Pericarditis Major Organ Infl ammation

Pan et al. 2010 . Classic RT-induced liver toxic- ity presents with anicteric hepatomegaly and ascites, with onset usually occurring months after the completion of RT although it can occur more rapidly Chopra and Bogart 2009 ; Pan et al. 2010 . Elevated alkaline phosphatase 2× the upper limit of normal ULN is a commonly reported fi nding; pathologic fi ndings are similar to veno- occlusive diseasesinusoidal obstructive syndrome VODSOS Lawrence et al. 1995 ; Chopra and Bogart 2009 ; Pan et al. 2010 . Nonclassic presentations are usually seen in the setting of hepatocellular carcinoma with ele- vated liver transaminases 5× ULN Pan et al. 2010 . Other potential signs of liver toxicity include thrombocytopenia and coagulopathy. Cumulative radiation doses to the liver should be 28–32 Gy to decrease the risk of liver toxic- ity Pan et al. 2010 . Concurrent hepatic disease, secondary to hepatitis B, hepatitis C or the under- lying malignancy, is a potential risk factor for RT-induced hepatitis Pan et al. 2010 . Synergistic risk secondary to concomitant chemotherapy is likely but poorly defi ned. Infectious etiologies, metastases, and drug-induced hepatitis must be considered and ruled out Chopra and Bogart 2009 . Treatment includes diuretics as needed. The use of steroids and anticoagulants has been suggested; since the underlying pathology is sim- ilar to VODSOS, an analogous treatment strat- egy could be considered although this is not evidence-based. Liver failure is often irreversible in adult patients Pan et al. 2010 . Pediatric data are lacking. The presence of focal nodular hyper- plasia has been noted as a late effect after liver RT Bouyn et al. 2003 .

13.7.4 Nephropathy

Acute RT-induced kidney injury is usually sub- clinical with signs and symptoms such as decreased glomerular fi ltration rate and protein- uria occurring in the subacute time period Dawson et al. 2010 . Chronic injury occurs with a long latency and the development of hyperten- sion, elevated creatinine and renal failure, although the risk in the pediatric population receiving multimodal chemoradiotherapy appears low Dawson et al. 2010 ; Bölling et al. 2011 . Acute injury can rarely present with a hemolytic- uremic type syndrome or an increased creatinine, with the total RT dose to the kidney being the most important risk factor Dawson et al. 2010 . Data on incidence in children are lacking. In their review, Dawson et al. 2010 recommend a mean kidney dose of 10 Gy with TBI and 18 Gy with bilateral partial kidney irradiation. Although multiple factors can infl uence kidney function after HSCT, in their review of 92 children after TBI and HSCT, Gerstein et al. 2009 found a very low incidence of persistent renal dysfunc- tion with cumulative fractionated RT doses 12 Gy. Treatment may include low-protein diet, fl uid and salt restriction, use of antihypertensives and diuretics as needed, treatment of anemia, and, if necessary, dialysis Cassady 1995 .

13.7.5 Cystitis

RT to the bladder and urethra can acutely lead to urinary frequency, urgency and dysuria; inconti- nence is rarely seen in the acute period Marks et al. 1995 ; Chopra and Bogart 2009 . The mecha- nism for acute symptoms is unclear; smooth mus- cle edema as well as infl ammation and injury to the epithelial cell layer are proposed mechanisms Marks et al. 1995 . Bladder toxicity is unlikely to occur with cumulative fractionated RT doses 40–50 Gy Viswanathan et al. 2010 . Concurrent chemotherapy, especially with cyclophospha- mide, ifosfamide or busulfan, is an additional potential risk factor Payne et al. 2013 . Anesthetic agents e.g., pyridium and antispasmodics e.g., oxybutynin can be used symptomatically Chopra and Bogart 2009 . Pediatric data on acute RT-induced cystitis are lacking but is a potential complication in the treatment of pelvic tumors. Urinary tract infections should be considered and ruled out Chopra and Bogart 2009 . Hematuria is an unlikely early complication but should be treated with two-way Foley catheter insertion for copious bladder irrigation. Patients who are refractory to such therapy may benefi t from HBO or intravesical therapy Payne et al. 2013 .