Does this chest radiograph belong to a survivor of childhood cancer? Radiographic findings suggesting previous treatment for childhood cancer - a review

Abstract

The growing population of long-term survivors of childhood cancer in the United States estimated in 2009 to be nearly 330,000 mandates familiarity with imaging findings that may be related to prior disease, therapy and toxicities. More than 24% of these patients have survived more than 30 years from the time of diagnosis of their malignancy. Thus, imagers of adult as well as pediatric patients should be cognizant of findings seen in this patient cohort. This image-based review will discuss findings demonstrated on chest radiographs that may suggest that the imaged patient is a childhood cancer survivor.

Figure 1. Residual post-therapy mediastinal mass

18-year-old man diagnosed with Stage IV B nodular sclerosing Hodgkin’s disease was treated with chemotherapy and 2550cGy mantle and 800 cGy whole lung irradiation. Residual mediastinal mass persisted over the subsequent 8 years from initial imaging at diagnosis through follow-up. A. Posteroanterior chest radiograph at the time of diagnosis shows a large anterior mediastinal mass which extends bilaterally from the midline. B and C. A follow-up posteroanterior chest radiograph obtained 8 years from diagnosis shows residual superior mediastinal widening that corresponds to the residual masses shown on the corresponding computed tomography image, C.

Figure 1. Residual post-therapy mediastinal mass

18-year-old man diagnosed with Stage IV B nodular sclerosing Hodgkin’s disease was treated with chemotherapy and 2550cGy mantle and 800 cGy whole lung irradiation. Residual mediastinal mass persisted over the subsequent 8 years from initial imaging at diagnosis through follow-up. A. Posteroanterior chest radiograph at the time of diagnosis shows a large anterior mediastinal mass which extends bilaterally from the midline. B and C. A follow-up posteroanterior chest radiograph obtained 8 years from diagnosis shows residual superior mediastinal widening that corresponds to the residual masses shown on the corresponding computed tomography image, C.

Figure 1. Residual post-therapy mediastinal mass

18-year-old man diagnosed with Stage IV B nodular sclerosing Hodgkin’s disease was treated with chemotherapy and 2550cGy mantle and 800 cGy whole lung irradiation. Residual mediastinal mass persisted over the subsequent 8 years from initial imaging at diagnosis through follow-up. A. Posteroanterior chest radiograph at the time of diagnosis shows a large anterior mediastinal mass which extends bilaterally from the midline. B and C. A follow-up posteroanterior chest radiograph obtained 8 years from diagnosis shows residual superior mediastinal widening that corresponds to the residual masses shown on the corresponding computed tomography image, C.

Figure 2. Calcification of residual mediastinal mass

24-year-old survivor of Stage IIIB nodular sclerosing Hodgkin’s disease diagnosed at the age of 15-years. His disease was refractory to standard chemotherapy prompting autologous bone marrow transplantation and 2100 cGy mediastinal radiation. A and B. A, posteroanterior and, B, lateral chest radiographs at diagnosis show a bulky anterior mediastinal mass extending through the thoracic inlet on the right, into the right neck. C. C, Follow-up posteroanterior chest radiograph 6 years later show significant reduction in the mediastinal mass with development of dense calcifications.

Figure 2. Calcification of residual mediastinal mass

24-year-old survivor of Stage IIIB nodular sclerosing Hodgkin’s disease diagnosed at the age of 15-years. His disease was refractory to standard chemotherapy prompting autologous bone marrow transplantation and 2100 cGy mediastinal radiation. A and B. A, posteroanterior and, B, lateral chest radiographs at diagnosis show a bulky anterior mediastinal mass extending through the thoracic inlet on the right, into the right neck. C. C, Follow-up posteroanterior chest radiograph 6 years later show significant reduction in the mediastinal mass with development of dense calcifications.

