

Section 132

OTHER THERAPEUTIC MODALITIES:YesOther Therapeutic Modality(mark if patient received)No

If yes, include applicable guideline sections below:

Applicable guideline sections

Radioiodine therapy (I-131 thyroid ablation)

Sections 133, 134

Systemic MIBG (in therapeutic doses)

Section 135

Bioimmunotherapy

Section 136

CANCER SCREENING GUIDELINES
Patient type
All patients

Cancer type
Colorectal

Age at first screening
Standard risk: Age 50 years

Applicable guideline sections (mark as indicated)
Section 139

Highest risk:
XRT: Age 35 or 10 years after XRT(whichever occurs last)
HNPCC: Puberty
FAP: Age 21 years
IBD: 8 years after diagnosis

PST REV 10-08

Lung

Highest risk: At entry into LTFU

Section 141

Oral

Highest risk: At entry into LTFU

Section 142

Skin

Highest risk: At entry into LTFU

Section 144

Page 6 of 7

CANCER SCREENING GUIDELINES (cont)Females

BreastStandard risk: Age 20 years

Section 137F

Highest risk: At puberty

Males

CervicalAll females: 3 years after first vaginal
intercourse, or age at 21, whicheveroccurs first

Section 138F

Endometrial

Highest risk: Age 35 years

Section 140F

Prostate

Males >45 years (see guideline)

Section 143M

Testicular

N/A (see guideline)

Section 145M

GENERAL HEALTH SCREENING
All patients

PST REV 10-08

X

Section 146

Page 7 of 7

Long-Term Follow-Up Guidelines
for Survivors of Childhood, Adolescent,and Young Adult Cancers
Version 3.0 – October 2008

Radiation
Reference Guide

Copyright 2008 © Children’s Oncology GroupAll rights reserved worldwide

Children’s Oncology Group
Long-Term Follow-Up Guidelines for Survivors of Childhood,
Adolescent, and Young Adult Cancers
Version 3.0 – October 2008

RADIATION REFERENCE GUIDE
Content

Page

Instructions

2

Dose Calculation Examples

3

Radiation Fields Defined6

Radiation Fields by Anatomic Region

7

Guideline Section Numbers by Anatomic Region

8

TBI

9

Skin, bones, soft tissues

10

Brain/neuroendocrine axis, cranium, face, eye, ear

11

Oral cavity

12

Neck/thyroid

13

Breast

14

Lungs

15

Heart

16

Spleen17

Esophagus

18

Liver

19

Bowel

20

Kidneys21

Bladder/urinary tract

22

Female reproductive system

23

Male reproductive system

24

Musculoskeletal system (growth problems, fracture)25

Musculoskeletal system (scoliosis/kyphosis)

26

Acknowledgment:
Special thanks to Shweta Bhatia for preparing all
illustrations included in this Radiation Reference Guide

Radiation Reference Guide
Page 1

Determining Applicability of Radiation Sectionsfor Specific Patients Based on Exposure

GENERAL CONSIDERATIONS:• The radiation sections of the COG Long-Term Follow-Up Guidelines (Sections 38 – 91) areorganized by anatomic region from the head downward. For specifics regarding relevant
exposures to each anatomic region and radiation field, refer to the applicable pages of thisRadiation Reference Guide and to the Figures in this introductory section.
• To determine specific screening guidelines by section number for an individual patient, use
the “Patient-Specific Guideline Identification Tool” in Appendix I together with this Radiation
Reference Guide.
RADIATION DOSE CALCULATIONS:
Some sections of the COG Long-Term Follow-Up Guidelines relevant to radiation exposure
include dose specifications. These specifications indicate the minimum dose of radiation that isbelieved (based on available evidence and the recommendations of the expert panel) to placepatients sufficiently at risk of the referenced late effect to recommend screening. For guideline
sections that have a minimum specified dose, the following considerations apply in determining
the applicability of the section for a patient based on his/her radiation exposure.
Sections with minimum dose specifications are applicable to a patient only if:
1. Patient received radiation to any field(s) relevant to the particular guideline section at > thespecified minimum dose†OR
2. Patient received a combination of radiation to any relevant field(s)† plus relevant spinal
radiation‡ and/or TBI, the sum of which is > the specified minimum dose§†

Total dose to each field should include boost dose, if given. If patient received radiation tomore than one field relevant to a particular guideline section during a single planned course ofradiation treatment (excluding spinal radiation and TBI), the field that received the largest
radiation dose should be used in making the determination as to the applicability of theindicated guideline section(s). Exception: If patient received radiation to the same field at
different times (e.g., at time of diagnosis AND at relapse), these doses should be added
together when considering the applicability of the indicated guideline section.

‡

Use the largest dose of radiation delivered to the spinal field(s) specified in the guideline
section§Whole lung radiation, if given, should be included in minimum dose calculations for Sections
65, 66, 67, 68, 73, and 91.
EXAMPLES:
Examples of radiation dose calculations are provided on the following pages.

Radiation Reference Guide
Page 2RADIATION DOSE CALCULATION EXAMPLES

Example 1
Guideline section:
Section 68 (female); potential late effect = breast cancer
Minimum dose specification:
Radiation > 20 Gy
Relevant radiation fields:
Chest (thorax)
Whole lungMediastinal
AxillaMini-Mantle
MantleExtended Mantle
TLI
STLI
TBI
Clinical example:
Patient received the following radiation doses to these relevant fields:- Axillary: 12 Gy- Mediastinum: 18 Gy- TBI: 10 Gy
Step 1:
If radiation was given to more than one field relevant to the guideline section, select the largest
dose received:= 18 Gy (Mediastinum)
Step 2:
Add TBI dose, if received:
18 Gy
+ TBI
10 Gy
28 Gy
This patient received a total dose of 28 Gy of radiation potentially impacting the breast.
Therefore, Guideline Section 68 regarding screening for breast cancer, which is indicated forradiation doses > 20 Gy, is applicable.
Note: See Info Link in Section 68 for patients who received TBI alone, as screening may also be
indicated for these patient based on clinical considerations.

Radiation Reference Guide
Page 3

Example 2
Guideline section:
Section 73; potential late effect = esophageal stricture
Minimum dose specification
Radiation > 30 Gy
Relevant radiation fields:
Spine (cervical, thoracic, whole)
Cervical (neck)
Supraclavicular
Chest (thorax)
Whole lungMediastinal
Mini-Mantle
MantleExtended mantle
Hepatic
Renal
Upper quadrant (right, left)Spleen (partial, entire)
Paraaortic
Flank/hemiabdomen (right, left)
Whole abdomen
Inverted Y
TLI
STLI
Clinical example:
Patient received the following radiation doses:- Chest (thorax): 25 Gy- Hepatic: 20 Gy- Thoracic spine: 18 Gy- Lumbar spine: 24 Gy- TBI: 12 Gy
Step 1:
If radiation given to more than one non-spinal field, select the highest dose received:= 25 Gy (Chest/thorax)
Step 2:
Add the largest relevant* spinal dose to highest non-spinal dose:Thoracic spine = 18 Gy+ Chest(thorax) 25 Gy
43 Gy*Largest dose of radiation delivered to the spinal field(s) specified in the guideline section

Radiation Reference Guide
Page 4

Step 3:
Add TBI dose, if received, to total:
43 Gy
+ TBI
12 Gy
55 Gy
This patient received a total dose of 55 Gy of radiation potentially impacting the esophagus.
Therefore, Guideline Section 73 regarding screening for esophageal stricture, which is indicatedfor radiation doses > 30 Gy, is applicable.

