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This information is produced and provided by the National Cancer Institute (NCI). The information in this topic may have changed since it was written. For the most current information, contact the National Cancer Institute via the Internet web site at http://cancer.gov or call 1-800-4-CANCER.
The gastrointestinal (GI) tract is part of the digestive system, which processes nutrients (vitamins, minerals, carbohydrates, fats, proteins, and water) in foods that are eaten and helps pass waste material out of the body. The GI tract includes the stomach and intestines (bowels). The stomach is a J-shaped organ in the upper abdomen. Food moves from the throat to the stomach through a hollow, muscular tube called the esophagus. After leaving the stomach, partly-digested food passes into the small intestine and then into the large intestine (colon). The last 6 inches of the large intestine are the rectum and the anal canal. The anal canal ends at the anus (the opening of the large intestine to the outside of the body).Anatomy of the lower digestive system, showing the colon and other organs.
GI complications are common in cancer patients. Complications are medical problems that occur during a disease, or after a procedure or treatment. They may be caused by the disease, procedure, or treatment, or may have other causes. This summary describes the following GI complications and their causes and treatments:
This summary is about GI complications in adults with cancer. Treatment of GI complications in children is different than treatment for adults.
With constipation, bowel movements are difficult or don't happen as often as usual.
Constipation is the slow movement of stool through the large intestine. The longer it takes for the stool to move through the large intestine, the more it loses fluid and the drier and harder it becomes. The patient may be unable to have a bowel movement, have to push harder to have a bowel movement, or have fewer than their usual number of bowel movements.
Certain medicines, changes in diet, not drinking enough fluids, and being less active are common causes of constipation.
Constipation is a common problem for cancer patients. Cancer patients may become constipated by any of the usual factors that cause constipation in healthy people. These include older age, changes in diet and fluid intake, and not getting enough exercise. In addition to these common causes of constipation, there are other causes in cancer patients.
Other causes of constipation include:
An assessment is done to help plan treatment.
The assessment includes a physical exam and questions about the patient's usual bowel movements and how they have changed.
The following tests and procedures may be done to help find the cause of the constipation:
There is no "normal" number of bowel movements for a cancer patient. Each person is different. You will be asked about bowel routines, food, and medicines:
For patients who have colostomies, care of the colostomy will be discussed.
Treating constipation is important to make the patient comfortable and to prevent more serious problems.
It's easier to prevent constipation than to relieve it. The health care team will work with the patient to prevent constipation. Patients who take opioids may need to start taking laxatives right away to prevent constipation.
Constipation can be very uncomfortable and cause distress. If left untreated, constipation may lead to fecal impaction. This is a serious condition in which stool will not pass out of the colon or rectum. It's important to treat constipation to prevent fecal impaction.
Prevention and treatment are not the same for every patient. Do the following to prevent and treat constipation:
When constipation is caused by opioids, treatment may be drugs that stop the effects of the opioids or other medicines, stool softeners, enemas, and/or manual removal of stool.
Fecal impaction is a mass of dry, hard stool that will not pass out of the colon or rectum.
Fecal impaction is dry stool that cannot pass out of the body. Patients with fecal impaction may not have gastrointestinal (GI) symptoms. Instead, they may have problems with circulation, the heart, or breathing. If fecal impaction is not treated, it can get worse and cause death.
A common cause of fecal impaction is using laxatives too often.
Repeated use of laxatives in higher and higher doses makes the colon less able to respond naturally to the need to have a bowel movement. This is a common reason for fecal impaction. Other causes include:
Certain types of mental illness may lead to fecal impaction.
Symptoms of fecal impaction include being unable to have a bowel movement and pain in the abdomen or back.
The following may be symptoms of fecal impaction:
These symptoms should be reported to the health care provider.
Assessment includes a physical exam and questions like those asked in the assessment of constipation.
The doctor will ask questions similar to those for the assessment of constipation:
The doctor will do a physical exam to find out if the patient has a fecal impaction. The following tests and procedures may be done:
A fecal impaction is usually treated with an enema.
The main treatment for impaction is to moisten and soften the stool so it can be removed or passed out of the body. This is usually done with an enema. Enemas are given only as prescribed by the doctor since too many enemas can damage the intestine. Stool softeners or glycerin suppositories may be given to make the stool softer and easier to pass. Some patients may need to have stool manually removed from the rectum after it is softened.
Laxatives that cause the stool to move are not used because they can also damage the intestine.
A bowel obstruction is a blockage of the small or large intestine by something other than fecal impaction.
Bowel obstructions (blockages) keep the stool from moving through the small or large intestines. They may be caused by a physical change or by conditions that stop the intestinal muscles from moving normally. The intestine may be partly or completely blocked. Most obstructions occur in the small intestine.
Physical changes
If the intestine is blocked by physical causes, it may decrease blood flow to blocked parts. Blood flow needs to be corrected or the affected tissue may die.
Conditions that affect the intestinal muscle
The most common cancers that cause bowel obstructions are cancers of the colon, stomach, and ovary.
Other cancers, such as lung and breast cancers and melanoma, can spread to the abdomen and cause bowel obstruction. Patients who have had surgery on the abdomen or radiation therapy to the abdomen have a higher risk of a bowel obstruction. Bowel obstructions are most common during the advanced stages of cancer.
Assessment includes a physical exam and imaging tests.
The following tests and procedures may be done to diagnose a bowel obstruction:
Treatment is different for acute and chronic bowel obstructions.
Acute bowel obstruction
Acute bowel obstructions occur suddenly, may have not occurred before, and are not long-lasting. Treatment may include the following:
Patients with symptoms that keep getting worse will have follow-up exams to check for signs and symptoms of shock and to make sure the obstruction isn't getting worse.
Chronic, malignant bowel obstruction
Chronic bowel obstructions keep getting worse over time. Patients who have advanced cancer may have chronic bowel obstructions that cannot be removed with surgery. The intestine may be blocked or narrowed in more than one place or the tumor may be too large to remove completely. Treatments include the following:
Diarrhea is frequent, loose, and watery bowel movements.
Diarrhea is frequent, loose, and watery bowel movements. Acute diarrhea lasts more than 4 days but less than 2 weeks. Symptoms of acute diarrhea may be loose stools and passing more than 3 unformed stools in one day. Diarrhea is chronic (long-term) when it goes on for longer than 2 months.
Diarrhea can occur at any time during cancer treatment. It can be physically and emotionally stressful for patients who have cancer.
In cancer patients, the most common cause of diarrhea is cancer treatment.
Causes of diarrhea in cancer patients include the following:
Assessment includes a physical exam, lab tests, and questions about diet and bowel movements.
Because diarrhea can be life-threatening, it is important to find out the cause so treatment can begin as soon as possible. The doctor may ask the following questions to help plan treatment:
Tests and procedures may include the following:
Treatment of diarrhea depends on what is causing it.
Treatment depends on the cause of the diarrhea. The doctor may make changes in medicines, diet, and/or fluids.
Radiation enteritis is inflammation of the intestine caused by radiation therapy.
Radiation enteritis is a condition in which the lining of the intestine becomes swollen and inflamed during or after radiation therapy to the abdomen, pelvis, or rectum. The small and large intestine are very sensitive to radiation. The larger the dose of radiation, the more damage may be done to normal tissue. Most tumors in the abdomen and pelvis need large doses of radiation. Almost all patients receiving radiation to the abdomen, pelvis, or rectum will have enteritis.
Radiation therapy to kill cancer cells in the abdomen and pelvis affects normal cells in the lining of the intestines. Radiation therapy stops the growth of cancer cells and other fast-growing cells. Since normal cells in the lining of the intestines grow quickly, radiation treatment to that area can stop those cells from growing. This makes it hard for tissue to repair itself. As cells die and are not replaced, gastrointestinal problems occur over the next few days and weeks.
Doctors are studying whether the order that radiation therapy, chemotherapy, and surgery are given affects how severe the enteritis will be.
Symptoms may begin during radiation therapy or months to years later.
Radiation enteritis may be acute or chronic:
The total dose of radiation and other factors affect the risk of radiation enteritis.
Only 5% to 15% of patients treated with radiation to the abdomen will have chronic problems. The amount of time the enteritis lasts and how severe it is depend on the following:
Acute and chronic enteritis have symptoms that are a lot alike.
Patients with acute enteritis may have the following symptoms:
Symptoms of acute enteritis usually go away 2 to 3 weeks after treatment ends.
Symptoms of chronic enteritis usually appear 6 to 18 months after radiation therapy ends. It can be hard to diagnose. The doctor will first check to see if the symptoms are being caused by a recurrent tumor in the small intestine. The doctor will also need to know the patient's full history of radiation treatments.
Patients with chronic enteritis may have the following signs and symptoms:
Assessment of radiation enteritis includes a physical exam and questions for the patient.
Patients will be given a physical exam and be asked questions about the following:
Treatment depends on whether the radiation enteritis is acute or chronic.
Acute radiation enteritis
Treatment of acute enteritis includes treating the symptoms. The symptoms usually get better with treatment, but if symptoms get worse, then cancer treatment may have to be stopped for a while.
Treatment of acute radiation enteritis may include the following:
Chronic radiation enteritis
Treatment of chronic radiation enteritis may include the following:
Check NCI's list of cancer clinical trials for U.S. supportive and palliative care trials about constipation, impaction, and bowel obstruction and diarrhea that are now accepting participants. The list of trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.
Editorial changes were made to this summary.
If you have questions or comments about this summary, please send them to Cancer.gov through the Web site's Contact Form. We can respond only to email messages written in English.
Call 1-800-4-CANCER
For more information, U.S. residents may call the National Cancer Institute's (NCI's) Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237) Monday through Friday from 8:00 a.m. to 8:00 p.m., Eastern Time. A trained Cancer Information Specialist is available to answer your questions.
Chat online
The NCI's LiveHelp® online chat service provides Internet users with the ability to chat online with an Information Specialist. The service is available from 8:00 a.m. to 11:00 p.m. Eastern time, Monday through Friday. Information Specialists can help Internet users find information on NCI Web sites and answer questions about cancer.
Write to us
For more information from the NCI, please write to this address:
Search the NCI Web site
The NCI Web site provides online access to information on cancer, clinical trials, and other Web sites and organizations that offer support and resources for cancer patients and their families. For a quick search, use the search box in the upper right corner of each Web page. The results for a wide range of search terms will include a list of "Best Bets," editorially chosen Web pages that are most closely related to the search term entered.
There are also many other places to get materials and information about cancer treatment and services. Hospitals in your area may have information about local and regional agencies that have information on finances, getting to and from treatment, receiving care at home, and dealing with problems related to cancer treatment.
Find Publications
The NCI has booklets and other materials for patients, health professionals, and the public. These publications discuss types of cancer, methods of cancer treatment, coping with cancer, and clinical trials. Some publications provide information on tests for cancer, cancer causes and prevention, cancer statistics, and NCI research activities. NCI materials on these and other topics may be ordered online or printed directly from the NCI Publications Locator. These materials can also be ordered by telephone from the Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237).
PDQ is a comprehensive cancer database available on NCI's Web site.
PDQ is the National Cancer Institute's (NCI's) comprehensive cancer information database. Most of the information contained in PDQ is available online at NCI's Web site. PDQ is provided as a service of the NCI. The NCI is part of the National Institutes of Health, the federal government's focal point for biomedical research.
PDQ contains cancer information summaries.
The PDQ database contains summaries of the latest published information on cancer prevention, detection, genetics, treatment, supportive care, and complementary and alternative medicine. Most summaries are available in two versions. The health professional versions provide detailed information written in technical language. The patient versions are written in easy-to-understand, nontechnical language. Both versions provide current and accurate cancer information.
Images in the PDQ summaries are used with permission of the author(s), artist, and/or publisher for use within the PDQ summaries only. Permission to use images outside the context of PDQ information must be obtained from the owner(s) and cannot be granted by the National Cancer Institute. Information about using the illustrations in the PDQ summaries, along with many other cancer-related images, are available in Visuals Online, a collection of over 2,000 scientific images.
The PDQ cancer information summaries are developed by cancer experts and reviewed regularly.
Editorial Boards made up of experts in oncology and related specialties are responsible for writing and maintaining the cancer information summaries. The summaries are reviewed regularly and changes are made as new information becomes available. The date on each summary ("Date Last Modified") indicates the time of the most recent change.
PDQ also contains information on clinical trials.
A clinical trial is a study to answer a scientific question, such as whether one method of treating symptoms is better than another. Trials are based on past studies and what has been learned in the laboratory. Each trial answers certain scientific questions in order to find new and better ways to help cancer patients. Some patients have symptoms caused by cancer treatment or by the cancer itself. During supportive care clinical trials, information is collected about how well new ways to treat symptoms of cancer work. The trials also study side effects of treatment and problems that come up during or after treatment. If a clinical trial shows that a new treatment is better than one currently being used, the new treatment may become "standard." Patients who have symptoms related to cancer treatment may want to think about taking part in a clinical trial.
Listings of clinical trials are included in PDQ and are available online at NCI's Web site. Descriptions of the trials are available in health professional and patient versions. Many cancer doctors who take part in clinical trials are also listed in PDQ. For more information, call the Cancer Information Service 1-800-4-CANCER (1-800-422-6237).
Last Revised: 2013-01-24
If you want to know more about cancer and how it is treated, or if you wish to know about clinical trials for your type of cancer, you can call the NCI's Cancer Information Service at 1-800-422-6237, toll free. A trained information specialist can talk with you and answer your questions.
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Three and easy for Forest
Nottingham Forest's start to the season went from solid to spectacular as they notched up their third consecutive Sky Bet Championship win with a 3-0 drubbing of fellow promotion hopefuls Bolton.
Billy Davies' side had claimed 1-0 victories over Huddersfield and Blackburn but goals from Jamie Mackie, Andy Reid and Henri Lansbury steered them to a rather more emphatic success over Wanderers, who played much of the second half with 10 men after Darren Pratley had been shown a second yellow card.
Having collected nine points from three games, it is the best start Forest have made in the Championship since 1997, following a summer when owner Fawaz Al Hasawi has financed nine new additions at the City Ground, at a cost of more than £5million.
Forest were without three strikers through injury, with Darius Henderson joining Simon Cox and Dexter Blackstock in the treatment room, and it left defender Greg Halford to be drafted in to an unfamiliar role as a target man up front.
But the situation did little to dent the hosts' firepower, as they made a storming start that saw them take the lead after only two minutes and go on to claim a comfortable win.
Radoslaw Majewski's clever pass was matched by an equally confident finish from Mackie, the B#1million summer addition from QPR, who swept a shot beyond the advancing Adam Bogdan and inside the far post.
Forest were getting plenty of space to threaten in wide positions, with both full-backs coming close. Chris Cohen saw Bogdan get down well at his near post to claim his cross-shot, while Eric Lichaj had the goalkeeper looking on nervously as his clever, curling effort narrowly cleared the bar at the far post.
Craig Davies came close with a diving header for Bolton, David Wheater had a powerful header, which bounced down onto the line off the crossbar, ruled out for offside and Rob Hall flashed a shot wide.
But it was referee Mark Haywood who was to take centre stage as he failed to send off Mohamed Kamara for a two-footed tackle on Reid, opting instead to show a lenient yellow card.
Haywood also cautioned Pratley for an elbow on Adlene Guedioura and, when the referee failed to give a free-kick for Forest when Marc Tierney had clearly hauled back Reid, it was too much for the Irishman, who reacted with an angry challenge of his own on Kamara.
Reid could himself easily have been sent off, as harsh as that might have been given what had gone before, but he was shown a yellow card.
And it proved to be decisive moment as, five minutes into the second half, Majewski delivered another good ball, this time from the right, for Reid to double Forest's advantage, with an emphatic finish from six yards.
Pratley looped a header into the side-netting after a wicked bounce had left Forest goalkeeper Karl Darlow in no man's land - while Halford saw a shot bounce back off the post as Forest pushed again, with another swift counter.
But, in the build-up to that move, Pratley had lunged in with a late tackle on Cohen which spelt bad news for the Bolton man. Referee Haywood, who had played the advantage, went back to show a second yellow and a subsequent red, in the 53rd minute.
By the 65th minute, the game was as good as over as Lansbury dived in bravely send a stooping header inside the far post to make it 3-0, attacking an incisive delivery from Mackie.
Lichaj and Mackie both flashed shots narrowly wide as Forest looked to increase Bolton's misery.
Source: PA
Source: PA