Figure 2. Calcification of residual mediastinal mass

24-year-old survivor of Stage IIIB nodular sclerosing Hodgkin’s disease diagnosed at the age of 15-years. His disease was refractory to standard chemotherapy prompting autologous bone marrow transplantation and 2100 cGy mediastinal radiation. A and B. A, posteroanterior and, B, lateral chest radiographs at diagnosis show a bulky anterior mediastinal mass extending through the thoracic inlet on the right, into the right neck. C. C, Follow-up posteroanterior chest radiograph 6 years later show significant reduction in the mediastinal mass with development of dense calcifications.

Figure 2. Calcification of residual mediastinal mass

24-year-old survivor of Stage IIIB nodular sclerosing Hodgkin’s disease diagnosed at the age of 15-years. His disease was refractory to standard chemotherapy prompting autologous bone marrow transplantation and 2100 cGy mediastinal radiation. A and B. A, posteroanterior and, B, lateral chest radiographs at diagnosis show a bulky anterior mediastinal mass extending through the thoracic inlet on the right, into the right neck. C. C, Follow-up posteroanterior chest radiograph 6 years later show significant reduction in the mediastinal mass with development of dense calcifications.

Figure 3. Relapse lymphoma

9-year-old boy diagnosed with Stage IA Hodgkin’s disease right neck achieved complete remission with chemotherapy. At routine follow-up 3.5 years later, left hilar relapse was suspected. A. and B. A, posteroanterior and lateral, B, chest radiographs show stable post-therapy appearance of the thoracic structures. C. and D. Posteroanterior chest radiograph shows slight increased density left hilum which, on the lateral view, D, is shown to represent an ovoid nodule (lines). E., and F., E, axial non-contrast T1- and, F, T2-weighted images of the chest show right paratracheal (long arrows), left hilar and subcarinal (short arrows) adenopathy consistent with disease relapse.

Figure 3. Relapse lymphoma

9-year-old boy diagnosed with Stage IA Hodgkin’s disease right neck achieved complete remission with chemotherapy. At routine follow-up 3.5 years later, left hilar relapse was suspected. A. and B. A, posteroanterior and lateral, B, chest radiographs show stable post-therapy appearance of the thoracic structures. C. and D. Posteroanterior chest radiograph shows slight increased density left hilum which, on the lateral view, D, is shown to represent an ovoid nodule (lines). E., and F., E, axial non-contrast T1- and, F, T2-weighted images of the chest show right paratracheal (long arrows), left hilar and subcarinal (short arrows) adenopathy consistent with disease relapse.

Figure 3. Relapse lymphoma

9-year-old boy diagnosed with Stage IA Hodgkin’s disease right neck achieved complete remission with chemotherapy. At routine follow-up 3.5 years later, left hilar relapse was suspected. A. and B. A, posteroanterior and lateral, B, chest radiographs show stable post-therapy appearance of the thoracic structures. C. and D. Posteroanterior chest radiograph shows slight increased density left hilum which, on the lateral view, D, is shown to represent an ovoid nodule (lines). E., and F., E, axial non-contrast T1- and, F, T2-weighted images of the chest show right paratracheal (long arrows), left hilar and subcarinal (short arrows) adenopathy consistent with disease relapse.

Figure 3. Relapse lymphoma

9-year-old boy diagnosed with Stage IA Hodgkin’s disease right neck achieved complete remission with chemotherapy. At routine follow-up 3.5 years later, left hilar relapse was suspected. A. and B. A, posteroanterior and lateral, B, chest radiographs show stable post-therapy appearance of the thoracic structures. C. and D. Posteroanterior chest radiograph shows slight increased density left hilum which, on the lateral view, D, is shown to represent an ovoid nodule (lines). E., and F., E, axial non-contrast T1- and, F, T2-weighted images of the chest show right paratracheal (long arrows), left hilar and subcarinal (short arrows) adenopathy consistent with disease relapse.