Example 3
Guideline section:
Section 55; potential late effect = central adrenal insufficiency
Minimum dose specification:
Radiation > 40 Gy
Relevant radiation fields:
CranialOrbital/eye
Ear/infratemporal
Nasopharyngeal
Waldeyer’s Ring
Clinical example:
Patient received 24 Gy cranial radiation at time of diagnosis. Five years later patient relapsed
and was given an additional course of 24 Gy cranial radiation.
Step 1:
If patient received radiation to the same field at different times (e.g., at time of diagnosis AND at
relapse), these doses should be added together when considering the applicability of theindicated guideline section
24 Gy (Cranial radiation at diagnosis)+ 24 Gy (Cranial radiation at relapse)
48 Gy
Step 2:
Add TBI dose, if received:
48 Gy
+ TBI
0 Gy
48 Gy
This patient received a total dose of 48 Gy of radiation potentially impacting thebrain/neuroendocrine axis. Therefore, Guideline Section 55 regarding screening for central
adrenal insufficiency, which is indicated for radiation doses > 40 Gy, is applicable.

Radiation Reference Guide
Page 5RADIATION FIELDS DEFINED
Field

Definition

Total body irradiation (TBI)

Entire body; encompassing all radiation fields

CranialAny field involving the cranium, head, brain and/or face

Waldeyer’s Ring

Nasopharyngeal and oropharyngeal (tonsils and adenoids)

Spine – cervical

Including some or all of the cervical spine (C1 – C7)

Spine – thoracic

Including some or all of the thoracic spine (T1 – T12)

Spine – lumbar

Including some or all of the lumbar spine (L1 – L5)

Spine – sacral

Including some or all of the sacral spine (S1 – S5)

Spine – whole

Including the cervical, thoracic, lumbar and sacral spine

Mini-mantle

Bilateral cervical (neck), supraclavicular and axillary fields (excludes mediastinal
and lung)

MantleBilateral cervical (neck), supraclavicular, mediastinal, hilar, and axillary fields

Extended mantle

Mantle and paraaortic fields

Subtotal lymphoid (STLI)

Mantle + paraaortic + splenic

Inverted Y

Paraaortic + pelvic +/- splenic

Total lymphoid (TLI)

Mantle + inverted Y (paraaortic/pelvic) + splenic

Chest (thorax)

May include any of the following: Mediastinal, hilar, whole lung, chest wallMediastinal

Mediastinum and bilateral hilar fields

Abdomen(also commonly referred
to as “upper abdomen”)

Top of diaphragm to iliac crests (bilaterally), including the following fields:- Hepatic- Upper quadrant (right, left)- Renal/renal bed- Paraaortic- Spleen (partial, entire)- Flank/hemiabdomen (right, left)

Paraaortic

Paraaortic lymph nodes (generally from T10 to L4 cephalad-caudad, and thetransverse processes laterally) +/- splenic

Renal

Renal bed

Flank/hemiabdomen

Top of diaphragm to iliac crest (unilateral; medial border along contralateralvertebral bodies)
Note: Most hemiabdominal fields do not extend beyond the iliac crest; however,in some cases, depending on tumor location, the hemiabdominal field may haveextended into the pelvis. If the hemiabdominal field extended below the iliac
crest, exposure to pelvic fields should be considered in assessing risk for latesequeale.

Whole abdomen

Includes all abdominal and pelvic fields

PelvisIliac crest to 3 cm below ischium, including the following fields:- Pelvic- Iliac- Vaginal- Inguinal- Prostate- Femoral- Bladder

Radiation Reference Guide
Page 6

Radiation Fields by Anatomic Region

Radiation Reference Guide
Page 7

Guideline Radiation Section Numbers by Anatomic Region

Radiation Reference Guide
Page 8

Relevant Guideline Radiation Sections for Patients who Received
TOTAL BODY IRRADIATION (TBI)

Total Body Irradiation (TBI)

Fields

Dose

SectionNumbers

TBI

Any

38
39
42
43
44
49
50
56
60
62
63
64
§
68
69
70
71
§
78
79
83
84
86
88

Potential Late Effects
Secondary benign or malignant neoplasms
Dysplastic nevi/skin cancer
Brain tumor
Neurocognitive deficits
Clinical leukoencephalopathy
Metabolic syndrome
Growth hormone deficiency
Cataracts
Dental abnormalities
Thyroid nodules
Thyroid cancer
Hypothryoidism
Breast cancer
Breast tissue hypoplasia
Pulmonary toxicity
Cardiac toxicity
Colorectal cancer
Renal toxicity
Uterine vascular insufficiency
Gonadal dysfunction (ovarian)
Gonadal dysfunction (testicular)
Musculoskeletal growth problems§

Screening may be indicated for patients who received TBI alone - see Info Link in this section

Radiation Reference Guide
Page 9Relevant Guideline Radiation Sections for Patients who Received
RADIATION WITH POTENTIAL IMPACT TO:
Skin, Bones, Soft Tissues

Skin, Soft Tissues, Bones Relevant Fields
All radiation fields:
CranialOrbital/Eye
Ear/Infratemporal
Nasopharyngeal
Oropharyngeal
Waldeyer’s Ring
Spine (cervical, thoracic, lumbar,
sacral, whole)
Cervical (neck)
Supraclavicular
Chest (thorax)
Whole lungMediastinal
AxillaMini-Mantle
MantleExtended mantle
Hepatic
Renal
Upper quadrant (right, left)Spleen (partial, entire)
Paraaortic
Flank/Hemiabdomen (right, left)
Whole abdomen
Inverted Y
PelvicVaginalProstate
Bladder
Iliac
Inguinal
FemoralTesticular
Extremity (upper, lower)
Total lymphoid irradiation (TLI)
Subtotal lymphoid irradiation (STLI)
Total body irradiation (TBI)

Potential impact
to
Skin
Bones
Soft Tissues

Fields

Dose

SectionNumbersAll

Any38, 39All except TBI

Any40, 41

Potential Late Effects
Secondary benign or malignant neoplasms
Dysplastic nevi
Skin cancer
Dermatologic changes
Bone malignancies

Radiation Reference Guide
Page 10

Relevant Guideline Radiation Sections for Patients who Received
RADIATION WITH POTENTIAL IMPACT TO:
Brain/Neuroendocrine Axis, Cranium, Face, Eye, Ear

Brain/Cranium/Sensory –Relevant Fields:
CranialOrbital/Eye
Ear/infratemporal
Nasopharyngeal
Waldeyer’s Ring
TBI

Potential Impact To

Relevant Fields

Brain
Neuroendocrine axis
Cranium
Face

CranialOrbital/eye
Ear/infratemporal
Nasopharyngeal
Waldeyer’s Ring
TBI
Cranial
Ear/infratemporal
TBI
CranialOrbital/eye
TBI
Cranial
Ear/infratemporal
Nasopharyngeal
Waldeyer’s Ring
TBI

Brain

Eye

Ear

Dose

SectionNumbers

Potential Late Effects

Any42, 46*, 47*,
48*, 49, 50,
51*
45**
52,** 53,**54,** 55**
43, 44

Brain tumor, Craniofacial abnormalities*, Chronicsinusitis*, Overweight/ obesity*, Metabolic syndrome,
Growth hormone deficiency, Precocious puberty*
Cerebrovascular complications
Hyperprolactinemia, Central hypothyroidism,
Gonadotropin deficiency, Central adrenal insufficiency
Neurocognitive deficit, Clinical leukoencephalopathy

Any>30 Gy***56
57**

Cataracts
Ocular toxicity>30 Gy***58**

Ototoxicity

Any>18 Gy***>40 Gy****TBI not associated with these sections**TBI included for dose calculation purposes only; this section not applicable to patients who received TBI alone***This/these section(s) applicable to patient only if:†
1) Patient received radiation to any field(s) relevant to the particular guideline section at > the specified minimum doseOR 2) Patient received a combination of radiation to any relevant field(s) and TBI, the sum of which is > the specified minimum dose††

Notes: Total dose to each field should include boost dose, if given. If patient received radiation to more than one field relevant to aparticular guideline section during a single planned course of radiation treatment (excluding TBI), the field that received the largest
radiation dose should be used in making the determination as to the applicability of the indicated guideline section(s). Exception: If
patient received radiation to the same field at different times (e.g., at time of diagnosis AND at relapse), these doses should be added
together when considering the applicability of the indicated guideline section.

