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If you had $500 and a week to live, what would you do?
Please answer below in the comments.
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—Please no inappropriate, rude, or suggestive content. I will not publish your comment if you fail to follow this guideline.
Have fun and don't forget to ask your friends and family! 🙂

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After reading my last post myself afterwards, I was convinced that it was my worst post ever. So, I request all of you that if you haven't read it already, please don't. Let me just talk about something different.
My name, as you all know, is Sinjini . But, the spelling of my name should have been Shinjini because that's the actual Bengali word. So, in Hindi, my name should be written using 'Shalgamwala sha' . But, my father had written 'Sinjini' in my birth certificate.
When I was in the sixth standard, I first became aware of the fact that most of my friends and also some teachers pronounce my name exactly like its spelling. I used to become very irritated that I was being called by a different name. It was always "Sinjini", "Sinjini" and "Sinjini", but never "Shinjini". Then, I told some of my friends, with whom I interacted the most, the actual pronounciation of my name. After requesting them repeatedly, they gradually started calling me "Shinjini". I don't really blame them for calling me 'Sinjini' because I can't blame them. It's not their fault if they correctly pronounce what is written.
I have often asked my father the reason for which he had written that spelling. Every time, his reply has been the same. He says that writing just 'S' and not 'Sh' implies that my name should be pronounced as 'Shinjini'. He says that trying to change the spelling in the birth certificate itself will give us enough trouble for a lifetime. According to him, another reason had also motivated him to write that spelling. He had intended to keep the spelling very simple so that I would not suffer throughout my life like him and my mother for a long and complicated spelling. "Would one additional letter have made my name so complicated?", is what I ask him in return. His reason is not entirely rubbish. I have seen different people writing his name in different ways. His name is Saumyabrata Sengupta( quite long!). I have seen rarely seen that correct spelling written anywhere. It's either 'Soumyabrata', 'Soumyobroto', 'Soumobrata', etc. If he writes the correct spelling somewhere and somebody else pronounces it, the pronounciation is deliberately wrong!
For my mother, it is still worse. Her name is Nabanipa. A very similar and a very common name is Nabanita. So, people always write Nabanita Sengupta! Even if her name is pronounced laying special emphasis on the 'p', nobody writes 'p'. The spelling of her name has been changed to 'Nabanipa' for her bank account after repeated efforts.
In future, I can't expect many people to call me 'Shinjini', specially if I move out of West Bengal. I also can't try to correct everybody. So, I will have to live with that spelling for the rest of my life. After all, it's my name, it's my indentity.


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Police Services
The San Diego Unified Police Department is a fully accredited police agency employing full-time sworn police officers, community service officers, and a full complement of support staff. While our primary role is to maintain order and security on and near school facilities, school police officers provide far more than standard law enforcement efforts. We also take a leading edge, proactive role in creating the positive learning environment in which superb education is not only possible, but also probable.
Today, the San Diego Unified School District Police Department is recognized as a leader in school-based community policing. A big part of that success is due to the vast resources available to the department, including the latest in technological tools such as state-of-the-art computer equipment, high-speed access to law enforcement databases and automated analysis and reporting systems.
In addition to physical resources, school police personnel are encouraged to spend more quality time in developing positive interpersonal relationships with those in our schools and in our community. Personnel engage in daily contact with students, teachers, staff, and members of the community to help promote a positive learning environment with the schools, and to build ever-growing cooperative partnerships among the schools and the surrounding communities. As a result, the students benefit most of all by being better able to concentrate their time and attention on what matters most: learning and growing.
Contact Us
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segunda-feira, 13 de junho de 2011
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I do have a few questions for you if it's allright. Could it be only me or does it look as if like a few of these remarks come across as if they are left by brain dead folks? :-P And, if you are writing at other online social sites, I would like to keep up with anything new you have to post. Could you make a list of all of your social community pages like your twitter feed, Facebook page or linkedin profile?
Feel free to visit my blog; San Diego Cafe


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UK Iraq war inquiry denounces Tony Blair
A long-awaited official report into the Iraq war has been published in London and delivers a crushing verdict on the former prime minister Tony Blair, accusing him of deliberately exaggerating the Iraq threat. The report concludes that the 2003 invasion was not a "last resort", Saddam Hussein posed "no imminent threat", preparations were "wholly inadequate", and Britain chose to join the US invasion before peaceful options had been exhausted. In a previously unpublished memo from July 2002, Blair told George W Bush: "I will be with you, whatever." A total of 179 British soldiers, along with 4,491 US service members and 150,000 Iraqis, died over the course of the 11-year conflict. The Chilcot inquiry, named for author Sir John Chilcot, sheds light on US-UK consultations, as the well as wide-ranging failures of the UK intelligence services, including the so-called "dodgy dossier" used to "sex up" the case for war. The Bush administration repeatedly overrode advice from the UK on how to oversee Iraq after the invasion, including how to address the involvement of the United Nations, the control of Iraqi oil money and the extent to which better security should be put at the heart of the military operation, the Chilcot inquiry concludes.
Chilcot delivers crushing verdict on Blair and the Iraq war
Earlier, Chilcot said he hoped the report – which is five times the length of Tolstoy's War and Peace – would ensure that Britain did not go to war in the future without a more thorough assessment of the potential disadvantages. Here we look at the divergent post-conflict fates of the war's architects, Blair and Bush; Jonathan Freedland examines the importance of the Chilcot report; and Joshua Rozenberg says the inquiry has left the door open for Blair to be prosecuted. Alex Salmond, the former Scottish first minister, said he believed there "must now be a consideration of what political or legal consequences are appropriate for those responsible". In response, Blair said he still believed it had been "better to remove Saddam Hussein". Here is a summary of the Chilcot report.
Bush, Blair and the Chilcot report: the diverging fates of Iraq war orchestrators
Clinton and Obama campaign together after FBI recommends no charges in email inquiry
The FBI director, James Comey, chastised Hillary Clinton for the "extremely careless" way in which she handled emails on her private server while she was secretary of state, but Comey in effect lifted the threat of criminal charges in the matter by recommending none should be brought. It was widely believed a criminal indictment could have wrecked Clinton's election prospects. Comey said "it is possible that hostile actors gained access" to the server situated at the Clintons' home in Chappaqua, New York. Hours later, Clinton and Barack Obama campaigned together in North Carolina. "Nothing makes for a quicker getaway after a narrow brush with the law than Air Force One," writes Dan Roberts. Meanwhile, Donald Trump weighed in on the FBI decision, saying "The system is rigged. General Petraeus got in trouble for far less. Very very unfair! As usual, bad judgment." And in day two of our Voices of America series, we reveal that despite Trump's denial of climate change, at the Republican presidential contender's Palm Beach estate and the other properties that bear his name in south Florida, the water is already creeping up bridges and advancing on access roads, lawns and beaches because of sea-level rise.
FBI rebukes Clinton but recommends 'no charges' in email investigation
Pistorious sentenced to six years for murder
Olympian Oscar Pistorius has been sentenced to six years for the murder of his girlfriend Reeva Steenkamp on Valentine's Day 2013. Pistorius, 29, was initially convicted of culpable homicide and sentenced to five years. After an appeal by state prosecutors, he was convicted of murder last year, a crime which carries a mandatory sentence of 15 years. But the judge in the case said the athlete was "genuinely remorseful". Doup De Bruyn, a lawyer who has represented the Steenkamp family, acknowledged their disappointment. "There is nothing [the family] can do about the sentence. Nothing will bring Reeva back. The best thing to do is to maintain a dignified silence."
Oscar Pistorius sentenced to six years in jail for Reeva Steenkamp murder
Louisiana officers suspended amid protests after black man's death
Overnight protests have been staged in Baton Rouge and two Louisiana policemen placed on administrative leave after an unarmed black man was shot "four to six times" in the chest and back following an altercation with police outside a convenience store. Video posted on Twitter appeared to show Alton Sterling, 37, lying on the ground with two officers holding him down while he was shot. The store's owner, Abdul Muflahi, told WAFB-TV that the first officer used a Taser on Sterling and the second officer tackled the man. He said that as Sterling fought to get the officer off him, the first officer shot him "four to six times". Sterling's death brings the number of people killed by police in the US in 2016 to 558.
Protests in Baton Rouge after Louisiana police shoot Alton Sterling dead
Ronaldo and Bale, two of soccer's great players, go head-to-head
Wales and Portugal face off in the Euro 2016 semi-finals today in a match that could be decided by the skills of their respective star players, Gareth Bale and Cristiano Ronaldo. Barney Ronay writes that an outsider might be forgiven for thinking the match was "some kind of celebrity cage fight. King Meringue versus the Welsh Prince, with a supporting cast to pass the towels and hold the spit bucket." Statistically, they're neck-and-neck, with both teams scoring 12 goals in the tournament and three of these from Bale and Ronaldo.
How Gareth Bale and Cristiano Ronaldo devote their talent to their teams
In case you missed it ...
Amazon's progress toward an army of helpful robots is one step closer: a prize for the best warehouse-working "picker" machine has gone to a robot designed by a team from TU Delft Robotics Institute and Delft Robotics, both based in the Netherlands.
Amazon moves one step closer toward army of warehouse robots


text:
Last updated:
Total Qatar is looking forward to recruiting technically qualified Qatari graduates who are ready to work in the oil and gas industry and providing them with a career path, said Stephane Michel (pictured), managing director of Total E&P Qatar.
Speaking to Gulf Times, Michel said Qatarisation was one of the strategic exercises of Total Qatar and Qatar Career Fair was one of the opportunities in this regard.