Figure 3. Relapse lymphoma

9-year-old boy diagnosed with Stage IA Hodgkin’s disease right neck achieved complete remission with chemotherapy. At routine follow-up 3.5 years later, left hilar relapse was suspected. A. and B. A, posteroanterior and lateral, B, chest radiographs show stable post-therapy appearance of the thoracic structures. C. and D. Posteroanterior chest radiograph shows slight increased density left hilum which, on the lateral view, D, is shown to represent an ovoid nodule (lines). E., and F., E, axial non-contrast T1- and, F, T2-weighted images of the chest show right paratracheal (long arrows), left hilar and subcarinal (short arrows) adenopathy consistent with disease relapse.

Figure 3. Relapse lymphoma

9-year-old boy diagnosed with Stage IA Hodgkin’s disease right neck achieved complete remission with chemotherapy. At routine follow-up 3.5 years later, left hilar relapse was suspected. A. and B. A, posteroanterior and lateral, B, chest radiographs show stable post-therapy appearance of the thoracic structures. C. and D. Posteroanterior chest radiograph shows slight increased density left hilum which, on the lateral view, D, is shown to represent an ovoid nodule (lines). E., and F., E, axial non-contrast T1- and, F, T2-weighted images of the chest show right paratracheal (long arrows), left hilar and subcarinal (short arrows) adenopathy consistent with disease relapse.

Figure 3. Relapse lymphoma

9-year-old boy diagnosed with Stage IA Hodgkin’s disease right neck achieved complete remission with chemotherapy. At routine follow-up 3.5 years later, left hilar relapse was suspected. A. and B. A, posteroanterior and lateral, B, chest radiographs show stable post-therapy appearance of the thoracic structures. C. and D. Posteroanterior chest radiograph shows slight increased density left hilum which, on the lateral view, D, is shown to represent an ovoid nodule (lines). E., and F., E, axial non-contrast T1- and, F, T2-weighted images of the chest show right paratracheal (long arrows), left hilar and subcarinal (short arrows) adenopathy consistent with disease relapse.

Figure 3. Relapse lymphoma

9-year-old boy diagnosed with Stage IA Hodgkin’s disease right neck achieved complete remission with chemotherapy. At routine follow-up 3.5 years later, left hilar relapse was suspected. A. and B. A, posteroanterior and lateral, B, chest radiographs show stable post-therapy appearance of the thoracic structures. C. and D. Posteroanterior chest radiograph shows slight increased density left hilum which, on the lateral view, D, is shown to represent an ovoid nodule (lines). E., and F., E, axial non-contrast T1- and, F, T2-weighted images of the chest show right paratracheal (long arrows), left hilar and subcarinal (short arrows) adenopathy consistent with disease relapse.

Figure 4. Progressive radiation fibrosis

19-year-old woman diagnosed with Stage IIA nodular sclerosing Hodgkin’s disease was treated with chemotherapy and 2550 cGy modified mantle irradiation. One year after completing therapy, she developed disease relapse treated with intensive chemotherapy, autologous stem cell rescue and radiation therapy to the lower cervical spine and porta hepatis. A. At diagnosis, the posteroanterior chest radiograph showed right paratracheal adenopathy and bilateral superior mediastinal widening, which improved with therapy. B. By 3-years later, straightening of the left mediastinum and early cephalad retraction of the left hilum is noted. C. Progression of cephalad retraction of the left hilum, coarsening of post-radiation scarring at 11 years, D, from diagnosis are evident and progressed in parallel with decreasing pulmonary function, ultimately leading to her demise.

Figure 4. Progressive radiation fibrosis

19-year-old woman diagnosed with Stage IIA nodular sclerosing Hodgkin’s disease was treated with chemotherapy and 2550 cGy modified mantle irradiation. One year after completing therapy, she developed disease relapse treated with intensive chemotherapy, autologous stem cell rescue and radiation therapy to the lower cervical spine and porta hepatis. A. At diagnosis, the posteroanterior chest radiograph showed right paratracheal adenopathy and bilateral superior mediastinal widening, which improved with therapy. B. By 3-years later, straightening of the left mediastinum and early cephalad retraction of the left hilum is noted. C. Progression of cephalad retraction of the left hilum, coarsening of post-radiation scarring at 11 years, D, from diagnosis are evident and progressed in parallel with decreasing pulmonary function, ultimately leading to her demise.