Radiation Reference Guide
Page 11

Relevant Guideline Radiation Sections for Patients who Received
RADIATION WITH POTENTIAL IMPACT TO:
Oral Cavity

Oral Cavity – Relevant Fields:
CranialNasopharyngeal
Oropharyngeal
Waldeyer’s Ring
Spine (cervical, whole)
Cervical (neck)
Supraclavicular
Mini-Mantle
MantleExtended Mantle
TLI
STLI
TBI

Potential
impact toOral cavity

Fields
CranialNasopharyngeal
Oropharyngeal
Waldeyer’s Ring
Spine (cervical, whole)
Cervical (neck)
Supraclavicular
Mini-Mantle
MantleExtended Mantle
TLI
STLI
TBI

Dose

Section Numbers

Any59*, 60>40 Gy***61**

Potential Late Effects
Xerostomia
Salivary gland dysfunction
Dental abnormalities
Osteoradionecrosis*TBI not associated with this section**TBI included for dose calculation purposes only; this section not applicable to patients who received TBI alone***This section applicable to patient only if:
1) Patient received radiation to any field(s) relevant to the particular guideline section at > the specified minimum
†
dose
†

‡

OR 2) Patient received a combination of radiation to any relevant field(s) plus relevant spinal radiation and/or TBI,
the sum of which is > the specified minimum dose†

Notes: Total dose to each field should include boost dose, if given. If patient received radiation to more than one field
relevant to a particular guideline section during a single planned course of radiation treatment (excluding spinal
radiation and TBI), the field that received the largest radiation dose should be used in making the determination as tothe applicability of the indicated guideline section(s). Exception: If patient received radiation to the same field at
different times (e.g., at time of diagnosis AND at relapse), these doses should be added together when considering theapplicability of the indicated guideline section.

‡

Use the largest dose of radiation delivered to the spinal field(s) specified in the guideline section

Radiation Reference Guide
Page 12Relevant Guideline Radiation Sections for Patients who Received
RADIATION WITH POTENTIAL IMPACT TO:
Neck/Thyroid

Neck/thyroid – Relevant Fields:
CranialNasopharyngeal
Oropharyngeal
Waldeyer’s Ring
Spine (cervical, whole)
Cervical (neck)
Supraclavicular
Chest (thorax)
Whole lungMediastinal
Mini-Mantle
MantleExtended Mantle
TLI
STLI
TBI
Potential impact toThyroid
Carotid artery

Subclavian artery

Fields
CranialNasopharyngeal
Oropharyngeal
Waldeyer’s Ring
Spine (cervical, whole)
Cervical (neck)
Supraclavicular
Chest (thorax)
Whole lungMediastinal
Mini-Mantle
MantleExtended Mantle
TLI, STLI, TBI
Spine (cervical, whole)
Cervical (neck)
Supraclavicular
Chest (thorax)
Whole lungMediastinal
Mini-Mantle
MantleExtended Mantle
TLI, STLI, TBI

DoseSection #Potential Late Effects

Any62, 63, 64

Thyroid nodules
Thyroid cancer
Hypothyroidism>40 Gy**65*

Hyperthyroidism

66*

Carotid artery disease67*

Subclavian arterydisease>40 Gy***TBI included for dose calculation purposes only; this section not applicable to patients who received TBI alone**This section applicable to patient only if:
1) Patient received radiation to any field(s) relevant to the particular guideline section at > the specified†
minimum dose†‡OR 2) Patient received a combination of radiation to any relevant field(s) plus relevant spinal radiation and/or
TBI, the sum of which is > the specified minimum dose†

Notes: Total dose to each field should include boost dose, if given. If patient received radiation to more than one
field relevant to a particular guideline section during a single planned course of radiation treatment (excluding
spinal radiation and TBI), the field that received the largest radiation dose should be used in making thedetermination as to the applicability of the indicated guideline section(s). Exception: If patient received radiation to
the same field at different times (e.g., at time of diagnosis AND at relapse), these doses should be added together
when considering the applicability of the indicated guideline section.

‡

Use the largest dose of radiation delivered to the spinal field(s) specified in the guideline section

Radiation Reference Guide
Page 13

Relevant Guideline Radiation Sections for Females who Received
RADIATION WITH POTENTIAL IMPACT TO THE:
BreastBreast – Relevant Fields:
Chest (thorax)
Whole lungMediastinal
AxillaMini-Mantle
MantleExtended Mantle
TLI
STLI
TBI

Potential
impact to
BreastFieldsChest (thorax)
Whole lungMediastinal
AxillaMini-Mantle
MantleExtended Mantle
TLI
STLI
TBI

Dose

SectionNumbers

Any

69>20 Gy*68§

Potential Late Effects
Breast hypoplasia
Breast cancer§

Screening may be indicated for patients who received TBI alone - see Info Link in Section 68*This section applicable to patient only if:
1) Patient received radiation to any field(s) relevant to the particular guideline section†at > the specified minimum doseOR 2) Patient received a combination of radiation to any relevant field(s) and TBI, the sum†of which is > the specified minimum dose†

Notes: Total dose to each field should include boost dose, if given. If patient received
radiation to more than one field relevant to a particular guideline section during a single
planned course of radiation treatment (excluding TBI), the field that received the largest
radiation dose should be used in making the determination as to the applicability of theindicated guideline section(s). Exception: If patient received radiation to the same field at
different times (e.g., at time of diagnosis AND at relapse), these doses should be added
together when considering the applicability of the indicated guideline section.

