Long-Term
Follow-Up
Guidelines
for Survivors of Childhood,
Adolescent, and Young Adult
Cancers

Appendix I

Materials
for ClinicalApplications
Version 4.0
October 2013

Copyright 2013 © Children’s Oncology GroupAll rights reserved worldwide

Contents
Reference Materials

3

Abbreviations

4

Chemotherapy Agents

7

Summary of Cancer Treatment

8

Instructions

9

Summary Form Template (Abbreviated)

11

Summary Form Template (Comprehensive)

12

Summary Form Key

14

Patient-Specific Guideline Identification Tool

23

Instructions

24

Patient-Specific Guideline Identification Tool (version 4.0)

25

Section Number Comparison – COG LTFU Guidelines Version 3.0 vs 4.0

31

Radiation Reference Guide

36

Contents

37

Determining Applicability of Radiation Sections for Specific Patients Based on Exposure

30

Radiation Dose Calculation Examples

39

Radiation Fields Defined40

Radiation Fields by Anatomic Region

41

Guideline Radiation Section Numbers by Anatomic Region

42

Total Body Irradiation

43

Skin, Bones, Soft Tissues

44

Brain/Neuroendocrine Axis, Cranium, Face, Eye, Ear

45

Oral Cavity

46

Neck/Thyroid

47

Breast

48

Lungs

49

Heart

50

Spleen51

Esophagus

52

Liver

53

Bowel

54

Kidneys55

Bladder/Urinary Tract

56

Female Reproductive System

57

Male Reproductive System

58

Musculoskeletal System (Growth Problems, Radiation-Induced Fracture)59

Musculoskeletal System (Scoliosis/Kyphosis)

60

COG LTFU Guidelines 8 – Page 2

Version 4.0 – October 2013 – Contents

Long-Term
Follow-Up
Guidelines
for Survivors of Childhood,
Adolescent, and Young Adult
Cancers

Reference
Materials

Version 4.0
October 2013

Copyright 2013 © Children’s Oncology GroupAll rights reserved worldwideAbbreviations
Abbreviation

Definition

AAP-CIDP

American Academy of Pediatrics Committee on Infectious Disease Prevention

ABR

Brainstem auditory evoked responses

AFP

Alpha fetoprotein

ACS

American Cancer Society

AHA

American Heart Association

ALT

Alanine aminotransferase

AST

Aspartate aminotransferase

ATM

Ataxia telangiectasia cancer susceptibility gene located on chromosome 11

AVN

Avascular necrosis

BAER

Brainstem auditory evoked responses

BCNU

Carmustine

BMD

Bone mineral density

BMI

Body mass index

BRCA1

Breast cancer, early onset gene (cancer susceptibility gene located on chromosome 17)

BRCA2

Breast cancer 2, early onset gene (cancer susceptibility gene located on chromosome 13)

BUN

Blood urea nitrogen

Ca

Calcium

CBC

Complete blood count

CCG

Children’s Cancer Group

CCNU

Lomustine

CD-4

Cluster of differentiation antigen associated with helper T lymphocyte

CDC

Centers for Disease Control

cGVHD

Chronic graft versus host disease

Cl

Chloride

CNS

Central nervous system

CO2

Carbon dioxide

COG

Children’s Oncology GroupCSF

Cerebral spinal fluidCT

Computed tomography

CXR

Chest radiograph

DES

Diethylstilbestrol

DEXA

Dual energy x-ray absorptiometry

DLCO

Diffusion capacity of carbon monoxide

DOE

Dyspnea on exertion

EBMTEuropean Group for Blood and Marrow Transplant

ECHO

Echocardiogram

EKG

Electrocardiogram

EIA

Enzyme immunoassay

FAP

Familial adenomatous polyposis

FNA

Fine needle aspirate

FSH

Follicle stimulating hormoneGH

Growth hormone

GVHD

Graft versus host disease

COG LTFU Guidelines Reference Materials – Page 4

Version 4.0 – October 2013 – Abbreviations

Abbreviations (cont)Abbreviation

Definition

Gy

Gray

HBcAb

Hepatitis B core antibody

HBsAg

Hepatitis B surface antigen

HCT

Hematopoietic cell transplant

HCV

Hepatitis C virus

HDL

High-density lipoproteins

HIB

Haemophilus influenza B

HIV

Human immunodeficiency virus

HNPCC

Hereditary nonpolyposis colorectal cancer

HPF

High power field

HPV

Human papilloma virus

HRT

Hormonal replacement therapy

Hz

Hertz

IBD

Inflammatory bowel disease

K

Potassium

I-131

Iodine 131 radioisotope

IQ

Intelligence quotient

IT

Intrathecal

IV

Intravenous

IVIG

Intravenous immunoglobulin

KUB

Kidneys, ureters, bladder radiograph

LH

Luteinizing hormone

MIBG

Iodine-131-meta-iodobenzylguanidine

Mg

Magnesium

MOPP

Mechlorethamine, Oncovin, Procarbazine, Prednisone

MRI

Magnetic resonance imaging

MUGA

Multiple Gated Acquisition scanNa

SodiumNCEP

National Cholesterol Education Program

NCHS

National Center for Health Statistics

NF1

Neurofibromin 1 (neurofibromatosis) cancer susceptibility gene located on chromosome 17

NSAIDs

Non-steroidal anti-inflammatory drugs

OAE

Otoacoustic emissions

OCP

Oral contraceptive pills

PAP

Papanicoulau

PCR

Polymerase chain reaction

PFTs

Pulmonary function tests

p53

Cancer susceptibility gene located on chromosome 17 associated with familial cancers

PO

By mouth

PO4

Phosphate

PRN

As needed

PSA

Prostate specific antigen

QCT

Quantitative computed tomography

COG LTFU Guidelines Reference Materials – Page 5

Version 4.0 – October 2013 – Abbreviations

Abbreviations (cont)Abbreviation

Definition

QTc

Corrected QT interval

RB1

Retinoblastoma gene – cancer susceptibility gene located on chromosome 13

RBC

Red blood cell

RDA

Recommended daily allowance

RUQ

Right upper quadrant

SCUBA

Self-contained underwater breathing apparatus

SDStandard deviation

SOB

Shortness of breath

T4

Thyroxine

TBI

Total body irradiation

TPN

Total parenteral nutrition

TSH

Thyroid stimulating hormone

U/A

Urinalysis

USPSTF

United States Preventive Services Task Force

VOD

Veno-occlusive disease

VZIG

Varicella zoster immunoglobulin

COG LTFU Guidelines Reference Materials – Page 6

Version 4.0 – October 2013 – Abbreviations

Chemotherapy Agents
Generic Name

Additional Name(s)Classification

Generic Name

Additional Name(s)Classification

AsparaginaseElspar®

EnzymeMercaptopurine

6-Mercaptopurine
6-MP
Purinethol®

Antimetabolite

Methotextrate

Amethopterin
Folex®
Mexate®
Trexall®

Antimetabolite

Mitoxantrone

Novantrone®

Anthracycline antibiotic

Prednisone

Deltasone®
Methylprednisolone
Prednisolone

Corticosteroid

Procarbazine

Matulane®
Natulan®

Alkylating agent

Temozolomide

Temodal®
Temodar®

Non-classical alkylator

Teniposide

VM-26
Vumon®

Epipodophyllotoxin

Thioguanine

Lanvis®
Tabloid®
6-Thioguanine
6-TG

Antimetabolite

Thiotepa

Thioplex®

Alkylating agent

Vinblastine

VBL
Velban®
Velbe®

Plant alkaloid

Vincristine

Oncovin®
VCR
Vincasar®
Vincrex®

Plant alkaloid

Erwinia asparaginase
Kidrolase®
L-asparaginase
Oncaspar®
PEG-asparaginase
Bleomycin

Blenoxane®

Anti-tumor antibiotic

BusulfanBusulfex®

Alkylating agent

Busulphan
Myleran®
Carboplatin

CBDCA
Paraplatin®

Heavy metal

CarmustineBCNU
BiCNU®

Alkylating agent

Chlorambucil

Leukeran®

Alkylating agent

Cisplatin

CDDP
Cisplatinum
Platinol®

Heavy metal

Cyclophosphamide

CPM
Cytoxan®
Neosar®
Procytox®

Alkylating agent

Cytarabine

Ara-C
Cytosar®
Cytosar-U®
Cytosine arabinoside

Antimetabolite

Dacarbazine

DTIC
DTIC-Dome®

Non-classical alkylator

Dactinomycin

Actinomycin-D
Cosmegen®

Anti-tumor antibiotic

Daunorubicin

Cerubidine®
Daunomycin
DaunoXome®

Anthracycline antibiotic

Dexamethasone

Decadron®

Corticosteroid

Doxorubicin

Adriamycin®
Doxil®
Rubex®

Anthracycline antibiotic

Epirubicin

Ellence®
Pharmorubicin PFS®

Anthracycline antibiotic

Etoposide

VePesid®
VP-16

Epipodophyllotoxin

Idarubicin

Idamycin®

Anthracycline antibiotic

Ifosfamide

Ifex®

Alkylating agent

Lomustine

CeeNU®
CCNU

Alkylating agent

Mechlorethamine

Mustargen®
Nitrogen Mustard

Alkylating agent

Melphalan

Alkeran®

Alkylating agent

COG LTFU Guidelines Reference Materials – Page 7

Version 4.0 – October 2013 – Chemotherapy AgentsLong-Term
Follow-Up
Guidelines
for Survivors of Childhood,
Adolescent, and Young Adult
Cancers

Summaryof Cancer
Treatment

Version 4.0
October 2013

Copyright 2013 © 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 of Childhood, 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, ispresumed. Patients who do not have a comprehensive treatment summary should be instructed to obtain one from the institution(s) where they received theirtreatment. 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 of administration for all agents, cumulative doses for alkylators, bleomycin, and anthracyclines, and designation of “high dose” versus “standard dose” for methotrexate 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 is defined as
all single doses < 1000 mg/m2. See Section 33 (male) or 34 (female) of Guidelines for anthracycline 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 ofradiation fields, see page 3 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 these guidelines, the following information regarding the survivor’s diagnosis andtreatment is required, at minimum:•

Survivor’s sex•

Survivor’s date of birth•

Date of cancer diagnosis•

Date cancer therapy was completed•

Names of all chemotherapy agents received. Note: For a list of chemotherapy agents addressed by these guidelines (Sections 10–43), 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 in Appendix 7.

•

Cumulative dose of all anthracycline chemotherapy received (i.e., doxorubicin, daunorubicin, idarubicin, mitoxantrone and epirubicin), and age at first anthracycline dose (if unknown, age at first anthracycline dose is presumed to be age at diagnosis). Note: For anthracycline isotoxic dose-equivalent conversion,see Sections 33 (male) or 34 (female) of Guidelines. For doses in mg/kg, multiply by 30 to obtain equivalent dosing in mg/m2 (example: 2 mg/kg =60 mg/m2).