Figure 4. Progressive radiation fibrosis

19-year-old woman diagnosed with Stage IIA nodular sclerosing Hodgkin’s disease was treated with chemotherapy and 2550 cGy modified mantle irradiation. One year after completing therapy, she developed disease relapse treated with intensive chemotherapy, autologous stem cell rescue and radiation therapy to the lower cervical spine and porta hepatis. A. At diagnosis, the posteroanterior chest radiograph showed right paratracheal adenopathy and bilateral superior mediastinal widening, which improved with therapy. B. By 3-years later, straightening of the left mediastinum and early cephalad retraction of the left hilum is noted. C. Progression of cephalad retraction of the left hilum, coarsening of post-radiation scarring at 11 years, D, from diagnosis are evident and progressed in parallel with decreasing pulmonary function, ultimately leading to her demise.

Figure 5. Anthracycline-induced cardiomyopathy

This 12-year-old patient was diagnosed with nodular sclerosing Hodgkin’s disease and received multiagent chemotherapy that included anthracycline. Pathologic examination revealed Grade 2 of 3 anthracycline cardiac toxicity. A. Posteroanterior chest radiograph obtained about 1 year after completion of therapy demonstrate cardiomegaly, bilateral pleural effusions and pulmonary vascular congestion indicative of congestive heart failure.

Figure 6. Breast hypoplasia

This 49-year-old woman was diagnosed with Wilm’s tumor at age 5 years and received 1200 cGy whole lung irradiation for pulmonary metastases as well as 1200cGy abdominal radiation therapy for primary disease and hepatic metastases. A. and B. A., posteroanterior and lateral, B., chest radiographs demonstrate hypoplasia of both breasts. The anteroposterior diameter of the chest is narrow from radiation-induced rib dysplasia.

Figure 6. Breast hypoplasia

This 49-year-old woman was diagnosed with Wilm’s tumor at age 5 years and received 1200 cGy whole lung irradiation for pulmonary metastases as well as 1200cGy abdominal radiation therapy for primary disease and hepatic metastases. A. and B. A., posteroanterior and lateral, B., chest radiographs demonstrate hypoplasia of both breasts. The anteroposterior diameter of the chest is narrow from radiation-induced rib dysplasia.

Figure 7. Chest wall deformity and scoliosis

At the age of 6 years, this boy was diagnosed with Ewings sarcoma family of tumors right chest wall. He received multiagent chemotherapy, surgical resection and 504 cGy external beam irradiation. Over the course of 7 years, he developed significant scoliosis. A. Axial chest computed tomography at the time of diagnosis shows the soft tissue mass arising from the right lateral chest wall. B. Posteroanterior chest radiograph obtained 2 years after completion of therapy show chest wall deformity due to resection of several right thoracic ribs and pulmonary scarring. Note absence of a visible scoliosis. C. Scoliosis series was obtained 7 years after therapy completion due to the presence of a ‘thoracic hump’ demonstrates a 52 degree mid-thoracic rotoscoliosis.

Figure 7. Chest wall deformity and scoliosis

At the age of 6 years, this boy was diagnosed with Ewings sarcoma family of tumors right chest wall. He received multiagent chemotherapy, surgical resection and 504 cGy external beam irradiation. Over the course of 7 years, he developed significant scoliosis. A. Axial chest computed tomography at the time of diagnosis shows the soft tissue mass arising from the right lateral chest wall. B. Posteroanterior chest radiograph obtained 2 years after completion of therapy show chest wall deformity due to resection of several right thoracic ribs and pulmonary scarring. Note absence of a visible scoliosis. C. Scoliosis series was obtained 7 years after therapy completion due to the presence of a ‘thoracic hump’ demonstrates a 52 degree mid-thoracic rotoscoliosis.