Radiation Reference Guide
Page 14

Relevant Guideline Radiation Sections for Patients who Received
RADIATION WITH POTENTIAL IMPACT TO:
Lungs

Lungs – Relevant
Fields:Chest (thorax)
Whole lungMediastinal
AxillaMini-Mantle
MantleExtended Mantle
TLI
STLI
TBI

Potential
impact to
Lungs

FieldsChest (thorax)
Whole lungMediastinal
AxillaMini-Mantle
MantleExtended Mantle
TLI
STLI
TBI

Dose
Any

SectionNumbers70

Potential Late Effects
Pulmonary toxicity

Radiation Reference Guide
Page 15

Relevant Guideline Radiation Sections for Patients who Received
RADIATION WITH POTENTIAL IMPACT TO:
Heart

Heart – Relevant Fields:
Spine (thoracic, whole)
Chest (thorax)
Whole lungMediastinal
MantleExtended Mantle
Hepatic
Renal
Upper quadrant (right, left)Spleen (partial, entire)
Paraaortic
Flank/hemiabdomen (right, left)
Whole abdomen
Inverted Y
TLI
STLI
TBI

Potential
impact toHeart

Fields

Dose

SectionNumbers

Potential Late Effects

Spine (thoracic, whole)
Chest (thorax)
Whole lungMediastinal
MantleExtended Mantle
Hepatic
Renal
Upper quadrant (right, left)Spleen (partial, entire)
Paraaortic
Flank/hemiabdomen (right, left)
Whole abdomen
Inverted Y
TLI
STLI
TBI

Any*

71

Cardiac toxicity* Note: Frequency of screening is determined by dose and age at exposure

Radiation Reference Guide
Page 16

Relevant Guideline Radiation Sections for Patients who Received
RADIATION WITH POTENTIAL IMPACT TO:
SpleenSpleen – Relevant Fields:
Left upper quadrant
Spleen (entire)
Paraaortic*
Left flank/hemiabdomen
Whole abdomen
Inverted Y*
TLI
STLI
TBI
*If spleen in field
Potential
impact to
SpleenFieldsLeft upper quadrant
Spleen (entire)
Paraaortic*
Left flank/hemiabdomen
Whole abdomen
Inverted Y*
TLI
STLI
TBI

Dose
>40 Gy***SectionNumbers

Potential Late
Effects72**

Functional asplenia*If spleen in field**TBI included for dose calculation purposes only; this section not applicable to patients who
received TBI alone***This section applicable to patient only if:
1) Patient received radiation to any field(s) relevant to the particular guideline section at > the†specified minimum dose†OR 2) Patient received a combination of radiation to any relevant field(s) and TBI, the sum ofwhich is > the specified minimum dose†

Notes: Total dose to each field should include boost dose, if given. If patient received radiation tomore than one field relevant to a particular guideline section during a single planned course ofradiation treatment (excluding TBI), the field that received the largest radiation dose should be usedin making the determination as to the applicability of the indicated guideline section(s). Exception: If
patient received radiation to the same field at different times (e.g., at time of diagnosis AND at
relapse), these doses should be added together when considering the applicability of the indicatedguideline section.

Radiation Reference Guide
Page 17

Relevant Guideline Radiation Sections for Patients who Received
RADIATION WITH POTENTIAL IMPACT TO:
Esophagus

Esophagus – Relevant Fields:
Spine (cervical, thoracic, whole)
Cervical (neck)
Supraclavicular
Chest (thorax)
Whole lungMediastinal
Mini-Mantle
MantleExtended mantle
Hepatic
Renal
Upper quadrant (right, left)Spleen (partial, entire)
Paraaortic
Flank/hemiabdomen (right, left)
Whole abdomen
Inverted Y
TLI
STLI
TBI
Potential
impact to

FieldsDose

Esophagus

Spine (cervical, thoracic, whole)
Cervical (neck)
Supraclavicular
Chest (thorax)
Whole lungMediastinal
Mini-Mantle
MantleExtended mantle
Hepatic
Renal
Upper quadrants (right, left)Spleen (partial, entire)
Paraaortic
Flank/hemiabdomen (right, left)
Whole abdomen
Inverted Y
TLI, STLI, TBI>30 Gy**SectionNumbers

Potential Late
Effects73*

Esophageal stricture*TBI included for dose calculation purposes only; this section not applicable to patients who
received TBI alone**This section applicable to patient only if:
1) Patient received radiation to any field(s) relevant to the particular guideline section at > the†specified minimum dose†OR 2) Patient received a combination of radiation to any relevant field(s) plus relevant spinal‡
radiation and/or TBI, the sum of which is > the specified minimum dose†

Notes: Total dose to each field should include boost dose, if given. If patient received radiation tomore than one field relevant to a particular guideline section during a single planned course ofradiation treatment (excluding spinal radiation and TBI), the field that received the largest radiationdose should be used in making the determination as to the applicability of the indicated guideline
section(s). Exception: If patient received radiation to the same field at different times (e.g., at timeof diagnosis AND at relapse), these doses should be added together when considering theapplicability of the indicated guideline section.
‡

Use the largest dose of radiation delivered to the spinal field(s) specified in the guideline section

Radiation Reference Guide
Page 18

Relevant Guideline Radiation Sections for Patients who Received
RADIATION WITH POTENTIAL IMPACT TO:
Liver

Liver – Relevant Fields:
Extended mantle
Hepatic
Renal
Upper quadrant (right, left)Spleen (partial, entire)
Paraaortic
Flank/hemiabdomen (right, left)
Whole abdomen
Inverted Y
TLI
STLI
TBI
Potential
impact to
Liver

FieldsDose

Extended mantle
Hepatic
Renal
Upper quadrant (right, left)Spleen (partial, entire)
Paraaortic
Flank/hemiabdomen (right, left)
Whole abdomen
Inverted Y
TLI
STLI
TBI

>30 Gy**SectionNumbers

Potential Late
Effects74*

Hepatic fibrosis
Cirrhosis

75*

Cholecystitis*TBI included for dose calculation purposes only; this section not applicable to patients who
received TBI alone**These sections applicable to patient only if:
1) Patient received radiation to any field(s) relevant to the particular guideline section at > the†specified minimum dose†OR 2) Patient received a combination of radiation to any relevant field(s) and TBI, the sum ofwhich is > the specified minimum dose†

Notes: Total dose to each field should include boost dose, if given. If patient received radiation tomore than one field relevant to a particular guideline section during a single planned course ofradiation treatment (excluding TBI), the field that received the largest radiation dose should be usedin making the determination as to the applicability of the indicated guideline section(s). Exception: If
patient received radiation to the same field at different times (e.g., at time of diagnosis AND at
relapse), these doses should be added together when considering the applicability of the indicatedguideline section.

Radiation Reference Guide
Page 19

Relevant Guideline Radiation Sections for Patients who Received
RADIATION WITH POTENTIAL IMPACT TO:
Bowel
Potential
Impact To
Bowel

Relevant Fields

Dose

Spine (thoracic, lumbar, sacral, whole)
Extended mantle
Hepatic
Renal
Upper quadrant (right, left)Spleen (partial, entire)
Paraaortic
Flank/hemiabdomen (right, left)
Whole abdomen
Inverted Y
PelvicVaginalProstate
Bladder
Iliac
Inguinal
FemoralTLI, STLI, TBI>30 Gy**SectionNumbers

Potential Late Effects

76*

Bowel obstruction

77*

Chroninc enterocolitis
FistulaStrictures§

78

Colorectal cancer§

Screening for colorectal cancer may be indicated for patients who received TBI alone - see Info Link in Section 78*TBI included for dose calculation purposes only; this section not applicable to patients who received TBI alone**This section applicable to patient only if:
1) Patient received radiation to any field(s) relevant to the particular guideline section at > the specified†
minimum dose†‡OR 2) Patient received a combination of radiation to any relevant field(s) plus relevant spinal radiation and/or
TBI, the sum of which is > the specified minimum dose†

Notes: Total dose to each field should include boost dose, if given. If patient received radiation to more than one
field relevant to a particular guideline section during a single planned course of radiation treatment (excluding
spinal radiation and TBI), the field that received the largest radiation dose should be used in making thedetermination as to the applicability of the indicated guideline section(s). Exception: If patient received radiation to
the same field at different times (e.g., at time of diagnosis AND at relapse), these doses should be added together
when considering the applicability of the indicated guideline section.
‡