•

For carboplatin:•––

Whether any dose was myeloablative (i.e., given as conditioning for HCT).

––

Whether survivor was < age 1 at time of diagnosis

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)

COG LTFU Guidelines Summary of Cancer Treatment – Page 9

Version 4.0 – October 2013 – Instructions

Summary of Cancer Treatment – Instructions (cont)•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 dose to 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 of radiation fields addressed by these guidelines (Sections 44–102), see “Radiation” portion of the Patient-Specific Guideline Identification Tool in Appendix 1; for definition of radiation fields, see page 3 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 120–152), see “Surgery” portion of
the Patient-Specific Guideline Identification Tool in Appendix 1.

•

Names of all other therapeutic modalities. Note: For list of other therapeutic modalities addressed by these guidelines (Sections 153–156), 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 also available in electronic format at www.survivorshipguidelines.org). These
templates were originally developed by the COG Nursing Clinical Practice Subcommittee under the leadership 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 anda working group from the National Cancer Institute. The abbreviated form contains all data elements currently necessary for generation of patient-specificrecommendations from the COG LTFU Guidelines, and meets the minimum data requirements for initial use of the “Passport for Care” web-based 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 for each childhood cancer survivor when feasible,
including a record of all therapeutic exposures with applicable dates, details of administration, and cumulative doses of all agents, including those not currently
addressed by these guidelines.
In addition to the treatment summary templates, a “key” for completing the comprehensive 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.

COG LTFU Guidelines Summary of Cancer Treatment – Page 10

Version 4.0 – October 2013 – Instructions (cont)Summary of Cancer Treatment (Abbreviated)
Demographics
Name:

Sex:

Date of Birth:

Cancer Diagnosis
Diagnosis:
Chemotherapy:

Date of Diagnosis:
❑ Yes

❑ No

Date Therapy Completed:

If yes, complete chart below
Additional Information†

Drug Name†Anthracyclines: Include cumulative dose in mg/m2 and age at first dose (see section 33 or 34 of Guidelines for isotoxic dose conversion);

Carboplatin: Indicate if dose was myeloablative and if patient was diagnosed at less than 1 year of age;
Methotrexate and Cytarabine: Indicate route of administration (i.e., IV, IM, SQ, PO, IT, IO);IV Methotrexate and Cytarabine: Indicate if “high dose” (any single dose ≥ 1000 mg/m2) or “standard dose” (all single doses < 1000 mg/m2)
Note: Cumulative doses, if known, should be recorded for all agents, particularly for alkylators and bleomycin.

Radiation:

❑ Yes

❑ No

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

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

❑ Yes

❑ No

❑ No

If yes, complete chart below

Procedure

Other Therapeutic Modalities ❑ Yes❑ Yes

Site (if applicable)❑ No

If yes, answer questions below

Did this patient receive radioiodine therapy (I-131 thyroid ablation)?
Did this patient receive systemic MIBG (in therapeutic doses)?
Did this patient receive bioimmunotherapy?

Laterality (if applicable)

❑ Yes

❑ Yes
❑ Yes

❑ No
❑ No

❑ No

Summary prepared by:

COG LTFU Guidelines Summary of Cancer Treatment – Page 11

Date prepared:

Version 4.0 – October 2013 – Summary (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:

Race/Ethnicity: (see list #1)

SS#

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)

❑ Yes

Date:

❑ No

If yes, provide information below

Site(s):Subsequent malignant neoplasm(s)Laterality: ❑ Right ❑ Left ❑ NA
❑ Yes

Date:

❑ No

Date therapy completed:

If yes, provide information below

Type: (see list #4)

Stage/Site(s):Date therapy completed:

Cancer Treatment Summary
Protocol(s)❑ YesAcronym/Number

Chemotherapy❑ No

If yes, provide information below

Title/Description

❑ Yes

❑ No

Initiated

Completed

On-Study

If yes, provide information below

Drug Name

Route

Additional Information†(see list # 5)(see list #6)(see list #7)†Anthracyclines: Include cumulative dose in mg/m2 and age at first dose (see section 28 of Guidelines for isotoxic dose conversion);

Carboplatin: Indicate if dose was myeloablative and if patient was diagnosed at less than 1 year of age;
IV Methotrexate and Cytarabine: Indicate if “high dose” (any single dose ≥ 1000 mg/m2) or “standard dose” (all single doses < 1000 mg/m2);
Note: Cumulative doses, if known, should be recorded for all agents, particularly for alkylators and bleomycin.

COG LTFU Guidelines Summary of Cancer Treatment – Page 12

Version 4.0 – October 2013 – Summary (Comprehensive)Summary of Cancer Treatment (Comprehensive) (cont)
Radiation❑ Yes

Site/Field❑ No

Laterality

If yes, complete chart below
Start Date

Stop Date

Fractions

Dose per Initial
Fraction Dose
(Gy)*
(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

❑ Yes

Type

Source(see list #11)

(see list #12)

❑ No

If yes, complete chart below
Date of Infusion

Conditioning Regimen

Institution/Treating MD(see list #13)

Tandem? Yes No
GVHD prophylaxis/treatment (For transplant patients only)
Type

❑ Yes

❑ No

If yes, complete chart below

First Dose

Last Dose(see list #14)
Was this patient ever diagnosed with chronic graft-versus-host disease (cGVHD)?
Surgery

❑ Yes

❑ No

Date

❑ Yes

❑ No

If yes, complete chart below

Procedure

Site (if applicable)

Laterality (if applicable)

Surgeon/Institution(see list #15)

Other Therapeutic Modalities

❑ Yes

❑ No

If yes, complete chart below

Therapy

Route

Cumulative Dose (if known)(see list # 16)(see list #6)(see list #7)

Complications/Late Effects
Problem

❑ Yes

❑ No

If yes, complete chart below

Date onset

Date resolved(see list #17)

Status❑ Active ❑ Resolved❑ Active ❑ Resolved❑ Active ❑ Resolved❑ Active ❑ Resolved❑ Active ❑ Resolved

Adverse Drug Reactions/Allergies
Drug

❑ Yes

❑ No

If yes, complete chart below

Reaction

Date

Status❑ Active ❑ Resolved❑ Active ❑ Resolved

Additional Information/Comments

❑ Yes

❑ No

If yes, provide information below

Summary prepared by: (name/title/institution)

Date prepared:

Summary updated by: (name/title/institution)

Date updated:

COG LTFU Guidelines Summary of Cancer Treatment – Page 13

Version 4.0 – October 2013 – Summary (Comprehensive)Key for Completing Summary of Cancer Treatment Form
(Comprehensive Version)#1: Race/Ethnicity#2: Cancer Diagnosis (cont)

Asian

Germ cell tumor (extracranial) (cont)Black/African American

Teratoma

Caucasian (non-Hispanic/non-Latino)

MatureHispanic or Latino

Immature

Native American/Alaskan Native

With malignant transformation

Native Hawaiian/Pacific Islander

Germ cell tumor, other, specify:

Multi-racial/multi-ethnic

Langerhans cell histiocytosis

Other (specify):

Leukemia#2: Cancer Diagnosis

Acute lymphoblastic leukemia

Central Nervous System Tumor

Acute myeloid leukemia

Astrocytoma

Chronic myeloid leukemia

Cerebellar astrocytoma

Myelodysplastic syndrome

Supratentorial astrocytoma

Myeloproliferative disorder

Brainstem glioma

Leukemia, other, specify:

Choroid plexus neoplasm

Liver tumor

Craniopharyngioma

Hepatoblastoma

Ependymoma

Hepatocellular carcinoma

Germ cell tumor, intracranial

Liver tumor, other, specify:

Optic glioma

Lymphoma

Pineal tumor

Hodgkin lymphoma

PNET

Non-Hodgkin lymphoma

Cerebellar (medulloblastoma)

Lymphoblastic lymphoma

Supratentorial PNET

Burkitt’s lymphoma

Spinal cord tumor, intramedullary
CNS tumor, other, specify:
Endocrine tumor

Large cell lymphoma
Anaplastic large cell lymphoma
Diffuse large B-cell lymphoma

Adrenal tumor (non-neuroblastoma)

Lymphoma, other, specify:

Thyroid tumor

Nasopharyngeal carcinoma

Parathyroid tumor

Neuroblastoma

Gastroenteropancreatic tumor

Ganglioneuroblastoma

Multiple endocrine neoplasia syndrome

Renal tumor

Endocrine tumor, other, specify:

Wilms tumor

Germ cell tumor (extracranial)

Clear cell sarcoma

Seminoma

Renal cell carcinoma

Germinoma

Renal tumor, other:Dysgerminoma

Retinoblastoma

Non-seminomas

Sarcoma

Yolk sac tumor

Ewing’s sarcoma/peripheral PNET

Embryonal carcinoma

Osteogenic sarcoma

Choriocarcinoma

Rhabdomyosarcoma

COG LTFU Guidelines Summary of Cancer Treatment – Page 14

Version 4.0 – October 2013 – Summary Key

Key for Completing Summary of Cancer Treatment Form
(Comprehensive Version) (cont)#2: Cancer Diagnosis (cont)#4 Subsequent Malignancy Diagnosis (cont)

Sarcoma (cont)

Gastrointestinal cancer (cont)

Soft tissue sarcoma (nonrhabdomyosarcomatous)

Pancreatic cancer

Alveolar soft part sarcoma

Other GI cancer, specify:

Fibrosarcoma

Leukemia

Leiomyosarcoma

Acute lymphoblastic leukemia

Liposarcoma

Acute myeloid leukemia

Malignant fibrous histiocytoma

Chronic myeloid leukemia

Malignant peripheral nerve sheath tumor

Myelodysplastic syndrome

Neurofibrosarcoma

Myeloproliferative disorder

Synovial sarcoma

Leukemia, other, specify:

Undifferentiated sarcoma

Lung cancer

Sarcoma, other, specify:

Lymphoma

Skin cancer

Hodgkin lymphoma

Basal cell carcinoma

Non-Hodgkin lymphoma

Malignant melanoma

Lymphoblastic lymphoma

Squamous cell carcinoma

Burkitt’s lymphoma

Skin cancer, other, specify:

Large cell lymphoma

Malignancy, other, specify:

Post-transplant lymphoproliferative disorder (PTLD)

Diagnosis, other, specify:

Lymphoma, other, specify:#3: Hereditary/Congenital History

Peripheral nerve sheath tumor/Schwannoma/Acoustic neuroma

Congenital heart disease

Renal cancer

Congenital disease, other, specify:

Renal cell carcinoma

Hemihypertrophy

Clear cell sarcoma

Neurofibromatosis, specify: Type I, Type II

Other renal cancer, specify:

Down syndrome

SarcomaSyndrome, other, specify:

Ewing’s sarcoma/peripheral PNET

Hereditary condition, other, specify:

Osteogenic sarcoma

None

Rhabdomyosarcoma

Unknown

Soft tissue sarcoma (nonrhabdomyosarcomatous)#4: Subsequent Malignancy Diagnosis

Undifferentiated sarcoma

Bladder cancer

Other sarcoma, specify:

Breast cancer

Skin cancer

Central nervous system tumor

Basal cell carcinoma

Malignant, specify type and location:

Malignant melanoma

Meningioma, specify location:

Squamous cell carcinoma

Other CNS tumor, specify type:

Thyroid cancer

Cervical cancer

Other malignancy, specify:

Gastrointestinal cancer

None

Esophageal cancer

Unknown

Stomach cancer
Colorectal cancer
Hepatocellular carcinoma

COG LTFU Guidelines Summary of Cancer Treatment – Page 15

Version 4.0 – October 2013 – Summary Key

Key for Completing Summary of Cancer Treatment Form
(Comprehensive Version) (cont)#5: Chemotherapy#5: Chemotherapy (cont)

Asparaginase

Temozolomide

Bleomycin

Teniposide (VM-26)

BusulfanThioguanine (6-TG)

Carboplatin
Myeloablative dose? ❑ Yes ❑ No
Diagnosed at less than 1 year of age? ❑ Yes ❑ No

Thiotepa

Carmustine (BCNU)
Chlorambucil
Cisplatin
Cladribine
Clofarabine
Cyclophosphamide
Cytarabine
If IV: Any single dose ≥ 1000 mg/m2? ❑ Yes ❑ No
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? ❑ Yes ❑ No
Mitoxantrone
Oxaliplatin
Paclitaxel
Prednisone
Procarbazine

COG LTFU Guidelines Summary of Cancer Treatment – Page 16

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 andoptional 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

Version 4.0 – October 2013 – Summary Key

Key for Completing Summary of Cancer Treatment Form
(Comprehensive Version) (cont)#8: Radiation Site/Field (cont)#8: Radiation Site/Field (cont)Spine

Other, specify:

Spine – cervical

None

Spine – thoracic

Unknown

Spine – lumbar

Add comment:

Spine – sacral#9: Radiation Boost

Spine – whole

Tumor bed, specify location:

Axilla, specify: Right, left, bilateral

Other location, specify:

ThoraxNone

Chest (thorax)

Unknown

Whole lung, specify: ❑ Right ❑ Left ❑ Bilateral

Add comment:

Mediastinal#10: Radiation Type

Chest, other, specify:

Brachytherapy

Abdomen

Conformal

Hepatic

External beam (conventional)

Renal, specify: ❑ Right ❑ Left ❑ Bilateral

IMRT

Upper quadrant, specify: ❑ Right ❑ Left ❑ Bilateral

Proton beam

Spleen, specify: partial, entire

Stereotactic

Paraaortic
Flank/hemiabdomen, specify: ❑ Right ❑ Left; specify:
Extended below iliac crest: ❑ Yes ❑ No

Other, specify:

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)

COG LTFU Guidelines Summary of Cancer Treatment – Page 17

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

Version 4.0 – October 2013 – Summary Key

Key for Completing Summary of Cancer Treatment Form
(Comprehensive Version) (cont)#13: Hematopoietic Cell Transplant – Conditioning Regimen (cont)#16: Other Therapeutic Modalities

Fludarabine

Systemic Radiation

MelphalanRadioiodine therapy (I-131 thyroid ablation)

Thiotepa

Systemic MIBG (in therapeutic doses)

TBI

Other, specify:

Other, specify:

Bioimmunotherapy

Unknown

Hematopoietic growth factors:#14: GVHD Prophylaxis/Treatment

G-CSF

ATG

Erythropoietin

Cyclosporine

Thrombopoietin

Methotrexate

Bioimmunotherapy (cont)

MMF (mycophenolate mofetil)Interferon:Prednisone
PUVA

Alpha interferon
Gamma interferon

SirolimusInterleukin:

Tacrolimus

IL-2

Other, specify:

IL-11

None

Other, specify:

Unknown

Monoclonal antibody, specify type:#15: Surgery

Retinoic acid, specify type:

Amputation, specify: ❑ Right ❑ Left ❑ Bilateral; specify site:

Other, specify:

Central venous catheter

Other therapeutic modality, specify:

Cystectomy

None

Enucleation, specify: ❑ Right ❑ Left ❑ Bilateral

Unknown

Hysterectomy#17: Complications/Late Effects (by system)

Laparotomy

Psychosocial

Limb sparing procedure, specify: ❑ Right ❑ Left ❑ Bilateral; specify site:

Behavioral problems/behavioral change

Nephrectomy, specify: ❑ Right ❑ Left ❑ Bilateral

Educational problems

Neurosurgery – brain

Under-/Unemployment

Neurosurgery – spinal cord

Dysfunctional marital relationship

Oophoropexy

Dependent living

Oophorectomy, specify: ❑ Right ❑ Left ❑ Bilateral

Fatigue

Orchiectomy, specify: ❑ Right ❑ Left ❑ Bilateral

Limitations in healthcare access and/or insurance

Pelvic surgery

Psychosocial disability due to pain

Thoracic surgery*

Anxiety

Splenectomy

Depression

Thyroidectomy

Suicidal ideation

Other, specify:

Post-traumatic stress

None

Psychosocial disability due to pain

Unknown

Social withdrawal

Add comment:*Thoracic surgery includes: thoracotomy, chest wall surgery, rib resection, pulmonary
lobectomy, pulmonary metastasectomy, and pulmonary wedge resection

COG LTFU Guidelines Summary of Cancer Treatment – Page 18

Version 4.0 – October 2013 – Summary Key

Key for Completing Summary of Cancer Treatment Form
(Comprehensive Version) (cont)#17: Complications/Late Effects (by system) (cont)#17: Complications/Late Effects (by system) (cont)Psychosocial (cont)

DentalRisky behaviors

Dental abnormalities

Tobacco use

Enamel dysplasia

Alcohol abuse

Root thinning/shortening

Substance abuse

Tooth/root agenesis

Other, specify:

Microdontia

Psychosocial maladjustment

Periodontal disease

Impaired quality of life

Tooth decay

Psychosocial complication, other, specify:

Malocclusion

OcularXerostomia (salivary gland dysfunction)

Cataract

Osteoradionecrosis

Enophthalmos

Temporomandibular joint dysfunction

Orbital hypoplasia

Dental complication, other, specify:

Glaucoma

Cardiovascular

Keratitis

Arrhythmia

Xerophthalmia (keratoconjunctivitis sicca)

Atherosclerotic heart disease

Lacrimal duct atrophy

Cardiomyopathy

Optic chiasm neuropathy

Congestive heart failure

Retinopathy

Myocardial infarction

Telangiectasia

Pericardial fibrosis

Maculopathy

Pericarditis

Papillopathy

Subclinical left ventricular dysfunction

Chronic painful eye

Valvular disease

Visual impairment (uncorrectable)

Carotid artery disease

Ocular nerve palsy

Subclavian artery disease

Gaze paresis

Thrombosis/vascular insufficiency (related to central line)

Nystagmus

Vasospastic attacks (Raynaud’s phenomenon)

Papilledema

Cardiovascular complication, other, specify:

Optic atrophy

Pulmonary

Ocular complication, other, specify:

Bronchiolitis obliterans

Auditory

Interstitial pneumonitis

Eustachian tube dysfunction

Pulmonary fibrosis

Hearing loss (requires hearing aids? ❑ Yes ❑ No

Pulmonary dysfunction

Specify type: ❑ Sensorineural hearing loss ❑ Conductive hearing loss

Acute respiratory distress syndrome (ARDS)

Otosclerosis

Obstructive lung disease

Tinnitus

Restrictive lung disease

Tympanosclerosis

Chronic bronchitis

VertigoBronchiectasis

Auditory complication, other, specify:

Pulmonary complication, other, specify:
Gastrointestinal/Hepatic
Abdominal adhesions
Bowel obstruction

COG LTFU Guidelines Summary of Cancer Treatment – Page 19

Version 4.0 – October 2013 – Summary Key

Key for Completing Summary of Cancer Treatment Form
(Comprehensive Version) (cont)#17: Complications/Late Effects (by system) (cont)#17: Complications/Late Effects (by system) (cont)

Gastrointestinal/Hepatic (cont)

Endocrine/Metabolic (cont)

Bowel strictures

Adrenal insufficiency

Fecal incontinencePrimary adrenal insufficiency (adrenal gland failure)

Cholelithiasis

Secondary (central) adrenal insufficiency (ACTH deficiency)

Cholecystitis

Hyperprolactinemia

Chronic enterocolitis

Growth deceleration

Esophageal stricture

Growth hormone deficiency

FistulaShort stature (< 5th percentile)

Malabsorption

Endocrine/metabolic complication, other, specify:

Nutritional deficiency

Musculoskeletal

Vitamin B12, folate or carotene deficiency

Amputation, specify type and site:

Cirrhosis

Osteonecrosis (avascular necrosis – AVN), specify site:

Hepatic fibrosis

Craniofacial abnormalities

Hepatic dysfunction

Impaired cosmesis

Chronic hepatitis (non-infectious)

Contractures

Iron overload

Functional and activity limitation, specify:

Venocclusive disease (VOD) of the liver

Hypoplasia, specify site:

Focal nodular hyperplasia

Kyphosis

Gastrointestinal/hepatic complication, other, specify:

Limb length discrepancy

Endocrine/Metabolic

Limb salvage, specify type and site:

Hypothyroidism

Phantom pain

Primary hypothyroidism (thyroid gland failure)

Prosthesis, malfunction (poor fit, loosening, non-union, fracture)

Secondary (central) hypothyroidism (TR/TSH deficiency)

Prosthesis, revision required due to growthHyperthyroidism

Reduced bone mineral density

Thyroid nodule

Residual limb integrity problems

Precocious puberty

Fracture (radiation-induced)

Gonadal dysfunction/failure

Increased energy expenditure (related to amputation/limb salvage)

Gonadotropin deficiency (LH/FSH deficiency) [central gonadal failure]

Fibrosis (musculoskeletal)

Gonadal dysfunction – testicular: See Reproductive (male)

Scoliosis

Gonadal dysfunction – ovarian: See Reproductive (female)

Short stature

Metabolic syndrome

Shortened trunk height

Overweight (Age 2–20 yrs: BMI for age ≥ 85 – <95%ile;
Age > 20 yrs: BMI 25 to 29.9)

