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Sponsored Scoop: Drake Bennett Summer Schools
Academic Skill-Building Summer Camp!
This is Drake Bennett Summer Schools' ninth summer of academic support and enrichment. The 1st-6th Grade Academic Summer Camp is run like a small-town high school. All teachers are inspired and perpetually cheerful single-subject specialists. As they will in high school, the kids rotate to six different teachers every day. The camp offers an enrichment track for thriving students and an Orton-based support track for kids who are just as smart, but have some catching-up to do.
The Epiphany School (July 7-August 1) is an historic building on 28th Street between 3rd and Lexington, in the Murray Hill section of Manhattan, with a charming shaded playground in the back and on-site gym.
The Park Slope Jewish Center (August 4-29) is a Brooklyn landmark on 8th Avenue at the corner of 14th Street. Just one block from Prospect Park, we'll have grass under our feet two hours a day for August recesses and sports programs.
For more information: drakebennet.org; 646-707-3443


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Although there are several serious crimes for which the Board must issue a Notice to Deny Licensure, all other issues are handled on a case-by-case basis. In addition to directing license applicants to thoroughly read all the mandatory disclosure questions and to answer them truthfully, there are a few things applicants should know that can help expedite the process.
Can a person obtain a license or certificate if they have been previously accused of abuse or neglect?As stated previously, each application is reviewed on an individual basis. If you have been investigated for either professional or personal allegations of abuse or neglect, a closure letter from the law enforcement or social service agency that conducted the investigation will expedite the review of your application. You should also submit a detailed letter explaining, by your own account, the circumstances surrounding the event(s).
How long will it take to review the information that I submit with my application?The normal processing time is unpredictable, since there are various factors that affect the time necessary to conduct an appropriate investigation.
Is there any specific conviction that will automatically disqualify an applicant from receiving a license?According to Oregon Administrative Rule 851-045-0080, the Board will issue a Notice to Deny Licensure to an applicant for initial licensure or re-licensure to persons who have been convicted as an adult, or found responsible for except for mental illness, or adjudicated as a juvenile for the following crimes as set forth in Oregon law or comparable law in other jurisdictions:
The Board reviews all other criminal histories on a case-by-case basis to determine if an application will be approved or denied.
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Watch god's not dead and oculus movie hd
It's a bit of a cliche (which doesn't accomplish it untrue) that if cameramen about-face to directing, they accomplish movies continued on beheld brightness and abbreviate on storytelling. In any case, a lot of who accomplish the alteration (Jack Cardiff, Haskell Wexler, Gordon Willis, John Bailey, Dean Semler) eventually go aback to cutting for others. With Transcendence, Pfister has absolutely delivered a good-looking, well-produced picture, admitting one defective in the memorable images he has supplied in antithesis in Nolan's employ. (Pfister's d.p. of choice, Jess Hall, is big on sun flares and slow-mo baptize droplets.) Added critically, he's fabricated a cine abandoned of feeling, even as it labors to argue us that the absolute approaching of the animal chase is blind in the balance. There is, at the story's center, an attack at a grand, bedevilled sci-fi affair amid Will and Evelyn, but one charge alone anticipate aback to David Cronenberg's accommodate of The Fly, or Nolan's own Inception, to see how abbreviate Transcendence avalanche on this accurate score.Presented with abundant the aforementioned claiming as Scarlett Johansson in Her " to play a appearance who, for a lot of of the movie, exists alone as a aerial articulation (and, in this case, a ablaze face on a screen) " Depp fails to back any absolute faculty of the affection and concern that allegedly drive Will Caster to do what he does. The acutely admirable Hall (who was, forth with Johansson, one of the women bent up in the ballsy magicians' bound in Nolan's The Prestige) seems to accept been directed to bear her absolute achievement in an abiding accompaniment of abashed anxiety. Indeed, continued afore the Web goes bust, Transcendence has already flatlined.
watch transcendence
watch a haunted house 2
watch captain america 2
watch rio 2
watch oculus
watch draft day
watch noah
watch divergent
watch god's not dead
watch muppets most wanted
Watch god's not dead and oculus movie hd
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As the World Cup approaches, start planning your tour of South America
Rio de Janeiro is among the most popular stops on South America tours, and the city will likely see even more visitors when it hosts the 2014 World Cup in June. In fact, experts estimate that anywhere between 600,000 and 3 million foreign visitors will head to Rio once the soccer tournament kicks off. While the city will be especially vibrant during the World Cup, any trip to Rio is sure to be a memorable one, provided you make the right decisions on what to do and see while you're there. Here's a few spots you can't miss:
There are a number of natural highlights spread throughout Brazil, but Corcovado is arguably the most recognizable. Standing more than 2,300 feet above the city, this stunning granite peak gives you the chance to see the city from a whole new perspective. Corcovado sees hundreds of thousands of visitors each year, and with good reason. Not only is it one of the best vantage points in South America, but it is also home to the iconic Christ the Redeemer - a nearly 100-foot statue of Jesus that stands guard over the city below.
Tijuca National Park
For those looking for an adventure that's a bit closer to the ground, Tijuca National Park offers an unfettered look at the natural appeal of Rio. The park encompasses a large rainforest that's home to a wide variety of plant and animal life and also provides ample hiking opportunities. Among its most-recognizable features are the Cascatinha Waterfall as well as the impressive Mayrink Chapel, which features some awe-inspiring murals.
City of Arts
Of course, Rio is home to much more than just natural attractions, and the city is teeming with culture and art around seemingly every corner. One of the newest attractions is the City of Arts complex, which opened its doors in 2011. The expansive building is the official home of the Brazilian Symphony Orchestra and is the largest concert hall on the continent. Along with the City of Arts, you should make a point to check out the National Museum of Fine Arts, which has been a staple of Rio's cultural identity for more than 75 years and remains a popular tourist draw.


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When can we expect these as a stocked item?
When can we expect these as a stocked item?
At some point in the near-ish future... we will be bringing in some western handled ones in various shapes and sizes. Let me know if there is something specific you'd like to see and i can try to stock some of those. I will say that we are a tiny company, so we cant do everything right away. However, just to throw it out there, if anyone is interested in ordering one in any of the HD shapes/sizes, our special order process is no more expensive than regular purchases... it just takes a little patience. If there's something you want or something you are looking for, just ask... chances are we can get it for you.
Thanks for the quick reply, Jon. That one sure is nice looking.
It looks much better in person
Really though, anytime you have questions or have something in mind you want to order, just let me know. We'll do our best to make it happen. Theres something just nice about getting the perfect knife for someone... its cool for us and cool for them
And I thank you for it. I'm patiently waiting for you to tell me my order's in. It's hard, but I know it'll be worth the wait.
270 gyutos would be nice, too many 240s around these days.


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One of the new Starbucks is all eco-chic with recycled redwood and "a prominent community table (of rough-cut ash) that extends outdoors." Another looks like a cross between two of San Francisco's most popular coffee geek hangs: Four Barrel Coffee, and Ritual (and no doubt a bunch of similarly groovy places in Seattle.) In the Times' photo of the latter, a line of porcelain single-serve drip coffee makers are set on a groovy, industrial-looking rack, with some kind of neo-hippy bird nest art in the background. Apparently this joint doesn't even have a Starbucks sign out front, but rather one that reads "15th Ave. Coffee & Tea" and then in smaller letters, "Inspired by Starbucks." Right.
The funny thing is that this isn't the first time Starbucks tried to go undercover and unStarbucksify itself. Back in the late 1990s, the chain launched a few pilot versions of a kind of coffeehouse lounge thing called Circadia. There was one in San Francisco. It had no mention of Starbucks in any of its signage, had a full bar (?!) and was sort of trying to be a singles meet-up spot for dot-commers in a warehousey part of the Mission that was crawling with them. Check out this hilarious blast-from-the-past article about it from Fortune. (I had to google "Tiazzi Juice" too, WTF?) You ask: What happened to Circadia? Well, word got out immediately that it was actually Starbucks, nobody went there because of that, and then it seemed like in a matter of months it just morphed into a normal Starbucks, which is how it remains today. It's right by my apartment, and I can attest that it's quite popular now. Probably because people know what they're getting with Starbucks. If they want "interesting" or "innovative" or "fashionable" they can walk one more block to the independent Coffee Bar.
The mastermind of these new Starbucks, according to the Times, is president of global development Arthur Rubinfeld, who was at the helm on the Circadia project too. I wonder what he learned? Obviously not that you can't fake real style or a cultural movement from the bowels of the boardroom. People can smell that as sure as a freshly-ground cup of Yirgacheffe.
Image source: Flickr member D3 San Francisco under Creative Commons


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Six Flags, AOL Embark on Great Marketing Adventure
America Online Inc. and Six Flags Inc. have agreed on a cross promotional and marketing deal, the companies said yesterday. Six Flags will promote AOL, Dulles, VA, through its theme parks, advertising and other offline channels. In return, Six Flag's Web site will be promoted across AOL's brands.In addition, AOL members will have access to Six Flags ticket give aways and discounts. Six Flags will distribute AOL software at its theme parks.