Use the largest dose of radiation delivered to the spinal field(s) specified in the guideline section
Bowel – Relevant Fields:
Spine (thoracic, lumbar,
sacral, whole)
Extended mantle
Hepatic
Renal
Upper quadrant (right, left)Spleen (partial, entire)
Paraaortic
Flank/hemiabdomen (right, left)
Whole abdomen
Inverted Y
PelvicVaginalProstate
Bladder
Iliac
Inguinal
FemoralTLI, STLI, TBI

Radiation Reference Guide
Page 20

Relevant Guideline Radiation Sections for Patients who Received
RADIATION WITH POTENTIAL IMPACT TO:
Kidneys

Kidneys – Relevant Fields:
Extended Mantle
Hepatic
Renal
Upper quadrant (right, left)Spleen (partial, entire)
Paraaortic
Flank/hemiabdomen (right, left)
Whole abdomen
Inverted Y
TLI
STLI
TBI

Potential
impact to
Kidneys

FieldsDose

Extended Mantle
Hepatic
Renal
Upper quadrant (right, left)Spleen (partial, entire)
Paraaortic
Flank/hemiabdomen (right, left)
Whole abdomen
Inverted Y
TLI
STLI
TBI

Any dose

SectionNumbers
79

Potential Late
Effects
Renal toxicity

Radiation Reference Guide
Page 21

Relevant Guideline Radiation Sections for Patients who Received
RADIATION WITH POTENTIAL IMPACT TO:
Bladder / Urinary Tract

Potential
Impact To
Bladder
Urinary tract

Relevant Fields
Spine (sacral, whole)
Flank/hemiabdomen (right, left)*
Whole abdomen
Inverted Y
PelvicVaginalProstate
Bladder
Iliac
Inguinal
TLI
TBI

Dose

SectionNumbers

Potential Late Effects

Any dose82§

Bladder malignancy>30 Gy***80**

Hemorrhagic cystitis

81**

Urinary tract toxicity§

TBI not applicable to this section*Only if field extended below iliac crest**TBI included for dose calculation purposes only; this section not applicable to patients who received TBI alone***This section applicable to patient only if:
1) Patient received radiation to any field(s) relevant to the particular guideline section at > the specified†
minimum dose†‡OR 2) Patient received a combination of radiation to any relevant field(s) plus relevant spinal radiation and/or
TBI, the sum of which is > the specified minimum dose†

Notes: Total dose to each field should include boost dose, if given. If patient received radiation to more than one
field relevant to a particular guideline section during a single planned course of radiation treatment (excluding
spinal radiation and TBI), the field that received the largest radiation dose should be used in making thedetermination as to the applicability of the indicated guideline section(s). Exception: If patient received radiation to
the same field at different times (e.g., at time of diagnosis AND at relapse), these doses should be added together
when considering the applicability of the indicated guideline section.

Bladder/Urinary Tract– Relevant Fields:
Spine (sacral, whole)
Flank/hemiabdomen (right, left)*
Whole abdomen
Inverted Y
PelvicVaginalProstate
Bladder
Iliac
Inguinal
TLI/TBI*Only if field extended below iliac crest

Radiation Reference Guide
Page 22

Relevant Guideline Radiation Sections for Patients who Received
RADIATION WITH POTENTIAL IMPACT TO:
Female Reproductive System

Potential
Impact To
Femalereproductive
systemRelevant Fields

Dose†

Spine (lumbar, sacral, whole)
Flank/hemiabdomen (right, left)*
Whole abdomen
Inverted Y
PelvicVaginalBladder
‡
Iliac
TLI
†
TBI

Any dose

SectionNumbers

Potential Late Effects

83

Uterine vascularinsufficiency

84

Gonadal dysfunction(ovarian)

85

Vaginal fibrosis/stenosis*Only if field extended below iliac crest†

Sections 83 and 84 only‡

Sections 84 and 85 only

Female Reproductive System Relevant Fields:†
Spine (lumbar, sacral, whole)
Flank/hemiabdomen (right, left)*
Whole abdomen
Inverted Y
PelvicVaginalBladder
‡
Iliac
TLI
†
TBI
*Only if field extended below iliac crest†

Sections 83 and 84 only‡

Sections 84 and 85 only

Radiation Reference Guide
Page 23

Relevant Guideline Radiation Sections for Patients who Received
RADIATION WITH POTENTIAL IMPACT TO:
Male Reproductive System

Potential Impact
To

Relevant Fields

Dose

SectionNumbers

Potential Late Effects

Male reproductive
systemFlank/hemiabdomen (right, left)*
Whole abdomen
Inverted Y
PelvicProstate
Bladder
Iliac
Inguinal
FemoralTesticular
TLI
TBI

Any dose86

Gonadal dysfunction (testicular):Germ cell failure

>20
Gy***

87**

Gonadal dysfunction (testicular):
Leydig cell failure*Only if field extended below iliac crest**TBI included for dose calculation purposes only; this section not applicable to patients who received TBI alone***This section is applicable to patient only if:
1) Patient received radiation to any field(s) relevant to the particular guideline section at > the specified minimum
†
dose
†

OR 2) Patient received a combination of radiation to any relevant field(s) and TBI, the sum of which is > the specified
minimum dose†

Notes: Total dose to each field should include boost dose, if given. If patient received radiation to more than one field
relevant to a particular guideline section during a single planned course of radiation treatment (excluding TBI), the fieldthat received the largest radiation dose should be used in making the determination as to the applicability of the indicatedguideline section(s). Exception: If patient received radiation to the same field at different times (e.g., at time of diagnosis
AND at relapse), these doses should be added together when considering the applicability of the indicated guideline
section.

Male Reproductive System– Relevant Fields:
Flank/hemiabdomen(right, left)*
Whole abdomen
Inverted Y
PelvicProstate
Bladder
Iliac
Inguinal
FemoralTesticular
TLI
TBI*Only if field extended below iliac crest

Radiation Reference Guide
Page 24

Relevant Guideline Radiation Sections for Patients who Received
RADIATION WITH POTENTIAL IMPACT TO THE:
Musculoskeletal System(Growth Problems, Radiation-Induced Fracture)

Musculoskeletal System - Relevant Fields
All fields from neck downward
Spine (cervical, thoracic, lumbar, sacral, whole)
Cervical (neck)
Supraclavicular
Chest (thorax)
Whole abdomen
Whole lung
Inverted Y
Mediastinal
PelvicAxillaVaginalMini-Mantle
Prostate
MantleBladder
Extended mantle
Iliac
Hepatic
Inguinal
Renal
FemoralUpper quadrant (right, left)
Extremity (upper, lower)
Spleen (partial, entire)
TLI
Paraaortic
STLI
Flank/hemiabdomen
TBI(right, left)

Potential
impact to

FieldsMusculoskeletal
systemAll fields from neckdownward except testicular(see list above)

Dose

SectionNumbers

Potential Late
Effects

Any

88

Musculoskeletal
growth problems>40 Gy**91*

Radiation-induced
fracture*TBI included for dose calculation purposes only; this section not applicable to patients who
received TBI alone**This section applicable to patient only if:
1) Patient received radiation to any field(s) relevant to the particular guideline section at > the†specified minimum dose†OR 2) Patient received a combination of radiation to any relevant field(s) plus relevant spinal‡
radiation and/or TBI, the sum of which is > the specified minimum dose†