Reduced/uneven growth

Obesity (Age 2–20 yrs: BMI for age ≥ 95%ile; Age > 20 yrs, BMI ≥ 30)

Central Nervous System (CNS)

Underweight (FTT)

Clinical leukoencephalopathy

Musculoskeletal complication, other, specify:

Insulin resistanceWith imaging abnormalities

Impaired glucose tolerance

Without imaging abnormalities

Diabetes mellitus

Learning disorder/disability

Type I

Math

Type II

Reading

Gestational
Dyslipidemia

COG LTFU Guidelines Summary of Cancer Treatment – Page 20

Other, specify:
Motor deficit

Version 4.0 – October 2013 – Summary Key

Key for Completing Summary of Cancer Treatment Form
(Comprehensive Version) (cont)#17: Complications/Late Effects (by system) (cont)#17: Complications/Late Effects (by system) (cont)Central Nervous System (CNS) (cont)

Urinary (cont)

Neurocognitive deficit, specify:

Proteinuria

Diminished IQ

Chronic UTI

Executive function (planning/organization)

Asymptomatic bacteriuria

Sustained attention

Neobladder perforation

MemoryUrinary tract obstruction (due to retroperitoneal fibrosis)

Processing speed

Stricture, urinary tract, specify:

Visual-motor integration

Urinary complication, other, specify:

Fine motor dexterity

Reproductive – Female

LanguageBreast tissue hypoplasia

Moyamoya

Uterine vascular insufficiency

Cavernomas

Adverse pregnancy outcome

AtaxiaPregnancy complications

Movement disorder

Delivery complications

Neurogenic bladder

Fetal malposition

Neurogenic bowel

Low birthweight infant

Paralysis

Spontaneous abortion

Occlusive cerebral vasculopathy

Premature labor

Seizures

Neonatal death

StrokeGonadal dysfunction – ovarian

CNS complication, other, specify:

Primary ovarian failure

Peripheral Nervous System (PNS)

Delayed/arrested puberty

Peripheral sensory neuropathy

Premature menopause

Peripheral motor neuropathy

Infertility

PNS complication, other, specify:

Inability to conceive (despite normal ovarian function)

Urinary

Dyspareunia

Hydronephrosis, specify: Right, left, bilateral

Symptomatic ovarian cysts

Hypertension

Pelvic adhesions

MononephricPsychosexual dysfunction

Renal insufficiency

Vaginal stenosis/fibrosis

Renal glomerular disorder#17: Complications/Late Effects (by system) (cont)

Hyperfiltration
Renal tubular disorder

Reproductive – Male
Gonadal dysfunction – testicularHypophosphatemic rickets

Germ cell failure

Renal Fanconi syndrome

Azoospermia

Renal tubular acidosis

Oligospermia

Vesicoureteral reflux
Bladder fibrosis

Infertility
Leydig cell failure

Urinary incontinence

Hypogonadism (testosterone deficiency)

Reservoir calculi

Delayed/arrested puberty

Dysfunctional voiding
Hemorrhagic cystitis

COG LTFU Guidelines Summary of Cancer Treatment – Page 21

Version 4.0 – October 2013 – Summary Key

Key for Completing Summary of Cancer Treatment Form
(Comprehensive Version) (cont)#17: Complications/Late Effects (by system) (cont)
Reproductive – Male (cont)Psychosexual 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
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

COG LTFU Guidelines Summary of Cancer Treatment – Page 22

Version 4.0 – October 2013 – Summary Key

Long-Term
Follow-Up
Guidelines
for Survivors of Childhood,
Adolescent, and Young Adult
Cancers

Patient-Specific
Guideline
Identification
Tool
Version 4.0
October 2013

Copyright 2013 © Children’s Oncology GroupAll rights reserved worldwide

Instructions for Using the Patient-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 modality that 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, andindicated conditions.

3.

Compile a list of all section numbers generated during steps 1 and 2. Include the following sections as applicable:––

Sections 1–6

Applicable to all patients––

Section 7

Patients diagnosed before 1972––

Section 8

Patients diagnosed before 1993––

Section 9

Patients diagnosed between 1977 and 1985––

Section 10

All patients who received chemotherapy––

Sections 103–110

All patients who underwent hematopoietic cell transplant

––

––

•

Section 103 is for patients with autologous transplant only•

Section 104 is for males only•

Section 105 is for females only

Sections 111–119

Patients with history of chronic graft-vs-host (cGVHD) disease*•*Section 116 is for patients with active cGVHD only•

*Section 118 is for females only

Section 166

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 is indicated, follow the instructions for “Determining Applicability of Radiation
Sections for Specific Patients Based on Exposure” (see page 56 of Guidelines or page 36 of the Radiation Reference Guide within Appendix I). Delete fromyour list those radiation section(s) for which this patient did not receive the minimum radiation exposure at which the section(s) become applicable.

5.

You now have a finalized list of all guideline sections applicable to this patient.

COG LTFU Guidelines Patient-Specific Guideline Identification Tool – Page 24

Version 4.0 – October 2013 – Instructions

Patient-Specific Guideline Identification Tool (version 4.0)
(Applicable Guideline Sections indicated in Bold/Red; M=Male; F=Female)
Name:

Sex: ❑ M ❑ F

Cancer Diagnosis: _________________

Date of Diagnosis: _________❑ Sections 1–6 applicable to all patients

Prior to 1972: ❑Prior to 1993: ❑1977–1985: ❑CHEMOTHERAPY: ❑ Yes ❑ No

Section 7
Section 8
Section 9

Date of Birth:

End Therapy Date: _____________
LTFU guidelines are applicable to patients who are ≥ 2 years
following completion of cancer therapy.

If yes: ✓ Section 10 and applicable guidelines for specific chemotherapy agents below

Chemotherapy Agent(mark if patient received)

Applicable guideline sections

Asparaginase

Section 40

Bleomycin

Section 35

BusulfanSections 11(M), 12(M), 13(F), 14, 15, 16

Carboplatin – all doses– myeloablative dose or age < 1 year at diagnosis

Sections 11(M), 12(M), 13(F), 14, 21, 22
See also: Section 20

Note: Myeloablative dose = conditioning for HCT

Carmustine

Sections 11(M), 12(M), 13(F), 14, 15

Chlorambucil

Sections 11(M), 12(M), 13(F), 14

Cisplatin

Sections 11(M), 12(M), 13(F), 14, 20, 21, 22

Cyclophosphamide

Sections 11(M), 12(M), 13(F), 14, 17, 18

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

Section 25

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

Cytarabine: High-dose IV

Sections 23, 24

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

Dacarbazine

Sections 11(M), 12(M), 13(F), 14

Dactinomycin

Section 36

Daunorubicin*
Cumulative dose: ______ mg/m2
Age at first dose: ______

Sections 32, 33(M), 34(F)Cumulative dose × 1 =______ mg/m2 = doxorubicin isotoxic dose

Dexamethasone

Sections 37, 38, 39

Doxorubicin*
Cumulative dose: ______ mg/m2
Age at first dose: ______

Sections 32, 33(M), 34(F)Cumulative dose × 1 =______ mg/m2 = doxorubicin isotoxic dose

Epirubicin*
Cumulative dose: ______ mg/m2
Age at first dose: ______

Sections 32, 33(M), 34(F)Cumulative dose × 0.67 = ______ mg/m2 = doxorubicin isotoxic dose

Etoposide (VP-16)

Section 43

Idarubicin*
Cumulative dose: ______ mg/m2
Age at first dose: ______

Sections 32, 33(M), 34(F)Cumulative dose × 5 =______ mg/m2 = doxorubicin isotoxic dose

Ifosfamide

Sections 11(M), 12(M), 13(F), 14, 17, 19

Lomustine

Sections 11(M), 12(M), 13(F), 14, 15

Mechlorethamine

Sections 11(M), 12(M), 13(F), 14

Melphalan

Sections 11(M), 12(M), 13(F), 14

Mercaptopurine (6-MP)

Section 26*Use formulas below to convert to doxorubicin isotoxic equivalents prior to calculating total cumulative anthracycline dose:
Doxorubicin – multiply total dose × 1
Daunorubicin – multiply total dose × 1
Epirubicin – multiply total dose × 0.67
Idarubicin – multiply total dose × 5
Mitoxantrone – multiply total dose × 4
Note: There is a paucity of literature to support isotoxic dose conversion; however, the above conversion factors may be used for convenience in order to gauge screening
frequency. Clinical judgment should ultimately be used to determine indicated screening for individual patients.

COG LTFU Guidelines Patient-Specific Guideline Identification Tool – Page 25

Version 4.0 – October 2013 – Guideline Identification Tool

Chemotherapy Agent (cont)(mark if patient received)

Applicable guideline sections

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

Sections 27, 28, 29

Methotrexate: High-dose IV, IT, IO

Sections 30, 31

Mitoxantrone* (see footnote on previous page)
Cumulative dose: ______ mg/m2
Age at first dose: ______

Sections 32, 33(M), 34(F)Cumulative dose × 4 = ______ mg/m2 = doxorubicin isotoxic dose

Prednisone

Sections 37, 38, 39

Procarbazine

Sections 11(M), 12(M), 13(F), 14

Temozolomide

Sections 11(M), 12(M), 13(F), 14

Teniposide (VM-26)

Section 43

Thioguanine (6-TG)

Section 26

Thiotepa

Sections 11(M), 12(M), 13(F), 14

Vinblastine

Sections 41, 42

Vincristine

Sections 41, 42

RADIATION: ❑ Yes ❑ No

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

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 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 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§Whole lung radiation, if given, should be included in minimum dose calculations for Sections 75, 76, 77(F), 83, and 102.