subset: commoncrawl


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What do players say about VDragonball
New depth. New challenges. And a whole new universe to explore. The most immersive Dragonball game I have ever played.– Michael E
A great improvement in every aspect, this is a great leap forward for vDragonball. Content, depth, balance, complexity, combined to deliver a game for every taste. 5 stars.– L0tt0
VDragonball just went Super Saiyan– Nitro22000
Simply irresistible! From the first moment of playing you are drawn into a different world, one you could only imagine. The number of different options you have while playing the game keeps you entertained no matter what, whether you are battling to save the Universe or battling for Zeni - there will be something here for you! 10/10– AdamW
VDragonball the best Dragonball-Z game for a web browser ever created, no one even comes close– supersaiyan5
Get ready to ready to enjoy hours of genuine entertainment while exploring a detailed Dragonball Z universe.– Stephen H


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Bonus Sketches: February 2011
Free CK Bonus Sketches Download! Try scrapbooking variations on the February 2011 sketch plus several additional sketches based on layouts in this issue, You can download them in a PDF file for your binder.
Check out this sketch in action!
To learn more about the opportunity to gather with other scrapbookers and learn new techniques while creating beautiful scrapbook layouts, check out the CK Events Scrappin' with Sketches class.
For more inspiring layouts, check out the February 2011 issue of Creating Keepsakes magazine.
Related Links:
Bonus Sketches: November/December 2010
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text: Carl Paladino appeared on Fox Business last night and knocked Vice-President Joe Biden for comparing the Tea Party to terrorists. "Here you've got Joe Biden calling the American people terrorists. Who terrorized who? The President of the United States terrorized the elderly by telling them that they are not going to get a check. Read More


