Effects of Radiation Therapy in Survivors of Wilms's Tumor

Abstract

Of 30 children treated for Wilms's tumor at the University of California Hospitals, San Francisco, between 1926 and 1956, 16 survived five years. The survival of these 16 patients and the related data were previously reported (7, 8, 10). Thirteen of these 16 survivors had received irradiation either as a postoperative measure, or both preoperatively and postoperatively. As would be expected when large doses of ionizing radiation have been delivered to young children, bodily changes were observed in later years. The factors responsible for these changes are the subject of this report. Method and Material In 1960 an attempt was made to locate the 13 irradiated five-year survivors for follow-up examination. One of the 13, we learned, had died of pulmonary tuberculosis eleven years after treatment. On necropsy, no evidence of Wilms's tumor had been present. The 12 remaining survivors answered by telephone or letter and, within the next eighteen months, 9 of them appeared for examination. Each examination included a complete blood count, a urinalysis, spine roentgenograms, and full-body photographs (Figs. 1 to 6). For 2 of 3 survivors unable to return, recent roentgenograms were available. In 1 instance these had been made at a previous follow-up visit, and in the other roentgenograms and photographs were obtained through the assistance of the Health Department in the State of Washington, where the patient resided. The youngest of the 12 survivors was seven years four months of age, the oldest, thirty-four years. At the time of this study, 4 of the 6 males returning for examination were more than thirteen years of age. Four females were more than eighteen years of age and 2 others were seven and nine years old. Ten of the 12 patients had been less than two years of age when treated. Of those older than two years at the time of treatment, 1 was three and the other five years of age. Five of the survivors had received postoperative irradiation only. Midplane doses of external radiation (200 kv, h.v.l. 0.9 mm. Cu) were given, calculated from 1,000 r in sixteen days to 3,000 r in thirty-one days. The remaining 7 each received approximately equally divided doses of preoperative and postoperative radiation. The cumulative midplane doses, computed from the beginning of the preoperative course to the completion of postoperative therapy ranged from 2,700 r in ninety-three days to 5,200 r in eighty-seven days. Although field roentgenograms, if taken, were unavailable for review, it was apparent that in most of the patients the treatment fields crossed the midline. Field diagrams in the records and skin changes in the treatment area confirmed this observation. One patient (Case III) had roentgen evidence of a pulmonary mass, presumed to be metastatic (Fig. 1, C and D), which was treated with a total dose of 1,500 r in twenty-six days with disappearance of the mass. Observations