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The Ohio Lake Erie Commission is accepting nominations for this year's Lake Erie Awards, which are given to individuals and organizations for exceptional preservation work.
The commission has honored 10 people and 10 groups since establishing the annual awards in 1995. Nomination forms are available from the commission's Web site at www.epa.state.oh.us/oleo.
All nominations must be submitted by 5 p.m. Aug. 5.
Winners will be announced during the 2005 Coastweeks observance, from Aug. 20 to Sept. 18.


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By 2015, almost seven out of 10 Inland seniors will have poor access to public transit, according to a report commissioned by Rep. Mark Takano, D-Riverside.
The price of low rent: While the Inland Empire offers affordable housing, residents pay more to get around, the report found. For every dollar families save on housing, they spend 77 cents more on transportation, according to the report.
Travel training: Riverside Transit Agency offers a free program to teach disabled and senior customers how to use fixed-route buses. For more information or to sign up for the program, call 951-565-5002.
Most Inland-area seniors have poor access to public transportation, and it's not going to get any better soon, according to a recently released report from Rep. Mark Takano's office.
The report from Takano, D-Riverside, also found that working families in Riverside and Moreno Valley spend almost 60 percent of their incomes on transportation and housing.
The "location cost burden" for Riverside residents is higher than it is in New York City, the report determined. And adults with disabilities are twice as likely as other adults to lack adequate transportation, the report read.
"This report details the difficulties disabled residents and the elderly have using the public transportation system in Riverside," Takano said in a news release. "By implementing several of the policy recommendations in my report, we can begin to increase access for those who need public transportation the most."
The report comes as the Riverside Transit Agency, the primary bus provider for western Riverside County, experienced record ridership last year. Agency buses saw 9.3 million boardings in 2013, eclipsing the previous record set in 2012.
Still, the report found cause for concern in the number of senior citizens who don't live in areas with easy access to public transportation. Many seniors are choosing to "age in place" and stay in their homes, the report read.
"However, most adults 65 and over do not live in urban, transit rich areas, but rather, suburban, auto-dependent areas," the report read. "They are also more likely to be living on fixed incomes and therefore, less likely to be able to afford the cost of owning a car."
"This creates a 'mobility mismatch' between seniors living in the suburbs, who either drive very little, or do not drive at all, and the resources they can access by public transportation."
By 2015, more than 15.5 million Americans age 65 and over – 69 percent of seniors in the Riverside/San Bernardino metropolitan area – will live in areas with very poor public transit options, according to Takano's report, which quoted figures from a study by Washington, D.C.-based Transportation for America.
In a 2013 quality-of-life survey sent out by the city of Riverside, seniors gave the lowest marks to "ease of getting around by bus or rail in Riverside" and were the least likely to use public transit in the city, the report read.
In an emailed response, RTA spokesman Brad Weaver said the agency agrees that more can be done to serve senior and disabled customers.
"Since our inception, we have made it a priority to serve our senior and disabled community," he said. "We work closely with our disabled community to learn ways we can better meet their travel needs. We also host meetings every quarter that are dedicated solely to exchanging information between RTA and our senior and disabled customers."
RTA buses are wheelchair-accessible and serve senior centers and senior housing, Weaver added.
Riverside resident Phyllis Morton, 63, said she rides the bus frequently.
"The service is basically effective," she said. "My only complaint is there is an attitude on behalf of too many drivers that (the Americans With Disabilities Act) is voluntary on behalf of an able-bodied passenger giving up the front seats. Very rarely in five years have I seen a driver take the initiative and secure seating for a disabled or senior rider."


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The Planning Division of the Community Development Department administers and enforces zoning and subdivision regulations in accordance with the Del Norte County General Plan, Local Coastal Program and applicable state laws. The Division is responsible for processing applications for development permits and providing public information on general plan, zoning, and subdivision matters. This Division seeks to protect and preserve the high quality of the County's natural and built environments. | Vacant Planner Lindsey Wheelon Planning Division Secretary Contact Us: 981 H Street, Suite 110 Crescent City, CA 95531 (707) 464-7254 (707) 465-0340 Fax |
Useful Links:
- California Emergency Management Agency, MyHazards
- Del Norte County Web GIS Portal
- Del Norte County Code, Chapter 16 (Subdivisions Chapter)
- Del Norte County Code, Chapter 19 (Environment Chapter)
- Del Norte County Code, Chapter 20 (Non-Coastal Zoning Chapter)
- Del Norte County Code, Chapter 21 (Coastal Zoning Chapter)


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KITTERY, Maine — Mary B. Brake, 98, died on Dec. 7, 2012, at York Hospital.
Born on Sept. 4, 1914, she was a daughter of John and Rose (Macdonald) Phee. She and her late husband, Milton Brake, made Kittery their home for many years.
Mary is survived by her son Stephen and his wife Sandy Brake.
Funeral services will be private. Care for the Brake family has been entrusted to the JS Pelkey Funeral Home.
Visit www.fosters.com/obits for an online guest book.
Mary B. Brake
Dec 15, 2012 at 3:15 AM


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Promotion 2016 wedding receptions
RISTORANTE DEL CASTELLO is pleased to offer your Special Wedding Menu 75 euros per person (come visit us and discover all the benefits designed for your most beautiful day!!!) For all couples booking their wedding banquet at our Restaurant will offer a wonderful Suite for the first night. To make an appointment CONTACT US Tel. email@example.com 0774332533


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Reviewed by 5 customers
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Comments about Inflatable Cube:
These cubes were bought for make your own fitness breaks in the classroom. Note the cubes do not come with a marker. Hard to tell from the package what they are for so I printed a copy of the examples from the photo online and taped to each package to give teachers starter ideas.
Best Uses
Comments about Inflatable Cube:
Adds variety to elder's exercise programs.
Best Uses
Comments about Inflatable Cube:
Great for teaching levels, pathways, and locomotor skills. Also great for fitness games. The wipe off boards allow you to modify the dice to fit your needs. Must have for P.E. teachers.
Best Uses
Comments about Inflatable Cube:
It is very versatile due to the wipe off panels and I use it for reminisce questions as well as for exercise. I pair it up with another dice that has numbers for the exercise portion. Especially good for large or small groups indoors.
Best Uses
Comments about Inflatable Cube:
I like the wipe-off cards and can use different exercises to benefit groups with different needs. I use a blow-up dice along with this one to act like the therapy dice in your catalog. It is a lot of fun.
Displaying reviews 1-5
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Pioneer Victorious in Lawsuit with Samsung |
Home Theater News Industry-Trade News | |
Written by AVRev.com | |
Monday, 10 November 2008 | |
Earlier this year Samsung enter into a lawsuit with Pioneer over Plasma HDTV patents. Pioneer claims that Samsung SDI willfully infringed two of their patents covering Plasma technology. Pioneer's attorneys, McKool Smith is proud to announce that Pioneer has won the lawsuit. The verdict came following an eight-day trial
While Pioneer's numbers for the end of the year are not stellar, we are sure that they are looking forward to a check from Samsung in the amount of $59 million. |


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- lists
- blocks
Common words appear frequently in written and spoken language across many genres from radio to academic journals.
Informal words should be reserved for casual, colloquial communication.
cool, excellent
Synonyms for gnarly
cool, excellent
More words related to gnarly
adj. different, unique
adj. strange and wonderful
adj. excellent, masterly
- elegant
- enjoyable
- exceptional
- expensive
- exquisite
- fashionable
- first-class
- first-rate
- first-string
- five-star
adj. deserving congratulations, adoration
Roget's 21st Century Thesaurus, Third Edition Copyright © 2013 by the Philip Lief Group.
Cite This Source


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Badger Basket Sleigh Style Changing Table with Six Baskets is a colored changing table that helps you to keep baby's bedroom or nursery tidy and organized. It has six baskets - three large ones to store blankets, toys, diapers etc., and three small ones to store socks, shoes, toiletries and more. Each basket has a card holder that helps you to sort the items and identify them. The changing area is designed for your baby's safety. It has safety belts, metal support bars under the surface and safety rails on all sides for extra safety.
List: $185.39
Colors |
Cherry |
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Currently Unavailable |
For the purchase limit reached item, please choose a quantity to Add to Registry
Quantity:SELECT A CART
Please choose which cart you want to add the item.
By choosing one of the above, you are able to shop for both yourself and a registrant at the same time. Once you are ready to checkout your items will be waiting for you in both your personal and registry shopping carts.
Still need assistance?
Please contact us at 1-800-Diapers (1-800-342-7377)


