**8. Pulmonary disease**

Pulmonary disease is an uncommon but important late effect observed in survivors of WT. In a report from the NWTS on 6449 survivors WT survivors from NWTS 1–4 after a median follow up of 17.9 years, 64 fully evaluable and 16 partially evaluable cases of pulmonary disease were identified. The 15-year cumulative incidence of pulmonary disease was 4.0% among fully evaluable and 4.8%among fully and partially evaluable patients who received WLI for pulmonary metastases at initial diagnosis. In contrast, 15-year cumulative incidence of pulmonary disease was much lower (<0.5%) among those who did not receive WLI. Survivors who had lung RT for relapse treatment had higher rates of pulmonary disease than those who had lung RT at initial treatment (hazard ratio [HR] 1.7). Survivors who received abdominal RT only had higher rates than those who received no RT at all (HR 3.5) [41]. Foster et al. reported on 280 WT survivors compared to 625 age and sex-matched controls for childhood cancer from St. Jude Children's Hospital [42]. At a median follow up of 26 years, compared to controls, survivors had an excess grade 2 to 4 obstructive (11.7 vs. 2.9%, P < 0.01), restrictive (9.6 vs. 0.2%, P < 0.01), and diffusion (10.4 vs. 0.3%, P < 0.01) pulmonary impairments. Adjusting for smoking status, pulmonary diffusion defects were associated with doxorubicin (RR 3.9) and restrictive deficits with chest radiation (RR 12.3).