"There are about 30 Qataris in key positions in our organisation , out of the 160 employees of Total in the country. Most of these employees are in finance, human resources, communication, public relations and many more. But we are looking forward to recruiting more Qataris who are technically qualified," he said.
"More than the number of people, we are looking towards the quality of the candidates. No qualified Qatari candidate will have any problem in finding a suitable job in our organisation."
Michel said that at present 15 positions were open for Qataris. "We have received around 150 resumes from the Career Fair so far. We will have the interviews very soon. This will give us an opportunity to select the most suitable candidates."
He said the company offered training opportunities for the newly recruited staff. "In some cases we employ people and once they get some job experience we further provide them with training facilities."
Michel said Total was ready to sponsor Qatari students and provide them with scholarships. "Representatives from Total visited different schools and interacted with Qatari students. Through these activities, we aim to motivate students to take appropriate courses."
He said the Total Summer School Qatar and Total Middle East Summer School were meant to further this aim. "This is one part of our corporate social responsibility and we aim to reach out to maximum number of nationals in the country. We hope to engage as many Qataris as possible in our organisation and look forward to receiving more and more young nationals."
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Advisory Council Speaker in Cairo
Metro station at Ras Bu Fontas
Qatar 'capable of overcoming challenges of the blockade'
Winds, dust and poor visibility expected from Saturday
QCDC wraps up summer career camp for students
Local dates festival attracts thousands of visitors
Philippine School gets three-year institutional accreditation again
HBKU education travel initiative a boon for graduate students
Local artists' works offer visitors new insights


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2008 Grammy Nominations
I hope this is indie enough for you guys. Some very intriguing nominees at this year's Grammy Awards, including Feist, Justice and Amy Winehouse. I haven't really had time to digest this yet. Here's the official press release.
Foo Fighters, Vince Gill, Herbie Hancock, Kanye West and Amy Winehouse vie for Album Of The Year at 50th Annual GRAMMY® Awards Feb. 10, 2008 Kanye West Leads Nominations with Eight; Amy Winehouse Earns Six Feist, Ledisi, Paramore, Taylor Swift and Amy Winehouse Up for Best New Artist
SANTA MONICA, Calif.--(BUSINESS WIRE)--Nominations for the 50th Annual GRAMMY® Awards were announced today by The Recording Academy® reflecting one of the most diverse years ever with the Album Of The Year category alone representing the country, hip-hop, jazz, pop and rock genres. The press event was held at The Music Box @ Fonda in Hollywood and was attended by national and international media, as well as key music industry executives.
Artists reading nominations this morning included Akon, Chester Bennington (of Linkin Park), Fergie, Vince Gill, Dave Grohl (Foo Fighters), Herbie Hancock, Jimmy Jam, Taylor Hawkins (Foo Fighters), George Lopez, Mike Shinoda (of Linkin Park) and Taylor Swift. The 50th Annual GRAMMY Awards will be held on "GRAMMY Sunday," Feb. 10, 2008, at STAPLES Center in Los Angeles and once again will be broadcast live in high definition TV and 5.1 surround sound on CBS from 8 11:30 p.m. (ET/PT). Kanye West tops the nominations with eight, Amy Winehouse garners six, and the Foo Fighters, Jay-Z, Timbaland, Justin Timberlake, and T-Pain each earn five nods. Akon, Dierks Bentley, Chris Daughtry, Feist, Tim McGraw, John
Newton, Ne-Yo, Rihanna, and Bruce Springsteen receive four each. "This year's nominations truly reflect a diverse and talented community of artists and creators who represent some of the most exceptional music of the year," said Neil Portnow, President/CEO of The Recording Academy. "The GRAMMY Awards process once again has yielded a comprehensive group of
excellent nominees and coupled with the fact that it's our milestone 50th year, this year's telecast promises music fans a spectacular show filled with stellar performances and unique 'GRAMMY Moments' for which Music's Biggest Night has come to be renowned."
Following is a sampling of nominations in 110 categories from the GRAMMY Awards' 31 Fields:
Nominees for Album Of The Year are:
Echoes, Silence, Patience & Grace -- Foo Fighters
These Days -- Vince Gill
River: The Joni Letters -- Herbie Hancock
Graduation -- Kanye West
Back To Black -- Amy Winehouse
Nominees for Record Of The Year are:
"Irreplaceable" -- Beyoncé
"The Pretender" -- Foo Fighters
"Umbrella" -- Rihanna Featuring Jay-Z
"What Goes Around...Comes Around" -- Justin Timberlake
"Rehab" -- Amy Winehouse
Best New Artist nominees are:
Taylor Swift
Amy Winehouse
Song Of The Year nominees include:
"Before He Cheats" -- John Kear & Chris Tompkins, songwriters (Carrie
"Hey There Delilah" -- Tom Higgenson, songwriter (Plain White T's)
"Like A Star" -- Corinne Bailey Rae, songwriter (Corinne Bailey Rae)
"Rehab" -- Amy Winehouse, songwriter (Amy Winehouse)
"Umbrella" -- Shawn Carter, Kuk Harrell, Terius "Dream" Nash & Christopher
Stewart, songwriters (Rihanna Featuring Jay-Z)
Nominations for Best Pop Vocal Album go to:
Lost Highway -- Bon Jovi
The Reminder -- Feist
It Won't Be Soon Before Long -- Maroon 5
Memory Almost Full -- Paul McCartney
Back To Black -- Amy Winehouse
Best Pop Collaboration With Vocals nods go to:
"Steppin' Out" -- Tony Bennett & Christina Aguilera
"Beautiful Liar" -- Beyoncé & Shakira
"Gone Gone Gone (Done Moved On)" -- Robert Plant & Alison Krauss
"The Sweet Escape" -- Gwen Stefani & Akon
"Give It To Me" -- Timbaland Featuring Nelly Furtado & Justin Timberlake
Best Pop Instrumental Performance nominees are:
"Off The Grid" -- Beastie Boys
"Paris Sunrise #7" -- Ben Harper & The Innocent Criminals
"Over The Rainbow" -- Dave Koz
"One Week Last Summer" -- Joni Mitchell
"Simple Pleasures" -- Spyro Gyra
For Best Dance Recording, the nominees are:
"Do It Again" -- The Chemical Brothers
"D.A.N.C.E." -- Justice
"Love Today" -- Mika
"Don't Stop The Music" --Rihanna
"Love Stoned/I Think She Knows" -- Justin Timberlake
Nominations for Best Solo Rock Vocal Performance go to:
"Timebomb" -- Beck
"Only Mama Knows" -- Paul McCartney
"Our Country" -- John Mellencamp
"Radio Nowhere" -- Bruce Springsteen
"Come On" -- Lucinda Williams
Best Rock Album nominees are:
Daughtry -- Daughtry
Revival -- John Fogerty
Echoes, Silence, Patience & Grace -- Foo Fighters
Magic -- Bruce Springsteen
Sky Blue Sky -- Wilco
Nods for Best Rock Song go to:
"Come On" -- Lucinda Williams, songwriter (Lucinda Williams)
"Icky Thump" -- Jack White, songwriter (The White Stripes)
"It's Not Over" -- Chris Daughtry, Gregg Wattenberg, Mark Wilkerson & Brett
Young, songwriters (Daughtry)
"The Pretender" -- Dave Grohl, Taylor Hawkins, Nate Mendel & Chris Shiflett,
songwriters (Foo Fighters)
"Radio Nowhere" -- Bruce Springsteen, songwriter (Bruce Springsteen)
Nominees for Best R&B Performance By A Duo Or Group With Vocals are:
"Same Girl" -- R. Kelly Featuring Usher
"Disrespectful" -- Chaka Khan Featuring Mary J. Blige
"Hate That I Love You" -- Rihanna Featuring Ne-Yo
"Baby" -- Angie Stone Featuring Betty Wright
"Bartender" -- T-Pain Featuring Akon
For Best Contemporary R&B Album, the nominees are:
Konvicted -- Akon
Just Like You -- Keyshia Cole
Fantasia -- Fantasia
East Side Story -- Emily King
Because Of You -- Ne-Yo
Best Urban/Alternative Performance nods go to:
"Make A Baby" -- Vikter Duplaix
"That's The Way Of The World" -- Dwele
"Daydreamin'" -- Lupe Fiasco Featuring Jill Scott
"Fantasy" -- Meshell Ndegeocello
"Dream" -- Alice Smith
Best Rap/Sung Collaboration nods go to:
"I Wanna Love You" -- Akon Featuring Snoop Dogg
"Kiss, Kiss" -- Chris Brown & T-Pain
"Let It Go" -- Keyshia Cole Featuring Missy Elliott & Lil' Kim
"Umbrella" -- Rihanna Featuring Jay-Z
"Good Life" -- Kanye West Featuring T-Pain
Nominees for Best Rap Song are:
"Ayo Technology" -- N. Hills, Curtis Jackson, Timothy Mosley & Justin
Timberlake, songwriters (50 Cent Featuring Justin Timberlake & Timbaland)
"Big Things Poppin' (Do It)" -- Clifford Harris & Byron Thomas, songwriters
"Can't Tell Me Nothing" -- A. Davis & Kanye West, songwriters (Kanye West)
"Crank That (Soulja Boy)" -- Soulja Boy Tell'Em, songwriter (Soulja Boy
"Good Life" -- A. Davis, F. Najm & K. West, songwriters (Kanye West
Featuring T-Pain)
For Best Rap Album, the nominees are:
Finding Forever -- Common
Kingdom Come -- Jay-Z
Hip Hop Is Dead -- Nas
T.I. vs T.I.P. -- T.I.