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 eachparticular patient based on their exposures•

For examples of radiation dose calculations, see pages 39–41 of the “Radiation Reference Guide”

Radiation by field§(mark all that apply)

Applicable guideline sections

All Radiation Fields
All radiation fields including TBI

Any dose

Sections 44, 45

All radiation fields except TBI

Any dose

Sections 46, 47

Any dose

Sections 44, 45, 48, 49, 50, 55, 64, 69, 71, 72, 73, 77(F)‡, 78(F), 79, 80(M), 81(F), 84, 85, 90‡,
91, 95(F), 96(F), 98(M), 100

Total Body Irradiation (TBI)
Total body irradiation (TBI)‡Screening may be indicated; refer to Info Link in this section§See instructions above

COG LTFU Guidelines Patient-Specific Guideline Identification Tool – Page 26

Version 4.0 – October 2013 – Guideline Identification Tool

Radiation by field§(mark all that apply)

Applicable guideline sections

Head/Brain
Cranial[Any field involving the cranium/
head, brain, and/or face]

Any dose

Sections 48, 49, 50, 52, 53, 54, 55, 56(M), 57(F), 64, 68, 69, 71, 72, 73

Minimum dose
specifications
apply

See Pages 45–47 of the Radiation Reference Guide within Appendix I to determine theapplicability of the following sections for this patient:
Sections 51, 58(M), 59(F), 60, 61(M), 62(F), 63, 65, 66, 67, 70, 74, 75

Orbital/Eye

Any dose

Sections 48, 52, 53, 54, 55, 56(M), 57(F), 64

Minimum dose
specifications
apply

See Page 45 of the Radiation Reference Guide within Appendix I to determine the applicability of
the following sections for this patient:
Sections 51, 58(M), 59(F), 60, 61(M), 62(F), 63, 65

Any dose

Sections 48, 49, 50, 52, 53, 54, 55, 56(M), 57(F)Minimum dose
specifications
apply

See Page 45 of the Radiation Reference Guide within Appendix I to determine the applicability of
the following sections for this patient:
Sections 51, 58(M), 59(F), 60, 61(M), 62(F), 63, 66, 67

Any dose

Sections 48, 52, 53, 54, 55, 56(M), 57(F), 68, 69, 71, 72, 73

Minimum dose
specifications
apply

See Pages 45–47 of the Radiation Reference Guide within Appendix I to determine theapplicability of the following sections for this patient:
Sections 51, 58(M), 59(F), 60, 61(M), 62(F), 63, 66, 67, 70, 74, 75

Any dose

Sections 68, 69, 71, 72, 73

Minimum dose
specifications
apply

See Pages 46, 47 of the Radiation Reference Guide within Appendix I to determine theapplicability of the following sections for this patient:
Sections 70, 74, 75

Any dose

Sections 48, 52, 53, 54, 55, 56(M), 57(F), 68, 69, 71, 72, 73

Minimum dose
specifications
apply

See Pages 45–47 of the Radiation Reference Guide within Appendix I to determine theapplicability of the following sections for this patient:
Sections 51, 58(M), 59(F), 60, 61(M), 62(F), 63, 66, 67, 70, 74, 75

Spine (cervical)[Including some or all of thecervical spine (C1–C7)]

Any dose

Sections 68, 69, 71, 72, 73, 100

Minimum dose
specifications
apply

See Pages 46, 47, 52, 59 of the Radiation Reference Guide within Appendix I to determine theapplicability of the following sections for this patient:
Sections 70, 74, 75, 76, 83, 102

Spine (thoracic)
Age at time of XRT: ______[Including some or all of thethoracic spine (T1–12)]

Any dose

Sections 80(M), 81(F), 100, 101

Minimum dose
specifications
apply

See Pages 50, 52, 54, 59, 60 of the Radiation Reference Guide within Appendix I to determine theapplicability of the following sections for this patient:
Sections 83, 88, 89, 90, 102

Spine (lumbar)[Including some or all of thelumbar spine (L1–L5)]

Any dose

Sections 95(F), 96(F), 100

Minimum dose
specifications
apply

See Pages 54, 57, 59 of the Radiation Reference Guide within Appendix I to determine theapplicability of the following sections for this patient:
Sections 88, 89, 90, 102

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

Any dose

Sections 94, 95(F), 96(F), 100

Minimum dose
specifications
apply

See Pages 54, 56, 57, 59 of the Radiation Reference Guide within Appendix I to determine theapplicability of the following sections for this patient:
Sections 88, 89, 90, 92, 93, 102

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

Any dose

Sections 68, 69, 71, 72, 73, 80(M), 81(F), 94, 95(F), 96(F), 100, 101

Minimum dose
specifications
apply

See Pages 46, 47, 50, 52, 54, 56, 57, 59, 60 of the Radiation Reference Guide within Appendix I
to determine the applicability of the following sections for this patient:
Sections 70, 74, 75,76, 83, 88, 89, 90, 92, 93, 102

Ear/Infratemporal

Nasopharyngeal

Oropharyngeal

Waldeyer’s ring
(Nasopharyngeal +Oropharyngeal)
Spine§See instructions on page 26

COG LTFU Guidelines Patient-Specific Guideline Identification Tool – Page 27

Version 4.0 – October 2013 – Guideline Identification Tool

Radiation by field§(mark all that apply)

Applicable guideline sections

Neck
Cervical (neck)
Supraclavicular

Any dose

Sections 68, 69, 71, 72, 73, 100

Minimum dose
specifications
apply

See Pages 46, 47, 52, 59 of the Radiation Reference Guide within Appendix I to determine theapplicability of the following sections for this patient:
Sections 70, 74, 75, 76, 83, 102

Mini-Mantle[Includes cervical (neck),supraclavicular, axillary]Any dose

Sections 68, 69, 71, 72, 73, 78(F), 79, 100

Minimum dose
specifications
apply

See Pages 46–49, 52, 59 of the Radiation Reference Guide within Appendix I to determine theapplicability of the following sections for this patient:
Sections 70, 74, 75, 76, 77(F), 83, 102

Mantle[Includes bilateral cervical (neck),supraclavicular, mediastinal, hilar,
axillary)
Age at time of XRT: ______

Any dose

Sections 68, 69, 71, 72, 73, 78(F), 79, 80(M), 81(F), 100, 101

Minimum dose
specifications
apply

See Pages 46–50, 52, 59, 60 of the Radiation Reference Guide within Appendix I to determine theapplicability of the following sections for this patient:
Sections 70, 74, 75, 76, 77(F), 83, 102

Extended Mantle[Includes mantle + paraaortic]

Any dose

Sections 68, 69, 71, 72, 73, 78(F), 79, 80(M), 81(F), 84, 91, 100, 101

Minimum dose
specifications
apply

See Pages 46–50, 52–55, 59, 60 of the Radiation Reference Guide within Appendix I to determine
the applicability of the following sections for this patient:
Sections 70, 74, 75, 76, 77(F), 83, 86, 87, 88, 89, 90, 102

Any dose

Sections 68, 69, 71, 72, 73, 78(F), 79, 80(M), 81(F), 84, 91, 100, 101

Minimum dose
specifications
apply

See Pages 46–55, 59, 60 of the Radiation Reference Guide within Appendix I to determine theapplicability of the following sections for this patient:
Sections 70, 74, 75, 76, 77(F), 82, 83, 86, 87, 88, 89, 90, 102

Any dose

Sections 68, 69, 71, 72, 73, 78(F), 79, 80(M), 81(F), 84, 91, 94, 95(F), 96(F), 97(F), 98(M), 100,
101

Minimum dose
specifications
apply

See Pages 46–60 of the Radiation Reference Guide within Appendix I to determine theapplicability of the following sections for this patient:
Sections 70, 74, 75, 76, 77(F), 82, 83, 86, 87, 88, 89, 90, 92, 93, 99(M), 102

AxillaAny dose

Sections 78(F), 79, 100

Age at time of XRT: ______

Minimum dose
specifications
apply

See Pages 48, 49, 59 of the Radiation Reference Guide within Appendix I to determine theapplicability of the following sections for this patient:
Sections 77(F), 102

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)

Any dose

Sections 78(F), 79, 80(M), 81(F), 100, 101

Minimum dose
specifications
apply

See Pages 47–50, 52, 59, 60 of the Radiation Reference Guide within Appendix I to determine theapplicability of the following sections for this patient:
Sections 75, 76, 77(F), 83, 102

Whole lungAny dose

Sections 78(F), 79, 80(M), 81(F), 100, 101

Mediastinal

Any dose

Sections 71, 72, 73, 78(F), 79, 80(M), 81(F), 100, 101[Includes mediastinum plus
bilateral hilar]

Minimum dose
specifications
apply

See Pages 47–50, 52, 59, 60 of the Radiation Reference Guide within Appendix I to determine theapplicability of the following sections for this patient:
Sections 74, 75, 76, 77(F), 83, 102

Mini-Mantle

See “Neck”

See “Neck” (above)

Excludes mediastinal and lungAge at time of XRT: ______

Subtotal Lymphoid (STLI)[Includes mantle + paraaortic +spleen]Age at time of XRT: ______

Total Lymphoid (TLI)[Includes mantle + inverted Y +spleen]Age at time of XRT: ______

AxillaThoraxChest (thorax):

Age at time of XRT: ______[May include any of the following:
mediastinal, hilar, whole lung,chest wall]Age at time of XRT: ______§See instructions on page 26

COG LTFU Guidelines Patient-Specific Guideline Identification Tool – Page 28

Version 4.0 – October 2013 – Guideline Identification Tool

Radiation by field§(mark all that apply)

Applicable guideline sectionsThorax (cont)
MantleSee “Neck”

See “Neck” (page 5)

Extended Mantle

See “Neck”

See “Neck” (page 5)

Subtotal Lymphoid (STLI)

See “Neck”

See “Neck” (page 5)

Total Lymphoid (TLI)

See “Neck”

See “Neck” (page 5)

Any abdominal field*
Age at time of XRT: ______

Any dose

Sections 80(M), 81(F), 84, 91, 100, 101

Minimum dose
specifications
apply

See Pages 50–55, 59, 60 of the Radiation Reference Guide within Appendix I to determine theapplicability of the following sections for this patient:
Sections 82 (if spleen in field*), 83, 86, 87, 88, 89, 90, 102*includes left upper quadrant, entire spleen, left flank/hemiabdomen, and paraaortic if
spleen in field

Extended mantle

See “Neck”

See “Neck” (page 5)

Subtotal Lymphoid (STLI)

See “Neck”

See “Neck” (page 5)

Total Lymphoid (TLI)

See “Neck”

See “Neck” (page 5)

Inverted Y[Includes paraaortic and pelvic +spleen]Any dose

Sections 80(M), 81(F), 84, 91, 94, 95(F), 96(F), 97(F), 98(M), 100, 101

Minimum dose
specifications
apply

See Pages 50–60 of the Radiation Reference Guide within Appendix I to determine theapplicability of the following sections for this patient:
Sections 82 (if spleen in field), 83, 86, 87, 88, 89, 90, 92, 93, 99(M), 102

Whole abdomen
Age at time of XRT: ______[Includes all abdominal and pelvic
fields]Any dose

Sections 80(M), 81(F), 84, 91, 94, 95(F), 96(F), 97(F), 98(M), 100, 101

Minimum dose
specifications
apply

See Pages 50–60 of the Radiation Reference Guide within Appendix I to determine theapplicability of the following sections for this patient:
Sections 82, 83, 86, 87, 88, 89, 90, 92, 93, 99(M), 102

Any dose

Sections 94 (except femoral), 95(F) (except iliac/inguinal/femoral), 96(F) (except inguinal/
femoral), 97(F) (except inguinal/femoral), 98(M), 100

Minimum dose
specifications
apply

See Pages 54, 56 (except femoral), 57 (except prostate/inguinal/femoral), 58 (except vaginal),
and 59 of the Radiation Reference Guide within Appendix I to determine the applicability of thefollowing sections for this patient:
Sections 88, 89, 90, 92 (except femoral), 93 (except femoral), 99(M), 102