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Latest News
Another Gulf mystery: Who's in charge of oil spill research?
WASHINGTON — As an unprecedented amount of oil fouls the Gulf of Mexico, research scientists and ocean experts say the Obama administration's efforts to discover the magnitude of the damage are surprisingly uncoordinated.
If the government's higher estimates are accurate, the BP oil blowout already is the world's worst accidental oil spill ever.
Despite a spill that may already total more than 150 million gallons of oil, however, neither federal officials nor BP has mounted a speedy, focused inquiry to understand its impact.
The result:
- There's no comprehensive strategy for scientific inquiry in the Gulf. Therefore, there's no central system for organizing the research, sharing information or avoiding duplication.
That so much about the spill remains unknown is "kind of mind-boggling," said Frank Muller-Karger, a professor of biological oceanography at the University of South Florida. He said that one of the biggest problems he sees is the lack of a "war-room-type scenario" to coordinate all the research.
Christopher F. D'Elia, the dean of the School of the Coast and Environment at Louisiana State University, agrees.
"In my view, this is one of those all-hands-on-deck moments and we need to be devoting the resources necessary to understand this spill in every dimension regardless of who pays, because ultimately we'll pay a lot more as a nation if we don't do it right."
To be sure, federal officials and the Deepwater Horizon Unified Command have described a growing research effort. Since Memorial Day, six research vessels and 10 underwater monitors have been deployed. Just this week, Woods Hole Oceanographic Institution — a preeminent research organization in Massachusetts — launched an unmanned research vehicle with a sensor to detect oil.
And Friday, the National Oceanic and Atmospheric Administration agreed, at the urging of a group of East Coast senators, to begin making long-term projections for the path of the spill and its potential impact beyond Gulf shores.
"Coastal communities up and down the Atlantic . . . have raised concerns over the BP spill getting caught in the Loop Current and affecting the East Coast," said Sen. Bob Menendez, D-N.J., who led the request. "Science-based probabilities like these help these communities understand the current threat of oil reaching their shores and will help ensure full preparedness."
Scientists involved in the research, however, say they remain in the dark and don't know if enough is being done.
A group of more than 200 federal and university ocean scientists, who recently issued a report for a June 3 symposium on the Deepwater Horizon spill, called for central coordination of the research.
They also appealed for more research on the extent of subsurface plumes of oil, how oil and gas is mixed in the water, how the oil is changing over time and where it's moving, and what the chemicals from the oil and the dispersants used to break it down will do to the ocean and its creatures.
D'Elia of Louisiana State University said the federal government should do more to share what its own scientists are learning and bring in outside researchers.
"Whatever the federal government is up to — it may be well planned internally within the federal government, but the involvement of the outside research world is inadequate in my view," he said.
The reaction by scientists to the Obama administration's handling of the research echoes criticism of the government overall response. Governors and other state officials along the Gulf coast complain about the lack of resources and about the slowness of a cleanup. Residents rail at BP for the loss of their jobs, for its claims process and for BP's efforts to limit its legal liability from the spill.
Others say BP has manipulated information, making estimates of the amount of gushing crude impossible to determine and assessments of the health effects on workers, residents and wildlife difficult to make.
However, the criticism about the scientific research into the spill is widespread.
"It's a huge and difficult problem. This is very, very challenging," D'Elia said. "But what we're seeing right now is very little in the way of federal resources have been allocated to the external research community to do work."
Nancy Rabalais, an oceanographer and the director of the Louisiana Universities Marine Consortium, said there is considerable mystery in the Gulf.
"There's no single entity that's coordinating all the results and data from the research that's going on, whether it's within a (federal) agency or agency-funded or BP-funded. I can't say and I'm not sure anybody can say" what her fellow scientists are working on. "We don't know if it's adequately covered right now."
Stan Senner, the director of conservation science at the advocacy group Ocean Conservancy, who coordinated science and restoration programs for the state of Alaska after the Exxon Valdez oil spill, said that some government officials want to shift funds quickly to onshore restoration work and curtail funds for research of the oil's impacts. He said he agreed with the sense of urgency about habitat restoration, but also said it was important to study the effects on the environment over the long term.
"It's not just science for the sake of science," he said, "but it's so we can better assess the risk in the future and understand the true impact of events like this."
Robert Gagosian, the president of the Consortium for Ocean Leadership, which represents ocean research institutions and aquariums and manages a program on ocean drilling research, said the U.S. needs a national science plan to study the oil in the Gulf and improvements in its "woefully underfunded" ocean observing system.
A former director of the Woods Hole center and a marine geochemist, Gagosian and others say they're concerned about how the $500 million BP has promised for research and restoration gets spent. He said he hoped it would be handled through peer-reviewed grants.
With BP's interest in preserving its business, some worry whether the proper criteria will be used in assessing what research should be done.
Jeff Short, a former NOAA scientist who's now with the conservation group Oceana, said that by insisting that BP pay for the research, the government is ceding control over what studies are conducted.
"I find myself wondering why would BP want to guide money into projects that would clearly show much larger environmental damage than would have come to light otherwise," he said.
BP announced on June 15 that it had picked six scientists to oversee a review of proposals for the $500 million, and that their work would be independent.
One of the six — Jorge Imberger, the director of the Centre for Water Research at the University of Western Australia — said it hasn't been decided yet how the money will be divided.
Imberger said his committee had been about to send out requests for proposals, "but now, politics seems to have gotten in the way."
The day after BP announced its panel, the White House issued a statement that said that part of these funds would be spent with input from governors and other state and local officials.
Some observers have questioned how independent the science committee could be if BP selected it. Natural Resources Defense Council director Peter Lehner suggested that the company give the money to the National Academy of Sciences and let the academy choose how to disburse the funds.
The first $25 million of the BP funds was quickly distributed to Louisiana State University, the Florida Institute of Oceanography at the University of South Florida and a consortium led by Mississippi State University.
BP isn't telling the universities how to use the money, said Steven Lohrenz, a professor of biological oceanography at the University of Southern Mississippi, one of the schools receiving part of the funds.
Lohrenz said that NOAA and other federal agencies are doing their best, but their budgets are strapped.
"It's very appropriate for BP to step up and fund the research," he said. "What we would like to see in a perfect world is a more coordinated research strategy with additional resources coming in from a variety of sources and try to maximize the capabilities we have."
The main restraint on research has been lack of funds, Lohrenz said. "This is such a massive event. There's so much about it that's unprecedented."
NOAA said that the research wouldn't be limited by BP's willingness to fund it, but, in a statement in response to questions, the agency said that BP has been the source of funding for "many, but not all" of the research missions.
The National Science Foundation, an independent federal agency, has given more than two dozen awards totaling more than $3 million for research on the oil spill.
In a written response to questions, NOAA said it hadn't issued any formal requests for scientific research proposals.
"This is an unusual crisis response and there is a flexibility built into these science missions that will enable the most pressing scientific questions to be pursued and answered," the agency said.
Ocean Leadership Consortium summary of scientists' meeting on the Deepwater Horizon oil spill
Are sea turtles burning alive? Groups to sue BP, Coast Guard
Health of Exxon Valdez cleanup workers was never studied
GOP's false talking point: Jones Act blocks Gulf help
Oil found in Gulf crabs raises new food chain fears
More McClatchy oil spill coverage
Check out McClatchy's politics blog: Planet Washington


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California Valley farms could grow clean energy
Central San Joaquin Valley farmers are well known for growing a bounty of crops, but energy advocates say the region's farms and ranches also could be cultivating leadership in adopting clean energy.
Farmers, government officials, and utility representatives will meet Wednesday and Thursday at the Southern California Edison's AgTAC Center in Tulare for the inaugural Farming Clean Energy Conference.
Conference organizers say the event is designed to spotlight the Valley's clean energy potential, possible challenges and examples of successful clean energy projects.
With plenty of sun and some of the nation's most productive agricultural land, the Valley already is home to several farm-based renewable energy projects, including dairy waste-to-natural gas projects and photovoltaic solar farms.
Among the large-scale solar projects in the Valley are a 1.13-megawatt, $3.2 million system at Clovis-based P-R Farms and Paramount Farms' $7.5 million, 1.1-megawatt system covering about 8 acres in Lost Hills in Kern County.
But advocates say the potential exists for more.
"We know that times are tough, but this is a tremendous opportunity for the Valley, and we want to make sure that people are thinking and talking about developing clean energy," said Paul Johnson, executive director of the San Joaquin Valley Clean Energy Organization and a conference presenter. The nonprofit organization was created by the California Partnership for the San Joaquin Valley to help coordinate a regional approach to increasing the level of clean energy investments in the Valley.
Read the complete story at fresnobee.com