Notes: Total dose to each field should include boost dose, if given. If patient received radiation tomore than one field relevant to a particular guideline section during a single planned course ofradiation treatment (excluding spinal radiation and TBI), the field that received the largest radiationdose should be used in making the determination as to the applicability of the indicated guideline
section(s). Exception: If patient received radiation to the same field at different times (e.g., at timeof diagnosis AND at relapse), these doses should be added together when considering theapplicability of the indicated guideline section.
‡

Use the largest dose of radiation delivered to the spinal field(s) specified in the guideline section

Radiation Reference Guide
Page 25

Relevant Guideline Radiation Sections for Patients who Received
RADIATION WITH POTENTIAL IMPACT TO THE:
Musculoskeletal System(Scoliosis/Kyphosis)

Musculoskeletal System
Scoliosis/Kyphosis –Relevant Fields:
Spine (thoracic, whole)
Chest (thorax)
Whole lungMediastinal
MantleExtended Mantle
Hepatic
Renal
Upper quadrant (right, left)Spleen (partial, entire)
Paraaortic
Flank/hemiabdomen (right, left)
Whole abdomen
Inverted Y
TLI
STLI

Potential impact toFields

Dose

SectionNumbers

Potential Late
Effects

Musculoekeletal system

Spine (thoracic, whole)
Chest (thorax)
Whole lungMediastinal
MantleExtended Mantle
Hepatic
Renal
Upper quadrant (right, left)Spleen (partial, entire)
Paraaortic
Flank/hemiabdomen(right, left)
Whole abdomen
Inverted Y
TLI
STLI

Any

89

Scoliosis

90

Kyphosis

Radiation Reference Guide
Page 26

Radiation Reference Guide - Index by Radiation Field
RADIATION FIELD

SEE PAGESPOTENTIALLY RELEVANT SECTION NUMBERS

ALL RADIATION FIELDS:
All radiation fields including TBI

9-10

All radiation fields except TBI

10

Any dose:
Sections 38, 39
Any dose:
Sections 40, 41

TOTAL BODY IRRADIATION (TBI):
Total body irradiation (TBI)

9

Any dose:‡
Sections 38, 39, 42, 43, 44, 49, 50, 56, 60, 62, 63, 64, 68F , 69F, 70,‡
71M/F, 78 , 79, 83F, 84F, 86M, 88‡

Screening may be indicated; refer to Info Link in this section

HEAD/BRAIN:
Cranial

10-13

Any dose:
Sections 42, 43, 44, 46, 47, 48, 49, 50, 51M/F, 56, 59, 60, 62, 63, 64
Minimum dose specifications apply:
Sections 45, 52M/F, 53, 54 M/F, 55, 57, 58, 61, 65, 66

Orbital/Eye

10-11

Any dose:
Sections 42, 46, 47, 48, 49, 50, 51M/F, 56
Minimum dose specifications apply:
Sections 45, 52M/F, 53, 54M/F, 55, 57

Ear/Infratemporal

10-11

Any dose:
Sections 42, 43, 44, 46, 47, 48, 49, 50, 51M/F
Minimum dose specifications apply:
Sections 45, 52M/F, 53, 54M/F, 55, 58

Nasopharyngeal

10-13

Any dose:
Sections 42, 46, 47, 48, 49, 50, 51M/F, 59, 60, 62, 63, 64
Minimum dose specifications apply:
Sections 45, 52M/F, 53, 54M/F, 55, 58, 61, 65, 66

Oropharyngeal

10, 12-13

Any dose:
Sections 59, 60, 62, 63, 64
Minimum dose specifications apply:
Sections 61, 65, 66

Waldeyer’s Ring

10-13

Any dose:
Sections 42, 46, 47, 48, 49, 50, 51M/F, 59, 60, 62, 63, 64
Minimum dose specifications apply:
Sections 45, 52M/F, 53, 54M/F, 55, 58, 61, 65, 66

Spine (cervical)

10, 12-13, 18, 25

Spine (thoracic)

10, 16, 18, 20, 25-26

Any dose:
Sections 59, 60, 62, 63, 64, 88
Minimum dose specifications apply:
Sections 61, 65, 66, 67, 73, 91
Any dose:
Sections 71M/F, 88, 89, 90
Minimum dose specifications apply:
Sections 73, 76, 77, 78, 91

Spine (lumbar)

10, 20, 23, 25

Any dose:
Sections 83F, 84F, 88
Minimum dose specifications apply:
Sections 76, 77, 78, 91

Spine (sacral)

10, 20, 22-23, 25

Spine (whole)

10, 12-13, 16, 18,
20, 22-23, 25-26

Any dose:
Sections 82, 83F, 84F, 88
Minimum dose specifications apply:
Sections 76, 77, 78, 80, 81, 91
Any dose:
Sections 59, 60, 62, 63, 64, 71M/F, 82, 83F, 84F, 88, 89, 90
Minimum dose specifications apply:
Sections 61, 65, 66, 67, 73, 76, 77, 78, 80, 81, 91

SPINE:

Radiation Reference Guide
Index – Page 1

RADIATION FIELD

SEE PAGESPOTENTIALLY RELEVANT SECTION NUMBERS

NECK:
Cervical (neck)
Supraclavicular

10, 12-13, 18, 25

Any dose:
Sections 59, 60, 62, 63, 64, 88
Minimum dose specifications apply:
Sections 61, 65, 66, 67, 73, 91

Mini-Mantle

10, 12-15, 18, 25

Any dose:
Sections 59, 60, 62, 63, 64, 69F, 70, 88
Minimum dose specifications apply:
Sections 61, 65, 66, 67, 68F, 73, 91

Mantle10, 12-16, 18, 25-26

Any dose:
Sections 59, 60, 62, 63, 64, 69F, 70, 71M/F, 88, 89, 90
Minimum dose specifications apply:
Sections 61, 65, 66, 67, 68F, 73, 91

Extended Mantle

10, 12-16, 18-21,
25-26

Any dose:
Sections 59, 60, 62, 63, 64, 69F, 70, 71M/F, 79, 88, 89, 90
Minimum dose specifications apply:
Sections 61, 65, 66, 67, 68F, 73, 74, 75, 76, 77, 78, 91

Subtotal Lymphoid (STLI)

10, 12-21, 25-26

Any dose:
Sections 59, 60, 62, 63, 64, 69F, 70, 71M/F, 79, 88, 89, 90
Minimum dose specifications apply:
Sections 61, 65, 66, 67, 68F, 72, 73, 74, 75, 76, 77, 78, 91

Total Lymphoid (TLI)

10, 12-26

Any dose:
Sections 59, 60, 62, 63, 64, 69F, 70, 71M/F, 79, 82, 83F, 84F, 85F,
86M, 88, 89, 90
Minimum dose specifications apply:
Sections 61, 65, 66, 67, 68F, 72, 73, 74, 75, 76, 77, 78, 80, 81, 87M, 91

Axilla10, 14-15, 25

Any dose:
Sections 69F, 70, 88
Minimum dose specifications apply:
Sections 68F, 91

Mini-Mantle

See “Neck”

See “Neck” (above)

MantleSee “Neck”

See “Neck” (above)

Extended Mantle

See “Neck”

See “Neck” (above)

Subtotal Lymphoid (STLI)

See “Neck”

See “Neck” (above)

Total Lymphoid (TLI)

See “Neck”

See “Neck” (above)

Chest (thorax):