Graduation -- Kanye West


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A light earthquake magnitude 4.5 (ml/mb) has struck on Tuesday, 45 kilometers (28 miles) from Jarm in Afghanistan. Event id: us20008tjd. Ids that are associated to the earthquake: us20008tjd. The temblor was picked up at 18:38:08 / 6:38 pm (local time epicenter). Exact time and date of earthquake 21/03/17 / 2017-03-21 14:08:08 / March 21, 2017 @ 2:08 pm UTC/GMT. Exact location of event, longitude 70.849 East, latitude 36.4547 North, depth = 133.13 km. A tsunami warning has not been issued (Does not indicate if a tsunami actually did or will exist). The epicenter was at a depth of 133.13 km (83 miles).
Closest city/cities or villages, with min 5000 pop, to hypocenter/epicentrum was Farkhār, Fayzabad, Ishqoshim. Country/countries that might be effected, Afghanistan (c. 29 121 000 pop), Tajikistan (c. 7 487 000 pop). Epicenter of the earthquake was 77 km (48 miles) from Fayzabad (c. 44 400 pop), 75 km (46 miles) from Ishqoshim (c. 26 000 pop), 66 km (41 miles) from Ashkāsham (c. 12 100 pop), 46 km (28 miles) from Jurm (c. 12 100 pop), 90 km (56 miles) from Farkhār (c. 10 500 pop).
In the past 24 hours, there have been one, in the last 10 days three, in the past 30 days ten and in the last 365 days one hundred and thirty-five earthquakes of magnitude 3.0 or greater that have been detected nearby. There are an estimated 13,000 light quakes in the world each year. Earthquakes 4.0 to 5.0 are often felt, but only causes minor damage.
Did you feel it?
How did you respond? Did any furniture slide, topple over, or become displaced? Leave a comment or report about activity, shaking and damage at your home, city and country. This information comes from the USGS Earthquake Notification Service. Read more about the earthquake, Seismometer information, Date-Time, Location, Distances, Parameters and details about this quake, recorded: 45 km S of Jarm, Afghanistan.
Copyright © 2017 earthquakenewstoday.com All rights reserved.


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Lora Hunt Jeffries' Indiana Home Page:Information about David Peffley
David Peffley (b. Abt. 1740, d. September 1807)
Notes for David Peffley:
Descendants can be in DAR.
More About David Peffley:
Date born 2: Abt. 1740
More About David Peffley and Maria Sherrick:
Marriage 1: Abt. 1768, Bethel, Lancaster County, Pennsylvania.
Marriage 2: Abt. 1768, Bethel, Berks County, Pennsylvania.
Children of David Peffley and Maria Sherrick are:
- +Abraham Peffley, b. Abt. 1785, Bethel, Berks County, Pennsylvania, d. 1826, Bethel, Berks County, Pennsylvania.


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Royal Pimand
Royal Pimand Hotel is a budget accommodation with free self parking and a lift.
The hotel is set in a convenient location 7 km away from Siam Niramit.
There are 38 guestrooms featuring deluxe upper floors double room, deluxe double room and standard double room equipped with climate control, cable TV with on-demand movies, an individual safe, a private balcony and a work desk.
Several dining options include Dine in the Dark which offer menus of Thai and Vegetarian meals and placed 750 meters away from the hotel.
Guests can reach Royal Pimand Hotel from Suvarnabhumi International airport within 25 minutes' drive.
Guests can take advantage of 24-hour front desk, laundry and room service.
Royal Pimand Hotel delights guests with a wellness center and a sauna.


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A young man comes to Maryland, takes some community college classes, uses his computer skills to get a job in which he gains a security clearance.
Still in his 20s, he finds information about government activity that troubles him. He decides to share it with the world.
In its broad outlines, the case of Edward Snowden, the 29-year-old intelligence contractor who last week revealed the existence of two top secret National Security Agency eavesdropping programs, hews closely to the contours set by Army Pfc. Bradley Manning, the 25-year-old soldier now being court-martialed at Fort Meade for releasing hundreds of thousands of classified documents.


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Renal Cell Carcinoma
Synonyms and related keywords: renal cell adenocarcinoma, hypernephroma, hypernephroid tumor, Grawitz tumor, von Hippel-Lindau syndrome, VHL syndrome, VHL disease, hereditary papillary renal carcinoma, HPRC, familial renal oncocytoma, FRO, Birt-Hogg-Dube syndrome, BHDS, hereditary renal carcinoma, HRC, Stauffer syndrome, renal cancer, pheochromocytoma, pancreatic cysts, epididymal cystadenomas, endolymphatic sac tumors, central nervous system hemangioblastomas, retinal angiomas, islet cell tumors, fibrofolliculomas, colonic polyps, colonic tumors, pulmonary cysts, paraneoplastic syndromes, hypercalcemia, nonmetastatic hepatic dysfunction, polyneuromyopathy, amyloidosis, anemia, dermatomyositis, hypertension, varicocele, cigarette smoking, obesity, unopposed estrogen therapy, asbestos exposure, cystic kidney disease, renal dialysis, tuberous sclerosis, renal cell carcinoma
Background: Renal cell carcinoma accounts for approximately 3% of adult malignancies and 90-95% of neoplasms arising from the kidney. It is characterized by a lack of early warning signs, diverse clinical manifestations, resistance to radiation and chemotherapy, and infrequent but reproducible responses to immunotherapy agents such as interferon alpha and interleukin (IL)-2. New agents, such as sorafenib and sunitinib, having anti-angiogenic effects through targeting multiple receptor kinases, have activity in patients failing immunotherapy. In the past, these tumors were believed to derive from the adrenal gland; therefore, the term hypernephroma was used often.
Pathophysiology: The tissue of origin for renal cell carcinoma is the proximal renal tubular epithelium. Renal cancer occurs in both a sporadic (nonhereditary) and a hereditary form, and both forms are associated with structural alterations of the short arm of chromosome 3 (3p). Genetic studies of the families at high risk for developing renal cancer led to the cloning of genes whose alteration results in tumor formation. These genes are either tumor suppressors (VHL, TSC) or oncogenes (MET).
At least 4 hereditary syndromes associated with renal cell carcinoma are recognized: (1) von Hippel-Lindau (VHL) syndrome, (2) hereditary papillary renal carcinoma (HPRC), (3) familial renal oncocytoma (FRO) associated with Birt-Hogg-Dube syndrome (BHDS), and (4) hereditary renal carcinoma (HRC).
VHL disease is transmitted in an autosomal dominant familial multiple-cancer syndrome, which confers predisposition to a variety of neoplasms, including the following:
- Renal cell carcinoma with clear cell histologic features
- Pheochromocytoma
- Pancreatic cysts and islet cell tumors
- Retinal angiomas
- Central nervous system hemangioblastomas
- Endolymphatic sac tumors
- Epididymal cystadenomas
Renal cell carcinoma develops in nearly 40% of patients with VHL disease and is a major cause of death among these patients. Deletions of 3p occur commonly in renal cell carcinoma associated with VHL disease. The VHL gene is mutated in a high percentage of tumors and cell lines from patients with sporadic (nonhereditary) clear cell renal carcinoma. Several kindreds with familial clear cell carcinoma have a constitutional balanced translocation between 3p and either chromosome 6 or chromosome 8. Mutations of the VHL gene result in the accumulation of hypoxia inducible factors (HIFs) that stimulate angiogenesis through vascular endothelial growth factor and its receptor (VEGF and VEGFR, respectively). VEGF and VEGFR are important new therapeutic targets.
HPRC is an inherited disorder with an autosomal dominant inheritance pattern; affected individuals develop bilateral, multifocal papillary renal carcinoma. Germline mutations in the tyrosine kinase domain of the MET gene have been identified.
Individuals affected with FRO can develop bilateral, multifocal oncocytoma or oncocytic neoplasms in the kidney. BHDS is a hereditary cutaneous syndrome. Patients with BHDS have a dominantly inherited predisposition to develop benign tumors of the hair follicle (ie, fibrofolliculomas), predominantly on the face, neck, and upper trunk, and are at risk of developing renal tumors, colonic polyps or tumors, and pulmonary cysts.
- In the US: The age-adjusted incidence of renal cell carcinoma has been rising by 3% per year. Approximately 36,160 new cases of renal cell carcinoma were diagnosed in 2005, and more than 12,660 affected individuals died. The greatest increase in incidence currently is observed in African Americans.
- Internationally: Number of deaths worldwide from kidney cancer was expected to exceed 100,000 in 2001.
Mortality/Morbidity: Renal cell carcinoma is the sixth leading cause of cancer death. The 5-year survival rates initially reported by Robson in 1969 were 66% for stage I renal carcinoma, 64% for stage II, 42% for stage III, and only 11% for stage IV. Except for stage I, these survival statistics have remained essentially unchanged for several decades.
Race: Renal cell carcinoma is more common in people of Northern European ancestry (Scandinavians) and North Americans than in those of Asian or African descent. In the United States, its incidence has been equivalent among whites and African Americans, but incidence among African Americans is increasing rapidly.
Sex: Renal cell carcinoma is twice as common in men as in women. The male-to-female ratio is 2:1.
Age: This condition occurs most commonly in the fourth to sixth decades of life, but the disease has been reported in younger people who belong to family clusters.
History: Renal cell carcinoma may remain clinically occult for most of its course. The classic triad of flank pain, hematuria, and flank mass is uncommon (10%) and is indicative of advanced disease. Twenty-five to thirty percent of patients are asymptomatic, and their renal cell carcinomas are found on incidental radiologic study.