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Our tea party was this past Sunday. We had quite a spread- 4 different kinds of tea sandwiches, two different kinds of scones, cookies, tarts and some vegan treats. Katie (with some help from Wendy and Tony made all the food.) Since it turned out to be 80 degrees, I made mint iced tea and fruited water. We did have some hot tea later in the night. Katie brought her wedding china dessert plates, and Amy brought some of her grandmother's tea cups.My favorite treat was the lemon cheesecake tarts. I fell in love with Amy's grandmothers tea cups. She even gifted me a beautiful yellow cup and saucer. I will treasure it forever. Now I need to start building my collection of vintage tea cups. Floral patterns always get me!
It was a relaxing Sunday spent with friends. I stamped some favor boxes so everyone could take treats when they left. Most importantly it let all of us reconnect and a few even made some new friends. As Victoria said, "tea parties should be a regular thing." I agree :)
all photos by margaret haas


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This information is produced and provided by the National Cancer Institute (NCI). The information in this topic may have changed since it was written. For the most current information, contact the National Cancer Institute via the Internet web site at http://cancer.gov or call 1-800-4-CANCER.
Fortunately, cancer in children and adolescents is rare, although the overall incidence of childhood cancer has been slowly increasing since 1975.[1] Children and adolescents with cancer should be referred to medical centers that have a multidisciplinary team of cancer specialists with experience treating the cancers that occur during childhood and adolescence. This multidisciplinary team approach incorporates the skills of the primary care physician, pediatric surgical subspecialists, radiation oncologists, pediatric medical oncologists/hematologists, rehabilitation specialists, pediatric nurse specialists, social workers, and others to ensure that children receive treatment, supportive care, and rehabilitation that will achieve optimal survival and quality of life. (Refer to the PDQ Supportive and Palliative Care summaries for specific information about supportive care for children and adolescents with cancer.)
Guidelines for pediatric cancer centers and their role in the treatment of pediatric patients with cancer have been outlined by the American Academy of Pediatrics.[2] At these pediatric cancer centers, clinical trials are available for most types of cancer that occur in children and adolescents, and the opportunity to participate in these trials is offered to most patients/families. Clinical trials for children and adolescents with cancer are generally designed to compare potentially better therapy with therapy that is currently accepted as standard. Most of the progress made in identifying curative therapies for childhood cancers has been achieved through clinical trials. Information about ongoing clinical trials is available from the NCI Web site.
Dramatic improvements in survival have been achieved for children and adolescents with cancer.[1] Between 1975 and 2002, childhood cancer mortality has decreased by more than 50%. For Hodgkin lymphoma, the 5-year survival rate has increased over the same time from 81% to more than 94% for children and adolescents.[1] Childhood and adolescent cancer survivors require close follow-up since cancer therapy side effects may persist or develop months or years after treatment. (Refer to the PDQ summary on Late Effects of Treatment for Childhood Cancer for specific information about the incidence, type, and monitoring of late effects in childhood and adolescent cancer survivors.)
Overview of Childhood Hodgkin Lymphoma
Childhood Hodgkin lymphoma is one of the few pediatric malignancies that shares aspects of its biology and natural history with an adult cancer. When treatment approaches for children were modeled after those used for adults, substantial morbidities (primarily musculoskeletal growth inhibition) resulted from the unacceptably high radiation doses. Thus, new strategies utilizing chemotherapy and lower-dose radiation were developed. Approximately 90% to 95% of children with Hodgkin lymphoma can be cured, prompting increased attention to devising therapy that produces less long-term morbidity for these patients. Contemporary treatment programs use a risk-adapted approach in which patients receive multiagent chemotherapy with or without low-dose involved-field radiation therapy. Prognostic factors used in determining chemotherapy intensity include stage, presence or absence of B symptoms (fever, weight loss, and night sweats), and/or bulky disease.
Hodgkin lymphoma comprises 6% of childhood cancers. In the United States, the incidence of Hodgkin lymphoma is age-related and is highest among adolescents aged 15 to 19 years (29 cases per million per year), with children ages 10 to 14 years, 5 to 9 years, and 0 to 4 years having approximately threefold, eightfold, and 30-fold lower rates, respectively.[3] In non-European Union countries, there is a similar rate in young adults but a much higher incidence in childhood.[4]
Hodgkin lymphoma has the following unique epidemiological features:
Epstein-Barr virus and Hodgkin lymphoma
Epstein-Barr virus (EBV) has been implicated in the causation of Hodgkin lymphoma. A large proportion of patients with Hodgkin lymphoma have high EBV titers, suggesting that an enhanced activation of EBV may precede the development of Hodgkin lymphoma in some patients. EBV genetic material can be detected in Reed-Sternberg cells from some patients with Hodgkin lymphoma.
The incidence of EBV-associated Hodgkin lymphoma also shows the following distinct epidemiological features:
EBV serologic status is not a prognostic factor for failure-free survival in pediatric and young adult Hodgkin lymphoma patients.[10,13,14,15,17] Patients with a prior history of serologically confirmed infectious mononucleosis have a fourfold increased risk of developing EBV-positive Hodgkin lymphoma; these patients are not at increased risk for EBV-negative Hodgkin lymphoma.[18]
Immunodeficiency and Hodgkin lymphoma
Among individuals with immunodeficiency, the risk of Hodgkin lymphoma is increased, although not as high as the risk of non-Hodgkin lymphoma.
Characteristics of Hodgkin lymphoma presenting in the context of immunodeficiency are as follows:
Clinical Presentation
The following presenting features of Hodgkin lymphoma result from direct or indirect effects of nodal or extranodal involvement and/or constitutional symptoms related to cytokine release from Reed-Sternberg cells.
Prognostic Factors
As the treatment of Hodgkin lymphoma has improved, factors that are associated with outcome have become more difficult to identify. Several factors, however, continue to influence the success and choice of therapy. These factors are interrelated in the sense that disease stage, bulk, and biologic aggressiveness are frequently codependent. Further complicating the identification of prognostic factors is their use in determining the aggressiveness of therapy. For example, in a report from the German-Austrian Pediatric multicenter trial DAL-HD-90, bulky disease was not a prognostic factor for outcome on multivariate analysis. However, in this study, boost irradiation doses were given to patients who had postchemotherapy residual disease, which could have obfuscated the relevance of bulky disease at presentation.[26] This underscores the complexity in determining prognostic factors.
Pretreatment factors associated with an adverse outcome in one or more studies include the following:
Prognostic factors identified in selected multi-institutional studies include the following:
The rapidity of response to initial cycles of chemotherapy also appears to be prognostically important and is being used in the research setting to determine subsequent therapy.[28,29,31] Positron emission tomography (PET) scanning is being evaluated as a method to assess early response in pediatric Hodgkin lymphoma. Fluorodeoxyglucose-PET avidity after two cycles of chemotherapy for Hodgkin lymphoma in adults has been shown to predict treatment failure and progression-free survival.[32,33,34] Further studies in children are required to assess the role of early response based on PET. The value of PET avidity to predict outcome and whether improved outcome can be achieved by altering the therapeutic strategy based on early PET response is to be determined.
Although prognostic factors will continue to change because of risk stratification and choice of therapy, parameters such as disease stage, bulk, systemic symptomatology, and early response to chemotherapy are likely to remain relevant to outcome.
Hodgkin lymphoma is characterized by a variable number of characteristic multinucleated giant cells (Reed-Sternberg cells) or large mononuclear cell variants (lymphocytic and histiocytic cells) in a background of inflammatory cells consisting of small lymphocytes, histiocytes, epithelioid histiocytes, neutrophils, eosinophils, plasma cells, and fibroblasts. The inflammatory cells are present in different proportions depending on the histologic subtype. It has been conclusively shown that Reed-Sternberg cells and/or lymphocytic and histiocytic cells represent a clonal population. Almost all cases of Hodgkin lymphoma arise from germinal center B cells that cannot synthesize immunoglobulin.[1,2] The histologic features and clinical symptoms of Hodgkin lymphoma have been attributed to the numerous cytokines, chemokines, and products of the tumor necrosis factor receptors (TNF-R) family secreted by the Reed-Sternberg cells.[3]
The hallmark of classic Hodgkin lymphoma is the Reed-Sternberg cell,[4] which has the following features:
Hodgkin lymphoma can be divided into the following two broad pathologic classes:[9,10]
Classical Hodgkin Lymphoma
Classical Hodgkin lymphoma is divided into the following four subtypes:
These subtypes are defined according to the number of Reed-Sternberg cells, characteristics of the inflammatory milieu, and the presence or absence of fibrosis.
Characteristics of the histological subtypes of classical Hodgkin lymphoma include the following:
A study of over 600 patients with nodular sclerosis Hodgkin lymphoma from three different university hospitals in the United States showed that two haplotypes in the HLA class II region were identified, which correlated with 70% increased risk of developing nodular sclerosis Hodgkin lymphoma.[13] Another haplotype was associated with a 60% decreased risk. It is hypothesized that these haplotypes result in atypical immune responses that lead to Hodgkin lymphoma.
Nodular Lymphocyte-Predominant Hodgkin Lymphoma
Staging and evaluation of disease status is undertaken at diagnosis and performed again early in the course of chemotherapy and at the end of chemotherapy.
Pretreatment Staging
The diagnostic and staging evaluation is a critical determinant in the selection of treatment. Initial evaluation of the child with Hodgkin lymphoma includes the following:[1,2]
Systemic symptoms
The following three specific constitutional symptoms (B symptoms) correlate with prognosis and are considered in assignment of stage:
Additional Hodgkin-associated constitutional symptoms without prognostic significance include the following:
Physical examination
Laboratory studies
Anatomic imaging
Anatomic information from CT is complemented by PET functional imaging, which is sensitive in determining initial sites of involvement, particularly sites too small to be considered abnormal by CT criteria.
Definition of bulky disease
The posteroanterior chest radiograph remains important since the criterion for bulky mediastinal lymphadenopathy used in North American protocols is defined by the ratio of the diameter of the mediastinal lymph node mass to the maximal diameter of the rib cage on an upright chest radiograph; a ratio of 33% or higher is considered bulky. This definition is no longer used in some European protocols because it does not influence risk classification.
The criteria for bulky peripheral (nonmediastinal) lymphadenopathy have varied per cooperative group study protocols from aggregate nodal masses exceeding 4 to 6 cm. This disease characteristic has not been consistently used among all groups for risk stratification.
Criteria for lymphomatous involvement by CT
Defining strict CT size criteria for the establishment of lymphomatous nodal involvement is complicated by a number of factors, such as overlap between benign reactive hyperplasia and malignant lymphadenopathy and obliquity of node orientation to the scan plane. Additional difficulties more specific to children include greater variability of normal nodal size with body region and age and the frequent occurrence of reactive hyperplasia.
General concepts to consider in regard to defining lymphomatous involvement by CT include the following:
Functional imaging
The recommended functional imaging procedure for initial staging is now PET.[4,5] In PET scanning, uptake of the radioactive glucose analog, 18-fluoro-2-deoxyglucose (FDG) correlates with proliferative activity in tumors undergoing anaerobic glycolysis. PET-CT, which integrates functional and anatomic tumor characteristics, is often used for staging and monitoring of pediatric patients with Hodgkin lymphoma. Residual or persistent FDG avidity has been correlated with prognosis and the need for additional therapy in posttreatment evaluation.[6,7,8,9]
General concepts to consider in regard to defining lymphomatous involvement by FDG-PET include the following:
FDG-PET has limitations in the pediatric setting. Tracer avidity may be seen in a variety of nonmalignant conditions including thymic rebound commonly observed after completion of lymphoma therapy. FDG-avidity in normal tissues, for example, brown fat of cervical musculature, may confound interpretation of the presence of nodal involvement by lymphoma.[4]
Establishing the Diagnosis of Hodgkin Lymphoma
After a careful physiologic and radiographic evaluation of the patient, the least invasive procedure should be used to establish the diagnosis of lymphoma.
Key issues to consider in choosing the diagnostic approach include the following:
Ann Arbor Staging Classification for Hodgkin Lymphoma
Stage is determined by anatomic evidence of disease using CT scanning in conjunction with functional imaging. The staging classification used for Hodgkin lymphoma was adopted at the Ann Arbor Conference held in 1971 [13] and revised in 1989.[14] Staging is independent of the imaging modality used.
Extralymphatic disease resulting from direct extension of an involved lymph node region is designated E. Extralymphatic disease can cause confusion in staging. For example, the designation E is not appropriate for cases of widespread disease or diffuse extralymphatic disease (e.g., large pleural effusion that is cytologically positive for Hodgkin lymphoma), which should be considered stage IV. If pathologic proof of noncontiguous involvement of one or more extralymphatic sites has been documented, the symbol for the site of involvement, followed by a plus sign (+), is listed. Current practice is to assign a clinical stage on the basis of findings of the clinical evaluation; however, pathologic confirmation of noncontiguous extralymphatic involvement is strongly suggested for assignment to stage IV.
Risk Stratification
After the diagnostic and staging evaluation data are acquired, patients are further classified into risk groups for the purposes of treatment planning. The classification of patients into low-, intermediate-, or high-risk categories varies considerably among the various pediatric research groups, and often even between different studies conducted by the same group, as summarized in Table 2.
Although all major research groups classify patients according to clinical criteria, such as stage and presence of B symptoms, extranodal involvement, or bulky disease, comparison of outcomes across trials is further complicated because of differences in how these individual criteria are defined.
Response Assessment
Further refinement of risk classification may be performed through assessment of response after initial cycles of chemotherapy or at its completion.
Interim response assessment
The interim response to initial therapy, which may be assessed on the basis of volume reduction of disease, functional imaging status, or both, is an important prognostic variable in both early- and advanced-stage pediatric Hodgkin lymphoma.[24,25] Definitions for interim response are variable and protocol specific, but can range from volume reductions of greater than 50% to the achievement of a complete response with a volume reduction of greater than 95% by anatomic imaging or resolution of FDG-PET avidity.[3,18,21]
The rapidity of response to early therapy has been used in risk stratification to tailor therapy in an effort to augment therapy in higher-risk patients or to reduce the late effects while maintaining efficacy.
Results of selected trials using interim response to titrate therapy
End of chemotherapy response assessment
Restaging is carried out upon the completion of all planned initial chemotherapy and may be used to determine the need for consolidative radiation therapy. Key concepts to consider include the following:
Historical Overview of Treatment for Hodgkin Lymphoma
Long-term survival has been achieved in children and adolescents with Hodgkin lymphoma using radiation, multiagent chemotherapy, and combined-modality therapy. In selected cases of localized lymphocyte-predominant Hodgkin lymphoma, complete surgical resection may be curative and obviate the need for cytotoxic therapy.
Treatment options for children and adolescents with Hodgkin lymphoma include the following:
Treatment Approaches
Contemporary treatment for pediatric Hodgkin lymphoma uses a risk-adapted and response-based paradigm that assigns the length and intensity of therapy based on disease-related factors such as stage, number of involved nodal regions, tumor bulk, the presence of B symptoms, and early response to chemotherapy by functional imaging. Age, gender, and histological subtype may also be considered in treatment planning.
Risk designation
Risk-adapted treatment paradigms
Histology-based therapy (stage I nodular lymphocyte-predominant Hodgkin lymphoma)
Histological subtype may direct therapy in patients with stage I completely resected, nodular lymphocyte-predominant Hodgkin lymphoma, whose initial treatment may be surgery alone.
This treatment approach is supported by the following findings from the literature:
Radiation Therapy
As discussed in the previous sections, most newly diagnosed children will be treated with risk-adapted chemotherapy alone or in combination with consolidative radiation therapy (RT). RT volumes can have variable and protocol-specific definitions, but generally encompass lymph node regions initially involved at the time of diagnosis, without extensive inclusion of uninvolved regions. RT field reductions are made to account for tumor regression with chemotherapy.[25]
Volume considerations
