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This information is produced and provided by the National Cancer Institute (NCI). The information in this topic may have changed since it was written. For the most current information, contact the National Cancer Institute via the Internet web site at http://cancer.gov or call 1-800-4-CANCER.
There are three main types of skin cancer:
BCC and SCC are the most common forms of skin cancer and are collectively referred to as nonmelanoma skin cancers. This summary only covers the treatment of nonmelanoma skin cancers. (Refer to the PDQ summary on Melanoma Treatment for more information.)
Incidence and Mortality
Nonmelanoma skin cancer is the most commonly occurring cancer in the United States. BCC is the more common type of the two nonmelanoma types, accounting for about three-quarters of nonmelanoma skin cancers.[1] The incidence of nonmelanoma skin cancer appears to be increasing in some,[2] but not all [3] areas of the United States. Overall U.S. incidence rates have likely been increasing for a number of years.[4] At least some of this increase may be attributable to increasing skin cancer awareness and resulting increasing investigation and biopsy of skin lesions.
Precise estimation of the total numbers and incidence rate of nonmelanoma skin cancer is not possible because reporting to cancer registries is not required. However, based on Medicare fee-for-service data, which were then extrapolated to the U.S. population, an estimated 2,152,500 persons were treated for nonmelanoma skin cancers in 2006.[4] That number would exceed all other cases of cancer estimated by the American Cancer Society for that year, which was about 1.4 million.[5] Although the two types of nonmelanoma skin cancer are the most common of all malignancies, they account for less than 0.1% of patient deaths caused by cancer.
Risk Factors
Epidemiologic evidence suggests that exposure to ultraviolet (UV) radiation and the sensitivity of an individual's skin to UV radiation are risk factors for skin cancer, though the type of exposure (i.e., high-intensity exposure and short-duration exposure vs. chronic exposure) and pattern of exposure (i.e., continuous pattern vs. intermittent pattern) may differ among the three main skin cancer types.[6,7,8] All three types of skin cancer are more likely to occur in individuals of light complexion who have had substantial exposure to sunlight, and skin cancers are more common in the southern latitudes of the Northern hemisphere. In addition, the immune system may play a role in pathogenesis of skin cancers.
Organ transplant recipients receiving immunosuppressive drugs are at an elevated risk of skin cancers, particularly SCC. Arsenic exposure also increases the risk of cutaneous SCC.[1] Serologic evidence from a population-based case-control study has shown a possible association between infection with the human papilloma virus (HPV) genus beta-species 1 and SCC.[9,10]
Related Summaries
Note: Other PDQ summaries containing information related to skin cancer include the following:
This evidence summary covers basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) of the skin, and the related noninvasive lesion actinic keratosis (viewed by some pathologists as a variant of in situ SCC ).[1] Although BCC and SCC are by far the most frequent types of nonmelanoma skin cancers, approximately 82 types of skin malignancies, with a wide range of clinical behaviors, fall into the category of nonmelanoma skin cancer.[2] Other types of malignant disease of the skin include the following:
(Refer to the PDQ summaries on Melanoma Treatment, Merkel Cell Carcinoma Treatment, Mycosis Fungoides and the Sézary Syndrome Treatment, and Kaposi Sarcoma Treatment for more information.)
BCC and SCC are both of epithelial origin. They are usually diagnosed on the basis of routine histopathology obtained from a shave, punch, or fusiform excisional biopsy.[1]
Basal Cell Carcinoma
BCC is at least three times more common than SCC in nonimmunocompromised patients. It usually occurs on sun-exposed areas of skin, and the nose is the most frequent site. Although there are many different clinical presentations for BCC, the most characteristic type is the asymptomatic nodular or nodular ulcerative lesion that is elevated from the surrounding skin, has a pearly quality, and contains telangiectatic vessels.