Figure 7. Chest wall deformity and scoliosis

At the age of 6 years, this boy was diagnosed with Ewings sarcoma family of tumors right chest wall. He received multiagent chemotherapy, surgical resection and 504 cGy external beam irradiation. Over the course of 7 years, he developed significant scoliosis. A. Axial chest computed tomography at the time of diagnosis shows the soft tissue mass arising from the right lateral chest wall. B. Posteroanterior chest radiograph obtained 2 years after completion of therapy show chest wall deformity due to resection of several right thoracic ribs and pulmonary scarring. Note absence of a visible scoliosis. C. Scoliosis series was obtained 7 years after therapy completion due to the presence of a ‘thoracic hump’ demonstrates a 52 degree mid-thoracic rotoscoliosis.

Figure 7. Chest wall deformity and scoliosis

At the age of 6 years, this boy was diagnosed with Ewings sarcoma family of tumors right chest wall. He received multiagent chemotherapy, surgical resection and 504 cGy external beam irradiation. Over the course of 7 years, he developed significant scoliosis. A. Axial chest computed tomography at the time of diagnosis shows the soft tissue mass arising from the right lateral chest wall. B. Posteroanterior chest radiograph obtained 2 years after completion of therapy show chest wall deformity due to resection of several right thoracic ribs and pulmonary scarring. Note absence of a visible scoliosis. C. Scoliosis series was obtained 7 years after therapy completion due to the presence of a ‘thoracic hump’ demonstrates a 52 degree mid-thoracic rotoscoliosis.

Figure 7. Chest wall deformity and scoliosis

At the age of 6 years, this boy was diagnosed with Ewings sarcoma family of tumors right chest wall. He received multiagent chemotherapy, surgical resection and 504 cGy external beam irradiation. Over the course of 7 years, he developed significant scoliosis. A. Axial chest computed tomography at the time of diagnosis shows the soft tissue mass arising from the right lateral chest wall. B. Posteroanterior chest radiograph obtained 2 years after completion of therapy show chest wall deformity due to resection of several right thoracic ribs and pulmonary scarring. Note absence of a visible scoliosis. C. Scoliosis series was obtained 7 years after therapy completion due to the presence of a ‘thoracic hump’ demonstrates a 52 degree mid-thoracic rotoscoliosis.

Figure 8. Rib dysplasia

This 49-year-old woman was diagnosed with non-Hodgkin’s lymphoma at age 9 years was treated with mediastinal radiation therapy and multiagent chemotherapy. A. and B. A., posteroanterior and lateral, B., chest radiographs demonstrate linear pulmonary scarring with mild cephalad retraction of the hila (arrows), a mild levoconvex mid-thoracic scoliosis (apex of the curve indicated by the arrowhead). The striking chest wall deformity with depression of the anterior chest wall resulted from radiation-induced rib dysplasia. Similarly, note the asymmetric size of the breasts (right smaller than left) and smaller volume of the right hemithorax compared to the left. The lateral view also readily demonstrates demineralization of the thoracic vertebral bodies. C. Posteroanterior chest radiograph at the time of diagnosis show extensive mediastinal, paratracheal and right hilar adenopathy coupled with a large right pleural effusion.

Figure 8. Rib dysplasia

This 49-year-old woman was diagnosed with non-Hodgkin’s lymphoma at age 9 years was treated with mediastinal radiation therapy and multiagent chemotherapy. A. and B. A., posteroanterior and lateral, B., chest radiographs demonstrate linear pulmonary scarring with mild cephalad retraction of the hila (arrows), a mild levoconvex mid-thoracic scoliosis (apex of the curve indicated by the arrowhead). The striking chest wall deformity with depression of the anterior chest wall resulted from radiation-induced rib dysplasia. Similarly, note the asymmetric size of the breasts (right smaller than left) and smaller volume of the right hemithorax compared to the left. The lateral view also readily demonstrates demineralization of the thoracic vertebral bodies. C. Posteroanterior chest radiograph at the time of diagnosis show extensive mediastinal, paratracheal and right hilar adenopathy coupled with a large right pleural effusion.