- Renal cell carcinoma is a unique and challenging tumor because of the frequent occurrence of paraneoplastic syndromes, including hypercalcemia, erythrocytosis, and nonmetastatic hepatic dysfunction (ie, Stauffer syndrome). Polyneuromyopathy, amyloidosis, anemia, fever, cachexia, weight loss, dermatomyositis, increased erythrocyte sedimentation rate, and hypertension also are associated with renal cell carcinoma. (For more information, see Paraneoplastic Syndromes.)
- Cytokine release by tumor (eg, IL-6, erythropoietin, nitric oxide) causes these paraneoplastic conditions.
- Resolution of symptoms or biochemical abnormalities frequently follows successful treatment of the primary tumor or metastatic foci.
- Gross hematuria with vermiform clots suggests upper urinary tract bleeding.
- Look for hypertension, supraclavicular adenopathy, and flank or abdominal mass with bruit.
- Approximately 30% of patients with renal carcinoma present with metastatic disease. Physical examination should include thorough evaluation for metastatic disease. Organs involved include:
- Lung (75%)
- Soft tissues (36%)
- Bone (20%)
- Liver (18%)
- Cutaneous sites (8%)
- Central nervous system (8%)
- Varicocele and findings of paraneoplastic syndromes raise clinical suspicion for this diagnosis.
Causes: A number of cellular, environmental, genetic, and hormonal factors have been studied as possible causal factors for renal cell carcinoma.
- Cigarette smoking doubles the risk of renal cell carcinoma and contributes to as many as one third of all cases. The risk appears to increase with the amount of cigarette smoking in a dose-dependent fashion.
- Obesity is another risk factor, particularly in women; increasing body weight has a linear relationship with increasing risk.
Lymphoma, Non-Hodgkin
Pyelonephritis, Acute
Pyelonephritis, Chronic
Wilms Tumor
Other Problems to be Considered:
Angiomyolipoma (benign neoplasm)
Oncocytoma (benign neoplasm)
Metastasis from distant primary
Metastatic melanoma
Renal adenoma (benign neoplasm)
Renal cyst
Renal infarct
Transitional cell carcinoma of renal pelvis
- Laboratory studies in the evaluation of renal cell carcinoma should include a workup for paraneoplastic syndromes. Initial studies are as follows:
- A large proportion of patients diagnosed with renal cancer have small tumors discovered incidentally on imaging studies. A number of diagnostic modalities are used to evaluate and stage renal masses, including the following:
- Determining whether a space-occupying renal mass is benign or malignant can be difficult. Radiologic studies should be tailored to enable further characterization of renal masses, so that nonmalignant tumors can be differentiated from malignant ones.
- Excretory urography is not used frequently in the initial evaluation of renal masses because of its low sensitivity and specificity. A small- to medium-sized tumor may be missed by excretory urography.
- Contrast-enhanced CT scanning has become the imaging procedure of choice for diagnosis and staging of renal cell cancer and has virtually replaced excretory urography and renal ultrasound. In most cases, CT imaging can differentiate cystic masses from solid masses and supplies information about lymph node, renal vein, and inferior vena cava involvement.
- Ultrasound examination can be useful in evaluating questionable cystic renal lesions if CT imaging is inconclusive. Large papillary renal tumors are frequently undetectable by renal ultrasound.
- Renal arteriography is not used in the evaluation of a suspected renal mass as frequently now as it was in the past. When inferior vena cava involvement is suspected, either inferior venacavography or MRI angiography is used. MRI is currently the preferred imaging technique. Knowledge of inferior vena cava involvement is important in planning the vascular aspect of the operative procedure.
- PET imaging remains controversial in kidney cancer. Its sensitivity for detecting metastatic lesions is better than for determining the presence of cancer in the renal primary site.
- Percutaneous cyst puncture and fluid analysis is used in the evaluation of potentially malignant cystic renal lesions detected by ultrasonography or CT imaging.
- Unusually clear cells with a cytoplasm rich in lipids and glycogen characterize clear cell carcinoma, which is most likely to show 3p deletion.
- Chromophilic tumors tend to be bilateral and multifocal and may have trisomy 7 and/or trisomy 17.
- Large polygonal cells with pale reticular cytoplasm characterize chromophobic carcinoma, which does not exhibit 3p deletion.
- Renal oncocytoma consists predominantly of eosinophilic cells, in a characteristic nested or organoid pattern, that rarely metastasize and do not exhibit 3p deletion or trisomy 7 or 17.
- Collecting duct carcinoma is an unusual variant characterized by a very aggressive clinical course. This tends to affect younger patients and may present with local or widespread advanced disease. These cells can have 3 different types of growth patterns, (1) acinar, (2) sarcomatoid, and (3) tubulopapillary. The sarcomatoid variant, which can occur with any histologic cell type, is associated with a significantly poorer prognosis.
Table 1. Pathologic Classification of Renal Cell Carcinoma
Cell Type
Growth Pattern
Cell of Origin
Clear cell
Most common
Acinar or sarcomatoid
Proximal tubule
Bilateral and multifocal
Papillary or sarcomatoid
Proximal tubule
Indolent course
Solid, tubular, or sarcomatoid
Cortical collecting duct
Rarely metastasize
Tumor nests
Cortical collecting duct
Collecting duct
Very aggressive
Papillary or sarcomatoid
Medullary collecting duct
- The Robson modification of the Flocks and Kadesky system is uncomplicated and is used commonly in clinical practice. This system was employed to correlate stage at presentation with prognosis. The Robson staging system is as follows:
- The tumor, nodes, and metastases (TNM) classification is endorsed by the American Joint Committee on Cancer (AJCC). The major advantage of the TNM system is that it clearly differentiates individuals with tumor thrombi from those with local nodal disease. In the Robson system, stage III inferior vena caval involvement (IIIA) is the same stage as local lymph node metastases (IIIB). Although patients with Robson stage IIIB renal carcinoma have greatly decreased survival rates, the prognosis for patients with stage Robson IIIA renal carcinoma is not markedly different from that for patients with Robson stage I or II renal carcinoma. The TNM classification system is as follows:
- Primary tumor (T)
- TX - Primary tumor cannot be assessed
- T0 - No evidence of primary tumor
- T1 - Tumor 7 cm or smaller in greatest dimension, limited to the kidney
- T2 - Tumor larger than 7 cm in greatest dimension, limited to the kidney
- T3 - Tumor extends into major veins or invades adrenal gland or perinephric tissues but not beyond the Gerota fascia
- T3a - Tumor invades adrenal gland or perinephric tissues but not beyond the Gerota fascia
- T3b - Tumor grossly extends into the renal vein(s) or vena cava below the diaphragm
- T3c - Tumor grossly extends into the renal vein(s) or vena cava above the diaphragm
- T4 - Tumor invading beyond the Gerota fascia
Medical Care: More than 50% of patients with renal cell carcinoma are cured in early stages, but outcome for stage IV disease is poor. The probability of cure is related directly to the stage or degree of tumor dissemination, so the approach is curative for early stage disease. Selected patients with metastatic disease respond to immunotherapy, but many patients can be offered only palliative therapy for advanced disease.
- The treatment options for renal cell cancer are surgery, radiation therapy, chemotherapy, hormonal therapy, immunotherapy, or combinations of these.
- Options for chemotherapy and endocrine-based approaches are limited, and no hormonal or chemotherapeutic regimen is accepted as a standard of care. Objective response rates, either for single or combination chemotherapy, usually are lower than 15%. Therefore, various biologic therapies have been evaluated.
- Renal cell carcinoma is an immunogenic tumor, and spontaneous regressions have been documented. Many immune modulators, such as interferon, IL-2 (aldesleukin [Proleukin]), bacillus Calmette-Guérin (BCG) vaccination, lymphokine-activated killer (LAK) cells plus IL-2, tumor-infiltrating lymphocytes, and nonmyeloablative allogeneic peripheral blood stem-cell transplantation, have been tried.
- Multi-kinase inhibitors
- Sorafenib
- On December 20, 2005, the US Food and Drug Administration granted approval for sorafenib (Nexavar), a small molecule Raf kinase and VEGF multi-receptor kinase inhibitor, for the treatment of patients with advanced renal cell carcinoma. This indication is based on the demonstration of improved progression-free survival in a large, multinational, randomized double-blind, placebo-controlled phase 3 study and a supportive phase 2 study. Overall survival results from the phase 3 study are preliminary at this time.
- The sorafenib phase 3 study was conducted in patients with advanced (unresectable or metastatic) renal cell carcinoma who had received one prior systemic treatment. Study endpoints included overall survival, progression-free survival, and response rate. Among 769 patients randomized, the median age was 59 years and 70% were male. Baseline patient and disease characteristics were well balanced. Regarding prior therapies, 93% had prior nephrectomies; 99% had received prior systemic therapies, including interleukin 2 (44%) and an interferon (68%). The median progression-free survival was 167 days in the sorafenib group versus 84 days in the placebo control group (HR 0.44; 95% CI for HR: 0.35-0.55), logrank p less than 0.000001). Time-to-progression was similarly improved. Tumor response was determined by independent radiologic review according to RECIST criteria. Overall, of 672 patients who were able to be evaluated for response, 7 (2%) sorafenib patients and 0 (0%) placebo patients had confirmed partialresponses.
- Sorafenib toxicities (based on an updated phase 3 study database of 902 patients) included reversible skin rashes in 40% and hand-foot skin reaction in 30%. Diarrhea was reported in 43%, treatment-emergent hypertension in 17%, and sensory neuropathic changes in 13%. Alopecia, oral mucositis, and hemorrhage also were reported more commonly on the sorafenib arm. The incidence of treatment-emergent cardiac ischemia/infarction events was higher in the sorafenib group (2.9%) compared with the placebo group (0.4%).