With advancements in systemic therapy, RT field definitions have evolved and become increasingly restricted. RT is no longer needed to sterilize all disease. Advancements in radiologic imaging allow more precise radiation target definition. Historically, concerns about the symmetry of growth in young children with unilateral disease involvement often prompted treatment of the contralateral tissues. With contemporary treatments utilizing 15 to 21 Gy, treatment of contralateral uninvolved sites is not necessary in all but perhaps the very young.
General trends in radiation treatment volume are summarized as follows:
A breast-sparing radiation-therapy plan using proton therapy is being evaluated to determine if there is a statistically significant reduction in dose.[29] Long-term results are awaited.
Considerations in IFRT Treatment Planning
Traditional definitions of lymph node regions can be helpful for defining IFRT but may not be sufficient. The following issues should be considered in IFRT treatment planning:
Radiation dose
The dose of radiation is also variously defined and often protocol specific. General considerations regarding radiation dose include the following:
Technical considerations
Technical considerations for the use of radiation therapy to treat Hodgkin lymphoma include the following:
Role of LD-IFRT in childhood and adolescent Hodgkin lymphoma
Because all children and adolescents with Hodgkin lymphoma receive chemotherapy, a question commanding significant attention is whether patients who achieve a rapid early response or a CR to chemotherapy require RT. Conversely, the judicious use of LD-IFRT may permit a reduction in the intensity or duration of chemotherapy below toxicity thresholds that would not be possible if single modality chemotherapy were used, thus decreasing overall acute and late toxicities.
Key points to consider in regard to the role of radiation in pediatric Hodgkin lymphoma include the following:
Additionally, when considering the role of RT in the initial management of Hodgkin lymphoma, one must carefully consider the endpoint that is being evaluated. Unlike most other pediatric malignancies, Hodgkin lymphoma is often salvageable if initial treatment does not result in a CR or if relapse occurs. For example, studies comparing combination chemotherapy with or without RT in adults with advanced-stage Hodgkin lymphoma showed that EFS was higher for patients who received initial chemotherapy and RT; however, OS was no different for patients whose initial therapy was chemotherapy alone.[35] Among adult Hodgkin lymphoma patients, study results conflict regarding whether adjuvant RT improves OS compared with chemotherapy alone, despite an improvement in EFS, because of the ability to effectively salvage patients who relapse after initial therapy.[36] Thus, it is not clear whether EFS or OS should be the appropriate endpoint for a trial comparing chemotherapy with or without radiation.
Finally, an inherent assumption is made in a trial comparing chemotherapy alone versus chemotherapy and radiation that the effect of radiation on EFS will be uniform across all patient subgroups. However, it is not clear how histology, presence of bulky disease, presence of B symptoms, or other variables affect the efficacy of postchemotherapy radiation.
All of the agents in original MOPP and ABVD regimens continue to be used in contemporary pediatric treatment regimens. COPP (substituting cyclophosphamide for mechlorethamine) has almost uniformly replaced MOPP as the preferred alkylator regimen in most frontline trials. Etoposide has been incorporated into treatment regimens as an effective alternative to alkylating agents in an effort to reduce gonadal toxicity and enhance antineoplastic activity.
Combination chemotherapy regimens used in contemporary trials are summarized in Table 4.
Results from Selected Clinical Trials
North American cooperative and consortium trials
The Pediatric Oncology Group organized two trials featuring response-based, risk-adapted therapy utilizing ABVE (doxorubicin [Adriamycin], bleomycin, vincristine, and etoposide) [41] for favorable low-stage patients and dose-dense ABVE-PC (prednisone and cyclophosphamide) for unfavorable advanced-stage patients in combination with 21 Gy IFRT.[32]
Key findings from these trials include the following:
The Children's Cancer Group (CCG) undertook a randomized controlled trial comparing survival outcomes in children treated with risk-adapted COPP/ABV hybrid chemotherapy alone with those treated with COPP/ABV hybrid chemotherapy plus LD-IFRT.[14] The study was closed early because of a significantly higher number of relapses among patients treated with chemotherapy alone. Long-term results include the following:[14,17]
Another CCG Study (COG-59704) evaluated response-adapted therapy featuring four cycles of the dose-intensive BEACOPP regimen followed by a gender-tailored consolidation for pediatric patients with stages IIB, IIIB with bulky disease, and IV Hodgkin lymphoma.[40][Level of evidence: 2Dii] For rapid early responding girls, an additional four courses of COPP/ABV (without IFRT) were given. Rapid early responding boys received two cycles of ABVD followed by IFRT. Slow early responders received four additional courses of BEACOPP and IFRT. Eliminating IFRT from the girl's therapy was intended to reduce the risk of breast cancer. Key findings from this trial include the following:[40]
The Stanford, St. Jude Children's Research Hospital, and Boston Consortium administered a series of risk-adapted trials over the last 20 years. Key findings include the following:
German multicenter trials
In the last 30 years, German investigators have implemented a series of risk-adapted trials evaluating gender-based treatments featuring multiagent chemotherapy with OPPA/COPP and IFRT.
Accepted Risk-Adapted Treatment Strategies for Newly Diagnosed Children and Adolescents with Hodgkin Lymphoma
Contemporary trials for pediatric Hodgkin lymphoma involve a risk-adapted, response-based treatment approach that titrates the length and intensity of chemotherapy and dose of radiation based on disease-related factors including stage, number of involved nodal regions, tumor bulk, the presence of B symptoms, and early response to chemotherapy as determined by functional imaging. In addition, vulnerability related to age and gender is also considered in treatment planning.
Treatment of Adolescents and Young Adults with Hodgkin Lymphoma
The treatment approach used for adolescents and young adults with Hodgkin lymphoma may vary based on community referral patterns and age restrictions at pediatric cancer centers. In patients with high-risk disease, the standard of care in medical oncology practices typically involves at least six cycles of ABVD chemotherapy that would deliver a cumulative anthracycline dose of 300 mg/m2.[48,49] In late-health outcomes studies of pediatric cancer survivors, the risk of anthracycline cardiomyopathy has been shown to exponentially increase after exposure to cumulative anthracycline doses of 250 mg/m2 to 300 mg/m2.[50,51] Subsequent need for mediastinal radiation can further enhance the risk of a variety of late cardiac events.[50,51,52] In an effort to optimize disease control and preserve both cardiac and gonadal function, pediatric regimens for low-risk disease most often feature a restricted number of cycles of ABVD or derivative combinations, whereas alkylating agents and etoposide are integrated into anthracycline-containing regimens for those with intermediate- and high-risk disease.
Participation in a clinical trial should be considered for adolescent and young adult patients with Hodgkin lymphoma. Information about ongoing clinical trials is available from the NCI Web site.
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage I childhood Hodgkin lymphoma, stage II childhood Hodgkin lymphoma, stage III childhood Hodgkin lymphoma and stage IV childhood Hodgkin lymphoma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
The excellent response to frontline therapy among children and adolescents with Hodgkin lymphoma limits opportunities to evaluate second-line (salvage) therapy. Because of the small number of patients that fail primary therapy, no uniform second-line treatment strategy exists for this patient population. Adverse prognostic factors after relapse include the following:[1][Level of evidence: 3iiA]
Children with localized favorable (relapse ≥12 months after completing therapy) disease recurrences whose original therapy involved reduced cycles of risk-adapted therapy or with chemotherapy alone and/or low-dose involved-field radiation therapy (LD-IRFT) consolidation have a high likelihood of achieving long-term survival following treatment with more intensive conventional chemotherapy.[5,6]
Key concepts in regard to treatment of refractory/recurrent Hodgkin lymphoma in children and adolescents are as follows:
Agents used alone or in combination regimens in the treatment of refractory/recurrent Hodgkin lymphoma include the following:
Brentuximab vedotin has been evaluated in adults with Hodgkin lymphoma. A phase I study in adults with CD30-positive lymphomas identified a recommended phase II dose of 1.8 mg/kg on an every 3-week schedule and showed an objective response rate of 50% (6 of 12 patients) at the recommended phase II dose.[13][Level of evidence: 2Div] A phase II trial in adults with Hodgkin lymphoma (N = 102) who relapsed after autologous stem cell transplantation showed a complete remission rate of 32% and a partial remission rate of 40%.[14,15] The number of pediatric patients treated with brentuximab vedotin is not sufficient to determine whether they respond differently than adult patients. There are ongoing trials to determine the toxicity and efficacy of combining brentuximab vedotin with chemotherapy.
Patients treated with HCT may experience relapse as late as 5 years after the procedure; they should be monitored for relapse and late treatment sequelae.
Response Rates for Primary Refractory Hodgkin Lymphoma
Salvage rates for patients with primary refractory Hodgkin lymphoma are poor even with autologous HCT and radiation. However, intensification of therapy followed by HCT consolidation has been reported to achieve long-term survival in some studies.
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with recurrent/refractory childhood Hodgkin lymphoma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
Children and adolescent survivors of Hodgkin lymphoma are at risk for numerous late complications of treatment related to radiation, specific chemotherapeutic exposures, and surgical staging. Adverse treatment effects may impact oral/dental health; musculoskeletal growth and development; endocrine, reproductive, cardiovascular and pulmonary function; and risk of secondary carcinogenesis. In the past 30 to 40 years, pediatric Hodgkin lymphoma therapy has changed dramatically to proactively limit exposure to radiation and chemotherapeutic agents, such as anthracyclines, alkylating agents, and bleomycin. When counseling individual patients about the risk for specific treatment complications, the era of treatment should be considered.
The following table summarizes late health effects observed in Hodgkin lymphoma survivors followed by a limited discussion of the common late effects. (Refer to the PDQ summary on Late Effects of Treatment for Childhood Cancer for a full discussion of the late effects of cancer treatment in children and adolescents.)
Male Gonadal Toxicity
Female Gonadal Toxicity
Thyroid Abnormalities
Cardiac Toxicity
Hodgkin lymphoma survivors exposed to doxorubicin or thoracic radiation therapy are at risk for long-term cardiac toxicity. The effects of thoracic radiation therapy are difficult to separate from those of anthracyclines because few children undergo thoracic radiation therapy without the use of anthracyclines. The pathogenesis of injury differs, however, with radiation primarily affecting the fine vasculature of the heart, and anthracyclines directly damaging myocytes.[19,20]
Radiation-associated cardiovascular toxicity
The risks to the heart are related to the amount of radiation delivered to different depths of the heart, volume and specific areas of the heart irradiated, total and fractional irradiation dose, age at exposure, and latency period.
Selected studies evaluating cardiovascular toxicity associated with radiation
(Refer to the Cardiovascular Disease in Select Cancer Subgroups: Hodgkin lymphoma section in the PDQ summary on Late Effects of Treatment for Childhood Cancer for information on studies evaluating cardiovascular toxicity associated with radiation.)
Anthracycline-related cardiac toxicity
Subsequent Neoplasms
The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.
Diagnosis and Staging
Added text about a Children's Oncology Group study that evaluated surveillance computed tomography (CT) and detection of relapse in intermediate-stage and advanced-stage Hodgkin lymphoma; the routine use of CT at the intervals used in this study did not improve outcome (cited Voss et al. as reference 31).
Treatment for Newly Diagnosed Children and Adolescents with Hodgkin Lymphoma
Added text to state that involved-nodal radiation therapy (RT) defines the treatment volume using the prechemotherapy positron emission tomography (PET)/CT scan that is obtained with the patient positioned in a similar manner to the position that will be used at the time of RT. This volume is later contoured onto the postchemotherapy-planning CT scan; the final treatment volume only includes the initially involved nodes with a margin, typically 2 cm.
Added text about involved-site RT, the indications for use, and the size of the treatment volumes.
Added text to state that proton therapy is currently being investigated and may further decrease the mean dose to the surrounding normal tissue compared with intensity-modulated RT or 3-dimensional conformal RT, without increasing the volume of normal tissue receiving lower-dose radiation.
Treatment of Primary Refractory/Recurrent Hodgkin Lymphoma in Children and Adolescents
Added Gorde-Grosjean et al. as reference 4.
This summary is written and maintained by the PDQ Pediatric Treatment Editorial Board, which is editorially independent of NCI. The summary reflects an independent review of the literature and does not represent a policy statement of NCI or NIH. More information about summary policies and the role of the PDQ Editorial Boards in maintaining the PDQ summaries can be found on the About This PDQ Summary and PDQ NCI's Comprehensive Cancer Database pages.
Purpose of This Summary
This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the treatment of childhood Hodgkin lymphoma. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.
Reviewers and Updates
This summary is reviewed regularly and updated as necessary by the PDQ Pediatric Treatment Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).
Board members review recently published articles each month to determine whether an article should:
Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.
The lead reviewers for Childhood Hodgkin Lymphoma Treatment are:
Any comments or questions about the summary content should be submitted to Cancer.gov through the Web site's Contact Form. Do not contact the individual Board Members with questions or comments about the summaries. Board members will not respond to individual inquiries.
Levels of Evidence
Some of the reference citations in this summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Pediatric Treatment Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations.
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The preferred citation for this PDQ summary is:
National Cancer Institute: PDQ® Childhood Hodgkin Lymphoma Treatment. Bethesda, MD: National Cancer Institute. Date last modified <MM/DD/YYYY>. Available at: http://cancer.gov/cancertopics/pdq/treatment/childhodgkins/HealthProfessional. Accessed <MM/DD/YYYY>.
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Combest, Chairman of the U.S. House of Representatives Agricultural Committee, and Stenholm, ranking member, addressed the Texas Commodity Symposium by telephone in Amarillo.
Stenholm and Combest each pointed to the bi-partisan support they garnered from the U.S. House for their bill, which was passed more than a month before the Senate decided to take up the issue.
"We had 291 votes for the bill in the House," Combest said. "And we were able to defeat some crippling amendments. This legislation has broad-based support."
"It's truly a bi-partisan bill," Stenholm said. 'If the Senate leadership allows that body to do what Larry has done in the House, they can accomplish a lot."
Stenholm said early proposals from the Senate fell far short of providing what he and Combest believe to be in the best interests of U.S. agriculture.
"Early proposals would have increased Conservation Reserve Program acreage to more than 40 million," Stenholm said. "And the numbers simply did not add up. We have to develop a bill that will pass screening from the Congressional Budget Office."
Combest said Senate debate appears to be following party lines. "They can't do a farm bill on a partisan basis," he said. "Right now, we're not sure what will happen." He said if the debate lingers past Dec. 31, farmers would be hurt. "If it's not passed this year, we can't implement it for the 2002 crop and we will be one more year under the current program, through which we've spent a lot of money for the past few years and will be in a position to do so again if we don't pass a new law.
"Also, farmers need to know as soon as possible. They can't plan their next crops with their bankers without knowing what the farm program will be."
Stenholm and Combest both believe the current funding level, $73.5 billion, will drop significantly if the Senate delays passage until 2002. They also argue that if the Senate delays until January it will have no incentive to work on farm legislation until much later in the year.
Combest said he was not pleased with the Senate's early bills and would "not cave in to that version just to get a bill passed." But he and Stenholm said, as time passes, the Senate version begins to become more and more like the House bill.
"If that continues, the legislation will be easier to conference," Combest said. "And I am committed to stay here as long as it takes to pass this legislation this year."
Points of contention between various Senate versions and the House bill include a large dairy expenditure in the Senate and more conservation with less commodity support. The Senate prefers a five-year law while the House proposes 10 years.
Stenholm said the House would have liked to include a mechanism to allow producers to adjust yields upward for payments. "If we had done that, the cost of the program would have gone up," he said.
"Also, we can't do anything in this legislation about the cost of regulations," Combest said. "That's not under our jurisdiction, but we are concerned about burdensome regulations."
Stenholm also defended the House bill as adhering to World Trade Organization requirements. "The Administration has criticized our bill for being illegal within the WTO," he said, "but that's not so. It gives us a strong position to negotiate trade."
Stenholm said he and Combest "stand shoulder to shoulder with the American farmer as they try to negotiate in the world markets."
Combest said he felt confident that "if the House and Senate pass a good farm bill, the President will sign it."
e-mail: email@example.com.


