Brain stem tumors are perhaps the most dreaded cancers in pediatric oncology, owing to their historically poor prognosis, yet they remain an area of intense research.  Brain stem tumors account for about 10 to 15% of childhood brain tumors.  Peak incidence for these tumors occurs around age 6 to 9 years.  The term brain stem glioma is often used interchangeably with brain stem tumor.  More precisely, glioma encompasses tumor pathology types such as ganglioglioma, pilcytic astrocytoma, diffuse astrocytoma, anaplastic astrocytoma, and glioblastoma multiforme.

Rarely, other tumor pathologies such as atypical teratoid/rhabdoid tumor (ATRT), primitive neuroectodermal tumor (PNET)/embryonal tumor, and hemangioblastoma occur at the brain stem. These entities are quite different from brain stem gliomas, and the following comments do not apply.

Classification:   Brain stem gliomas have been grouped in the past according to their pathology and location within the brain stem. Terms found in the medical literature include diffuse intrinsic gliomas, midbrain tumors, tectal gliomas, pencil gliomas, dorsal exophytic brain stem tumors, cervicomedullary tumors, focal gliomas, and cystic tumors.  A simpler way to classify these tumors is by two categories: diffuse intrinsic pontine glioma and focal brain stem glioma.
Symptoms:  Children with DIPG present with ataxia (clumsiness or wobbliness), weakness of a leg and/or arm, double vision, and sometimes headaches, vomiting, tilting of the head, or facial weakness. Double vision (diplopia) is the most common presenting symptom for these tumors.  Symptoms are usually present for 6 months or less at time of diagnosis.  Patients with focal brain stem gliomas may display some of the same symptoms, although not the usual combination of ataxia, weakness, and double vision. Duration of symptoms is often greater than 6 months before the focal brain stem tumor is diagnosed.

Diagnosis:  Throughout the United States, brain magnetic resonance imaging (MRI), with and without gadolinium contrast, remains the “gold standard” for diagnosis of brain stem gliomas.  Biopsy is seldom performed outside specialized biomedical research protocols for DIPG, unless the diagnosis of this tumor is in doubt.  Biopsy may be indicated for brain stem tumors that are focal or atypical, especially when the tumor is progressive or when surgical excision may be possible.

Diffuse intrinsic pontine gliomas (DIPG) insinuate diffusely throughout the normal structures of the pons (the middle portion of the brain stem), sometimes spreading to the midbrain (the upper portion of the brain stem) or the medulla (the bottom portion of the brain stem).  The term diffuse intrinsic glioma is synonymous.  By pathology, these tumors are most often a diffuse (sometimes referred to as fibrillary) astrocytoma (World Health Organization [WHO] grade II) or its higher-grade counterparts, anaplastic astrocytoma (WHO III) and glioblastoma multiforme (WHO IV).  Very rarely these tumors start in the medulla or midbrain.

Focal brain stem gliomas–perhaps 20% or more of brain stem gliomas–include tumors that are more circumscribed, focal, or contained at the brain stem.  These tumors may have cysts or grow out from the brain stem (i.e., exophytic).  These tumors more often arise in the midbrain or medulla, rather than the pons. Pathology for these tumors is frequently pilocytic astrocytoma (WHO I) or ganglioglioma (WHO I), although rarely diffuse astrocytoma (WHO II).

Treatment:  Since brain stem gliomas are relatively uncommon and require complex management, children with such tumors deserve evaluation in a comprehensive cancer center where the coordinated services of dedicated pediatric neurosurgeons, child neurologists, pediatric oncologists, radiation oncologists, neuropathologists, and neuroradiologists are available. In particular, for DIPG, because of its rarity and poor prognosis, children and their families should be encouraged to participate in clinical trials attempting to improve survival with innovative therapy.

Neurosurgery:  Surgery to attempt tumor removal is usually not possible or advisable for DIPG. By their very nature, these tumors invade diffusely throughout the brain stem, growing between normal nerve cells. Aggressive surgery would cause severe damage to neural structures vital for arm and leg movement, eye movement, swallowing, breathing, and even consciousness.

Surgery with less than total removal can be performed for many focal brain stem gliomas.  Such surgery often results in quality long-term survival, without administering chemotherapy or radiotherapy immediately after surgery, even when a child has residual tumor.  Surgery is particularly useful for tumors that grow out (exophytic) from the brain stem.