10, 13-16, 18, 25-26

Any dose:
Sections 62, 63, 64, 69F, 70, 71M/F, 88, 89, 90
Minimum dose specifications apply:
Sections 65, 66, 67, 68F, 73, 91

Whole lung10, 13-16, 25-26

Any dose:
Sections 62, 63, 64, 69F, 70, 71M/F, 88, 89, 90

Mediastinal

10, 13-16, 18, 25-26

Any dose:
Sections 62, 63, 64, 69F, 70, 71M/F, 88, 89, 90
Minimum dose specifications apply:
Sections 65, 66, 67, 68F, 73, 91

Mini-Mantle

See “Neck”

See “Neck” (above)

MantleSee “Neck”

See “Neck” (above)

Extended Mantle

See “Neck”

See “Neck” (above)

Subtotal Lymphoid (STLI)

See “Neck”

See “Neck” (above)

Total Lymphoid (TLI)

See “Neck”

See “Neck” (above)

AXILLA:

THORAX:

Radiation Reference Guide
Index – Page 2

RADIATION FIELD

SEE PAGESPOTENTIALLY RELEVANT SECTION NUMBERS

ABDOMEN:
10, 16-21, 25-26

Any dose:
Sections 71M/F, 79, 88, 89, 90
Minimum dose specifications apply:
Sections 72 (if spleen in field*), 73, 74, 75, 76, 77, 78, 91*includes left upper quadrant, entire spleen, left flank/hemiabdomen, andparaaortic if spleen in field

Extended mantle

See “Neck”

See “Neck” (page 2)

Subtotal Lymphoid (STLI)

See “Neck”

See “Neck” (page 2)

Total Lymphoid (TLI)

See “Neck”

See “Neck” (page 2)

Inverted Y

10, 16-26

Any dose:
Sections 71 M/F, 79, 82, 83F, 84F, 85F, 86M, 88, 89, 90
Minimum dose specifications apply:
Sections 72 (if spleen in field), 73, 74, 75, 76, 77, 78, 80, 81, 87M, 91

Whole abdomen

10, 16-26

Any dose:
Sections 71M/F, 79, 82, 83F, 84F, 85F, 86M, 88, 89, 90
Minimum dose specifications apply:
Sections 72, 73, 74, 75, 76, 77, 78, 80, 81, 87M, 91

10, 20, 22-25

Any dose:
Sections 82 (except femoral), 83F (except iliac/inguinal/femoral),
84F (except inguinal/femoral), 85F (except inguinal/femoral), 86M, 88
Minimum dose specifications apply:
Sections 76, 77, 78, 80 (except femoral), 81 (except femoral), 87M, 91

Inverted Y

See “Abdomen”

See “Abdomen” (above)

Whole abdomen

See “Abdomen”

See “Abdomen” (above)

Total Lymphoid (TLI)

See “Neck”

See “Neck” (page 2)

10, 24

Any dose:
Section 86M
Minimum dose specifications apply:
Section 87M

10, 25

Any dose:
Section 88
Minimum dose specifications apply:
Section 91

Any abdominal field**Includes: Hepatic, renal,
upper
quadrant (right, left), spleen (partial,
entire), paraaortic, flank/hemiabdomen(right, left)

PELVIS:Any pelvic field****Iliac crest to 3 cm below ischium.
Includes: Pelvic, vaginal, prostate, bladder,iliac, inguinal, femoral; Flank/hemiabdomen
included only if field extended below iliac
crest

TESTICULAR:
Testicular

EXTREMITIES:Extremity (Upper, Lower)

Radiation Reference Guide
Index – Page 3

Long-Term Follow-Up Guidelines
for Survivors of Childhood, Adolescent,and Young Adult Cancers
Version 3.0 – October 2008

Health Link
Index

Copyright 2008 © Children’s Oncology GroupAll rights reserved worldwide

Long-Term Follow-Up Guidelines for Survivors ofChildhood, Adolescent, and Young Adult Cancers
Version 3.0 – September 2008

Index to “Health Links” by Guideline Section Number
Guideline
Section(s)1Health Link Abbreviated Title

Health Link - Full Title

Introduction toLong-Term Follow-Up

Introduction to Long-Term Follow-Up after
Treatment for Childhood, Adolescent, or Young
Adult Cancer

Emotional Issues

Emotional Issues after Childhood Cancer

Educational Issues

Educational Issues Following Treatment forChildhood Cancer

Chronic Pain

Chronic Pain after Childhood Cancer

2

Finding Healthcare

Finding and Paying for Healthcare after Treatment
for Childhood Cancer

3

Hepatitis

Hepatitis after Childhood Cancer

4

Hepatitis

Hepatitis after Childhood Cancer

6

Dental Health

Dental Health Following Childhood Cancer
Treatment

7 (male)Male Health Issues

Male Health Issues after Treatment forChildhood Cancer

7 (female)

Female Health Issues

Female Health Issues after Treatment forChildhood Cancer

8

Reducing Risk of Cancers

Reducing the Risk of Second Cancers

9

Pulmonary HealthPulmonary Health

10

Cataracts

Cataracts after Treatment for Childhood Cancer

11

Bladder Health

Bladder Health After Childhood Cancer

12

Bladder Health

Bladder Health After Childhood Cancer

13

Kidney Health

Kidney Health after Childhood Cancer

Single Kidney Health

Keeping Your Single Kidney Healthy(for mononephric patients only)

Hearing Loss

Hearing Loss after Treatment for Childhood
Cancer

Educational Issues

Educational Issues Following Treatment forChildhood Cancer

14

15

Peripheral Neuropathy

Peripheral Neuropathy

16

Kidney Health

Kidney Health after Childhood Cancer

Single Kidney Health

Keeping Your Single Kidney Healthy(for mononephric patients only)

17

Diet and Physical Activity

Staying Healthy through Diet and Physical Activity

18

Educational Issues

Educational Issues Following Treatment forChildhood Cancer

21

Liver Health

Liver Health after Childhood Cancer

22

Bone Health

Keeping Your Bones Healthy after Childhood
Cancer
Health Link Index
Page 1

Guideline
Section(s)23

Health Link Abbreviated Title

Health Link - Full Title

Kidney Health

Kidney Health after Childhood Cancer

Single Kidney Health

Keeping Your Single Kidney Healthy(for mononephric patients only)

24

Liver Health

Liver Health after Childhood Cancer

25

Educational Issues

Educational Issues Following Treatment forChildhood Cancer

27

Reducing Risk of Cancers

Reducing the Risk of Second Cancers

28

Heart Health

Keeping Your Heart Healthy after Treatment forChildhood Cancer

29

Pulmonary HealthPulmonary HealthBleomycin Alert

Bleomycin Alert

31

Bone Health

Keeping Your Bones Healthy after Childhood
Cancer32

Osteonecrosis

Osteonecrosis

33

Cataracts

Cataracts after Treatment for Childhood Cancer

35

Peripheral Neuropathy

Peripheral Neuropathy

36

Raynaud’s Phenomenon

Raynaud’s Phenomenon

37

Reducing Risk of Cancers

Reducing the Risk of Second Cancers

38

Reducing Risk of Cancers

Reducing the Risk of Second Cancers

39

Skin HealthSkin Health after Childhood Cancer

Reducing Risk of Cancers

Reducing the Risk of Second Cancers

40

Skin HealthSkin Health after Childhood Cancer

43

Educational Issues

Educational Issues Following Treatment forChildhood Cancer

48

Diet and Physical Activity

Staying Healthy through Diet and Physical Activity

49

Diet and Physical Activity

Staying Healthy through Diet and Physical Activity

50

Growth Hormone
Deficiency

Endocrine Problems after Childhood Cancer:
Growth Hormone Deficiency

Hypopituitarism

Endocrine Problems after Childhood Cancer:
Hypopituitarism

51

Precocious Puberty

Endocrine Problems after Childhood Cancer:
Precocious Puberty

52

Hyperprolactinemia

Endocrine Problems after Childhood Cancer:
Hyperprolactinemia

53

Thyroid Problems

Thyroid Problems after Childhood Cancer

Hypopituitarism

Endocrine Problems after Childhood Cancer:
Hypopituitarism

Male Health Issues

Male Health Issues after Treatment forChildhood Cancer

Hypopituitarism

Endocrine Problems after Childhood Cancer:
Hypopituitarism

Female Health Issues

Female Health Issues after Treatment forChildhood Cancer

54 (male)