- Grade 3 and 4 AEs were unusual; only hand-foot skin reaction occurred at 5% or greater frequency in the sorafenib arm. Laboratory findings included asymptomatic hypophosphatemia in 45% versus 12% and serum lipase elevations in 41% versus 30% of sorafenib versus placebo patients, respectively. Grade 4 pancreatitis was reported in 2 sorafenib patients, although both patients subsequently resumed sorafenib, one at full dose.
- Physicians should be aware of the importance of frequent blood pressure monitoring and management, especially during the first 6 weeks after starting sorafenib, and the unusual laboratory alterations on sorafenib therapy. The recommended dose is 400 mg (two 200 mg tab) twice daily taken either 1 hour before or 2 hours after meals. Adverse events were accommodated by temporary dose interruptions or reductions to 400 mg once daily or 400 mg every other day.
- Sorafenib targets serine/threonine and receptor tyrosine kinases, including those of RAF, VEGFR-2,3, PDGFR-b, KIT, FLT-3, and RET.
- Further clinical studies evaluating the role of sorafenib in the first-line setting, in combination with other immunomodulators, are underway. Preliminary results appear promising.
- Sunitinib (Sutent)
- Sunitinib is another multi-kinase inhibitor approved by the FDA in January 2006 for the treatment of metastatic kidney cancer that has progressed after a trial of immunotherapy. The approval was based on the high response rate (40% partial responses) and a median time to progression of 8.7 months and an overall survival of 16.4 months.
- The receptor tyrosine kinases inhibited by sunitinib include VEGFR 1-3 and PDGFR a and b.
- Major toxicities (grade II or higher) include fatigue (38%), diarrhea (24%), nausea (19%), dyspepsia (16%), stomatitis (19%), and decline in cardiac ejection fraction (11%). Dermatitis occurred in 8%, and hypertension occurred in 5% of patients.
- A recent phase 3 study evaluating sunitinib in the first-line setting, compared against IFN-a, in patients with metastatic RCC demonstrated significant improvement in PFS and response rates compared against the control arm. These results are considered to be preliminary, and longer-term follow-up is necessary for conclusive results.
- Other multi-kinase inhibitors undergoing investigation for RCC
- Lapatinib is an EGFR and ErbB-2 dual tyrosine kinase inhibitor, which appears to have efficacy in the treatment of tumors, including RCC, which overexpress EGFR. This was recently reported in a phase 3 study in advanced RCC evaluating lapatinib against hormonal therapy in patients who had failed prior therapy.
- RAD001 (Everolimus) is a serine-threonine kinase inhibitor of mTOR, an important regulatory protein in cell signaling. A recent phase 2 trial in patients with metastatic RCC demonstrated promising preliminary clinical results.
- Future treatment strategies for advanced renal cell carcinoma will likely incorporate a combination of molecular approaches, using multidrug regimens consisting of small molecule kinase inhibitors with biologic therapies and/or immunomodulatory therapies.
- For early stage RCC, current and future treatment strategies would utilize these molecular approaches earlier in the adjuvant setting in order to improve overall survival rates. Indeed, a randomized phase 3 trial of sunitinib versus sorafenib versus placebo as adjuvant therapy in patients with resected RCC is currently ongoing and open for patient enrollment.
- Sorafenib
- Chemotherapy
- A recent phase 2 trial of weekly intravenous gemcitabine (600 mg/m2 on days 1, 8, and 15) with continuous infusion fluorouracil (150 mg/m2/d for 21 d in 28-d cycle) in patients with metastatic renal cell cancer produced a partial response rate of 17%. No complete responses were noted. Eighty percent of patients had multiple metastases, and 83% had received previous treatment. The mean progression-free survival duration of 28.7 weeks was significantly longer than that of historic controls.
- Floxuridine (5-fluoro 2'-deoxyuridine [FUDR]), 5-fluorouracil (5-FU), and vinblastine, paclitaxel (Taxol), carboplatin, ifosfamide, gemcitabine, and anthracycline (doxorubicin) all have been used. Floxuridine infusion has a mean response rate of 12%, while vinblastine infusion yielded an overall response rate of 7%. 5-FU alone has a response rate of 10%, but when used in combination with interferon, it had a 19% response rate in some studies.
- Renal cell carcinoma is refractory to most chemotherapeutic agents because of multidrug resistance mediated by p-glycoprotein. Normal renal proximal tubules and renal cell carcinoma both express high levels of p-glycoprotein. Calcium channel blockers or other drugs that interfere with the function of p-glycoprotein can diminish resistance to vinblastine and anthracycline in human renal cell carcinoma cell lines.
- Biologic therapies
- The interferons are natural glycoproteins with antiviral, antiproliferative, and immunomodulatory properties. The interferons have a direct antiproliferative effect on renal tumor cells in vitro, stimulate host mononuclear cells, and enhance expression of major histocompatibility complex molecules. Interferon-alpha, which is derived from leukocytes, has an objective response rate of approximately 15% (range 0-29%).
- Preclinical studies have shown synergy between interferons and cytotoxic drugs. In several prospective randomized trials, combinations do not appear to provide major advantages over single-agent therapy. Many different types and preparations of interferons have been used without any difference in efficacy.
- IL-2 is a T-cell growth factor and activator of T cells and natural killer cells. IL-2 affects tumor growth by activating lymphoid cells in vivo without affecting tumor proliferation directly.
- In the initial study by the National Cancer Institute, bolus intravenous infusions of high-dose IL-2 combined with LAK cells produced objective response rates of 33%. In subsequent multicenter trials, the response rate was 16%. Subsequent studies also showed that LAK cells add no definite therapeutic benefit and can be eliminated from the treatment. A high-dose regimen (600,000-720,000 IU/kg q8h for a maximum of 14 doses) resulted in a 19% response rate with 5% complete responses. The majority of responses to IL-2 were durable, with median response duration of 20 months. Eighty percent of patients who responded completely to therapy with IL-2 were alive at 10 years.
- Most patients responded after the first cycle, and those who did not respond after the second cycle did not respond to any further treatment. Therefore, the current recommendation is to continue treatment with high-dose IL-2 to best response (up to 6 cycles) or until toxic effects become intolerable. Treatment should be discontinued after 2 cycles if the patient has had no regression. Combinations of IL-2 and interferon or other chemotherapeutic agents such as 5-FU have not been shown to be more effective than high-dose IL-2 alone.
- Toxic effects associated with high-dose IL-2 are related to increased vascular permeability and secondary cytokine secretion (eg, IL-1, interferon gamma, tumor necrosis factor, nitric oxide). The management of high-dose IL-2 toxicities requires inpatient monitoring, often in an intensive care unit. The major toxic effect of high-dose IL-2 is a sepsis-like syndrome, which includes a progressive decrease in systemic vascular resistance and an associated decrease in intravascular volume due to capillary leak. Other toxic effects are fever, chills, fatigue, infection, and hypotension. High-dose IL-2 has been associated with a 1-4% incidence of treatment-related death and should be offered only to patients with no cardiac ischemia or significant impairment of renal or pulmonary functions. Management includes judicious use of fluids and vasopressor support to maintain blood pressure and intravascular volume and at the same time to avoid pulmonary toxicity due to noncardiogenic pulmonary edema from thecapillary leak. This syndrome is normally reversible.
- Other experimental approaches for treatment include immunomodulatory drugs, vaccines, and nonmyeloablative allogeneic peripheral blood stem-cell transplantation.
- The immunomodulator, lenalidomide (Revlimid), a derivative of thalidomide, inhibits VEGF, stimulates T and NK cells, and inhibits inflammatory cytokines. It has been evaluated extensively in hematologic malignancies and recently was reported to demonstrate efficacy in RCC regression and delayed time to progression in a phase 2 study of metastatic RCC.
- Vaccine trials are in early stages of development. Few antigens have been identified that induce T-cell responses from renal cell carcinoma. One example of vaccine strategy is to induce the gene for granulocyte-macrophage colony-stimulating factor (GM-CSF) into autologous cultured renal cell cancer lines by retroviral transduction. Patients then are immunized with irradiated tumor cells secreting large amounts of GM-CSF and are evaluated for immune responses and clinical tumor regression. Other approaches to vaccination include tumor lysates and dendritic cells. Autologous vaccine therapy is now being tried in combination with cytokine therapy.
- Nonmyeloablative allogeneic stem-cell transplantation is another research approach. This can induce sustained regression of metastatic renal cell carcinoma in patients who have had no response to conventional immunotherapy. In one recent trial, 19 patients with refractory metastatic renal cell carcinoma who had suitable donors received a preparative regimen of cyclophosphamide and fludarabine, followed by an infusion of peripheral blood stem cells from a human leukocyte antigen (HLA)-identical sibling or a sibling with a mismatch of a single HLA antigen. Patients with no response received as many as 3 infusions of donor lymphocytes. Two patients died of transplantation-related causes, and 8 died from progressive disease. In 10 patients (53%), metastatic disease regressed; 3 patients had a complete response, and 7 had a partial response. The durations of these responses continue to be assessed. Further trials are needed to confirm these findings and to evaluate long-term benefits.
- Multiple studies have been conducted using megestrol (Megace) in the treatment of renal cell carcinoma. No benefit has been shown except for appetite stimulation, so megestrol currently is not recommended. Antiestrogens such as tamoxifen (100 mg/m2/d or more) and toremifene (300 mg/d) also have been tried, with a response rate as low as that of most chemotherapeutic agents.
Surgical Care: Surgical resection remains the only known effective treatment for localized renal cell carcinoma, and it also is used for palliation in metastatic disease.