Focal brain stem tumors that arise at the top back of the midbrain (tectal gliomas) should be managed conservatively, without surgical removal. Nevertheless, shunt placement or ventriculostomy for hydrocephalus (see below) is frequently necessary. These tumors have been described to be stable for many years or decades without any intervention other than shunting.

Radiotherapy:  Conventional radiotherapy, limited to the involved area of tumor, is the mainstay of treatment for DIPG.  A total radiation dosage ranging from 5400 to 6000 cGy, administered in daily fractions of 150 to 200 cGy over 6 weeks, is standard.  Hyperfractionated (twice-daily) radiotherapy was used previously to deliver higher irradiation dosages, but such did not lead to improved survival.  Radiosurgery (e.g., gamma knife, Cyberknife) has no role in the treatment of DIPG.

Chemotherapy and other drug therapies:  The role of chemotherapy in DIPG remains unclear.  Studies to date with chemotherapy have shown little improvement in survival, although efforts (see below) through the Children’s Oncology Group (COG), Pediatric Brain Tumor Consortium (PBTC), and others are underway to explore further the use of chemotherapy and other drugs.  Drugs utilized to increase the effect of radiotherapy (radiosensitizers) have thus far shown no added benefit, but promising new agents are under investigation.  Immunotherapy with beta-interferon and other drugs to modify biologic response have shown disappointing results.  Intensive or high-dose chemotherapy with autologous bone marrow transplant or peripheral blood stem cell rescue has not demonstrated any effectiveness in brain stem gliomas and is not recommended.  Future clinical trials may incorporate medicines to interfere with cellular pathways (signal transfer inhibitors) or other approaches that alter the tumor or its environment.  For more information and a listing of the most up-to date trials, the reader is encouraged to check the websites of the National Institutes of Health clinical trials registry , the National Childhood Cancer Foundation/COG, and the PBTC .

In focal brain stem gliomas, chemotherapy, such as carboplatin/vincristine,  procarbazine/CCNU/vincristine, or temozolomide, may be useful in children whose tumors are progressive and not surgically accessible.  In children younger than age 3 years, chemotherapy may be preferable to radiotherapy because of the effects of irradiation on the developing brain.

Recurrent or Progressive Brain Stem Gliomas: Regrettably, DIPG has a high rate of recurrence or progression. At relapse, a variety of Phase I and Phase II drug trials are available through the national research consortiums COG and PBTC, as well as through individual pediatric institutions. Oral etoposide, temozolomide, and cyclophosphamide are drug options sometimes utilized outside a study.

Prognosis:  DIPG often follows an inexorable course of progression, despite therapy. A large majority of children die within a year of diagnosis. Focal brain stem glioma, however, can carry an exceptional prognosis, with long-term survivals frequently reported.

Other Management Issues:  Shunts: Less than half of children with brain stem tumors will develop obstructive hydrocephalus, requiring a shunt or ventriculostomy, at some time during the course of their illness.  Shunts are simple mechanical tubing devices that divert cerebrospinal fluid trapped in the brain’s ventricles above the tumor to another location in the body, typically the abdomen (peritoneum), as in a ventriculoperitoneal shunt.  A ventriculostomy is the surgical creation of an internal channel, often from the third ventricle to a lower portion of the brain, to allow cerebrospinal fluid to drain beyond the tumor.

Steroids:  Dexamethasone (brand name Decadron) is a steroid drug frequently administered to brain stem tumor patients for the swelling and “tightness” of their tumor at the base of their skull. Dexamethasone must be used sparingly!  Dexamethasone should never be prescribed prophylactically or “just in case.” That is, this steroid is an extremely effective medicine for symptomatic swelling associated with treatment of a brain stem glioma, particularly with radiotherapy.  However, dexamethasone is not necessary unless a child has symptomatic swelling.  Dexamethasone has a number of side effects which include mood changes, insomnia, weight gain, fluid retention, glucose instability, high blood pressure, and increased susceptibility to infection.

Brachytherapy is a form of radiotherapy where a radiation source is placed inside or next to the area requiring treatment. Brachytherapy is commonly used as an effective treatment for cervical, prostate, breast, and skin cancer and can also be used to treat tumours in many other body sites.

Brachytherapy can be used alone or in combination with other therapies such as surgery, External Beam Radiotherapy (EBRT) and chemotherapy.

A course of brachytherapy can be completed in less time than other radiotherapy techniques. This can help reduce the chance of surviving cancer cells dividing and growing in the intervals between each radiotherapy dose. Patients typically have to make fewer visits to the radiotherapy clinic compared with EBRT, and the treatment is often performed on an outpatient basis. This makes treatment accessible and convenient for many patients. These features of brachytherapy reflect that most patients are able to tolerate the brachytherapy procedure very well.