Inverted Y

See “Abdomen”

See “Abdomen” (above)

Whole abdomen

See “Abdomen”

See “Abdomen” (above)

Total lymphoid (TLI)

See “Neck”

See “Neck” (page 42)

Any dose

Section 98(M)Minimum dose
specifications
apply

See Page 58 of the Radiation Reference Guide within Appendix I to determine the applicability of
the following section for this patient:
Section 99(M)Any dose

Section 100

Minimum dose
specifications
apply

See Page 59 of the Radiation Reference Guide within Appendix I to determine the applicability of
the following section for this patient:
Section 102

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

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

Testicular
Testicular

Extremities
Extremity (Upper, Lower)

Hematopoietic Cell Transplant: ❑ Yes ❑ No
If yes: ✓ Section 103 (autologous HCT only), 104(M), 105(F), 106–110
If yes, does patient have any history of chronic graft-versus-host disease (cGVHD)?: ❑ Yes ❑ No If yes, ✓ Sections 111-119**116 – active cGVHD only
118(F) – females only
§See instructions on page 26

COG LTFU Guidelines Patient-Specific Guideline Identification Tool – Page 29

Version 4.0 – October 2013 – Guideline Identification Tool

Surgery: ❑ Yes ❑ No

If yes, include applicable guideline sections below:

Surgical procedure(mark if patient received)

Applicable guideline sections

Amputation

Section 120

Central venous catheter

Section 121

Cystectomy

Sections 122, 145, 146, 147(M), 148(F)Enucleation

Section 123

Hysterectomy

Section 124(F) [see also oophorectomy, if applicable, section 141(F) or 142(F)]Laparotomy

Section 125

Limb sparing procedure

Section 126

Nephrectomy

Section 127(M), 128(F)Neurosurgery – brain

Sections 129, 130, 131, 132, 133*, 134* (*If surgery involved the HPA axis)

Neurosurgery – spinal cord

Sections 135, 136, 137(M), 138(F), 139

Oophoropexy

Section 140(F)Oophorectomy – unilateral

Section 141(F)Oophorectomy – bilateral

Section 142(F)Orchiectomy – unilateral

Section 143(M)Orchiectomy – bilateral

Section 144(M)Pelvic surgery

Sections 145, 146, 147(M), 148(F)Splenectomy

Section 149

Thoracic surgery

Sections 150, 151

Thyroidectomy

Section 152

Other Therapeutic Modalities: ❑ Yes ❑ No

If yes, include applicable guideline sections below:

Other Therapeutic Modality(mark if patient received)

Applicable guideline sections

Radioiodine therapy (I-131 thyroid ablation)

Sections 153, 154

Systemic MIBG (in therapeutic doses)

Section 155

Bioimmunotherapy

Section 156

Cancer Screening Guidelines
Applicable guideline sections(mark as indicated)

Patient type

Cancer typeAge at first screening

All patients

Colorectal

Standard risk: Age 50 years
Highest risk:
XRT: Age 35 or 10 years after XRT (whichever occurs last)
HNPCC: Puberty
FAP: Age 21 years
IBD: 8 years after diagnosis

Section 159

Lung

Highest risk: At entry into LTFU

Section 161

Oral

Highest risk: At entry into LTFU

Section 162

Skin

Highest risk: At entry into LTFU

Section 164

BreastStandard risk: Age 40 years
Highest risk: At puberty

Section 157(F)

CervicalAll females: Age 21 years

Section 158(F)Endometrial

Highest risk: Age 35 years

Section 160(F)Prostate

Males ≥ 45 years (see guideline)

Section 163(M)Testicular

N/A (see guideline)

Section 165(M)Females

Males

General Health Screening
All patients✓

Section 166

COG LTFU Guidelines Patient-Specific Guideline Identification Tool – Page 30

Version 4.0 – October 2013 – Guideline Identification Tool

Long-Term
Follow-Up
Guidelines
for Survivors of Childhood,
Adolescent, and Young Adult
Cancers

Section Number
Comparison –COG LTFU
Guidelines
Version 3.0 vs 4.0
Version 4.0
October 2013

Copyright 2013 © Children’s Oncology GroupAll rights reserved worldwide

Section Number Comparison — COG LTFU Guidelines
Version 3.0 vs 4.0
Version 3

Version 4

Page

Version 3

Version 4

Page

1

1

2

Gender Potential Late EffectAdverse psychosocial/QoL
effects

23

28

35

Gender Potential Late EffectRenal toxicity: glomerular
injury; hypertension

1

2

4

Mental health disorders

24

29

36

Hepatic dysfunction

1

3

5

Risky behaviors

25

30

37

Neurocognitive deficits

1

4

6

Psychosocial disability due
to pain

26

31

39

Clinicalleukoencephalopathy

1

5

7

Fatigue

27

32

40

Acute myeloid leukemia

2

6

8

Limitations in healthcare
and insurance access

28 (male)

33

41

Male

Cardiac toxicity

28 (female)

34

43

FemaleCardiac toxicity

3

7

9

Chronic hepatitis B

29

35

45

Pulmonary toxicity

4

8

10

Chronic hepatitis C

30

36

47

No known late effects

5

9

11

HIV infection

31

37

48

6

10

12

Dental abnormalities

Reduced bone mineraldensity (BMD)

7 (male)

11

13

Male

Gonadal dysfunction(testicular): Reduced
fertility

32

38

50

Osteonecrosis (avascularnecrosis)

33

39

51

Cataracts

7 (male)

12

14

Male

Gonadal dysfunction(testicular): Testosterone
deficiency

34

40

52

No known late effects

35

41

53

Gonadal dysfunction(ovarian)

Peripheral sensory or
motor neuropathy

36

42

54

Acute myeloid leukemia;
myelodysplasia

Vasospastic attacks(Raynaud’s phenomenon)

37

43

55

Acute myeloid leukemia

38

44

58

Secondary benign ormalignant neoplasm

39

45

59

Dysplastic nevi; skincancer7 (female)

13

15

8

14

17

Female915

18

Pulmonary fibrosis

10

16

19

Cataracts

11

17

20

Urinary tract toxicity

12

18

21

Bladder malignancy

40

46

60

Dermatologic changes

13

19

22

Renal toxicity

41

47

61

Bone malignancies

14

20

23

Ototoxicity

42

48

62

15

21

25

Peripheral sensory
neuropathy

Brain tumor (benign ormalignant)

43

49

63

Neurocognitive deficits

16

22

26

Renal toxicity

44

50

65

17

(n/a)

Clinicalleukoencephalopathy

18

23

27

Neurocognitive deficits

45

51

67

19

24

29

Clinicalleukoencephalopathy

Cerebrovascularcomplications

46

52

68

Craniofacial abnormalities

20

25

31

No known late effects

47

53

69

Chronic sinusitis

21

26

32

Hepatic dysfunction; venoocclusive disease (VOD)

48

54

70

Overweight; obesity

49

(n/a)

22

27

[Removed from v4: Dyslipidemia]

33

Reduced bone mineraldensity (BMD)

COG LTFU Guidelines Section Number Comparison – Page 32[Removed from v4: Metabolic
syndrome]

Version 4.0 – October 2013 – Version 3.0 vs 4.0

Section Number Comparison — COG LTFU Guidelines
Version 3.0 vs 4.0 (cont)Version 3

Version 4

Page

50

55

72

51 (male)

56

74

51 (female)

57

52 (male)

Gender Potential Late EffectVersion 3

Version 4

Page

Gender Potential Late EffectGrowth hormone
deficiency

75

87

109

Cholelithiasis

76

88

110

Bowel obstruction

Male

Precocious puberty

77

89

111

75

FemalePrecocious puberty

Chronic enterocolitis;
fistula, strictures

58

76

Male

Hyperprolactinemia

78

90

112

Colorectal cancer

52 (female)

59

77

FemaleHyperprolactinemia

79

91

114

53

60

78

54 (male)

61

79

Male

Gonadotropin deficiency

Renal toxicity; renal
insufficiency;
hypertension

54 (female)

62

80

FemaleGonadotropin deficiency

80

92

115

Hemorrhagic cystitis

55

63

81

81

93

116

Urinary tract toxicity

82

94

117

83 (female)

95

118

FemaleUterine vascularinsufficiency

84 (female)

96

119

FemaleGonadal dysfunction(ovarian)

85 (female)

97

121

FemaleVaginal fibrosis/stenosis

86 (male)

98

122

Male

Gonadal dysfunction(testicular): Reduced
fertility

87 (male)

99

124

Male

Gonadal dysfunction(testicular): Testosterone
deficiency/insufficiency

88

100

125

Musculoskeletal growth
problems

126

Scoliosis/kyphosis

Central hypothyroidism

Central adrenal
insufficiency

56

64

82

Cataracts

57

65

83

Ocular toxicity

58

66

84

Ototoxicity (conductive
hearing loss)

58

67

85

Ototoxicity (sensorineural
hearing loss)

Bladder malignancy

59

68

86

Xerostomia; salivary gland
dysfunction

60

69

87

Dental abnormalities

61

70

88

Osteoradionecrosis

62

71

89

Thyroid nodules

63

72

90

Thyroid cancer

64

73

91

Hypothyroidism

89

101

65

74

92

Hyperthyroidism

90

(n/a)

66

75

93

Carotid artery disease

91

102

127

76

94

Subclavian artery disease

Radiation-induced fracture

67

92

103

130

68 (female)

77

95

FemaleBreast cancer

Myelodysplasia; acute
myeloid leukemia

69 (female)

78

97

FemaleBreast tissue hypoplasia

93 (male)

104

131

Male

Solid tumors

70

79

98

Pulmonary toxicity

93 (female)

105

132

FemaleSolid tumors

71 (male)

80

99

Male

Cardiac toxicity

94

106

133

Lymphoma

71 (female)

81

101

FemaleCardiac toxicity

95

107

134

Hepatic toxicity

72

82

103

Functional asplenia

96

108

135

73

83

105

Esophageal stricture

Osteonecrosis (avascularnecrosis)

(new)

84

106

Impaired glucose
metabolism/diabetes
mellitus

97

109

136

Reduced bone mineraldensity (BMD)

(new)

110

138

Renal toxicity

(new)

85

107

Dyslipidemia

98

111

139

Dermatologic toxicity

74

86

108

Hepatic fibrosis; cirrhosis;
focal nodular hyperplasia

99

112

140

Xerophthalmia(keratoconjunctivitis
sicca)

COG LTFU Guidelines Section Number Comparison – Page 33[Removed from v4: Kyphosis]

