The risk of a secondary acute leukemia with irradiation alone is much less than with chemotherapy. It is possible that newer combination chemotherapy regimens will prove to be less leukemogenic than older combinations that included alkylating agents such as mechlorethamine and procarbazine. The use of radiotherapy is associated with an increased risk of development of solid tumors, particularly breast and thyroid cancer, within the port. Thus, all female patients should be informed of the breast cancer risk and breast self examination should be initiated at an early age. In sexually mature males who will undergo combination chemotherapy or pelvic irradiation, consideration should be given to storing sperm, since seminiferous tissue is often irreparably damaged by chemotherapy or scattered irradiation.
Sperm storage is complicated by the fact that many patients have low sperm counts at presentation.
In order to maintain fertility in males, etoposide has been substituted for procarbazine in combination chemotherapy regimens, since it causes less gonadal damage. 15 Females may also become infertile and have early menopause. The risk may be decreased by oophoropexy to move gonads out of the radiotherapy field during laparotomy if pelvic irradiation is planned. Placement of titanium clips at the splenic hilum is strongly recommended to facilitate radiation therapy planning to shield the left kidney when the para-aortic nodes and splenic pedicle are to be irradiated. In addition, children will often show localized growth abnormalities after full-dose radiation.