- Radical nephrectomy, which remains the most commonly performed standard surgical procedure today for treatment of localized renal carcinoma, involves complete removal of the Gerota fascia and its contents, including a resection of kidney, perirenal fat, and ipsilateral adrenal gland, with or without ipsilateral lymph node dissection. Radical nephrectomy provides a better surgical margin than simple removal of the kidney, since perinephric fat may be involved in some patients. Twenty to thirty percent of patients with clinically localized disease develop metastatic disease after nephrectomy. Some surgeons believe that the adrenal gland should not be removed because of the low probability of ipsilateral adrenal metastasis and the morbidity associated with adrenalectomy. In the absence of distant metastatic disease with locally extensive and invasive tumors, adjacent structures such as bowel, spleen, or psoas muscle may be excised en bloc during radical nephrectomy.
- Lymph nodes may be involved in 10-25% of patients. The 5-year survival rate in patients with regional node involvement is substantially lower than in patients with stage I or II disease. Regional lymphadenectomy adds little in terms of operative time or risk and should be included in conjunction with radical nephrectomy.
- Approximately 5% of patients with renal cell carcinoma have inferior vena caval involvement. Tumor invasion of the renal vein and inferior vena cava usually occurs as a well-vascularized thrombus covered with its own intimal surface. In patients with renal vein involvement without metastases, radical nephrectomy is performed with early ligation of the renal artery but no manipulation of the renal vein. If the inferior vena cava is involved, then vascular control of the inferior vena cava is obtained both above and below the tumor thrombus, and the thrombus is resected intact, with subsequent closure of the vena cava. Patients with actual invasion of the inferior vena caval wall have poor prognoses, despite aggressive surgical approaches.
- At least 3 common approaches exist for removal of kidney cancer, as follows: (1) the transperitoneal approach, (2) the flank approach, and (3) the thoracoabdominal approach. Approach depends on tumor location and size and the body habitus of the patient. The thoracoabdominal approach offers the advantage of palpation of the ipsilateral lung cavity and mediastinum, as well as the ability to resect solitary pulmonary metastases.
- Laparoscopic nephrectomy is a less invasive procedure, incurs less morbidity, and is associated with shorter recovery time and less blood loss. The need for pain medications is reduced, but operating room time and costs are higher. Disadvantages include concerns about spillage and technical difficulties in defining surgical margins. Laparoscopic partial nephrectomy can be considered at centers with experience in this procedure for early stage renal cell cancer.
- Palliative nephrectomy should be considered in patients with metastatic disease for alleviation of symptoms such as pain, hemorrhage, malaise, hypercalcemia, erythrocytosis, or hypertension. Several randomized studies are now showing improved overall survival in patients presenting with metastatic kidney cancer who have nephrectomy followed by either interferon or IL-2. If the patient has good physiological status, then nephrectomy should be performed prior to immunotherapy. Reports have documented regression of metastatic renal cell carcinoma after removal of the primary tumor. Adjuvant nephrectomy is not recommended for inducing spontaneous regression; rather, it is performed to decrease symptoms or to decrease tumor burden for subsequent therapy in carefully controlled environments.
- About 25-30% of patients have metastatic disease at diagnosis, and fewer than 5% have solitary metastasis. Surgical resection is recommended in selected patients with metastatic renal carcinoma. This procedure may not be curative in all patients but may produce some long-term survivors. The possibility of disease-free survival increases after resection of primary tumor and isolated metastasis excision.
- Radiation therapy may be considered as the primary therapy for palliation in patients whose clinical condition precludes surgery, either because of extensive disease or poor overall condition.
- A dose of 4500 centigray (cGy) is delivered, with consideration of a boost up to 5500 cGy.
- Preoperative radiation therapy yields no survival advantage.
- Controversies exist concerning postoperative radiation therapy, but it may be considered in patients with perinephric fat extension, adrenal invasion, or involved margins. A dose of 4500 cGy is delivered, with consideration of a boost.
- Palliative radiation therapy often is used for local or symptomatic metastatic disease, such as painful osseous lesions or brain metastasis, to halt potential neurological progression. Surgery also should be considered for solitary brain or spine lesions, followed by postoperative radiotherapy.
- About 11% of patients develop brain metastasis during the course of illness. Renal cell carcinoma is a radioresistant tumor, but radiation treatment of brain metastasis improves quality of life, local control, and overall survival duration. Patients with untreated brain metastasis have a median survival time of 1 month, which can be improved with glucocorticoid therapy and brain irradiation. Stereotactic radiosurgery is more effective than surgical extirpation for local control and can be performed on multiple lesions.
The goals of pharmacotherapy are to induce remission, reduce morbidity, and prevent complications.
|Drug Name
|Aldesleukin (Proleukin) -- IL-2; T-cell growth factor and activator of T cells and natural killer cells. Affects tumor growth by activating lymphoid cells in vivo, without affecting tumor proliferation directly.
|Adult Dose
|600,000-720,000 IU/kg q8h for as many as 5 d or per protocol
|Pediatric Dose
|Not established
|Documented hypersensitivity; caution in patients with preexisting cardiac, pulmonary, CNS, hepatic, or renal impairment
|Corticosteroids may decrease antitumor effect; NSAIDs increase capillary leak syndrome; potentiates effects of antihypertensive medications
|D - Unsafe in pregnancy
|Caution in patients with preexisting cardiac, pulmonary, CNS, hepatic, or renal impairment
May cause sepsis-like syndrome due to "capillary leak"; other toxic effects are flu-like syndrome, fever, chills, fatigue, infection, myelosuppression, hepatic toxicity, neurological and neuropsychiatric findings, hypotension, erythema, rash, urticaria, and alteration in thyroid function (including hyperthyroidism and hypothyroidism); high-dose IL-2 has been associated with treatment-related deaths
|Drug Name
|Vinblastine (Velban, Alkaban-AQ) -- Vinca alkaloid with cytotoxic effect via mitotic arrest. Binds to specific site on tubulin, prevents polymerization of tubulin dimers, and inhibits microtubule formation.
|Adult Dose
|Per protocol
|Pediatric Dose
|Not established
|Documented hypersensitivity; IT use may result in death; severe bone marrow suppression; uncontrolled bacterial infection
|May reduce phenytoin plasma levels; mitomycin-C may increase toxicity significantly
|D - Unsafe in pregnancy
|IT use may result in death
Dose-limiting toxicity is myelosuppression; other toxic effects include nausea, vomiting, alopecia, neurologic effects, local skin damage (if extravasated)
|Drug Name
|Gemcitabine (Gemzar) -- Cytidine analog. After intracellular metabolism to active nucleotide, inhibits ribonucleotide reductase and competes with deoxycytidine triphosphate for incorporation into DNA.
|Adult Dose
|Per protocol
|Pediatric Dose
|Not established
|Documented hypersensitivity
|None reported
|D - Unsafe in pregnancy
|May cause myelosuppression (particularly thrombocytopenia); toxic effects include flu-like syndrome, LFT abnormalities, maculopapular rash, pruritus, nausea, vomiting, dyspnea, hematuria, proteinuria, and hemolytic-uremic syndrome
|Drug Name
|5-fluorouracil (Adrucil) -- Fluorinated pyrimidine antimetabolite that inhibits thymidylate synthase (TS) and interferes with RNA synthesis and function. Has cell-cycle specificity with activity in S phase. Inhibits thymidylate synthase by 5-FU metabolite F-dUMP. Metabolite FUTMP incorporates into RNA and F-dUTP incorporates into DNA, resulting in alteration of RNA processing and inhibition of DNA synthesis.
|Adult Dose
|Per protocol
|Pediatric Dose
|Not established
|Documented hypersensitivity; poor nutritional status; myelosuppression
|Increased risk of bleeding with anticoagulants, NSAIDs, platelet inhibitors, thrombolytic agents; other immunosuppressants exacerbate bone marrow toxicity; leucovorin enhances toxicity and antitumor activity when given before 5-FU; antifolate analogs (methotrexate and trimetrexate) increase formation of 5-FU metabolite; thymidine and uridine rescue host toxic effect
|D - Unsafe in pregnancy
|Nausea, oral and GI ulcers, depression of immune system, and hemopoiesis failure (eg, bone marrow suppression) may occur; main toxic effects include myelosuppression, mucositis, diarrhea, metallic taste in mouth, hand-foot syndrome, alopecia, dermatitis, increased pigmentation, cerebellar ataxia, somnolence, confusion, seizure, rarely acute encephalopathy, chest pain syndrome, ECG changes, cardiac enzyme elevation, blepharitis, tear duct stenosis, and cholestatic jaundice with biliary stenosis
|Drug Name
|Sorafenib (Nexavar) -- First oral multikinase inhibitor that targets serine/threonine and tyrosine receptor kinases in both the tumor cell and the tumor vasculature. Targets kinases involved in tumor cell proliferation and angiogenesis, thereby decreasing tumor cell proliferation. These kinases included RAF kinase, VEGFR-2, VEGFR-3, PDGFR-beta, KIT, and FLT-3. Indicated for advanced renal cell carcinoma.
|Adult Dose
|400 mg PO bid 1 h ac or 2 h pc
|Pediatric Dose
|Not established
|Documented hypersensitivity
|CYP450 2B6 and 2C8 inhibitor; predominantly eliminated by UGT1A1 pathway (caution when coadministered with other drugs eliminated by UGT1A1 [eg, irinotecan]); coadministration with warfarin may increase INR or bleeding
|D - Unsafe in pregnancy
|Common adverse reactions include hand or foot skin reaction and rash (modify dose); may increase risk of hemorrhage, cardiac ischemia and/or infarction, alopecia, pruritus, or diarrhea; caution with severe hepatic impairment (ie, Child-Pugh C)
|Drug Name
|Sunitinib (Sutent) -- Mulitkinase inhibitor that targets several tyrosine kinase inhibitors implicated in tumor growth, pathologic angiogenesis, and metastatic progression. Inhibits platelet-derived growth factor receptors (ie, PDGFR-alpha, PDGFR-beta), vascular endothelial growth factor receptors (ie, VEGFR1, VEGFR2, VEGFR3), stem cell factor receptor (KIT), Fms-like tyrosine kinase-3 (FLT3), colony-stimulating factor receptor type 1 (CSF-1R), and the glial cell-line–derived neurotrophic factor receptor (RET).