Brachytherapy represents an effective treatment option for many types of cancer. Treatment results have demonstrated that the cancer cure rates of brachytherapy are either comparable to surgery and EBRT, or are improved when used in combination with these techniques. In addition, brachytherapy is associated with a low risk of serious adverse side effects.

Types of Brachytheraphy

Different types of brachytherapy can be defined according to

• The placement of the radiation sources in the target treatment area
• The rate or ‘intensity’ of the irradiation dose delivered to the tumour,
• The duration of dose delivery

Source placement

The two main types of brachytherapy treatment in terms of the placement of the radioactive source are interstitial and contact.

• In the case of interstitial brachytherapy, the sources are placed directly in the target tissue of the affected site, such as the prostate or breast.
• Contact brachytherapy involves placement of the radiation source in a space next to the target tissue. This space may be a body cavity (intracavitary brachytherapy) such as the cervix, uterus or vagina; a body lumen (intraluminal brachytherapy) such as the trachea or oesophagus; or externally (surface brachytherapy) such as the skin. A radiation source can also be placed in blood vessels (intravascular brachytherapy) for the treatment of coronary in-stent restenosis.

Dose rate

• Medium-dose rate (MDR) brachytherapy is characterized by a medium rate of dose delivery, ranging between 2 Gy·h−1 to 12 Gy·h−1.
• High-dose rate (HDR) brachytherapy is when the rate of dose delivery exceeds 12 Gy·h−1. The most common applications of HDR brachytherapy are in tumours of the cervix, esophagus, lungs, breasts and prostate. Most HDR treatments are performed on an outpatient basis, but this is dependent on the treatment site.

Duration of dose delivery

The placement of radiation sources in the target area can be temporary or permanent.

• Temporary brachytherapy involves placement of radiation sources for a set duration before being withdrawn. The specific treatment duration will depend on many different factors, including the required rate of dose delivery and the type, size and location of the cancer. In LDR and PDR brachytherapy, the source typically stays in place up to 24 hours before being removed, while in HDR brachytherapy this time is typically a few minutes.
• Permanent brachytherapy, also known as seed implantation, involves placing small LDR radioactive seeds or pellets in the tumour or treatment site and leaving them there permanently to gradually decay. Over a period of weeks or months, the level of radiation emitted by the sources will decline to almost zero. The inactive seeds then remain in the treatment site with no lasting effect. Permanent brachytherapy is most commonly used in the treatment of prostate cancer.

Rectal Cancer Treatment by Stage,
Stage 0 Rectal Cancer
Stage I Rectal Cancer
Stage II Rectal Cancer
Stage III Rectal Cancer
Stage IV Rectal Cancer
Recurrent Rectal Cancer
Rectal cancer is staged much the same way as is colon cancer, but because the tumor is much lower down in the large intestine, the treatment options may vary. Surgery to remove the cancer is almost always the first treatment.

Stage 0 Rectal Cancer :

In Stage 0 rectal cancer, the tumor is located only on the inner lining of the rectum. To treat this early stage cancer, surgery can be performed to remove the tumor or a small section of the rectum where the cancer is located can be removed. Radiation treatment, given either externally (beamed in from the outside) or internally (radioactive beads are placed inside the rectum) may be considered.

Stage I Rectal Cancer:

Stage I rectal cancer is another early form or limited form of cancer. The tumor has broken through the inner lining of the rectum but has not made it past the muscular wall. Treatment usually involves:

Surgery to remove the tumor
If the tumor is small or you are very old or sick, radiation alone can be used to treat the tumor. This hasn’t proven to be as effective as surgery. Chemotherapy can also be added to heighten the effect of radiation.
Stage II Rectal Cancer:
Stage II rectal cancer is a little more advanced. The tumor has penetrated all the way through the bowel wall and may have invaded other organs, like the bladder, uterus, or prostate gland. However, lymph nodes are not involved at this stage. Treatment includes:

Surgery to remove all the organs involved with the cancer (wide-resection)
Radiation with chemotherapy is given before surgery, or after surgery; chemotherapy alone is given for 4 months after surgery.
Stage III Rectal Cancer:
In Stage III rectal cancer, the tumor has spread to the lymph nodes (small structures that are found throughout the body that produce and store cells that fight infection). Treatment includes:

Surgery to remove the tumor
Radiation with chemotherapy before or after surgery
Chemotherapy, if elected, after surgery

Stage IV Rectal Cancer:
In Stage IV rectal cancer, the tumor has spread to distant parts of the body (metastasized), often to the liver and lung. The tumor can be any size and sometimes is not that large.