BCC has a tendency to be locally destructive. High-risk areas for tumor recurrence after initial treatment include the central face (e.g., periorbital region, eyelids, nasolabial fold, or nose-cheek angle), postauricular region, pinna, ear canal, forehead, and scalp.[3] A specific subtype of BCC is the morpheaform type. This subtype typically appears as a scar-like, firm plaque. Because of indistinct clinical tumor margins, the morpheaform type is difficult to treat adequately with traditional treatments.[4]
BCCs are composed of nonkeratinizing cells derived from the basal cell layer of the epidermis. They are slow growing and rarely metastasize. However, they can result in serious deforming damage locally if left untreated or if local recurrences cannot be completely excised. BCCs often have a characteristic mutation in the patched 1 tumor suppressor gene (PTCH1), although the mechanism of carcinogenesis is not clear.[1]
Squamous Cell Carcinoma
SCCs also tend to occur on sun-exposed portions of the skin, such as the ears, lower lip, and dorsa of the hands. However, SCCs that arise in areas of non–sun-exposed skin or that originate de novo on areas of sun-exposed skin are prognostically worse because they have a greater tendency to metastasize than those that occur on sun-exposed skin that develop from actinic keratosis. People with chronic sun damage, sites of prior burns, arsenic exposure, chronic cutaneous inflammation as seen in longstanding skin ulcers, and sites of previous x-ray therapy are predisposed to the development of SCC.[4]
SCCs are composed of keratinizing cells. These tumors are more aggressive than BCCs and have a range of growth, invasive, and metastatic potential. Prognosis is associated with the degree of differentiation, and tumor grade is reported as part of the staging system.[2] A four-grade system (G1–G4) is most common, but two- and three-grade systems may also be used. Mutations in the PTCH1 tumor suppressor gene have been reported in SCCs removed from patients with a prior history of multiple BCCs.[5]
SCC in situ (also called Bowen disease) is a noninvasive lesion. It may be difficult to distinguish it pathologically from a benign inflammatory process.[1] The risk of development into invasive SCC is low, reportedly in the 3% to 4% range.[6]
Actinic Keratosis
Actinic keratoses are potential precursors of SCC, but the rate of progression is extremely low, and the vast majority do not become SCCs. These typically red, scaly patches usually arise on areas of chronically sun-exposed skin and are likely to be found on the face and dorsal aspects of the hand.
There are separate staging systems in the 7th edition of the American Joint Committee on Cancer's (AJCC) AJCC Cancer Staging Manual for carcinomas of the eyelid versus other skin surfaces.[1,2] The staging system for non-eyelid skin cancers is primarily designed for squamous cell carcinomas (SCCs). The staging system for carcinoma of the eyelid addresses carcinomas of all histologies.
Basal cell carcinoma (BCC) rarely metastasizes, thus, a metastatic work-up is usually not necessary. Regional lymph nodes should be routinely examined in all cases of SCC, especially for high-risk tumors appearing on the lips, ears, perianal and perigenital regions, or high-risk areas of the hand. In addition, regional lymph nodes should be examined with particular care in cases of SCCs arising in sites of chronic ulceration or inflammation, burn scars, or sites of previous radiation therapy treatment.
Table 2 has a separate list of risk features that should be evaluated for non-eyelid carcinomas; the relevant risk features should also be evaluated for SCCs of the eyelid. Even with relatively small tumor size, SCCs that occur in immunosuppressed patients tend to have more aggressive behavior than SCCs in nonimmunosuppressed patients. Although not a formal part of the AJCC staging system, it is recommended that centers prospectively studying SCC record the presence and type of immunosuppression in addition to the risk features listed in Table 2.
Staging for Cutaneous SCC and Other Cutaneous Carcinomas (Excluding Carcinoma of the Eyelid)
The American Joint Committee on Cancer has designated staging by TNM classification.[1] The TNM classification is used to stage both BCC and SCC.
Patients with a primary cutaneous SCC or other cutaneous carcinoma with no evidence (i.e., clinical, radiologic, or pathologic) of regional or distant metastases are divided into the following two stages:
In instances where there is clinical concern about extension of the tumor into bone and radiologic evaluation has been performed (and is negative), these data may be included to support the stage I versus stage II designation. Tumors that are 2 cm or less in size can be upstaged to stage II if they contain two or more high-risk features.