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WASHINGTON (Reuters) - The Obama administration said on Friday Verizon Communications Inc's Terremark unit will remain under contract as host of the federal website HealthCare.gov to better ensure a smooth end to Obamacare's open enrollment period on March 31.
Terremark's contract with the Department of Health and Human Services was due to expire on March 30, the day before the end of open enrollment for 2014, a time when high daily volumes are expected as consumers from 36 states rush to use to website to sign up for subsidized private health insurance. It would be extended for up to seven months, according to federal documents.
Hewlett-Packard Co has been named to replace Terremark as website host and operator of the department's federal data center as part of Obama's Patient Protection and Affordable Care Act.
"We extended Terremark's contract term in order to ensure a successful transition between the two contractors," said a statement issued by the Centers for Medicare and Medicaid Services, the Obamacare agency at HHS.
"HP and Terremark will work together so that the site runs smoothly for consumers during the remaining weeks of open enrollment," the statement said.
Terremark's replacement by HP came to light after the botched October 1 rollout of HealthCare.gov. The website was overwhelmed by technical problems for much of October and November.
Terremark's data center also experienced outages across the system that affected not only HealthCare.gov but also 14 healthcare exchanges run by individual states.
However, CMS had awarded the contract to HP several months before the launch.
The administration mounted an emergency operation to fix the site that has allowed enrollment to proceed relatively smoothly since early December. More than 4 million people have signed up for private health coverage through the federal and state marketplaces.
Terremark received $55.4 million under the original Obamacare marketplace contract, which was awarded in 2011. Federal documents said the new seven-month extension, valued at $58 million, includes a four-month base period and 30-day option periods.
Reporting by David Morgan; Editing by Mohammad Zargham