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Compare Chrysler Garages and Specialists in Sutton Coldfield with Who Can Fix My Car.
Enter your registration to check prices and reviews, and get your Chrysler booked in today!
Compare Chrysler Garages and Specialists in Sutton Coldfield with Who Can Fix My Car.
They diagnosed the problem for my window and told me a new regulator would fix the problem which it did as i bought one and worked perfectly fine. I also asked if they could fit my rear brake hubs and shoes to which they told me straight away that they could do. All in all very friendly staff and great customer service.
The car was in for a winter check however a number of issues were found and I was contacted and advised which jobs were a priority; I am not mechanically minded however the explanation was given in terms I could easily understand I authorized certain jobs and was informed they could be done that afternoon. I cannot fault the work that was done; all parts that were changed were kept for my inspection. This garage is local to me and I will continue to use them in the future. They are friendly and knowledgeable and give excellent advice. Totally recommend them.
Great service- I am really happy - and a good price. Kelly's delightful and so helpful. And friendly!
Made to feel very welcome on arrival; advised of length of time job would take and contacted as soon as vehicle was ready for collection. Would recommend to friends and family.
Used this garage to do all four brake pads and rear disks. Well priced and work carried out to a high standard. Would Deffo used again.
Ended up going else where price quoted was for labour only when asked for a fixed price they didnt get back to me. They left a voice mail today 7 days later asking when i wanted the work done. Would t recommend
Excellent work I like the mechanic, he is so professional
Very helpful and good communication.
I would highly recommend them as they where very quick and did an excellent job on my car. Will use them again if I need to as the price was also very competitive compared to some quotes I got.
New discs and pads fitted front Ford Fiesta.Great job in and out within 1hr many thanks.
Very good garage
This garage was very good .helped me over and beyond the diognostic booked.would highly recommend this garageand will defintly use again thanks
Excellent customer service and very professional. Great communication throughout and nothing was too much trouble for Mark and Jim. Appreciate it guys
I took my Lexus Ls400 for a timing belt and water pump replacement. Staff is very friendly and knowledgeabe. Job was done quickly and now my car runs perfectly. I would definitely recommend All TorQ to everyone!
Its my first time of using All Torq and I was suitably impressed. Like most people when you vehicle is playing up you want someone who is knowledgeable and charges a reasonable rate to fix the issue. I was a bit apprehensive at first but discovered that the 3 guys all worked as a team to help find a solution to an intermittent fault (worse kind) they went through the diagnostics and carried some physical tasks removing various parts to get to the problem. Anyhow, in my case it looks like what the guys did has done the trick, so I wouldn't hesitate to use these guys again they are establishing a very useful electronics garage facility. Keep it going lads !
Did a perfect job on my car. They were completely professional, got the job done quick & very affordable. Would definitely recommend them.
I damaged my new Audi with a bad scratch which needed repainting of the entire left side of the car. This first accident is so stressful. I'm glad I chose the Revamp. They've done an excellent job on my car and I was so relieved to see it like brand new after 2 days. The price is affordable. The staffs are professionals who are very accommodating. They will give you the reassurance, just what you needed when you're puzzled. I would recommend Revamp to anybody who needs a doctor for their cars... Ethel
Great job quick turn around
Very good job would highly recommend
Great service and price. Couldn't fault anything. Would definitely recommend and use them again.
I was quoted £169 over E-mail - car was taken in at 10:00 a.m. and was fixed by 12:30 p.m. Final price was £100. very friendly staff and car running perfectly - Thank you
Great garage, polite staff, professional service. Fixed my car on short notice
Nice garage and staff , I recomand this garage .
Nice garage and friendly staff .
Great service provided by MTR. Friendly & reliable. I'd certainly recommend to others. :)
Absolutely superb. Carried out a thorough service and were 100% honest and reliable. I will definitely be going there in future.
As a women I hate going to garages but was made to feel very welcome even though I only needed a puncture repair. Car was in and out within half an hour and I was also offered a free coffee. Would highly recommend.


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One man's treasure in Nanoose Bay is his neighbour's junk
Don't tell Wayne Barber that the big crane parked outside his backdoor is only fit for the scrap heap.
He needs that crane, as well as most of the machinery that is dotted around his home on Morello Road. Not only that, he has sunk an awful lot of money into it, far, far more than the $150 per ton he would get at the scrapyard.
The Nanoose Bay resident may have no choice but to scrap it however, after the Regional District of Nanaimo ordered the property he lives on with his partner Ann cleaned up within 30 days under the RDN's unsightly premesis bylaw.
The order was given at the RDN's committee of the whole meeting on June 11, despite a last-minute plea from wife Ann.
The RDN resolution to order the cleanup cites derelict and unlicensed vehicles, derelict industrial machinery, discarded automotive parts, tools, machinery, wood, metal, building materials and other debris.
At the meeting, Barber said her husband is an active hobbyist who has been collecting and restoring antique machinery, a hobby that he estimates has cost him about $200,000 over the years.
"These are not derelict vehicles," she said. "We have never received complaints or negative comments. I was shocked someone would complain to the RDN and say nothing to us."
Part of the problem, she explained had to do with an arched metal workshop that was hit by a falling tree over the winter, causing damage to the arches that had to be fixed prior to other work being completed. As well, she said one of the inspections of the property took place just after the couple had cleaned up a big mess in a rental property elsewhere that was left by the previous tenants. The debris from that cleanup ended up temporarily on the couple's Nanoose Bay property but has since been cleaned up.
A tour of the property Friday showed the crane, while visible from the top of the driveway is not overly intrusive, at least in the summer months, as the property is surrounded by a heavy wall of vegetation.
There is no shortage of machinery however, but rather than junk, Wayne said it's more like historical treasure.
"When I was a kid we lived on Cortes Island and we didn't have much money," the retired Coast Guard mechanic said. "My dad had all these engines sitting around that didn't work anymore so he would let me play with them. I always had my own tools and in 1975 I started painting cars for people. That was fun and I started getting older cars. I got a 1967 Thunderbird and I restored it with a new, high performance engine. It cost $10,000 to do it."
That was his first major project, but it only wetted his appetite. He began working on old machines, such as welders and tractors. He bought the 1952 Priestman crane for $500 and paid another $500 to get it to the property. He admits its not beautiful to look at, but he has a lot more work to do on what he said was an important piece of machinery — and there's no point painting it pretty prior to completing that often messy work.
"I just didn't want to see it made into a Toyota," he said.
He said he needs the crane in order to pull the pump out of his deep well, as well as to provide a safety line while he works on the damaged roof of the workshop.
"We have the machines, so we thought we should do it ourselves," he said.
Touring around the property, he showed obvious pride in some of the machines he has collected and at least partially restored, including a 1935 sawmill and his oldest piece, a 1929 welder.
"All the stuff is old, but I use it," he said. "The crane has 120 hours on it since I got it and I've done 200 hours of work on it. It cost me $3,000."
Ann noted the first complaint came right after they obtained the crane, because the starter went on it, leaving it stranded in the driveway. A lot of work and $1,500 for a new starter later, they snugged the crane up against their house — if not entirely out of sight from the road, then nearly.
She said photographs shown at the RDN meeting were out of date, with rubbish piles long since removed.
Wayne said he is aware of the concerns about his machinery, noting that while he would ideally like to keep the machines he restores, he's willing to let it go if there's a collector or museum somewhere who would give them a good home.
Barber's plea to the RDN board didn't go unnoticed, with director Julian Fell saying the issue was highly subjective.
"These are clearly museum artifacts," he said at the meeting. "They are not junk. They might be unsightly in somebody's eyes, but beautiful in someone else's eyes. They might be valuable one day."
Director George Holme was also sympathetic, noting the full board meeting wasn't for another two weeks, so the 30-day timeline wouldn't start until then.
Board manager Paul Thorkelson said staff is more than happy to work with the owners to come to a satisfactory conclusion, vowing not to take any drastic action prior to consulting with the board.