Version 4.0 – October 2013 – Version 3.0 vs 4.0

Section Number Comparison — COG LTFU Guidelines
Version 3.0 vs 4.0 (cont)Version 3

Version 4

Page

100

113

141

101

114

Gender Potential Late EffectXerostomia; salivary gland
dysfunction; dental
caries; periodontal
disease; oral cancer(squamous cell
carcinoma)
Pulmonary toxicity;
bronchiolitis obliterans;
chronic bronchitis;
bronchiectasis

142

102

115

144

Immunologic
complications

103

116

145

Functional asplenia

104

117

147

Esophageal stricture

105 (female)

118

148

106

119

149

Joint contractures

107

120

150

Amputation-related
complications

108

121

151

Thrombosis; vascularinsufficiency; infection ofretained cuff or line tract

109

122

152

Cystectomy-related
complications

110

123

153

Impaired cosmesis; poor
prosthetic fit; orbital
hypoplasia

111 (female)112
113
114 (male)

124

125
126
127

154

FemaleFemale156
MaleVersion 4

Page

119

135

166

Gender Potential Late Effect

Neurogenic bladder;urinary incontinence

120

136

167

Neurogenic bowel; fecal
incontinence

121 (male)

137

168

Male

Psychosexual dysfunction(male)

121 (female)

138

169

FemalePsychosexual dysfunction(female)

(new)

139

170

122 (female)

140

171

FemaleOophorectomy-related
complications

123 (female)

141

172

FemalePremature menopause

124 (female)

142

173

FemaleHypogonadism; infertility

125 (male)

143

174

Male

Gonadal dysfunction(testicular): reduced
fertility; testosterone
insufficiency

125 (male)

144

175

Male

Gonadal dysfunction(testicular): infertility;
testosterone deficiency

126

145

176

Scoliosis/Kyphosis

Urinary incontinence;urinary tract obstruction
Fecal incontinence

127

146

177

128 (male)

147

178

Male

Sexual dysfunction (male)

128 (female)

148

179

FemaleSexual dysfunction(female)129 (male)

(n/a)

131

149

180

Asplenia

130

150

182

Pulmonary dysfunction

(new)

151

183

Scoliosis/Kyphosis

Complications related tolimb sparing procedure

132

152

184

Hypothyroidism

133

153

185

Lacrimal duct atrophy

Hydrocele; renal toxicity

134

154

186

Hypothyroidism

155

187

Hypothyroidism
Insufficient information
currently available
regarding late effects ofbiological agentsPelvic floor dysfunction;
urinary incontinence;
sexual dysfunction
Adhesions; bowel
obstruction

155

158

Vaginal fibrosis/stenosis

Version 3[Removed from v4: Hydrocele]

114 (female)

128

159

Renal toxicity

135

115

129

160

Neurocognitive deficits

136

156

188

116

130

161

Motor and/or sensory
deficits

117

131

162

Seizures

118

132

163

Hydrocephalus; shunt
malfunction

137 (female)

157

189

FemaleBreast cancer

138 (female)

158

191

FemaleCervical cancer

Overweight/obesity

139

159

192

Diabetes insipidus

140 (female)

160

194

(new)
(new)

133
134

164
165

FemaleCOG LTFU Guidelines Section Number Comparison – Page 34

Colorectal cancer
FemaleEndometrial cancer

Version 4.0 – October 2013 – Version 3.0 vs 4.0

Section Number Comparison — COG LTFU Guidelines
Version 3.0 vs 4.0 (cont)Version 3

Version 4

Page

141

161

195

Lung cancer

142

162

196

Oral cancer

143 (male)

163

197

144

164

198

145 (male)

165

199

146

166

200

Gender Potential Late Effect

Male

Prostate cancer
Skin cancer

Male

Testicular cancer
General Health Screening(USPSTF link)

COG LTFU Guidelines Section Number Comparison – Page 35

Version 4.0 – October 2013 – Version 3.0 vs 4.0

Long-Term
Follow-Up
Guidelines
for Survivors of Childhood,
Adolescent, and Young Adult
Cancers

Radiation
Reference
Guide

Version 4.0
October 2013

Copyright 2013 © Children’s Oncology GroupAll rights reserved worldwide

Contents
Determining Applicability of Radiation Sections for Specific Patients Based on Exposure

38

Radiation Dose Calculation Examples

39

Radiation Fields Defined40

Radiation Fields by Anatomic Region

41

Guideline Radiation Section Numbers by Anatomic Region

42

Total Body Irradiation

43

Skin, Bones, Soft Tissues

44

Brain/Neuroendocrine Axis, Cranium, Face, Eye, Ear

45

Oral Cavity

46

Neck/Thyroid

47

Breast

48

Lungs

49

Heart

50

Spleen51

Esophagus

52

Liver

53

Bowel

54

Kidneys55

Bladder/Urinary Tract

56

Female Reproductive System

57

Male Reproductive System

58

Musculoskeletal System (Growth Problems, Radiation-Induced Fracture)59

Musculoskeletal System (Scoliosis/Kyphosis)

60

COG LTFU Guidelines Radiation Reference Guide

Version 4.0 – October 2013

Determining Applicability of Radiation Sectionsfor Specific Patients Based on Exposure
General Considerations•

The radiation sections of the COG Long-Term Follow-Up Guidelines (Sections 44–102) are organized 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 this Radiation 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 is believed (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, thefollowing 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 ≥ 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 ≥ thespecified minimum dose§†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 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 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 75, 76, 77, 83, and 102.

ExamplesExamples of radiation dose calculations are provided on the following page.

COG LTFU Guidelines Radiation Reference Guide – Page 38

Version 4.0 – October 2013

Radiation Dose Calculation Examples
Example 1
Guideline section

Minimum dose specification for screening

Relevant radiation
fieldsClinical example

Step 1

Step 2

Section 77 (female);potential late effect= breast cancer

Radiation ≥ 20 Gy

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

Patient received thefollowing radiation doses tothese relevant fields:

If radiation was given
to more than one field
relevant to the guideline
section, select thelargest dose received:

Add TBI dose, if
received:• Axillary: 12 Gy• Mediastinum: 18 Gy• TBI: 10 Gy

18 Gy
+ TBI

10 Gy
28 Gy

== 18 Gy (Mediastinum)This patient received a total dose of 28 Gy of radiation potentially impacting the breast. Therefore, Guideline Section 77 regarding screening forbreast cancer, which is indicated for radiation doses ≥ 20 Gy, is applicable.
Note: See Info Link in Section 77 for patients who received TBI alone or who received 10–19 Gy radiation potentially impacting the breast, as
screening may also be indicated for these patients based on clinical considerations, and after the clinician discusses the potential benefits andrisks/harms of screening with the patient.

Example 2
Guideline
sectionMinimum dose
specification forscreening

Relevant radiation
fieldsClinical example

Step 1

Step 2

Step 3

Section 83;
potential
late effect =esophageal
stricture

Radiation ≥ 30 Gy

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
STL

Patient received thefollowing radiation doses
to these relevant fields:

If radiation was given
to more than one field
relevant to the guideline
section, select thelargest dose received:

Add the largest relevant*spinal dose to highest
non-spinal dose

Add TBI dose, if
received:Thoracic spine+ TBI• Chest (thorax): 25 Gy• Hepatic: 20 Gy• Thoracic spine: 18 Gy• Lumbar spine: 24 Gy• TBI: 12 Gy== 25 Gy (Chest [thorax])

18 Gy+ Chest (thorax) 25 Gy

43 Gy
12 Gy
55 Gy

43 Gy
*Largest dose of radiationdelivered to the spinal
field(s) specified in theguideline section.

This patient received a total dose of 55 Gy of radiation potentially impacting the esophagus. Therefore, Guideline Section 83 regarding screening
for esophageal stricture, which is indicated for radiation doses ≥ 30 Gy, is applicable.

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Example 3
Guideline section

Minimum dose specification
for screening

Relevant radiation Clinical example
fieldsStep 1

Step 2

Section 63; potential
late effect = central
adrenal insufficiency

Radiation ≥ 30 Gy

CranialOrbital/eye
Ear/infratemporal
Nasopharyngeal
Waldeyer’s ringIf patient received radiation to the same
field at different times (e.g., at timeof diagnosis AND at relapse), thesedoses should be added together when
considering the applicability of theindicated guideline section.

Add TBI dose, if
received:

Patient received 24
Gy cranial radiation
at time of diagnosis.
Five years later
patient relapsed
and was given an
additional courseof 24 Gy cranialradiation.

48 Gy
+ TBI

0 Gy
48 Gy

24 Gy (Cranial radiation at diagnosis)+ 24 Gy (Cranial radiation at relapse)
48 Gy

This patient received a total dose of 48 Gy of radiation potentially impacting the brain/neuroendocrine axis. Therefore, Guideline Section 63
regarding screening for central adrenal insufficiency, which is indicated for radiation doses ≥ 30 Gy, is applicable.

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 (S–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

Paraaortic lymph nodes (generally from T10 to L4 cephalad-caudad, and the transverse processes laterally) ± splenic

Renal

Renal bed

Flank/hemiabdomen

Top of diaphragm to iliac crest (unilateral; medial border along contralateral vertebral bodies)• Paraaortic• Spleen (partial, entire• Flank/hemiabdomen (right, left)

Note: Most hemiabdominal fields do not extend beyond the iliac crest; however, in some cases, depending on tumor location, thehemiabdominal field may have extended into the pelvis. If the hemiabdominal field extended below the iliac crest, exposure topelvic fields should be considered in assessing risk for late sequeale.
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

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TESTICULARTOTAL BODY IRRADIATION (TBI)

Total lymphoid irradiation(TLI)

Extended mantle/Subtotal lymphoid irradiation (STLI)PELVIS

PelvicVaginalProstate
Bladder
Iliac
Inguinal
FemoralInverted Y/Whole abdoment/
FlankHemiabdomen** (right) (left)

ABDOMEN

Hepatic
Renal
Upper quadrant (right) (left)Spleen (partial) (entire)
Paraaortic
Flank/Hemiabdoment*(right) (left)

MantleTHORAX

Chest (thorax)
Whole LungMediastinal

Mini-Mantle

NECK

Cervical (neck)
Supraclavicular

AXILLA

HEAD/BRAIN

CranialOrbital/Eye
Ear/Infratemporal
Nasopharyngeal
Oropharyngeal
Waldeyer’s Ring

SPINE
Lumbar
Scracl

EXTREMITIES (Upper) (Lower)

Thoracic

CervicalRadiation Fields by Anatomic Region

If field did not extend below iliac crest.
If field extended below iliac crest.