Figure 9. Asymmetric clavicular growth

A 15-year-old boy was diagnosed with Stage IA Hodgkin’s disease of his right neck. In addition to multiagent chemotherapy, treatment included right hemi-mantle irradiation of 1500 cGy. A. Axial computed tomography image of the neck at the time of diagnosis. B. Chest x-ray obtained 15 years after completion of treatment demonstrates asymmetric clavicular growth. The right clavicle measures 2 cm shorter than the left.

Figure 9. Asymmetric clavicular growth

A 15-year-old boy was diagnosed with Stage IA Hodgkin’s disease of his right neck. In addition to multiagent chemotherapy, treatment included right hemi-mantle irradiation of 1500 cGy. A. Axial computed tomography image of the neck at the time of diagnosis. B. Chest x-ray obtained 15 years after completion of treatment demonstrates asymmetric clavicular growth. The right clavicle measures 2 cm shorter than the left.

Figure 10. Radiation-induced exostosis

A 7-year-old girl returned 4 years after undergoing bone marrow transplantation for chronic myelogenous leukemia because of a newly found “lump” in her right anterior chest. The preparative regimen for her bone marrow transplantation included total body irradiation. A, posteroanterior chest radiograph was obtained which demonstrated expansion of the right anterior seventh rib (arrow). B. Axial limited chest CT was performed through the rib for characterization of the abnormality shown on the chest radiograph and shows the typical appearance of an exostosis (skin marker).

Figure 10. Radiation-induced exostosis

A 7-year-old girl returned 4 years after undergoing bone marrow transplantation for chronic myelogenous leukemia because of a newly found “lump” in her right anterior chest. The preparative regimen for her bone marrow transplantation included total body irradiation. A, posteroanterior chest radiograph was obtained which demonstrated expansion of the right anterior seventh rib (arrow). B. Axial limited chest CT was performed through the rib for characterization of the abnormality shown on the chest radiograph and shows the typical appearance of an exostosis (skin marker).

Figure 10. Radiation-induced exostosis

A 7-year-old girl returned 4 years after undergoing bone marrow transplantation for chronic myelogenous leukemia because of a newly found “lump” in her right anterior chest. The preparative regimen for her bone marrow transplantation included total body irradiation. A, posteroanterior chest radiograph was obtained which demonstrated expansion of the right anterior seventh rib (arrow). B. Axial limited chest CT was performed through the rib for characterization of the abnormality shown on the chest radiograph and shows the typical appearance of an exostosis (skin marker).

Figure 11. Osteonecrosis

This 20 year-old woman was diagnosed with B-cell non-Hodgkin’s lymphoma at age 16-years and experienced multiple relapses of the disease. She was treated with multiagent chemotherapy that included high dose glucocorticoids. A posteroanterior chest radiograph showed changes of osteonecrosis of the left humeral headA. Dedicated radiographs of the shoulders confirmed the advanced osteonecrotic changes of both humeral heads with crescent signs (arrows), collapse of the articular surfaces, and intermixed areas of sclerosis and cystic changes.

Figure 11. Osteonecrosis

This 20 year-old woman was diagnosed with B-cell non-Hodgkin’s lymphoma at age 16-years and experienced multiple relapses of the disease. She was treated with multiagent chemotherapy that included high dose glucocorticoids. A posteroanterior chest radiograph showed changes of osteonecrosis of the left humeral headA. Dedicated radiographs of the shoulders confirmed the advanced osteonecrotic changes of both humeral heads with crescent signs (arrows), collapse of the articular surfaces, and intermixed areas of sclerosis and cystic changes.