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Although cancer predisposition syndromes are rare and malignancies arising in this context account for only 1–10% of childhood tumors, studies performed in affected patients and their families have been of unique value for the understanding of cancer development. Three classes of genes (tumor suppressor genes, oncogenes and stability genes) have been identified and shown to be involved in the pathogenesis of familial, as well as sporadic tumors. Cancer has long been recognized as a genetic disease of somatic cells. Despite improved understanding of the molecular basis of predisposition to cancer and better diagnostic tools, the care of these patients and their families remains a major challenge for the clinician. Medical, psychological, ethical and legal issues have to be considered. This review focuses on examples of each class of inherited cancer predisposition syndromes with special implications for patients in the pediatric age group, including retinoblastoma predisposition, Li-Fraumeni syndrome, multiple endocrine neoplasia disorders and Fanconi anemia. The genetic basis of cancer predisposition is discussed as well as the major concepts and controversies in the clinical management of these patients and their families.