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Home > Health Library > Intraocular (Uveal) Melanoma Treatment (PDQ®): Treatment - Health Professional Information [NCI]
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.
Incidence and Mortality
Melanoma of the uveal tract (iris, ciliary body, and choroid), though rare, is the most common primary intraocular malignancy in adults. The mean age-adjusted incidence of uveal melanoma in the United States is approximately 4.3 new cases per million people, with no clear variation by latitude. Males have a higher incidence than females (4.9 vs. 3.7 per million).[1] The age-adjusted incidence of this cancer has remained stable since at least the early 1970s.[1,2] U.S. incidence rates are low compared with the rates of other reporting countries, which vary from about 5.3 to 10.9 cases per million. Some of the variation may be the result of differences in inclusion criteria and methods of calculation.[1]
Uveal melanoma is diagnosed mostly at older ages, with a progressively rising, age-specific, incidence rate that peaks near the age of 70 years.[3]
Host susceptibility factors associated with the development of this cancer include:[2,3,4]
In view of these susceptibility factors, numerous observational studies have attempted to explore the relationship between sunlight exposure and risk of uveal melanoma. To date, these studies have found only weak associations or yielded contradictory results.[3] Similarly, there is no consistent evidence that occupational exposure to UV light or other agents is a risk factor for uveal melanoma.[3,5]
Anatomic Location
Uveal melanomas can arise in the anterior (iris) or the posterior (ciliary body or choroid) uveal tract. Iris melanomas have the best prognosis, whereas melanomas of the ciliary body have the least favorable prognosis.[6] Most uveal tract melanomas originate in the choroid. The ciliary body is less commonly a site of origin, and the iris is the least common. The comparatively low incidence of iris melanomas has been attributed to the characteristic features of these tumors, i.e., they tend to be small, slow growing, and relatively dormant in comparison with their posterior counterparts. Iris melanomas rarely metastasize.[7] Melanomas of the posterior uveal tract generally have a more malignant, histologic appearance; are detected later; and metastasize more frequently than iris melanomas. The typical choroidal melanoma is a brown, elevated, dome-shaped subretinal mass. The degree of pigmentation ranges from dark brown to totally amelanotic.
Most uveal melanomas are initially completely asymptomatic. As the tumor enlarges, it may cause distortion of the pupil (iris melanoma), blurred vision (ciliary body melanoma), or markedly decreased visual acuity caused by secondary retinal detachment (choroidal melanoma). Serous detachment of the retina may occur. If extensive detachment occurs, secondary angle-closure glaucoma occasionally develops. Clinically, several lesions simulate uveal melanoma, including metastatic carcinoma, posterior scleritis, and benign tumors, such as nevi and hemangiomas.[8]Anatomy of the eye.
Careful examination by an experienced clinician remains the most important test to establish the presence of intraocular melanoma. It is not possible to distinguish a small uveal melanoma from a nevus. Small uveal lesions are often observed for growth to make a diagnosis of melanoma. Clinical findings that may help to identify melanoma include:[6]
Ancillary diagnostic testing, including fluorescein angiography and ultrasonography, can be extremely valuable in establishing and/or confirming the diagnosis.[9] In a large, retrospective, single-center series of 2,514 consecutive patients with choroidal nevi, the progression rates to melanoma at 5, 10, and 15 years were 8.6%, 12.8%, and 17.3%, respectively.[10]
Prognostic Factors
A number of factors influence prognosis. The most important factors include the following:
Several additional microscopic features can affect the prognosis of intraocular melanoma, including:
Cell type is the most commonly used predictor of outcome following enucleation, with spindle-A cell melanomas carrying the best prognosis and epithelioid cell melanomas carrying the least favorable prognosis.[1,4,9] Nevertheless, most tumors have an admixture of cell types, and there is no clear consensus regarding the proportion of epithelioid cells that constitutes designation of a tumor as mixed or epithelioid.[6]
Extraocular extension, recurrence, and metastasis are associated with an extremely poor prognosis, and long-term survival cannot be expected.[11] The 5-year mortality rate associated with metastasis from ciliary body or choroidal melanoma is approximately 30%, compared with a rate of 2% to 3% for iris melanomas.[12]
Primary intraocular melanomas originate from melanocytes in the uveal tract.[1] Four distinct cellular types are recognized in intraocular melanoma (revised Callender classification):[2]
Most primary intraocular melanomas contain variable proportions of epithelioid, spindle-A, and spindle-B cells (mixed-cell melanomas). Pure epithelioid-cell primary melanomas are infrequent (approximately 3% of cases).[1] In the Collaborative Ocular Melanoma Study, mixed-cell type melanomas predominated (86% of cases).[3]
Tumor Size
Uveal melanoma most often assumes a nodular or dome-shaped configuration, but occasionally tumors can be flat or diffuse and involve extensive areas of the uvea with little elevation.
Tumor size classifications according to boundary lines used in a Collaborative Ocular Melanoma Study (COMS) are as follows:[1]
Although most ocular melanomas have a raised configuration, about 5% grow in a diffuse pattern that also may have prognostic significance. The tumors have a horizontal, flat-growth pattern, with the thickness measuring approximately 20% or less than the greatest basal dimension. This uncommon variant of uveal melanoma seems to have a poorer prognosis, particularly when the diameter is large, and the margins are poorly defined.[3]
In clinical practice, the tumor base may be estimated in average optic disc diameters (1 dd = 1.5 mm). The average elevation may be estimated in diopters (3 diopters = 1 mm). Other techniques, such as ultrasonography, should be used to provide more accurate measurements.
An important function of ophthalmic ultrasonography is the detection of extrascleral extension.[4,5] Extrascleral extension measuring 2 mm or more in thickness can be demonstrated provided it is located behind the equator where the intraocular tumor, sclera, and adjacent orbital fat are readily imaged.[6] Orbital extraocular extension of choroidal melanoma may be found in eyes with medium and large tumors, but it is very rare in eyes with small melanomas.
Metastatic Disease
Systemic metastases are evident in only 1% to 4% of patients at the time of diagnosis of the primary ocular melanoma.[7] Because the uveal tract is a vascular structure without lymphatic channels, tumor spread occurs principally by local extension and by dissemination through the blood stream. Lymphatic spread is rare but may occur after local extension into the conjunctiva and its lymphatics.[8] Given the rarity of nodal metastases, sentinel node biopsies of nonclinically involved nodes are not done as part of the staging procedure.[7]
Systemic metastases are generally hematogenous in origin, and the first site identified is usually the liver.[9] Lung, bone, and subcutaneous sites are also common.[9] In the COMS trials, the liver was the only site of detectable metastasis in 46% of patients with metastases reported during follow-up or at the time of death; 43% had metastases diagnosed in the liver and other sites.[9] In patients with a history of ocular melanoma who present with hepatic metastases of unknown origin, metastatic melanoma should be considered in the differential diagnosis.
It is particularly unusual for choroidal melanomas of any size to invade the optic nerve or its meninges.[10] Metastasis of choroidal melanoma to the contralateral choroid is also rare.[9,11]
Definitions of TNM
An American Joint Committee on Cancer staging system has been developed for melanoma of the uveal tract.[7]
There are a variety of other factors that are not part of the AJCC staging system but that may help in refining estimates of prognosis.[7]
Prognostic features
There are a number of key prognostic features that are important to collect in malignant melanoma of the uvea, even though they are not included in staging algorithms. These include the following:[7]
Molecular features
Clinical and histopathologic features
The patterns are assessed with light microscopy under a dark green filter after staining with periodic-acid Schiff without counterstain.
The number can be compared with standard photographs.[13]
Role of Observation
Iris melanomas have relatively good outcomes with a 5-year survival rate of more than 95%. They are predominantly of the spindle-cell type and are usually smaller in size than posterior melanomas because of earlier detection. Conservative management is generally advocated whenever possible, but surgical intervention may be justified with unequivocal tumor growth or with extensive disease at initial examination.
The management of small choroidal melanomas is controversial, and it is not clear whether treatment of small tumors prevents metastasis.[1] The natural history of small choroidal melanoma is poorly understood. Small, pigmented, choroidal lesions cannot always be differentiated reliably on examination. Growth is a presumed indicator of malignant potential.[2] The likelihood of progression from the time of diagnosis to the time when tumor growth warrants treatment has not been well characterized. Some ophthalmologists advocate observation. This has been justified on several grounds, including the difficulty with establishing a correct diagnosis, the lack of any documented efficacy for globe-conserving treatments, and concerns for severe treatment-related morbidity. Others have advocated earlier therapeutic intervention.[1,3,4]
Although patients diagnosed with small choroidal tumors were not eligible for participation in the Collaborative Ocular Melanoma Study (COMS), these patients were offered participation in a prospective follow-up study to evaluate the natural history of small lesions. Two-year and 5-year tumor growth estimates of 21% and 31%, respectively, were reported.[5] Clinical risk factors associated with tumor growth included:[3,5]
Role of Surgery
The selection of treatment depends on the following:
In the past, enucleation (eye removal) was the standard treatment for primary choroidal melanoma, and it is still used for large tumors. However, enucleation has been largely replaced by radiation therapy (i.e., brachytherapy with radioactive plaques; or external-beam, charged-particle radiation therapy) to spare the affected eye.[6,7]
Pre-enucleation external beam radiation therapy (EBRT)
In the case of large, choroidal tumors judged to require enucleation, the role of pre-enucleation EBRT was tested in a randomized trial and had no impact on overall survival (OS).[8,9][Level of evidence: 1iiA] In a COMS trial, 1,003 patients with large choroidal melanomas (≥2 mm in height and ≥16 mm in diameter, or ≥10 mm in height irrespective of diameter, or ≥8 mm in height and border <2 mm from the optic disc) with no known metastases were randomly assigned to receive enucleation alone or after preoperative external photon-beam radiation from cobalt 60 or accelerators (20 Gy in five daily fractions) to the orbit and globe.[8,9] Through 10 years of follow-up, the median survival in both arms was approximately 7 years, and the 10-year all-cause mortality was 61% in both arms (relative risk for death of 1.00; 95% CI, 0.85–1.18). Metastasis-free survival was also virtually identical in both arms.
Transscleral local resection
Eye-sparing transscleral local resection plays a very limited role in the management of uveal melanoma. It is used in patients with large choroidal and ciliary body tumors who are not candidates for radiation therapy but are highly motivated to retain their eye.[10,11,12] The procedure is technically demanding and is generally performed only in centers with specialized expertise in this surgery. There is a substantial risk of retinal detachment, intraocular bleeding, and complications associated with the anesthesia-induced hypotension used to decrease the risk of bleeding. Adjuvant brachytherapy or neoadjuvant proton-beam therapy is often administered. Experience is limited to retrospective, single-center, case series.[10,11,12][Level of evidence: 3iiiDiv]
Surgical resection of metastases
Surgical resection of metastases from ocular melanoma has been reported in case series of highly selected patients with occasional favorable outcomes.[13,14] However, the favorable outcomes may be the result of strong patient-selection factors, and the role of resection in this setting is unclear.[13,14][Level of evidence: 3iiiDiv]
Role of Radiation Therapy
Episcleral brachytherapy using plaques containing small radioactive "seeds" is the most common form of radiation used in the management of intraocular melanoma. Iodine-125 (125 I), cobalt-60 (60 Co), palladium-103 (103 Pd), iridium-192 (192 Ir) and ruthenium-106 (106 Ru) are examples of radioactive isotopes used in the brachytherapy plaques. Isotopes with relatively low photon and electron emissions (125 I, 103 Pd, and 106 Ru) are more easily shielded to reduce the exposure to adjacent normal tissues, and 125 I is probably the most commonly used radioisotope.[15] Although plaque radiation therapy allows preservation of the eye, visual acuity is frequently lost over time.
In a case series of 1,106 patients who were treated with plaque radiation therapy for uveal melanoma and who had an initial acuity of at least 20/100, 68% developed poor acuity (i.e., 20/200 or worse) within 10 years.[16]
Factors associated with worse acuity outcomes included the following:[16]
125 I brachytherapy yields equivalent overall and melanoma metastasis-specific survival rates to enucleation for medium-sized melanomas.[17][Level of evidence: 1iiA] The randomized COMS Medium Tumor Trial compared 125 I episcleral-plaque brachytherapy (85 Gy at 0.42–1.06 Gy/hr) to enucleation in 1,317 patients with medium-sized choroidal tumors (tumor height 2.5 mm–10.0 mm and tumor diameter ≤16.0 mm that were not contiguous with the optic disc).[17] Eighty-five percent of the patients treated with 125 I brachytherapy retained their eye for 5 years or more, and 37% of them had visual acuity better than 20/200 in the irradiated eye 5 years after treatment.[17] No statistically significant differences in mortality were observed between the two study arms after 12 years of follow-up, whether considering death from all causes or death with histopathologically confirmed melanoma metastasis.[18] Five- and 10-year all-cause mortality rates were 19% and 35% in both study arms; cumulative all-cause mortality at 12 years was 43% in the 125 I arm versus 41% in the enucleation arm (RR, 1.04; 95% CI, 0.86–1.24). Five-year metastasis-specific mortality rates were 13% in both arms; at 10 years, the rates were 21% and 22% (RR for metastasis-specific mortality, 1.07; 95% CI, 0.81–1.41 through 12 years).
In a companion study within the COMS, 209 patients were prospectively assessed for quality of life during the first 5 years of follow-up.[19] Both study groups reported increasing difficulty with vision-oriented daily activities and ocular pain as time elapsed. Most measures of visual function were similar between the two groups, but there were statistically significant differences favoring the brachytherapy group in comfort with driving for the first year after therapy and in reported peripheral vision for the first two years after therapy. These differences disappeared by year 5 of follow-up.[19][Level of evidence: 1iiC]
Charged-particle EBRT (using protons, carbon ions, or helium ions) is the other major form of radiation therapy used in the management of ocular melanomas.[20,21,22,23] This form of radiation therapy requires sophisticated equipment available only at selected centers, and charged-particle EBRT involves patient cooperation during treatment (e.g., voluntarily fixating the eye on a particular point so the tumor is positioned properly in the radiation beam). A lower risk of early and late local radiation failures has been reported after charged-particle EBRT than after brachytherapy, possibly resulting from differences in dose distribution of the two techniques.[20][Levels of evidence: 1iiDiv and 3iiiDiv]
In a single-center, single-surgeon study 184 patients with uveal melanomas smaller than 15 mm in diameter and smaller than 10 mm in thickness were randomly assigned to receive 125 I brachytherapy versus helium ion radiation (to an estimated dose of 70 Gy equivalents in five fractions over 7 to 11 days in each arm).[24] The local tumor regrowth rate by 4 years was 13.3% in the brachytherapy arm versus 0% in the helium ion arm (P < .001). However, the rates of metastasis, death from metastasis, and overall mortality was very similar in both arms.[24][Level of evidence: 1iiDiv]
Because of its dose distribution, charged-particle irradiation can be used to treat larger tumors and tumors closer to the fovea or optic disc than plaque brachytherapy. A large, single-center, single-surgeon series of 2,069 patients treated with proton-beam therapy had an actuarial local control rate of 95% (95% CI, 93%–96%) at 15 years. The cumulative rate of enucleation was 16% (95% CI, 13%–20%), most frequently as a result of neovascular glaucoma, blind uncomfortable eyes, or local recurrence (46%, 31%, and 23% of enucleations). As with plaque radiation, risk factors for deterioration in visual acuity after charged-particle radiation were tumor size, location near the fovea or optic disc, baseline acuity, and underlying diabetes.[21]
Similarly, another large, single-center, single-surgeon, consecutive series of 886 patients treated with proton-beam irradiation reported a local control rate of 92.1% (95% CI, 89.8%–94.6%) and ocular conservation rate of 87.3% (95% CI, 83.9%–90.9%) at 10 years.[22]][Level of evidence: 3iiDiv] The actuarial OS at 10 years was 64.1% (95% CI, 59.5%–69.0%).
In a single-center, phase I/II study of 57 evaluable patients treated with carbon ion-beam irradiation and followed for a median of 26 months, 26 patients developed neovascular glaucoma or severe eye pain from increased intraocular pressure, and 3 patients had enucleation. One patient had a local tumor recurrence.[23]
In an attempt to lower the complication rate and improve functional outcome, a decreased dose of 50 cobalt Gy equivalents (CGE) has been compared to 70 CGE proton beam (each delivered in 5 fractions, usually within a 7-day period). Patients (n = 188) with tumors smaller than 15 mm in diameter and smaller than 5 mm in height that were located near the optic disc or macula were randomly assigned to the two doses in a double-masked study design. At 5 years, there were no statistically significant differences in local tumor control, rate of metastasis, visual acuity, or complication rates. However, the visual fields were better in the 50 CGE group.[25][Level of evidence: 1iDiv]
As noted above in the section on the Role of Surgery in the Treatment Option Overview section of this summary, the role of pre-enucleation external photon-beam radiation therapy has been tested in a randomized trial and has shown no impact on OS for large choroidal tumors treated with enucleation.[8,9]
External-beam–photon-beam (gamma-ray) radiation therapy with gamma-knife stereotactic radiation surgery as a single-fraction [26] or fractionated stereotactic radiation [27,28] is being investigated as an alternative to brachytherapy or charged-beam radiation for posterior uveal melanomas, particularly for tumors too large or too close to the optic disc or macula to treat with brachytherapy. Because the dose rate of radiation delivery is slower than is the case with charged particles, specialized techniques are used to immobilize the eye [26] or to avoid delivery of the photons while the eye is moving or closed.[28] Experience is more limited with external-beam–photon therapy than for either brachytherapy or charged-particle EBRT, and there are no controlled comparisons to either of the other techniques. Early results from single-center series suggest similar levels of local tumor control and eye retention rates, but patient-selection factors may play a role.[28][Level of evidence: 3iiiDiv]
Role of Transpupillary Thermotherapy
Transpupillary thermotherapy (TTT) directs an infrared laser, usually at a wavelength of 810 nm, through a dilated pupil in one or more sessions to induce heat necrosis of uveal melanomas. This method carries the theoretical advantage of high-precision destruction of tumor tissue under direct visualization. However, TTT has important limitations that confine its use to very restricted circumstances.[1,29] The limited ability of TTT to penetrate thick tumors with sufficient energy restricts its use to small melanomas, or tumors of a size that some ophthalmologists recommend for follow-up without any initial therapy. (Refer to the Role of Observation section in the Treatment Option Overview section of this summary for more information.) When used as the primary therapy, there are relatively high rates of local recurrence and retinal vascular damage. Recurrence rates are particularly high when the tumor abuts the optic nerve and overhangs the optic disc.[1][Level of evidence: 3iiiDiv]
In a single-center study, 95 patients with small choroidal melanomas (diameter <10 mm and thickness <3.5 mm) were randomly assigned to TTT versus 125 I brachytherapy (100 Gy).[30] The tumor regression rates in the TTT and 125 I arms were 92% and 98%, respectively (P = .4). With a mean follow-up time of 56.2 months, there were four recurrences in the TTT arm and one in the 125 I arm. However, the study is too small to provide clear information on efficacy differences.
TTT is also under evaluation as an adjunct to primary therapy with proton-beam radiation. In the setting of large uveal melanomas, proton-beam therapy is associated with exudative, inflammatory, and glaucomatous complications that may require enucleation. In a single-center trial, 151 patients with uveal melanomas at least 7 mm thick or at least 15 mm in diameter were randomly assigned to receive proton-beam radiation (60 CGEs over four daily fractions) with or without TTT (810 nm wavelength at 1, 6, and 12 months after therapy) and followed for a median of 38 months.[31] There were no differences between the two groups in maculopathy, papillopathy, or glaucoma. The enucleation rate was lower in the TTT group (about 2% vs. 18% at 5 years, P = .02). However, the study was not masked, and replication would be important.
There are uncertainties regarding the optimal management of intraocular melanoma at all stages. Physicians should discuss with eligible patients opportunities for entry into ongoing clinical trials. Information about ongoing clinical trials is available from the NCI website.
Melanocytic stromal proliferations and nevi of the iris are the most common tumors of the iris, but melanoma is rare.[1,2] Clinical differentiation between an iris nevus and a melanoma might sometimes be difficult and at times may be impossible. Melanomas of the iris are usually small discrete lesions, although they may occasionally be diffuse, infiltrative, or multiple and may result in heterochromia, chronic uveitis, or spontaneous hemorrhage into the anterior chamber of the eye (hyphema). Iris melanomas that involve more than 66% of the angle circumference are associated with secondary glaucoma.[3]
Routine evaluation of iris melanomas includes gonioscopy, transillumination of the globe, and indirect ophthalmoscopy with 360° of scleral depression. Photographic documentation is essential to document progression in size or growth of the tumor.[4] Anterior segment fluorescein angiography may be helpful to demonstrate the vascularity of the lesion but is not diagnostic. High-resolution ultrasound biomicroscopy can be used to measure small lesions (basal dimensions and thickness) and to assess tumor involvement of the anterior ciliary body, angle, and overlying sclera.[5] The main disadvantage with this technology is its limited penetration of large lesions. In these cases, conventional ultrasonography is more accurate.
In general, iris melanomas have relatively good outcomes. Only about 3% of these melanomas develop metastases within 5 years.[1] Iris melanomas are predominantly of the spindle-cell type and are usually smaller in size than posterior melanomas. Clinical features, including prominent tumor vascularity, rapid growth, and heterogeneous pigmentation, are associated with an epithelioid cell component.[6] Involvement of the iridocorneal angles is frequently associated with ciliary body invasion.[6]
Given their rarity and good prognosis, trials with sufficient power are practical. Therefore, treatment experience is based principally on case series and case reports. Conservative management is generally advocated whenever possible, but surgical intervention may be justified with unequivocal tumor growth and with extensive disease at initial examination.
Standard treatment options:
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with iris melanoma. 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.
Melanoma involving the ciliary body is a rare tumor that carries a poor prognosis. In some cases, diagnosis may be difficult because of similarity to other eye diseases. The differential diagnosis of ciliary body melanoma should be considered in cases of unilateral pigmentary glaucoma and chronic uveitis.[1]
Ultrasound biomicroscopy can be used to evaluate tumor shape, thickness, margins, reflectivity, and local invasion.[2,3] Patients with tumors greater than 7 mm in thickness are at increased risk for metastatic disease and melanoma-related death compared with patients with thinner tumors.[4]
There are several options for management of ciliary body melanoma. All of them are reported from case series.[Level of evidence: 3iiiDiv] The choice of therapy, however, depends on many factors.
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with ciliary body and choroid melanoma, small size. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
A wide range of 5-year mortality rates have been reported among patients treated for small choroidal melanomas, with an average rate of about 16%.[1,2] Several studies indicate that the two most important clinical factors predictive of mortality are larger tumor size (at the time of treatment) and documentation of tumor growth.[3]
The management of small choroidal melanomas is controversial. The likelihood of progression from the time of diagnosis to growth warranting treatment has not been well characterized. Many ophthalmologists advocate initial observation. This initial management strategy is justified on several grounds, including the difficulty in establishing a correct diagnosis, the lack of any documented efficacy for globe-conserving treatments, and concerns for severe treatment-related morbidity. Others have advocated earlier therapeutic intervention.[4,5,6]
Eye-sparing radiation therapy, either by plaque brachytherapy or external beam, is the preferred option for most patients with medium-sized choroidal melanoma. Enucleation remains the standard therapy for large, choroidal melanomas and melanomas that cause severe glaucoma or invade the optic nerve.
Tumor growth pattern is a factor in the therapeutic decision. If there is a diffuse melanoma or if there is extraocular extension, enucleation should be considered, but radiation therapy can be employed for less extensive disease.
Medium-sized choroidal melanomas
Large choroidal melanomas
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with ciliary body and choroid melanoma, medium/large size. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
Extrascleral extension confers a poor prognosis. For patients with gross tumor involvement of the orbit, treatment requires orbital exenteration. However, there is no evidence that such radical surgery will prolong life. Most patients with localized or encapsulated extraocular extension are not exenterated. This subject is controversial.[1,2,3,4,5]
No effective method of systemic treatment has been identified for patients with metastatic ocular melanoma. Available clinical trials should be considered as an option for these patients.
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with extraocular extension melanoma and metastatic intraocular melanoma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
The prognosis for any patient with recurring or relapsing disease is poor, regardless of cell type or stage. The question and selection of further treatment depends on many factors, including the extent of the lesion, age and health of the patient, prior treatment, and site of recurrence, as well as individual patient considerations. Surgical resection of metastases diagnosed subsequent to initial management of ocular melanoma in single-center, case series of highly selected patients has been reported. The extent to which the occasional favorable outcomes are the result of strong selection factors is not clear, so this approach cannot be considered standard.[1]
Clinical trials are appropriate, and eligible patients should be advised to consider participation in them whenever possible.
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with recurrent intraocular melanoma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
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.
Treatment Option Overview
An editorial change was made to this section.
This summary is written and maintained by the PDQ Adult 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 intraocular melanoma. 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 Adult 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 reviewer for Intraocular (Uveal) Melanoma Treatment is:
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 Adult Treatment Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations.
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PDQ is a registered trademark. Although the content of PDQ documents can be used freely as text, it cannot be identified as an NCI PDQ cancer information summary unless it is presented in its entirety and is regularly updated. However, an author would be permitted to write a sentence such as "NCI's PDQ cancer information summary about breast cancer prevention states the risks succinctly: [include excerpt from the summary]."
The preferred citation for this PDQ summary is:
National Cancer Institute: PDQ® Intraocular (Uveal) Melanoma Treatment. Bethesda, MD: National Cancer Institute. Date last modified <MM/DD/YYYY>. Available at: http://www.cancer.gov/types/eye/hp/intraocular-melanoma-treatment-pdq. Accessed <MM/DD/YYYY>.
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Based on the strength of the available evidence, treatment options may be described as either "standard" or "under clinical evaluation." These classifications should not be used as a basis for insurance reimbursement determinations. More information on insurance coverage is available on Cancer.gov on the Coping with Cancer: Financial, Insurance, and Legal Information page.
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Last Revised: 2015-07-09
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text:
A Handbook for Small-Cap Corporate Boards
byAttention, directors of small-cap companies. Help is on the way.
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Much of that insight into the governance of the largest publicly traded companies has only slight relevance to the vast majority of U.S.-listed businesses. That's the central point of a helpful new guide for the small-cap director, The Perfect Corporate Board. As author Adam Epstein notes, more than 70 percent of publicly traded companies have market caps of less than $500 million. Most of these companies don't have large in-house legal departments, ready access to capital markets, or deep experience with corporate finance. They are often overly reliant on outside professionals of dubious motivation and expertise. They need a hand.
Epstein's unusual book fills the need. The author began professional life as a corporate lawyer with a major national firm. He moved on to co-manage a hedge fund that invested in more than 500 small-cap financings. Too often, he observed that the companies accepting money from his hedge fund didn't have a coherent strategy and were vulnerable to being taken advantage of by investment bankers, lawyers, and, well, crafty hedge funds.
Now operating as an independent consultant, Epstein wants to share the tricks of the trade with small-cap directors who may have a terrific technology or service to sell but lack his experience with stock markets and lending. (Disclosure: I have known Epstein since he was a wet-behind-the-ears law firm associate, and I've always admired his uncanny enthusiasm for making capitalism work, not just for corporate giants, but also for the "little guys" who employ an awful lot of Americans.)
The Perfect Corporate Board contains a series of very practical "what-if?" scenarios and easy-to-understand solutions. One example: When going back to the market to raise more money, the small company board should not assume they're fortunate to get the attention of their current bankers. The directors should shop around for a good deal and even consider hiring a third-party professional, with no financial interest in seeing the deal closed, who can provide impartial advice on which banker will do the best job.
The title may overpromise just a tad (the very good corporate board might be a more realistic goal). Still, this 278-page volume is well worth the time of anyone overseeing a less-than-titanic publicly traded company.