The mainstay of treatment is chemotherapy, but surgery to remove the tumor may also be recommended. Surgery, when performed, is often used to relieve or prevent blockage of the rectum or to prevent rectal bleeding. It is not generally considered a curative procedure. Surgeries of this type can also help a patient with stage IV rectal cancer live longer.

If there are only one or two liver tumors, they can be removed surgically. Other options include freezing the tumors (cryosurgery) or destroying them with microwaves or heat (radio frequency ablation). Other nonsurgical directed therapies include giving chemotherapy directly into the liver using radioactive isotopes (radio-embolization) or cutting off the blood supply to the tumor in the liver (embolization). Often, chemotherapy directly into the liver is used with embolization (chemo embolization).

Recurrent Rectal Cancer:
Recurrent rectal cancer means the cancer has come back after treatment. The cancer can recur near the site of the original cancer in the rectum (local recurrence) or in distant organs. Treatment includes:

Surgery to remove local recurrences; studies show that this can help patients live longer.
If surgery can’t remove all of the recurrences, many experts recommend chemotherapy with or without radiation. This can sometimes shrink the tumor enough to allow surgical removal of the tumor afterwards.

What Is Anemia?

Anemia is a condition that develops when your blood lacks enough healthy red blood cells or hemoglobin. Hemoglobin is a main part of redblood cells and binds oxygen. If you have too few or abnormal red blood cells, or your hemoglobin is abnormal or low, the cells in your body will not get enough oxygen. Symptoms of anemia — like fatigue — occur because organs aren’t getting what they need to function properly.

• Certain forms of anemia are hereditary and infants may be affected from the time of birth.
• Women in the childbearing years are particularly susceptible to iron-deficiency anemia because of the blood loss from menstruationand the increased blood supply demands during pregnancy.
• Older adults also may have a greater risk of developing anemia because of poor diet and other medical conditions.

There are many types of anemia. All are very different in their causes and treatments. Iron-deficiency anemia, the most common type, is very treatable with diet changes and iron supplements. Some forms of anemia — like the anemia that develops during pregnancy — are even considered normal. However, some types of anemia may present lifelong health problems.

What Causes Anemia?

There are more than 400 types of anemia, which are divided into three groups:

• Anemia caused by blood loss
• Anemia caused by decreased or faulty red blood cell production
• Anemia caused by destruction of red blood cells

Anemia Caused by Blood Loss

Red blood cells can be lost through bleeding, which often can occur slowly over a long period of time, and can go undetected. This kind of chronic bleeding commonly results from the following:

• Gastrointestinal conditions such as ulcers, hemorrhoids, gastritis(inflammation of the stomach), and cancer
• Use of nonsteroidal anti-inflammatory drugs (NSAIDs) such asaspirinor ibuprofen, which can cause ulcers and gastritis
• Menstruation and childbirth in women, especially if menstrual bleeding is excessive and if there are multiple pregnancies

Anemia Caused by Decreased or Faulty Red Blood Cell Production

With this type of anemia, the body may produce too few blood cells or the blood cells may not function correctly. In either case, anemia can result. Red blood cells may be faulty or decreased due to abnormal red blood cells or a lack of minerals and vitamins needed for red blood cells to work properly. Conditions associated with these causes of anemia include the following:

• Sickle cell anemia
• Iron-deficiency anemia
• Vitamin deficiency
• Bone marrow and stem cell problems
• Other health conditions

Sickle cell anemia is an inherited disorder that, in the U.S. affects mainly African-Americans and Hispanic Americans. Red blood cells become crescent-shaped because of a genetic defect. They break down rapidly, so oxygen does not get to the body’s organs, causing anemia. The crescent-shaped red blood cells can also get stuck in tiny blood vessels, causing pain.