***

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NECK

HEAD/BRAIN

Guideline Radiation Section Numbers by Anatomic Region

Neck/thyroid
71 72 73
74 75 76

Breast
77 78
Lungs
79

Esophagus
83
Heart
80 81

Liver/pancreas
84 85 Spleen
86 87
82
Kidneys
91

Bowel
88
89
Female Reproductive
90
95 96 97

Bladder/Urinary Tract
92 93 94

Male Reproductive
98 99

MUSCULOSKELETAL

THORAXABDOMEN

44
45
46
47

PELVIS

SKIN/ SOFT TISSUES/ BONESAXILLATOTAL BODY IRRADIATION (TBI)

44
45
48
49
50
55
64
69
71
72
73
77§
78
79
80
81
84
85
90§
91
95
96
98

Brain/Cranium/Sensory
48 49 50
51 52 53
54 55 56
57 58 59
60 61 62
Oral Cavity
63 64 65
68 69 70
66 67

100
101
102

§
Screening may be
indicated for patients
who received TBI
alone—see Info Link
in indicated section(s).

Note: Oral cavity,
neck/thyroid, heart,esophagus, and bowel
are affected byradiation to multiple
anatomic regions.

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Relevant Guideline Radiation Sections for Patients Who Received
Total Body Irradiation
Total Body
Irradiation (TBI)

SectionFields Dose Numbers Potential Late Effects
TBI
Any
44
Secondary benign or malignant neoplasms
45
Dysplastic nevi/skin cancer
48
Brain tumor
49
Neurocognitive deficits
50
Clinical leukoencephalopathy
55
Growth hormone deficiency
64
Cataracts
69
Dental abnormalities
71
Thyroid nodules
72
Thyroid cancer
73
Hypothryoidism
77§
Breast cancer
78
Breast tissue hypoplasia
79
Pulmonary toxicity
80
Cardiac toxicity (male)81
Cardiac toxicity (female)84
Impaired glucose metabolism/diabetes mellitus
85
Dyslipidemia
90§
Colorectal cancer
91
Renal toxicity
95
Uterine vascular insufficiency
96
Gonadal dysfunction (ovarian)98
Gonadal dysfunction (testicular)
100
Musculoskeletal growth problems§Screening may be indicated for patients who received TBI alone—see Info Link in this section.
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Relevant Guideline Radiation Sections for Patients Who Received
Radiation With Potential Impact to: Skin, Bones, Soft Tissues

Potential impact toFields

Dose

Section Numbers Potential Late Effects

Skin, Bones
Soft Tissues

All

Any

44, 45

Secondary benign or malignant neoplasms
Dysplastic nevi
Skin cancer

All except TBI

Any

46, 47

Dermatologic changes
Bone malignancies

COG LTFU Guidelines Radiation Reference Guide – Page 44

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)

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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 toFieldsDose

Brain
Neuroendocrine axis
Cranium
Face

CranialAny
Orbital/eye
Ear/infratemporal
Nasopharyngeal
Waldeyer’s ring
TBI

Section Numbers Potential Late Effects
48, 52*, 53*, 54*, Brain tumor
55, 56*, 57*
Craniofacial abnormalities*
Chronic sinusitis*
Overweight/obesity*
Growth hormone deficiency
Precocious puberty*≥ 18 Gy***

51**

Cerebrovascular complications≥ 30 Gy***61,** 62,** 63**

Gonadotropin deficiency
Central adrenal insufficiency≥ 40 Gy***58,** 59,** 60,**

Hyperprolactinemia
Central hypothyroidism

Brain

CranialAny
Ear/infratemporal
TBI49, 50

Neurocognitive deficit
Clinical leukoencephalopathy

Eye

CranialOrbital/eye
TBI

Any

64

Cataracts≥ 30 Gy***

65**

Ocular toxicity

Cranial≥ 30 Gy***
Ear/infratemporal
Nasopharyngeal
Waldeyer’s ring
TBI

66,**
67**

Ototoxicity (conductive hearing loss)
Ototoxicity (sensorineural hearing loss)

Ear*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 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 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., attime of diagnosis AND at relapse), these doses should be added together when considering the applicability of the indicated guideline section.

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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 toFields

Dose

Section Numbers Potential Late Effects

Oral cavity

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

Any

68*, 69

Xerostomia
Salivary gland dysfunction
Dental abnormalities≥ 40 Gy***

70**

Osteoradionecrosis*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 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 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 indicated guideline section.

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Relevant Guideline Radiation Sections for Patients Who Received
Radiation With Potential Impact to: Neck/Thyroid
Neck/thyroid Relevant Fields:
Mediastinal
CranialMini-mantle
Nasopharyngeal
MantleOropharyngeal
Extended mantle
Waldeyer’s ring
TLI
Spine (cervical, whole)
STLI
Cervical (neck)
TBI
Supraclavicular
Chest (thorax)
Whole lung

Potential impact toFields

Dose

Section Numbers Potential Late Effects

Thyroid
Carotid artery

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

Any71,$ 72,$ 73$

Thyroid nodules
Thyroid cancer
Hypothyroidism≥ 40 Gy***74*$%

Hyperthyroidism

75*

Carotid artery disease

Spine (cervical, whole)
Cervical (neck)
Supraclavicular
Chest (thorax)
Whole lungMediastinal
Mini-mantle
MantleExtended mantle
TLI, STLI, TBI≥ 40 Gy***

76*

Subclavian artery disease

Subclavian artery$Chest (thorax) and whole lung radiation are not applicable to this section%Cranial and nasopharyngeal radiation are not applicable to this section*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 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 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 indicated guideline section.

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Relevant Guideline Radiation Sections for Females Who Received
Radiation With Potential Impact to: Breast
Breast Relevant Fields:
Chest (thorax)
Whole lungMediastinal
AxillaMini-mantle
MantleExtended mantle
TLI
STLI
TBI

Potential impact toFields

Dose

Section Numbers Potential Late Effects

BreastChest (thorax)
Whole lungMediastinal
AxillaMini-mantle
MantleExtended mantle
TLI
STLI
TBI

Any

78

Breast hypoplasia≥ 10 Gy***

77§

Breast cancer§Screening may be indicated for patients who received TBI alone or for patients who received doses of 10-19 Gy. Screening is indicated for patients who

received ≥ 20 Gy—see Info Links in Section 77 for details***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 dose†OR
2. Patient received a combination of radiation to any relevant field(s), the sum of which is ≥ the specified minimum dose†OR
3. Received TBI alone†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 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 indicated guideline section.

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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 toFields

Dose

Section Numbers Potential Late Effects

Lungs

Chest (thorax)
Whole lungMediastinal
AxillaMini-mantle
MantleExtended mantle
TLI
STLI
TBI

Any

79

COG LTFU Guidelines Radiation Reference Guide – Page 49

Pulmonary toxicity

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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 toFieldsHeart

Spine (thoracic, whole) Any*
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

Dose

Section Numbers Potential Late Effects
80 (male)81 (female)

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

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Relevant Guideline Radiation Sections for Patients Who Received
Radiation With Potential Impact to: Spleen
Spleen Relevant Fields:
Left upper quadrant
Spleen (entire)
Paraaortic*
Left flank/hemiabdomen
Whole abdomen
Inverted Y*
TLI
STLI
TBI
*If spleen in field

Potential impact toFields

Dose

Section Numbers Potential Late Effects

SpleenLeft upper quadrant
Spleen (entire)
Paraaortic*
Left flank/
hemiabdomen
Whole abdomen
Inverted Y*
TLI
STLI
TBI

≥ 40 Gy***

82**

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 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 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 indicated guideline section.

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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 toFields

Dose

Section Numbers Potential Late Effects

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**

83*

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

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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 toFields

Dose

Section Numbers Potential Late Effects

Liver

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**86*

Hepatic fibrosis
Cirrhosis
Focal nodular hyperplasia

87*

Cholelithiasis*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 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 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 indicated guideline section.

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Relevant Guideline Radiation Sections for Patients Who Received
Radiation With Potential Impact to: Bowel
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
Femoral
TLI
STLI
TBI
Potential impact toFields

Dose

Section Numbers Potential Late Effects

Bowel

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**

88*

Bowel obstruction

89*

Chronic enterocolitis
FistulaStrictures

90§

Colorectal cancer§Screening for colorectal cancer may be indicated for patients who received TBI alone—see Info Link in Section 90*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†OR2) 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 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

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Relevant Guideline Radiation Sections for Patients Who Received
Radiation With Potential Impact to: Kidneys
Kidney 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 toFields

Dose

Section Numbers Potential Late Effects

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

Any

91

COG LTFU Guidelines Radiation Reference Guide – Page 55

Renal toxicity

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Relevant Guideline Radiation Sections for Patients Who Received
Radiation With Potential Impact to: Bladder/Urinary Tract
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

Potential impact toFields

Dose

Section Numbers Potential Late Effects

Bladder
Urinary tract

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

Any

94§

Bladder malignancy≥ 30 Gy***

92**

Hemorrhagic cystitis

93**

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†OR2) 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 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.

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Relevant Guideline Radiation Sections for Females Who Received
Radiation With Potential Impact to: Female Reproductive
SystemFemale 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 95 and 96 only
‡Sections 96 and 97 only
Potential impact toFieldsFemale reproductive
systemSpine (lumbar, sacral, whole)†
Any
Flank/hemiabdomen (right, left)*
Whole abdomen
Inverted Y
PelvicVaginalBladder
Iliac‡TLI
TBI†*Only if field extended below iliac crest†Sections 95 and 96 only
‡Sections 96 and 97 only

Dose

COG LTFU Guidelines Radiation Reference Guide – Page 57

Section Numbers Potential Late Effects
95

Uterine vascular insufficiency

96

Gonadal dysfunction (ovarian)97

Vaginal fibrosis/stenosis

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Relevant Guideline Radiation Sections for Males Who Received
Radiation With Potential Impact to: Male Reproductive System
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
Potential impact toFields

Dose

Section Numbers Potential Late Effects

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

Any

98

Gonadal dysfunction (testicular): Germ cell failure≥ 20 Gy***

99**

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†OR2) 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 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., attime of diagnosis AND at relapse), these doses should be added together when considering the applicability of the indicated guideline section.

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Relevant Guideline Radiation Sections for Patients Who Received
Radiation With Potential Impact to: 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 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
FemoralExtremity (upper, lower)
TLI
STLI
TBI

Potential impact toFields

Dose

Section Numbers Potential Late Effects

Musculoskeletal
systemAll fields from neck downward except
testicular (see list above)

Any

100

Musculoskeletal growth problems≥ 40 Gy***

102*

Radiation-induced fracture*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†OR2) 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 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., attime 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

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Relevant Guideline Radiation Sections for Patients Who Received
Radiation With Potential Impact to: Musculoskeletal System(Scoliosis/Kyphosis)
Musculoskeletal System 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

Section Numbers Potential Late Effects

Musculoskeletal
systemSpine (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

101

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Scoliosis/kyphosis

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