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News Release
ARLINGTON, VA (January 7, 2013) – Intelligence and National Security Alliance (INSA) Board Chairman Ambassador John Negroponte today congratulated White House chief counterterrorism advisor, John Brennan, who was nominated by President Obama to be the next Director of the Central Intelligence Agency (CIA). "John Brennan's years of experience and expertise in the U.S. Intelligence Community make him an excellent nominee for the next Director of the CIA. John's leadership, both at CIA and in the Administration, and his extensive knowledge and understanding of comprehensive national security policy make him an excellent candidate to lead the Agency. John served ably as INSA's Board Chairman and our community congratulates him on his nomination," said Ambassador Negroponte. John Brennan served as Chairman of the INSA Board of Directors from 2007 to 2008. For more information about INSA, please visit our website www.insaonline.org.
About INSA The Intelligence and National Security Alliance (INSA) is the premier intelligence and national security organization that brings together the public, private and academic sectors to collaborate on the most challenging policy issues and solutions. As a non-profit, non-partisan, public-private organization, INSA's ultimate goal is to promote and recognize the highest standards within the national security and intelligence communities. INSA has over 150 corporate members and several hundred individual members who are leaders and senior executives throughout government, the private sector and academia. To learn more about INSA visit www.insaonline.org.
Intelligence and National Security Alliance, 4301 Wilson Boulevard, Suite 910, Arlington, VA 22203 Phone: (703) 224-4672, Fax: (571) 777-8481. Website Terms of Use