54 (female)

Health Link Index
Page 2

Guideline
Section(s)Health Link Abbreviated Title

Health Link - Full Title

Hypopituitarism

Endocrine Problems after Childhood Cancer:
Hypopituitarism

Central Adrenal
Insufficiency

Endocrine Problems after Childhood Cancer:
Central Adrenal Insufficiency

Hypopituitarism

Endocrine Problems after Childhood Cancer:
Hypopituitarism

56

Cataracts

Cataracts after Treatment for Childhood Cancer

57

Eye Health

Keeping Your Eyes Healthy after Treatment forChildhood Cancer

58

Hearing Loss

Hearing Loss after Treatment for Childhood
Cancer

Educational Issues

Educational Issues Following Treatment forChildhood Cancer

59

Dental Health

Dental Health Following Childhood Cancer
Treatment

60

Dental Health

Dental Health Following Childhood Cancer
Treatment

61

Osteoradionecrosis

Osteoradionecrosis after Childhood Cancer

62

Thyroid Problems

Thyroid Problems after Childhood Cancer

63

Thyroid Problems

Thyroid Problems after Childhood Cancer

64

Thyroid Problems

Thyroid Problems after Childhood Cancer

65

Thyroid Problems

Thyroid Problems after Childhood Cancer

68 (female)

Breast Cancer

Breast Cancer following Treatment for Childhood
Cancer: Are You at Risk?

70

Pulmonary HealthPulmonary Health

71

Heart Health

Keeping Your Heart Healthy after Treatment forChildhood Cancer

Diet and Physical Activity

Staying Healthy through Diet and Physical Activity

Dental Health

Dental Health Following Childhood Cancer
Treatment

72

Splenic Precautions

Precautions for People Without a Functioning
Spleen73

GI Health

Gastrointestinal Health after Childhood Cancer

74

Liver Health

Liver Health after Childhood Cancer

75

GI Health

Gastrointestinal Health after Childhood Cancer

76

GI Health

Gastrointestinal Health after Childhood Cancer

77

GI Health

Gastrointestinal Health after Childhood Cancer

78

Colorectal Cancer

Colorectal Cancer Following Treatment forChildhood Cancer: Are You at Risk?

79

Kidney Health

Kidney Health after Childhood Cancer

Single Kidney Health

Keeping Your Single Kidney Healthy(for mononephric patients only)

Bladder Health

Bladder Health After Childhood Cancer

55

80

Health Link Index
Page 3

Guideline
Section(s)Health Link Abbreviated Title

Health Link - Full Title

81

Bladder Health

Bladder Health After Childhood Cancer82

Bladder Health

Bladder Health After Childhood Cancer

83 (female)

Female Health Issues

Female Health Issues after Treatment forChildhood Cancer

84 (female)

Female Health Issues

Female Health Issues after Treatment forChildhood Cancer

86 (male)

Male Health Issues

Male Health Issues after Treatment forChildhood Cancer

87 (male)

Male Health Issues

Male Health Issues after Treatment forChildhood Cancer

89

Scoliosis and Kyphosis

Scoliosis and Kyphosis after Treatment forChildhood Cancer

90

Scoliosis and Kyphosis

Scoliosis and Kyphosis after Treatment forChildhood Cancer

92

Reducing Risk of Cancers

Reducing the Risk of Second Cancers

93

Reducing Risk of Cancers

Reducing the Risk of Second Cancers

95

Liver Health

Liver Health after Childhood Cancer

GI Health

Gastrointestinal Health after Childhood Cancer

96

Osteonecrosis

Osteonecrosis

97

Bone Health

Keeping Your Bones Healthy afterChildhood Cancer

98

Skin HealthSkin Health after Childhood Cancer

99

Eye Health

Keeping Your Eyes Healthy after Treatment
for Childhood Cancer

100

Dental Health

Dental Health Following Childhood Cancer
Treatment

101

Pulmonary HealthPulmonary Health103

Splenic Precautions

Precautions for People Without a Functioning
Spleen104

GI Health

Gastrointestinal Health after Childhood Cancer

107

Amputation

Late Effects after Amputation for Childhood
Cancer109

Cystectomy

Cystectomy and Childhood Cancer

Kidney Health

Kidney Health after Childhood Cancer

110

Eye Health

Keeping Your Eyes Healthy after Treatment forChildhood Cancer

111 (female)

Female Health Issues

Female Health Issues after Treatment forChildhood Cancer

112

GI Health

Gastrointestinal Health after Childhood Cancer

113

Limb Sparing Procedures

Limb Sparing Procedures

114

Single Kidney Health

Keeping Your Single Kidney Healthy

Kidney Health

Kidney Health after Childhood Cancer
Health Link Index
Page 4

Guideline
Section(s)Health Link Abbreviated Title

Health Link - Full Title

115

Educational Issues

Educational Issues Following Treatment forChildhood Cancer

119

Neurogenic Bladder

Neurogenic Bladder Following Treatment forChildhood Cancer

121 (male)

Male Health Issues

Male Health Issues after Treatment forChildhood Cancer

123 (female)

Female Health Issues

Female Health Issues after Treatment forChildhood Cancer

124 (female)

Female Health Issues

Female Health Issues after Treatment forChildhood Cancer

125 (male)

Male Health Issues

Male Health Issues after Treatment forChildhood Cancer

128 (male)

Male Health Issues

Male Health Issues after Treatment forChildhood Cancer

130

Pulmonary HealthPulmonary Health131

Splenic Precautions

Precautions for People Without aFunctioning Spleen

132

Thyroid Problems

Thyroid Problems after Childhood Cancer

134

Thyroid Problems

Thyroid Problems after Childhood Cancer

135

Thyroid Problems

Thyroid Problems after Childhood Cancer

137 (female)

Breast Cancer

Breast Cancer following Treatment for Childhood
Cancer: Are You at Risk?

138 (female)

Reducing Risk of Cancers

Reducing the Risk of Second Cancers

139

Colorectal Cancer

Colorectal Cancer Following Treatment forChildhood Cancer: Are You at Risk?

140 (female)

Reducing Risk of Cancers

Reducing the Risk of Second Cancers

141

Reducing Risk of Cancers

Reducing the Risk of Second Cancers

142

Reducing Risk of Cancers

Reducing the Risk of Second Cancers

Dental Health

Dental Health Following Childhood Cancer
Treatment

143 (male)

Reducing Risk of Cancers

Reducing the Risk of Second Cancers

144

Reducing Risk of Cancers

Reducing the Risk of Second Cancers

Skin HealthSkin Health after Childhood Cancer

Health Link Index
Page 5