Indicated for advanced renal cell carcinoma. Reduces tumor size in patients with metastatic kidney cancer whose tumors have progressed following cytokine-based therapy.
|Adult Dose
|Standard dose: 50 mg PO qd on a schedule of 4 wk on treatment followed by 2 wk off treatment, then repeat cycle
Dose modification: Increase or reduce dose in 12.5-mg increments based on individual safety and tolerability
Coadministration with potent CYP4503A4 inhibitors: Minimum dose of 37.5 mg PO qd during treatment phase of cycle
Coadministration with CYP4503A4 inducers: Maximum dose of 87.5 mg PO qd during treatment phase of cycle
|Pediatric Dose
|Not established
|Documented hypersensitivity; concurrent administration with St John's wort
|Potent CYP4503A4 inhibitors (eg, ketoconazole, itraconazole, clarithromycin, atazanavir, indinavir, nefazodone, nelfinavir, ritonavir, saquinavir, telithromycin, voriconazole) may increase plasma concentrations; CYP4503A4 inducers (eg, dexamethasone, phenytoin, carbamazepine, rifampin, rifabutin, phenobarbital) may decrease plasma concentrations; St John's wort induces metabolism and decreases plasma concentrations unpredictably (do not take concurrently)
|D - Unsafe in pregnancy
|Common adverse effects include diarrhea, skin discoloration, mouth irritation, weakness, and altered taste; may cause fatigue, hypertension, bleeding, swelling, and hypothyroidism; in clinical trials, decreased left ventricular ejection fraction to below lower limits of normal in 15% of patients (monitor for CHF and discontinue if clinical manifestations of CHF develop); may cause hemorrhagic events that may include epistaxis or rectal, gingival, GI, genital, or wound bleeding
|Drug Name
|Interferon alfa 2a (Roferon A) and 2b (Intron A) -- Interferons are natural glycoproteins with antiviral, antiproliferative, and immunomodulatory properties.
They have direct antiproliferative effect on renal tumor cells, stimulate host mononuclear cells, and enhance expression of major histocompatibility complex molecules.
|Adult Dose
|6 million IU/m2 SC in combination with low-dose IL-2 or per protocol
|Pediatric Dose
|Not established
|Documented hypersensitivity; vaccination with live vaccine during and for 3 mo after completion of therapy
|Inhibits antitumor effects of cyclophosphamide; increases effects of phenytoin and phenobarbital; theophylline may increase toxicity; cimetidine may increase antitumor effects; zidovudine and vinblastine may increase toxicity
|C - Safety for use during pregnancy has not been established.
|Caution in brain metastases, severe hepatic or renal insufficiency, seizure disorders, multiple sclerosis, or compromised CNS; main toxic effects include flu-like syndrome, fatigue, anorexia, somnolence, confusion, depression, myelosuppression, mild and transient elevation in serum transaminases, mild proteinuria, hypocalcemia, acute renal failure, nephrotic syndrome, alopecia rashes, pruritus, irritation at injection site, chest pain, arrhythmias, congestive heart failure, impotence, decreased libido, menstrual irregularities, and increased incidence of spontaneous abortion
- For stage I and II disease, complete history, physical examination, chest radiographs, liver function tests, BUN and creatinine, and calcium are recommended every 6 months for 2 years, then annually for 5 years. Abdominal CT scan is recommended once at 4-6 months and then as indicated.
- For stage III renal cell carcinoma, physical examination, chest radiographs, liver function tests, BUN and creatinine, and calcium are recommended every 4 months for 2 years, every 6 months for 3 years, and then annually for 5 years. Abdominal CT scan should be performed at 4-6 months, then annually or as indicated.
- Spontaneous regression has been reported anecdotally in renal cell carcinoma. As many as 10% of patients with metastatic disease show no progression for more than 12 months. All systemic therapies are associated with treatment-related toxicity and low response, so close observation is an option for asymptomatic metastatic disease. Once evidence of progression or symptoms appears, appropriate therapy should be initiated.
- Careful surveillance of patients with end-stage renal disease by ultrasonography and CT scan is recommended.
- Avoidance of causative factors such as smoking, obesity, and other factors as described in Causes is recommended.
- Careful surveillance of patients with end-stage renal disease or VHL disease, those who have undergone renal transplantation, and other high-risk groups by ultrasonography and CT scan is recommended.
- Excruciating, sharp, bandlike back pain may be an early warning for cord compression due to metastatic renal cell carcinoma and should not be ignored. Urgent MRI should be performed to rule out cord compression, and high-dose dexamethasone therapy should be started.
- Metastatic disease has increased survival with (1) a long disease-free interval between initial nephrectomy and the appearance of metastases, (2) the presence of only pulmonary metastases, (3) good performance status, and (4) removal of the primary tumor. Five-year survival rates are as follows:
- After radical nephrectomy for stage I renal cell carcinoma, the 5-year survival rate is approximately 94%, and patients with stage II lesions have a survival rate of 79%. A tumor confined to the kidney is associated with a better prognosis.
- The 5-year disease-specific survival rate associated with T1 renal carcinoma is 95% and with stage T2 disease, 88%. Patients with T3 renal carcinoma had a 5-year survival rate of 59%, and those with T4 disease had a 5-year disease-specific survival rate of 20%.
- Patients with regional lymph node involvement or extracapsular extension have a survival rate of 12-25%. Although renal vein involvement does not have a markedly negative effect on prognosis, the 5-year survival rate for patients with stage IIIB renal cell carcinoma is 18%. In patients with effective surgical removal of the renal vein or inferior vena caval thrombus, the 5-year survival rate is 25-50%.
- Five-year survival rates for patients with stage IV disease are low (0-20%).
- A recent trial identified 5 prognostic factors for predicting survival in patients with metastatic renal-cell carcinoma. These factors are used to categorize patients with metastatic renal cell carcinoma into 3 risk groups. Patients in the favorable-risk group (zero risk factors) had a median survival of 20 months. Patients with intermediate risk (1 or 2 risk factors) had a median survival of 10 months, while patients in the poor-risk group (3 or more risk factors) had a median survival of only 4 months. The prognostic factors were as follows:
- Low Karnofsky performance status (less than 80%)
- High serum lactate dehydrogenase level (>1.5 times upper limit of normal)
- Low hemoglobin (below lower limit of normal)
- High "corrected" serum calcium (>10 mg/dL)
- No prior nephrectomy
Patient Education:
- Patients in the high-risk group should be made aware of the early signs and symptoms, and the need for early intervention for possible cure should be stressed.
- Patients in early stages who have undergone treatment should be educated about possible relapse.
- For excellent patient education resources, visit eMedicine's Kidneys and Urinary System Center and Cancer and Tumors Center. Also, see eMedicine's patient education articles Blood in the Urine and Renal Cell Cancer.
- In 25-30% of patients, renal cell carcinoma is asymptomatic and found incidentally on a radiologic study.
- A renal mass of indeterminate etiology should be monitored periodically by imaging study; intravenous pyelography (IVP), ultrasound, or CT scan. A cystic mass can be simply observed. Patients with a solid mass should have a complete workup, including evaluation for metastatic disease and vascular extension of the primary tumor.
- As many as one third of patients with clinically localized disease may develop metastatic disease after nephrectomy, so they should be monitored carefully.
- The major medical pitfall is ignoring a solid renal mass and failing to provide appropriate follow-up care.
- Renal cell carcinoma develops in nearly 40% of patients with VHL disease and is a major cause of death in patients with VHL disease. VHL disease and other hereditary forms are transmitted in an autosomal dominant manner. Family members of patients with these syndromes should be educated about familial multiple-cancer syndrome, and genetic counseling should be offered to the patients and family members.


text: The cold embraced her, wrapping its glittering fingers around her pale skin. The forest around her, coated with ice and crystal, was bleak and beautiful. She rested her hand against a tree, pausing to breathe. Crisp air filled her lungs, making her suddenly aware of how alive she was, how alive the world was, even under its frozen exterior.


text:
If you are facing any difficulty while placing an order, please do not hesitate to contact our Customer Care Department. Feel free to write at firstname.lastname@example.com.
Yes, you can email the address you want delivery at to our customer care department and we will verify your details and ship to an alternate address. In case the alternate shipping address falls outside the area serviced by our shipping partners or in case the product has already been shipped we will not be able to service your request.
Walls and Murals accepts all major credit and debit cards through SSL encrypted payment gateways of PayPal and it is absolutely risk free.
You can alternatively deposit cheques directly in our bank account or make RTGS/NEFT transfer.
