**8. Conclusion**

multifactorial, but RT certainly contributes to this process. The vast majority of secondary malignant neoplasm (SMN) appears within the radiation field. The cumulative incidence of SMNs at 25 years was 7.1% for children who received more than 50 Gy to the cranium compared to 1% for children who did not receive cranial irradiation. A linear dose response could be illustrated with an increased relative risk of 0.33% for gliomas and 1.06% for meningiomas per Gy. The chemotherapy contribution to the development of secondary CNS malignancy is more difficult to assess partly due to the use of combination chemotherapy regimens. Alkylating drugs, especially cyclophosphamide and epipodophyllotoxins, such as etoposide, have been reported to increase the cumulative incidence of second malignancies [77]. The presence of accompanying somatic mutations may predispose for the development of second malignancy. Patients with p53 (Li-Fraumeni syndrome) are more likely to develop SMN including sarcoma, primary brain tumor, and acute lymphoblastic leukemia (ALL).

Therapy may be tailored in order to avoid or reduce the combination of RT and certain chemotherapy agents. Alkylating drugs, especially cyclophosphamide and epipodophyllo‐ toxins, such as etoposide, have been reported to increase the cumulative incidence of second malignancies up to 4% [77]. Other somatic mutations such as the ataxia telangiectasia mutated gene (ATM) known to be involved in DNA repair may possibly play a role. Finally, metabo‐ lism and detoxification might also be involved in the development of second malignancy especially in those with acute nonlymphocytic leukemia (ANLL) and acute myeloid leuke‐

Palliative care for children has evolved, over the last two decades, as separate specialized entity. Its delivery encompasses the total care of children with life-limiting diseases, regard‐ less of outcome. It is worth noting that palliative care is applicable from the time of diagno‐ sis, through active and curative treatment, and afterwards. Timing is further complicated by the perceived sharp division between curative therapy and palliative care among pediatric oncologists and parents who view palliative care as giving up hope and representing failure.

Palliative care service includes improved communication and continuity of care across different disease and management stages. This care deals with assessment of physical, psychosocial, emotional, and spiritual needs, provision of comprehensive specialized pain and symptom management, and support with complex and ethical decision making. It is also concerned with enhanced awareness of diverse cultural beliefs about dying and death, specialized care of the dying patient, and provision of bereavement care. Education and staff support to improve delivery of care and respond to moral distress are additional important role [78, 79]. Palliative care services must better be organizationally situated within a pedia‐ tric oncology program. Without early integration of palliative care, the focus of care then centers on life-prolonging measures, which may result in painful and invasive procedures, additional unnecessary suffering, and futile resuscitation. Care may be missed if not ad‐

mia (AML).

**7. Palliative care**

468 Neurooncology - Newer Developments

Although the gap between the neuro-oncology services in HICs and LMICs is still huge, yet the continuous efforts performed by the LMICs assisted by different international organiza‐ tion, medical and scientific societies, and other international medical bodies can decrease and overcome this gap. Pediatric neuro-oncology service is a delicate art and science that is presented by a multidisciplinary team aimed at taking care of pediatric CNS tumors from the day of suspicion of the disease till long way across the adulthood life. The welfare of these patients is the concern of the multidisciplinary team along the journey of diagnosis, treat‐ ment, and prolonged extended follow-up. The team is concerned also with dealing with disease and treatment complications together with palliation of the symptoms faced by the patients. Much success was achieved; however, much effort is needed for more improve‐ ment of the quality of their life. Very long-term effects 30–40 years after treatment still need to be thoroughly investigated. Cerebrovascular diseases such as stroke, cognitive dysfunction leading to early dementia, secondary neoplasms, and peripheral neuropathy are likely to form real problem in the coming years.

The balance between survival and long-term side effects will certainly be a challenge for several decades. Tailored therapy to reduce and limit the need for radiation and chemotherapy will hopefully lead to improved outcomes with fewer adverse effects and morbidity.