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Quanterus Smith Scouting Report
Position: | DE |
Conference: | Independent |
School: | Western Kentucky Hilltoppers |
Year/Status: | Senior |
Jersey Number: | #93 |
Height & Weight: | 6'5 - 250 lbs. |
Draft Prediction: | Fifth Round |
2013 NFL Draft Prospect Scouting Report:
Quanterus Smith, DE, Western Kentucky
Western Kentucky defensive end Quanterus Smith has interesting potential as a pass rusher. Great get-up off the line and shows some quick-twitch talent. Bends around the corner and flexes shoulder down to work towards the quarterback. ACL tear late in the season raised red flags about his immediate impact. Unable to work out at Combine. Some doubt his work ethic and ability to adjust to NFL demands. Must add bulk to contribute as a run defender. Too thin through his base. Must add bulk and learn small details of his techniques.
Last Updated Apr-30-2013 by Matt De Lima
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Walmart 2002
The Rev. Rhett Baird, minister at the Unitarian Universalist Fellowship of Fayetteville, AK, spoke in June on behalf of the New York City Comptroller and the New York City pension systems, representing over 10,000,000 shares. He has graciously offered these reflections on "Power in the Process" describing this type of social action as a UU ministry.
Resolution: Global Human Rights Standards
Rev. Baird's Statement at the Walmart Meeting
Remarks by Rev. Rhett D. Baird, Minister
UU Fellowship of Fayetteville, AR
prepared September 8, 2002, at the request of the Unitarian Universalist Association
I was honored to have been asked to represent the New York City Comptroller and the New York City Pension Funds at the annual shareholders meeting of Wal-Mart in Fayetteville, Arkansas, on June 7, 2002. The pension fund owns 10,822,516 shares.
I was especially proud to be associated with the specific resolution, known as the "Global Human Rights Standards" resolution. It is my understanding that the resolution attracted sufficient votes (almost 4% in favor, 3% abstaining and 93% against) enabling the resolution to return next year as an item of business on the shareholder meeting agenda in June 2003, if it is the wish of the sponsor. It is certainly my hope that it will be introduced next year and I will be happy to again introduce the resolution if I am asked.
This was an extraordinary opportunity for a Unitarian Universalist social justice public witness and I was grateful for the opportunity:
- to have been there
- to have witnessed a major portion of the shareholder's meeting of the largest corporation in the world
- to have spoken words of my faith identity and values embodied in the resolution consistent with my own and certainly with many Unitarian Universalists in this country and throughout the world
- to have the 20,000 or more shareholders hear the speaking of the name of my congregation and my faith tradition and human values important to us.
I will report that I was courteously received at the meeting site by representatives of the legal department of Wal-Mart headquarters in Bentonville, Arkansas, just north of Fayetteville. I was treated honorably and, I believe, taken seriously. But, of course, one would expect such treatment if one is representing over 10,000,000 shares.
The meeting was held on the campus of the University of Arkansas in the basketball arena, one of the few places in Northwest Arkansas with a seating capacity sufficient to accommodate the shareholders. It was a packed crowd that day. Events began at 7 a.m. prior to the beginning of the official stockholder's meeting. Included in the early morning happenings was a parade-like event, with employee representatives from Wal-Mart stores all over the world entering the arena with their country's flag and music rooted in that tradition or culture or country.
No matter who you were and what your agenda was that morning, the experience described above was akin, for me, to a convocation of a mini-United Nations. A little less dignified perhaps and a little more upbeat, almost to the point of cheers. But certainly, on balance, a deeply moving experience. A visual experience that, for me, was deeply symbolic of hope...of hope that, maybe, just maybe, the diverse cultures that make up our blue globe hanging in space may find new and healthy ways to work together, to honor our differences and our commonalties, and to care for our earth together.
When my turn came to be on the agenda, I was welcomed and introduced by the Chairman of the Board. I read a prepared statement within the guidelines of the three minute time limit. A difficult task for a preacher, to be sure. When I concluded, the General Counsel for Wal-Mart responded to me on behalf of the Board of Directors. It felt like a personal conversation with 25,000 people listening in and watching our gigantic images on these massive screens used during the meeting which enabled the presenters to be seen by all in attendance. At the conclusion of his remarks, he said that the board recommends that the shareholders vote against the resolution.
Regardless of the outcome, the subject was taken seriously. The subject was on the table. The subject will return. It will invite people to think. To define their own values more clearly. To better inform themselves. To act on their own values. To participate in shaping the corporate values of Wal-Mart and the policies that impact and influence lives the world over.
In addition to reviewing the resolution that was introduced and the remarks made by me on that occasion, readers of this web-page may find it informative to review the ten page report on this webpage entitled Social Issues Service 2002 Company Report - A Wal-Mart Global Labor Standards by Peter DeSimone, dated May 10, 2002, bearing a copyright by Investor Responsibility Research Center. This was provided to me an informational item by the New York City Comptroller's Office. I found it to be a valuable educative tool for myself in understanding of the complex issues involved.
Although I never met Sam Walton, I have been aware for many years that he and I were fraternity brothers, in Beta Theta Pi, Sam at Missouri and I at Emory University in Atlanta. It is, indeed, a small world, and I could not close this piece without noting that connection and honoring the founder of Wal-Mart.
Rev. Rhett D. Baird, rbaird [at] uark [dot] edu
(479) 521-8446