Iron-deficiency anemia occurs because of a lack of the mineral iron in the body. Bone marrow in the center of the bone needs iron to make hemoglobin, the part of the red blood cell that transports oxygen to the body’s organs. Without adequate iron, the body cannot produce enough hemoglobin for red blood cells. The result is iron-deficiency anemia. This type of anemia can be caused by:

• An iron-poor diet, especially in infants, children, teens, vegans, and vegetarians
• The metabolic demands of pregnancy and breastfeeding that deplete a woman’s iron stores
• Menstruation
• Frequent blood donation
• Endurance training
• Digestive conditions such as Crohn’s disease or surgical removal of part of the stomach or small intestine
• Certain drugs, foods, and caffeinated drinks

Vitamin-deficiency anemia may occur when vitamin B12 and folate are deficient. These two vitamins are needed to make red blood cells. Conditions leading to anemia caused by vitamin deficiency include:

• Megaloblastic anemia: Vitamin B12 or folate or both are deficient
• Pernicious anemia: Poor vitamin B12 absorption caused by conditions such as Crohn’s disease, an intestinal parasite infection, surgical removal of part of the stomach or intestine, or infection with HIV
• Dietary deficiency: Eating little or no meat may cause a lack of vitamin B12, while overcooking or eating too few vegetables may cause a folate deficiency.
• Other causes of vitamin deficiency: pregnancy, certain medications,alcohol abuse, intestinal diseases such as tropical sprue and celiac disease

During early pregnancy, sufficient folic acid can help prevent the fetus from developing neural tube defects such asspina bifida.

Bone marrow and stem cell problems may prevent the body from producing enough red blood cells. Some of the stem cells found in bone marrow develop into red blood cells. If stem cells are too few, defective, or replaced by other cells such as metastatic cancer cells, anemia may result. Anemia resulting from bone marrow or stem cell problems include:

• Aplastic anemia occurs when there’s a marked reduction in the number of stem cells or absence of these cells. Aplastic anemia can be inherited, can occur without apparent cause, or can occur when the bone marrow is injured by medications, radiation,chemotherapy, or infection.
• Thalassemia occurs when the red cells can’t mature and grow properly. Thalassemia is an inherited condition that typically affects people of Mediterranean, African, Middle Eastern, and Southeast Asian descent. This condition can range in severity from mild to life-threatening; the most severe form is called Cooley’s anemia.
• Lead exposure is toxic to the bone marrow, leading to fewer red blood cells. Lead poisoning occurs in adults from work-related exposure and in children who eat paint chips, for example. Improperly glazed pottery can also taint food and liquids with lead.

Anemia associated with other conditions usually occurs when there are too few hormones necessary for red blood cell production. Conditions causing this type of anemia include the following:

Diabetes mellitus (or diabetes) is a chronic, lifelong condition that affects your body’s ability to use the energy found in food. There are three major types of diabetes: type 1 diabetes, type 2 diabetes, and gestational diabetes.

All types of diabetes mellitus have something in common. Normally, your body breaks down the sugars and carbohydrates you eat into a special sugar called glucose. Glucose fuels the cells in your body. But the cells need insulin, a hormone, in your bloodstream in order to take in the glucose and use it for energy. With diabetes mellitus, either your body doesn’t make enough insulin, it can’t use the insulin it does produce, or a combination of both.

Since the cells can’t take in the glucose, it builds up in your blood. High levels of blood glucose can damage the tiny blood vessels in yourkidneys, heart, eyes, or nervous system. That’s why diabetes — especially if left untreated — can eventually cause heart disease, stroke,kidney disease, blindness, and nerve damage to nerves in the feet.

Types of Diabetes Mellitus :

1. Type 1 Diabetes
2. Type 2 Diabetes
3. Gestational Diabetes
4. Other Forms of Diabetes

Type 1 Diabetes:

Type 1 diabetes is also called insulin-dependent diabetes. It used to be called juvenile-onset diabetes, because it often begins in childhood.

Type 1 diabetes is an autoimmune condition. It’s caused by the body attacking its own pancreas with antibodies. In people with type 1 diabetes, the damaged pancreas doesn’t make insulin.

This type of diabetes may be caused by a genetic predisposition. It could also be the result of faulty beta cells in the pancreas that normally produce insulin.

A number of medical risks are associated with type 1 diabetes. Many of them stem from damage to the tiny blood vessels in your eyes (called diabetic retinopathy), nerves (diabetic neuropathy), and kidneys (diabetic nephropathy). Even more serious is the increased risk of heart disease and stroke.

Treatment for type 1 diabetes involves taking insulin, which needs to be injected through the skin into the fatty tissue below. The methods of injecting insulin include:

1. Syringes
2. Insulin pens that use pre-filled cartridges and a fine needle
3. Jet injectors that use high pressure air to send a spray of insulin through the skin
4. Insulin pumps that dispense insulin through flexible tubing to a catheter under the skin of the abdomen