Stage III patients are those with either of the following:
Stage IV patients are those with any of the following:
Staging for Carcinomas of the Eyelid
The AJCC has designated staging by TNM classification.[2] The TNM classification is used to stage all cell types of eyelid carcinomas.
There is a wide range of treatment approaches, including excision, radiation therapy, cryosurgery, electrodesiccation and curettage, photodynamic or laser-beam light exposure, and topical therapies. Mohs micrographic surgery is a form of tumor excision that involves progressive radial sectioning and real-time examination of the resection margins until adequate uninvolved margins have been achieved, avoiding wider margins than needed. Each of these methods is useful in specific clinical situations. Depending on case selection, these methods have recurrence-free rates ranging from 85% to 95%.
A systematic review of 27 randomized controlled trials comparing various treatments for BCC has been published.[1] Eighteen of the studies were published in full, and nine were published in abstract form only. Only 19 of the 27 trials were analyzed by intention-to-treat criteria. Because the case fatality rate of BCC is so low, the primary endpoint of most trials is complete response and/or recurrence rate after treatment. Most of the identified studies had short follow-up times (only one study had a follow-up as long as 4 years) and were not of high quality. Short follow-up periods will lead to overestimates of tumor control. A literature review of recurrence rates in case series with long-term follow-up after treatment of BCCs indicated that only 50% of recurrences occurred within the first 2 years, 66% after 3 years, and 18% after 5 years.[2] A rule of thumb was that the 10-year recurrence rates were about double the 2-year recurrence rates.
Treatment for Basal Cell Carcinoma of the Skin
Treatment options include the following:
Excision with margin evaluation
This traditional surgical treatment usually relies on surgical margins ranging from 3 mm to 10 mm, depending on the diameter of the tumor. Re-excision may be required if the surgical margin is found to be inadequate on permanent sectioning. For example, in one trial, 35 of 199 (18%) primary BCCs were incompletely excised by the initial surgery and underwent a re-excision.[3] In addition, many laboratories examine only a small fraction of the total tumor margin pathologically. Therefore, the declaration of tumor-free margins can be subject to sampling error.[4]
Excision has been compared in randomized trials to radiation therapy, Mohs micrographic surgery, photodynamic therapy (PDT), and cryosurgery:
At 4 years (mean follow-up of 41 months), the actuarial failure rates (confirmed persistent or recurrent tumor) were 0.7% and 7.5% in the surgery and radiation therapy arms, respectively (P = .003). The cosmetic results were also rated as better after surgery by both patients and dermatologists, and also by three independent judges.[6] At 4 years, 87% of surgery patients rated cosmesis as good versus 69% of radiation therapy patients.[6][Level of evidence: 1iiDii]
After 30 months of follow-up, the recurrence rate was 5 out of 171 tumors (3%) in the excision group and 3 out of 160 (2%) in the Mohs micrographic surgery group (absolute difference = 1%; 95% confidence interval [CI], -2.5%–+3.7%; P = .724). There was no difference in complication rates, and overall cosmetic outcomes were similar. Total operative costs were nearly twice as high in the Mohs group (405.79 Euros vs. 216.86 Euros (P < .001).[3][Level of evidence 1iiDii]
At 3 months, the complete response (CR) rate in the surgery group was 51 out of 52 lesions (98%) versus 48 out of 53 lesions (91%) in the PDT group (P = .25). CR rates assessed at 12 months were 96% versus 83% (P = .15).[7][Level of evidence: 1iiDiv] The investigators interpreted the results as noninferiority of PDT, but the study may have been underpowered. Both the investigators and the patients, however, rated the cosmetic results as either excellent or good in a higher proportion of PDT treatments at each time point of follow-up. At 12 months, patient ratings of excellent or good were 98% versus 84% (P = .03) and investigator ratings were 79% versus 38% (P = .001).
