Late Effects	Causative Treatment	Signs and Symptoms	Screening and Diagnostic Tests	Management and Intervention
aAdapted from Schwartz et al.[37]
Overt hypothyroidism (elevated TSH, decreased T4)	Radiation: >20 Gy to the neck, cervical spine	Hoarseness, fatigue, weight gain, dry skin, cold intolerance, dry brittle hair, alopecia, constipation, lethargy, poor linear growth, menstrual irregularities, pubertal delay, bradycardia, hypotension	Free T4, TSH annually up to 10 years postradiation or if symptomatic, plot on growth chart	Refer to endocrinologist, T4 replacement, anticipatory guidance regarding symptoms of hyperthyroidism/ hypothyroidism
	Radiation: >7.5 Gy TBI
	Surgery: Partial or complete thyroidectomy
Compensated hypothyroidism (elevated TSH, normal T4)	Same as overt hypothyroidism with regard to radiation and surgery	Asymptomatic	Free T4, TSH annually up to 10 years postradiation or if symptomatic, plot on growth chart	Refer to endocrinologist, T4 to suppress gland activity
Thyroid nodules	Any dose radiation	Hoarseness, fatigue, weight gain, dry skin, cold intolerance, dry brittle hair, alopecia, constipation, lethargy, poor linear growth, menstrual irregularities, pubertal delay, bradycardia, hypotension	Free T4, TSH annually up to 10 years postradiation or if symptomatic, plot on growth chart, physical exam; ultrasound for technetium99m scan baseline and then as needed for symptoms	Refer to endocrinologist, thyroid scan, biopsy/resection
Hyperthyroidism decreased TSH, elevated T4	Same as overt hypothyroidism with regard to radiation	Nervousness, tremors, heat intolerance, weight loss, insomnia, increased appetite, diarrhea, moist skin, tachycardia, exophthalmus, goiter	Free T4, TSH annually up to 10 years postradiation or if symptomatic, plot on growth chart physical exam; ultrasound for technetium99m scan baseline and then as needed for symptoms, triiodothyronine (T3), antithyroglobulin, antimicrosomal antibody baseline, then as needed for symptoms	Refer to endocrinologist, propylthiouracil (PTU), propanol 131I, thyroidectomy

References

37. Schwartz C L, Hobbie WL, Constine LS, et al., eds.: Survivors of Childhood Cancer: Assessment and Management. St. Louis, Mo: Mosby, 1994.