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My own circumstances are complicated by an ordeal in 2008 that continues to hang over me.
As she put it in a recent interview, acting "requires a constant willingness to hang over the edge of a cliff."
Until the threshold of 270 was crossed, the stillness of the clammy night continued to hang over the city.
For years, that silence has continued to hang over some of the former students of Horace Mann.
If this story was true it would be just the sword he needed to hang over Jenkins.
A cloud seemed to hang over him; he was in a state of lethargy.
On this lay a piece of linen or woollen cloth, large enough to hang over the sides of the pot.
Unjust—that this black cloud should hang over one blameless as any of them!
The boots very short and finished with very broad straps which hang over the tops and down to the ancle.
It appeared to hang over a small body of troops upon the march.
a fusion of Old English hon "suspend" (transitive, class VII strong verb; past tense heng, past participle hangen), and Old English hangian (weak, intransitive, past tense hangode) "be suspended;" also probably influenced by Old Norse hengja "suspend," and hanga "be suspended." All from Proto-Germanic *khang- (cf. Old Frisian hangia, Dutch hangen, German hängen), from PIE *kank- "to hang" (cf. Gothic hahan, Hittite gang- "to hang," Sanskrit sankate "wavers," Latin cunctari "to delay;" see also second element in Stonehenge). As a method of execution, in late Old English (but originally specifically of crucifixion).
Hung emerged as past participle 16c. in northern England dialect, and hanged endured only in legal language (which tends to be conservative) and metaphors extended from it (I'll be hanged). Teen slang sense of "spend time" first recorded 1951; hang around "idle, loiter" is from 1830, and hang out (v.) is from 1811. Hang fire (1781) was originally used of guns that were slow in communicating the fire through the vent to the charge. To let it all hang out "be relaxed and uninhibited" is from 1967.
late 15c., "a sling," from hang (v.). Meaning "a curtain" is from c.1500; that of "the way cloth hangs" is from 1797. To get the hang of (something) "become capable" is from 1834, American English. Perhaps originally in reference to a certain tool or feat, but, if so, its origin has been forgotten. It doesn't seem to have been originally associated with drapery or any other special use of hang.
'To get the hang of a thing,' is to get the knack, or habitual facility of doing it well. A low expression frequently heard among us. In the Craven Dialect of England is the word hank, a habit; from which this word hang may perhaps be derived. [John Russell Bartlett, "Dictionary of Americanisms," New York, 1848]
Related Terms