At 1 year, there were no recurrences in the excision group versus three in the cryosurgery group (P = NS), but this is a very short follow-up time. Patients and five independent professionals who were blinded to the treatment arm rated the cosmetic outcomes. Their overall assessments favored excision.[8][Level of evidence 1iiDiv]
Mohs micrographic surgery
Mohs micrographic surgery is a specialized technique used with the intent to achieve the narrowest margins necessary to avoid tumor recurrence, while maximally preserving cosmesis. It is best suited to management of tumors in cosmetically sensitive areas or for tumors that have recurred after initial excision (e.g., eyelid periorbital area, nasolabial fold, nose-cheek angle, posterior cheek sulcus, pinna, ear canal, forehead, scalp, fingers, and genitalia).[9,10] It is also often used to treat tumors with poorly defined clinical borders.
Mohs micrographic surgery requires special training. The tumor is microscopically delineated, with serial radial resection, until it is completely removed as assessed with real-time frozen sections. Noncontrolled case series suggested that the disease control rates were superior to other treatment methods for BCC.[9,11,12] However, as noted in the section on excision, the disease control rate was not clearly better when directly compared to surgical excision of facial BCCs in a randomized trial of primary BCCs.[3]
Radiation therapy
Radiation therapy is particularly useful in the management of patients with primary lesions that would otherwise require difficult or extensive surgery (e.g., nose or ears).[13] Radiation therapy eliminates the need for skin grafting when surgery would result in an extensive defect. Cosmetic results are generally good, with a small amount of hypopigmentation or telangiectasia in the treatment port. Radiation therapy can also be used for lesions that recur after a primary surgical approach.[14] Radiation therapy is avoided in patients with conditions that predispose them to radiation-induced cancers, such as xeroderma pigmentosum or basal cell nevus syndrome.
As noted above, radiation therapy has been compared to excision in a randomized trial that showed better response and cosmesis associated with surgery.[5,6]
In a single-center, randomized trial, radiation was superior to cryotherapy in local control at 2 years in 93 patients with primary BCCs.[15] Patients were randomly assigned to receive either EBRT (130 kV x-rays, dosimetry depending upon lesion size) or cryotherapy (two freeze-thaw cycles with liquid nitrogen by spray gun). Patients with lesions on the nose or ear were excluded, since the investigators felt that electron beam therapy is the treatment of choice in these locations. By 1 year, the recurrence rates in the radiation and cryotherapy arms were 4% and 39%, respectively, in a per-protocol analysis. The investigators did not perform a statistical analysis, but the authors of a systematic literature review calculated a relative risk of 0.11 in favor of radiation (95% CI, 0.03–0.43).[1][Level of evidence 1iiDiv]
Curettage and electrodesiccation
This procedure is also sometimes called electrosurgery. It is a widely employed method for removing primary BCCs, especially superficial lesions of the neck, trunk, and extremities that are considered to be at low risk for recurrence. A sharp curette is used to scrape away the tumor down to its base, followed by electrodesiccation of the lesion base. Although it is a quick method for destroying the tumor, the adequacy of treatment cannot be assessed immediately since the surgeon cannot visually detect the depth of microscopic tumor invasion.
A Cochrane Collaboration systematic review found no randomized trials comparing this treatment method with other approaches.[1] In a large, single-center case series of 2,314 previously untreated BCCs managed at a major skin cancer unit, the 5-year recurrence rate of BCCs of the neck, trunk, and extremities was 3.3%. However, rates increased substantially for tumors larger than 6 mm in diameter at other anatomic sites.[16][Level of evidence 3iiiDii]
Cryosurgery may be considered for patients with small, clinically well-defined primary tumors. It is infrequently used for the management of BCC, but may be useful for patients with medical conditions that preclude other types of surgery.
Contraindications include abnormal cold tolerance, cryoglobulinemia, cryofibrinogenemia, Raynaud disease (in the case of lesions on hands and feet), and platelet deficiency disorders. Additional contraindications to cryosurgery include tumors of the scalp, ala nasi, nasolabial fold, tragus, postauricular sulcus, free eyelid margin, upper lip vermillion border, lower legs, and tumors near nerves. Caution should also be used before treating nodular ulcerative neoplasia more than 3 cm in diameter, carcinomas fixed to the underlying bone or cartilage, tumors situated on the lateral margins of the fingers and at the ulnar fossa of the elbow, or recurrent carcinomas following surgical excision.