The bank account details are :
Account Name : GRAFFITI
Bank : Kotak Mahindra Bank
Branch : 79, Old Rajinder Nagar Market, New Delhi – 110060, India
Account No.: 9011202311
IFSC Code : KKBK0000179
Yes, you can directly deposit cheque in any branch of Kotak Mahindra Bank and the account details are :
Account Name : GRAFFITI
Bank : Kotak Mahindra Bank
Branch : 79, Old Rajinder Nagar Market, New Delhi – 110060, India
Account No.: 9011202311
IFSC Code : KKBK0000179
Yes, when you use Credit/Debit Card to make payments , you are absolutely secure. All your payments of Credit/Debit card are processed through SSL encrypted payment gateways of Paypal and PayU.
Wall and Murals does not collect your debit/credit card data and your data is absolutely secure in SSL encrypted payment gateways.
Note : Walls and Murals will never ask you for your Credit/Debit card details.
When we receive an order, it will take around 5-7 business days for the order to get processed. Shipping agents will take another 5-7 days from the day of dispatch to deliver at your doorstep.
We normally ship within 5-7 business days and there are no delays.
In case of bulk orders or typical customizations where it is going to take more time, the actual time will be intimated to you before we start processing the order.
Yes, you will receive a confirmation email for your order.
Once your order has been completed and is ready for delivery, you will receive a confirmation email and you can keep track of your order.
Yes. Once the order is dispatched you will receive an email and can keep track of your order. You can send an email at firstname.lastname@example.com to keep track of your order placed.
No. You don't have to pay any taxes over the final amount quoted, as all our prices are inclusive of all taxes or applicable service charges.
In case the product you received is damaged in any way or has a fault or tempered packaging,please DO NOT accept your order and return the order back to the courier person.In addition, please call within 24 hours from receiving the order to our Customer Care Department on email at email@example.com we will resolve this to your satisfaction.
Refer to our RETURN & REFUND POLICY terms and conditions for further clarification.
In case the product you received is faulty or wrong order, please call within 24 hours from receiving the order to our Customer Care Department. Kindly confirm with our customer care department before shipping back the product.
Once your return is approved, you can courier back the faulty product, we will reimburse shipping charges and ensure full replacement at no extra charge. We ensure full replacements. Contact us on email at firstname.lastname@example.com we will resolve this to your satisfaction.
Refer to our RETURN & REFUND POLICY terms and conditions for further clarification.
All the products at Walls and Murals are customized orders. We cannot take back non faulty wallpaper as the product has been made individually to your specifications.
When we receive an order, it will take around 5-7 business days for the order to get processed and can vary from order-to-order as per the customization done. However, if you need products on urgent basis, you can contact our customer care department and we will try to accommodate your request.
Yes, you can place the order for one roll also. For further query send an email at email@example.com .
We cannot guarantee cancellation if the order is in design/production stage. We can try to accommodate your request but cannot assure you of cancellation. We cannot accept exchange/returns or any modifications when the order is in printing stage or dispatched.
Customized orders cannot be cancelled or modified once approved by you. Please refer to our Order Cancellation Policy.
We do free overseas shipping to most of the countries but at times there may be extra cost involved, you can contact our customer care department. We will not be responsible for any taxes or duties imposed on international orders and there may be shipping charges for some overseas destinations.
We ship free to : India, USA, Europe, Middle East, Asia...
Please email your queries at firstname.lastname@example.com for any query or further assistance.
Our products are priced in square feet, so please be careful when ordering. The minimum size that we accept for customized wallpaper is 20 square feet. There is no limit for maximum size. However, you need to consult our expert regarding quality and resolution of the image you want to print. Please send an email at email@example.com for any query or further assistance.
You can customize existing wallpaper as per your own requirement and space available. Just following simple steps to customize size:
Yes, choose any design and provide us the tallest and the widest point of that irregular shape and any other specifications and leave the rest to us. Please send an email at firstname.lastname@example.com for any query or further assistance.
The seamless rolls are available in two fixed sizes:
Regular Rolls (WXH) 4ft x10ft. and
Extended Rolls (WXH) 4ft x20ft.
Please check the size of the wall/area to be covered, before placing your order
You can choose any material, design and color as per your taste and style. You can install wallpaper in kitchen, bedroom, bathroom, dining room, living room, stair sides etc. or any available space you want to decorate. The only thing you need to take care is protect wallpapers from moist and wet surfaces. In addition, please avoid spaces that are in direct contact with water.
Yes, email or call us, our customer service team will help you to find the wallpaper design of your choice or you can customize your own wallpaper by uploading your image or using our customized options under the heading 'Print Your Picture' , 'Picture Collage' or 'Picture In Picture' . Send your queries at: email@example.com
We can only custom-size as per your desired wall dimensions by cropping on sides. Our wallpapers designs under the heading 'Creative Concepts' are in fixed size ratio. You can use the crop box to make adjustments in the original wallpaper and our designers work on customizing the design to your size.
We do not want our customers to wait for a long. Depending on the customization specifications and other photo enhancing levels chosen; your order would be dispatched within 5 to 7 business days.
We do provide B&W and other options on our customized orders only. But in case you want to personalize any wallpaper from our product list; feel free to contact us, we will work out a customized solution. Send an email at firstname.lastname@example.com.
Public Domain images are free to use. You can use the free hires images available on free websites. For those images that are not 'publicly available', either you need to buy from stock agencies or contact directly with the copyright holder to get the permission to print and use.
You have to take care that there is no copyright infringement.
Yes you can, But this will increase your production time and change delivery schedule.
Of course! You can create your own customized photo frames design and don't forget to send us and mention the same in "Special Instructions" section. However, if you have a specific request, kindly provide us detailed information regarding frame layout, photo frame design or alignment of photos. Send an email at email@example.com for further assistance.
The limit will depend on the layout you choose and wall measurement you provide. If there is any requirement regarding layout and placement of photos, please provide us detailed information and we will try to accommodate all your requests and will send you digital final proofs by email for approval. Send an email at email@example.com for further assistance.
You can create photo collage the way you want it to get displayed on the wall. If you have a specific request, kindly provide us detailed information regarding photo layout and placement of photos. The more detailed information you will give about your wallpaper, the faster will be the production at our end. Send an email at firstname.lastname@example.com for any further assistance. We will contact you and give you the options; it may involve extra cost depending upon the specifications given.
You don't need to worry. Upload your image on our website and we will check the resolution at our end and do the necessary touchups to make it of printable quality.
For detailed instructions regarding image resolution, read more....
You may or may not. All designs are color calibrated for best quality production, but these may not show in exact colors on your screen due to screen resolution, display card and software issue. But you can be rest assure that we use best technology to offer the best color output in all our prints.
No, wallpapers cannot be installed on a rough surface. We therefore suggest you to either choose a flat/smooth surface or always smooth out any rough spots with sandpaper and fill any holes or cracks with patching plaster. Refer our "Wall Preparation" section for more clarification on this type of issue.
With little care and regular maintenance our wallpapers can last for many years.
You can wipe wallpapers using clean dry cloth to remove dust particles. Avoid hard scrubbing and chemical based detergent to clean wallpapers. Sponge with water or dampen a clean cloth and wipe gently for long lasting wallpapers.
Walls and murals products are produced using high quality material for long lasting results. Our PVC-free wallpapers are non-toxic and eco-friendly.
Pease go through our "Installation Process" for complete know how. Simply follow the instructions and be an expert.
Walls and Murals offers wallpaper in 3 different materials.
Depends on the material you choose. If you choose un-gummed wallpapers you need to apply gum/paste to each panel before installation.
Yes, our wallpapers are DIY and can be easily installed. By following the instructions carefully you can easily install the products, if you need special assistance you can take help of any wallpaper contractor in your area.
If you need further assistance contact our Customer Care Department.
No, there will be no damage to the walls. All you need to do is carefully remove wallpapers and then wipe off the residue on your wall with a clean piece of cloth or sponge.
Walls can get damaged in a rare scenario where the base material is weak or if the wall has moisture in it or if the wall preparation before installation was not done properly.
We suggest not installing wallpapers on outside walls where there is direct exposure to sunlight as the UV rays would shorten the life span of the wallpaper. The wallpapers are meant to be for interior application.
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Barrier Island Real Estate Listings
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5 Bed • 8 Bath • 9,180 Sf • 1 Acres
15 Lighthouse Point Dr, Longboat Key
Just Steps From The White Sand Beaches Of Sarasota, The White House At Lighthouse Point Is An Exquisite Waterfront Home On 1.2 Acres In A Very Excl...View Listing
2 Acres
105 White Ave, Holmes Beach
Reduced $1,000,000! Nearly Two Full Acres On The Gulf Of Mexico. This Rare, Beachfront Compound Offers A Full 190 Feet On The Gulf Of Mexico's Azur...View Listing
2 Acres
3975 Shell Rd, Sarasota
Truly One-of-a-kind. 2.4 Acres With 264ft Of Frontage On The Beach. A Protected Deep-water Boat Dock. The Only Property On Coveted North Siesta Key...View Listing
4 Bed • 6 Bath • 5,079 Sf • 2 Acres
3975 Shell Rd, Sarasota
Truly One-of-a-kind. 2.4 Acres With 264ft Of Frontage On The Beach. A Protected Deep-water Boat Dock. The Only Property On Coveted North Siesta Key...View Listing
4 Bed • 5 Bath • 3,774 Sf • 4 Acres
Bochi Cir, Sarasota
Investor Alert!! Siesta Key Subdivision. Rare Opportunity To Purchase A Gated, Exclusive Enclave Of Five (5) Beautifully Furnished, Expansive Coa...View Listing
5 Bed • 7 Bath • 8,239 Sf • 1 Acres
4137 Higel Ave, Sarasota
Pre-construction To Be Built. Picture Yourself On A Private, .87 Acre Gulf-front Estate Enjoying The Best Of All Worlds. This Proposed Luxury Resid...View Listing
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