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Nation & World
Attack in Lebanon reflects ISIS' resolve to disrupt wide region
The Islamic State of Iraq and Syria apparently expanded its operations to Lebanon on Friday, narrowly failing to assassinate a top Shiite Muslim security official with a suicide car bomb just hours after a series of government raids captured at least 20 suspected militants described as being members of ISIS in a central Beirut hotel.
Maj. Gen. Abbas Ibrahim, the director of the powerful General Security Directorate, had passed a checkpoint in the Beqaa Valley on the highway linking Beirut and Damascus on Friday morning when a suicide car bomb exploded, killing at least two people and wounding dozens, but left his convoy unscathed.
Lebanon went on high alert last week after ISIS, which has been occasionally fighting the Lebanon-based Shiite radical group Hezbollah in Syria, took over a large swath of northern Iraq as part of its declared goal to turn the entire Levant region, which includes Syria, Lebanon, Iraq and Jordan, into an Islamic caliphate. ISIS presently controls much of eastern Syria and western and northern Iraq and has been pressing a conventional military offensive backed by disenfranchised Sunni tribes on Baghdad.
In Iraq, the nation's top Shiite cleric during a sermon on Friday urged Iraqis to unite to expel militants from the country and called for the formation of a new government.
Grand Ayatollah Ali al Sistani said a new government would help avoid "past mistakes," a thinly veiled critique of Nouri al Maliki, a Shiite politician who has served as Iraq's prime minister since 2006.
The cleric described ISIS as a "plague" on the region.
Friday's deadly car bombing came just hours after a series of raids by Lebanese security forces on a central Beirut hotel arrested 22 people and saw armed men chasing suspects through the streets of one of the capital's most cosmopolitan central districts. Earlier, the government announced that it had uncovered a plot to assassinate both Ibrahim and Parliament Speaker Nabih Berri, both prominent Shiite Muslim political figures and close allies of Hezbollah.
It was not precisely clear if the attack was directly aimed at Ibrahim in that spot, as some local security officials claimed, but he had been named a target by ISIS in the past because of his high-profile involvement in both cracking down on Syrian rebels along the Lebanese border as well as in negotiating the release of Lebanese hostages held in Syria.
Maj. Gen. Ibrahim Basbous of the Internal Security Forces told reporters on the scene that it seemed the car was meant to explode in Beirut and might have doubled back to hit Ibrahim's convoy in a incredible coincidence.
"The car was headed from the Beqaa to Beirut. ISF patrols chased it, compelling its driver to return to the Beqaa," Basbous said, according to local media reports.
Lebanon had been the victim of a dozen suicide bombings spanning from last summer until February by groups including al Qaida and ISIS in revenge for Hezbollah's strong support for the Syrian regime, a move that angered large swaths of Lebanon's Sunni population, which mostly has supported the rebels.
A series of arrests and military operations by both the government inside Lebanon and by Hezbollah along the Syrian-Lebanese border appeared to end the attacks. But fear that ISIS would reconstitute a militant network appeared to come true on Friday.
"This is why we're fighting in Syria," a Hezbollah commander said by instant messaging from Beirut; he asked to speak anonymously because the group does not allow members to speak to the press. "These Takfiris have shown they want to take over the entire region and have an agenda to fight Iran and destroy the Shiite government in Iraq. We know they will come for Lebanon again and are ready to fight them every day."
Lebanese Shiite frequently refer to ISIS and other Syrian rebel groups as Takfiris, an Arabic word that describes a radical strain of Islam that believes that insufficiently pious Muslims should be killed.
The commander said that Hezbollah's intelligence services, which have worked closely with the Lebanese army to prevent attacks, had discovered an ISIS financier working in Beirut who was arrested Thursday and gave interrogators information that led to Friday's raids and alerts.
His claim that Hezbollah provided the initial intelligence could not be confirmed.
Before any of the incidents on Friday, the Amal Party, led by Berri, had canceled a public meeting with the United Nations that the speaker planned to attend, because of an unspecified security threat.
Just hours later, intelligence agents and security forces descended on the Napoleon Hotel in the normally quiet Hamra district of Beirut, arresting suspects and raiding other locations throughout the city.
"There are more of these terrorists throughout the city," a security official, speaking anonymously because he lacks permission to speak to the media, said by text message. "We know who they are and there will be more arrests."