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Master-bilt MBR49-S Description
Master-Bilt's ergonomically sleek approach to refrigeration systems has earned its place at the top of the list of superior refrigeration.
The Master-Bilt MBR49-S Fusion two-section reach in refrigerator comes with:
- Two Stainless Solid Doors With Handles
- 4 Inch Casters
- 55-1/4 Inches Wide
- 49 Cubic Feet
This all stainless reach in refrigerator is equipped with an open door alarm to ensure that doors aren't accidentally left open, as well as a six month alarm system that reminds users to clean the condenser. The curved corner design of this refrigerator creates a stylishly modern appearance and also reduces chances of injury in slip-and-fall accidents. The heavy duty inside shelving is adjustable and vinyl-coated for easy cleaning.
The MBR23-S Fusion Energy Star reach in refrigerator features a digital thermometer, and is specially designed to function in high ambient temperatures. With 70 years in the refrigerator manufacturing business rest assured Master-Bilt exudes excellence and durability in every product.
Fusion Reach-In Refrigerator, two-section, 49.0 cubic feet, (2) hinged solid doors with handles, (8) adjustable heavy duty vinyl-coated shelves, stainless steel interior & exterior, digital thermometer, bottom mount compressor, 4" casters, 32 to 40 F operating temperature, 115v/60/1, 3/8 hp, 9.8' cord, NEMA 5-15P, 7.5 amps, UL, cUL, ETL, ENERGY STAR
*The warranty will not be honored for residential or non-commercial use of any Commercial Equipment.
Master-bilt MBR49-S Specifications
PDF Spec SheetManufacturer | Master-bilt |
Compressor Location | Top Mount |
Cubic Feet | 49 |
Door Type | Solid |
Evaporator Type | Capillary Tube |
Interior Material | Stainless Steel |
Sections | 2 |
Supports | Casters |
Thermometer Type | Digital |
Voltage | 115/60/1 |
Width (in) | 55 |
Weight | 482.00 |


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There are many other symptoms and if the hours that product not the dose at and key points and tips:
You may also suffer from a missed period, or parvovirus, venue E, part of being human and alive. It is now believed that many children struggle cold controlled can lead to esophageal cancer.
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text: The Fable Heroes wiki last edited by Deathawk on 12/24/16 08:20PM View full history OverviewFable Heroes is a brawler developed by Lionhead Studios and published by Microsoft Studios for the Xbox Live Arcade platform.Fable Heroes Initially started as part of Lionhead's "Creative Day" where members of the company can work on something outside of their priorities, the game was given the go ahead and a 5 man team was assigned to work on the project.Fable Heroes was released on May 2nd, 2012 as part of Microsoft's Arcade Next programGameplayFable Heroes is a hack and slash with a cartoony aesthetic. The player and up to 3 other AI or Human controlled partners take on enemies that exist within the Fable universe. While competing against each other, there are also leaderboards and unlockables.


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A treasure that kicks off football season for Ohio State fans. Read More »
Book Review – Six Good Innings: How One Small Town Became a Little League Giant by Mark Kreidler
A story of heart, hope, and heartbreak. Read More »
Book Review: My Lady of Cleves by Margaret Campbell Barnes
A historical novel that stood the test of time is perfect for book clubs. Read More »
Book Review: Women in Hats by Judy Sheehan
Women in Hats doesn't live up to the hype as a warm, humorous novel. Read More »
Book Review: The Guernsey Literary and Potato Peel Pie Society by Mary Ann Shaffer and Annie Barrows
With romance, suspense, tears, and laughter, this marvelous epistolary novel is bound to be the Book Club Hit of the Year. Read More »
Book Review: King of the Holly Hop – A Milan Jacovich Mystery by Les Roberts
Another Milan Jacovich mystery ignites when murder at his Cleveland high school reunion finds Jacovich investigating while destroying friendships, and his memories, in the process. Read More »
Book Review: This Land is Their Land – Reports from a Divided Nation by Barbara Ehrenreich
An important book about the social condition in the U.S., This Land is Their Land should be read by every American. Read More »
Book Review: 1001 Books for every Mood by Hallie Ephron
An invaluable addition to any reader's collection with an eclectic list of books. Read More »
Book Review: The Crossroads by Chris Grabenstein
The perfect ghost story for younger readers - just in time for summer reading. Read More »
Book Review: The Sugar Queen by Sarah Addison Allen
The Sugar Queen is a magical novel, a worthy successor to Allen's Garden Spells and Alice Hoffman's Practical Magic. Read More »


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Featured Blu-ray / DVD Review: Paranormal Activity 4
March 17th, 2013
Paranormal Activity 4 - Buy from Amazon: DVD or Blu-ray Combo Pack
Paranormal Activity has become the annual Halloween tradition, but there is reason to believe the moviegoing public is growing tired of the franchise. Paranormal Activity 4 made barely more in total than Paranormal Activity 3 earned during its opening weekend. (That said, Paranormal Activity 5 is already in the works, so the studio is still happy). Was the drop in box office numbers just a result franchise fatigue? Or was there a reason people aren't showing up anymore?
The movie begins in Carlsbad, California in September 2006 during happier times with Katie spending time with her family, including her nephew, Hunter, before we are given a titlecard telling us Hunter was abducted just a month later and after we see Katie take him, we are told their whereabouts are still unknown.
Flash forward six years to Henderson, Nevada. It's Halloween and Alex Nelson is Trick or Treating with her little brother, Wyatt, while being filmed by her boyfriend, Ben. As they are walking around the neighborhood, they see they have new neighbors, but the young boy is too shy to talk to them. When they get home, we meet her mother, Holly, and her father, Doug.
A few days later, Alex and Ben go out to her backyard where they have a treehouse. While checking it out, they see Robbie, the new neighbor's young kid. The next day, Robbie's mother falls ill, so he stays with the Nelsons. Robbie's a little weird and talks about having an invisible friend. He even crawls into Alex's bed while she's asleep. Robbie has to stay there a few more days, and weird things start to happen to the point where Alex thinks there's something supernatural at work. Of course her parents don't believe her, but she and Ben continue to research what is going on.
After about a week, Robbie's mother is finally well enough to come back from the hospital and Robbie goes home. This is where we finally meet his mother, and it turns out it's Katie! Dun dun dun...
I've reviewed the previous movies and at this point the feeling of deja vu is just too much. There are some new elements to the movie, including the new family and the Kinect shots are interesting. However, nearly everything else is borrowed from the other films. There's long shots of nothing, a few weird events, and people trying to figure out what's going on. If you are really into this franchise, then you will probably like this installment just as much as the other sequels. If you feel the sequels were a case study in declining returns, then you might think this is the weakest of the group. I wouldn't be surprised if many hit the fast forward button to speed through much of the movie.
Like last time, there are no extras on the DVD. The Blu-ray has the extended edition, which is ten minutes longer, and almost 30 minutes of deleted scenes. Also like last time, the audio and video are subpar for Blu-ray, especially the video. However, that's a necessity based on the plot of the movie. It has to look and sound like it was filmed by the characters themselves using consumer level cameras. The Blu-ray costs $5 or 25% more than the DVD, and it includes the DVD, which is a good deal.
The Paranormal Activity franchise is either in a rut, or is very reliable, depending on your point of view and Paranormal Activity 4 is very much like the previous films. Considering these films rely on tension and suspense, being reliable is not a good thing. The DVD has no extras and is worth a rental and absolutely nothing more. The Blu-ray Combo Pack is a better deal if you are intent on buying, but I think the replay value here is at the rental level regardless of the extras.
The Movie
The Extras
The Verdict
- Submitted by: C.S.Strowbridge
Filed under: Video Review, Paranormal Activity 4, Paranormal Activity, Stephen Dunham, Katie Featherston, Kathryn Newton, Matt Shively, Aiden Lovecamp, Brady Allen, Alexondra Lee