text: Enter to win two tickets to see B.o.B in New York City on Tuesday, November 29th at The Bowery Ballroom courtesy of Fuji right here. This contest starts right now and ends November 25th at 10 am EST. Good luck! Please note: this contest is for people within the Tri-State area only. No transportation of any kind will be provided. So there's that. Oh also, Happy Thanksgiving!


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Launch of HTC One may be delayed by Qualcomm S4 production halt
Consumers hoping to get their hands on a new Android phone powered by a Qualcomm S4 SoC (system on a chip) this spring may have to wait a few extra weeks. Reports are coming in that TSMC, the manufacturer of Qualcomm's Snapdragon S4 chip, abruptly stopped production of all their 28nm chips three weeks ago to make changes to the production process. Production is expected to be back in full swing in "short order" with supply levels reaching normal levels by the end of March.
The three week production halt of Qualcomm's S4 chip (which began before Mobile World Congress) could translate into supply shortages or even launch delays for a few Android phones this spring. The HTC One series relies on the S4 chip for the HTC One S and One XL (One X for AT&T). While the phones are expected to debut in Europe during the first week of April, T-Mobile USA, AT&T and other service providers in Europe have not announced exact release dates for the HTC One.
The Qualcomm S4 SoC has been in full production since early 2012, so it's hard to say how this production issue will actually affect the different OEMs who are using the chip in their phones. Handset delays of supply shortages will be directly affected by Qualcomm's inventory level before the production stoppage. We hope TSMC gets the production line back up and running in the next few days. Any more delays could cause a serious chip supply shortage for Qualcomm that could carry into the summer.


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Kids Reenact 'Game of Thrones,' 'Mad Men' + More Emmy-Nominated TV Shows [VIDEO]by Maggie Malach | PopCrush
What's better than binge-watching your favorite show? Cute kids reenacting scenes from the show!
The folks at Mom.me crafted the genius idea to have adorable children take on roles from 2014 Emmy-nominated shows such as 'Game of Thrones,' 'Mad Men' and 'House of Cards.' As you can imagine, the result is totally sweet — and totally hilarious!
Just in case you aren't already excited, here are a few of our favorite highlights: 'Game of Thrones' character Daenerys and her (stuffed) dragon throwing down some serious intimidation! (Spoiler: Flames are involved.)
Of course, we also cracked up watching a child channel Matthew McConaughey's 'True Detective' character, giving a long-winded speech about reincarnation. Major bonus points for the mustache, 'How to Lose a Guy in 10 Days' reference and for nailing the Oscar-winning actor's signature catchphrase "Alright, alright, alright."
Kids tell it like it is, and these spoofs are no exception. Watching a child mimic Jon Hamm's suave ad man pitch on 'Mad Men' or seeing two kids deadpan about cooking crystal meth in 'Breaking Bad' is too funny!
Check out all of the adorable parodies in the video above and catch the 2014 Emmy Awards when they air on NBC on Aug. 25.
You Need to Check Out These Celebs' Yearbook Photos!


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"For what can war but endless war still breed?"
John Milton
1618. The protestant nobles of Bohemia reject the election of the catholic Ferdinand of Styria as king and rise in open revolt against the Holy Roman Emperor. This seemingly local conflict is the spark which will ignite all of Europe, dooming it to three decades of warfare and sectarian violence: it is the Thirty Years' War!
Thirty Years' War, the wargame developed by HQ Studio and brought to life thanks to the AGE Engine, is coming to Steam!
Thirty Years' War explores a period and a subject which hasn't been touched by many other games, putting you at the head of one of many military machines taking part to the conflict. Fight across all of Europe on a massive map with more than 4600 regions, commanding hundreds of different unit types, and structuring your army into a chain of command of your liking with dozens of historical commanders! Gain an edge over your enemies with superior maneuvering and organized logistics! Direct your war effort by enacting political decisions and witness many historical events, which alter the course of the war!
"Not only a jewel of a game but an excellent history lesson" – Armchair General
Thirty Years' War is coming to Steam next week on June 14th. If you'd like to read more about the game, visit the product page.


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The support and discussion group is for people (of any age) who identify on the spectrum of GenderQueer/Non-Binary/Agender/GenderFluid/PolyGender, etc. The group also welcomes those who want to explore their identity, but who may not need or want to classify themselves. All individuals are encouraged to explore their individual selves, without concern or pressure that the next step need be 'transitioning,' and without concern about fitting into other people's definitions. Make up your own! The Diversity Center's GenderQueer Peer Support Group provides a supportive and interactive experience at the center. The group meets on the 2nd and 4th Tuesdays of each month.
For more information, contact Sean Senechal at email@example.com


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Citrus indica Tanaka - a progenitor species of cultivated Citrus
A group of enthusiastic cytogeneticists (Marlykynti Hynniewta, Surendra Kumar Malik and Satyawada Rama Rao) from North Eastern Hill University show that C. indica occupies a special taxonomic position, as reflected in the karyomorphological data.
The genus Citrus is an economically important horticultural crop known for its fruit and juice. In India, there are about 30 species of Citrus of which at least nine species are available throughout India, while 17 species are confined to the North-Eastern states of India, which have been classified as a hot spot for Citrus biodiversity and are threatened in their natural habitat as per the criteria fixed by the International Union for Conservation of Nature and Natural Resources (IUCN). Seven Indian Citrus species are considered endangered or nearly so, including C. Indica, C. macroptera, C. latipes, C. assamensis, C. ichangensis, C. megaloxycarpa and C. rugulosa.
C. indica (Tanaka, 1937) is supposed to be the most primitive species and perhaps the progenitor of cultivated Citrus. From the karyomorphological data it can be observed that the asymmetry index of different species of Citrus presently investigated had shown significant variation. C. medica, C. grandis and C. reticulata which are considered as true basic species are characteristic in having low asymmetry index of 1.87, 1.89 and 2.46 respectively. In the present investigation, the data from the karyomorphological observations on chromosome complements in 10 different Citrus species reflect that C. indica with its intermediate asymmetry index value (1.94) may be regarded as a true progenitor of cultivated Citrus. This study also supports the previous report that there are three true species of Citrus, viz. C. grandis, C. reticulata and C. medica.
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EasyStart Exercise Club
You can take advantage of our fitness facility at the Joslin Clinic by joining the EasyStart Exercise Club.
The staff will design an individualized, safe and effective exercise program for you and will answer any questions you may have regarding exercise and diabetes.
During these one-hour sessions, a clinical exercise physiology staff will measure your blood glucose response to exercise.
Your blood pressure and weight will be monitored on a weekly basis.
This program is open Mondays and Wednesdays 10am-12pm. People with diabetes as well as without diabetes are welcome.
Please contact us at (617) 732-2400 for the latest schedule and program cost.
Any member of our clinical exercise physiology staff will be happy to answer your questions regarding any of our programs.
Page last updated: November 07, 2019


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Nonprofit Organization
Individuals or groups who seek to form a nonprofit organization (defined as an unincorporated association) must register the organization with the office of California Secretary of State.
Secretary of State
Corporate Legal Review and filing
1500 11th Street, Room 390
Sacramento, CA 95814
(916) 657-5448
To register as a nonprofit association which is unincorporated:
Secretary of State
Limited Partnership Program
1500 11th Street, 3rd Floor
Sacramento, CA 95814
(916) 657-5448
Document Filing Support Unit
Sacramento, CA 94244-2250
Registration of nonprofit organizations required. Performance record of charities is also available.
Department of Justice
Office of the Attorney General
Registry of Charitable Trusts
1300 I Street, 11th Floor
Sacramento, CA 95814
(916) 445-2021
The Better Business Bureau keeps records of charitable organization's performance.
Better Business Bureau
400 S Street
Sacramento, CA 95814
(916) 443-6843
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