Edema is common following treatment, especially around the periorbital region, temple, and forehead. Treated tumors usually exude necrotic material after which an eschar forms and persists for about 4 weeks. Permanent pigment loss at the treatment site is unavoidable, so the treatment is not well suited to dark-skinned patients. Atrophy and hypertrophic scarring have been reported as well as instances of motor and sensory neuropathy.
As noted in the section above on radiation therapy, a small 93-patient trial comparing cryosurgery to radiation therapy, with only 1 year of follow-up, showed a statistically significant higher recurrence rate with cryosurgery than radiation (39% vs. 4%).[15]
In a small, single-center, randomized study, 88 patients were assigned to either cryosurgery in two freeze-thaw cycles or PDT using delta-aminolevulinic acid as the photosensitizing agent and 635 nm wavelength light with 60 J/cm2 energy delivered by Nd:YAG laser versus cryosurgery in two freeze-thaw cycles.[17] Overall clinical efficacy was similar in evaluable lesions at 1 year (5/39 recurrences for cryosurgery vs. 2/44 recurrences for PDT), but more re-treatments were needed with PDT to achieve complete responses.[17][Level of evidence 1iiD] Cosmetic outcomes favored PDT (93% good or excellent after PDT vs. 54% after cryosurgery, P < .001). In another randomized study of 118 patients, reported in abstract form only, cryosurgery was compared with PDT with methyl aminolevulinic acid.[18,19] Tumor control rates at 3 years were similar (74%), but cosmetic outcomes were better in the PDT group. These cryosurgery-PDT comparisons were reported on a per-protocol basis rather than an intent-to-treat basis.[18,19][Level of evidence 1iiDiv]
Photodynamic therapy
Photodynamic therapy with photosensitizers is used in the management of a wide spectrum of superficial epithelial tumors.[20] A topical photosensitizing agent such as 5-aminolevulinic acid or methyl aminolevulinate is applied to the tumor, followed by exposure to a specific wavelength of light (whether laser or broad band), depending upon the absorption characteristics of the photosensitizer. In the case of multiple BCCs, short-acting systemic (intravenous) photosensitizers such as verteporfin have been used investigationally.[21] Upon light activation, the photosensitizer reacts with oxygen in the tissue to form singlet oxygen species, resulting in local cell destruction.
In case series, PDT has been associated with high initial CR rates. However, substantial regrowth rates of up to 50% have been reported with long-term follow-up.[20] A randomized trial of PDT versus excision is summarized in the section on simple excision above.[7] Two small trials, one reported in abstract form only, comparing PDT with cryosurgery are summarized in the cryosurgery section above, showing similar antitumor efficacy but better cosmesis with PDT.[17,18,19]
Topical fluorouracil (5-FU)
Topical 5-FU, as a 5% cream, may be useful in specific limited circumstances. It is a Food and Drug Administration (FDA)-approved treatment for superficial BCCs in patients for whom conventional methods are impractical, such as individuals with multiple lesions or difficult treatment sites. Safety and efficacy in other indications have not been established.[22,23][Level of evidence: 3iiiDiv] Given the superficial nature of its effects, nonvisible dermal involvement may persist, giving a false impression of treatment success. In addition, the brisk accompanying inflammatory reaction may cause substantial skin toxicity and discomfort in a large proportion of patients.
Imiquimod topical therapy
Imiquimod is an agonist for the toll-like receptor 7 and/or 8, inducing a helper T-cell cytokine cascade and interferon production. It purportedly acts as an immunomodulator. It is available as a 5% cream and is used in schedules ranging from twice weekly to twice daily over 5 to 15 weeks. Most of the experience is limited to case series of BCCs that are less than 2 cm2 in area and that are not in high-risk locations (i.e., within 1 cm of the hairline, eyes, nose, mouth, ear; or in the anogenital, hand, or foot regions).[23] Follow-up times have also been generally short. Reported CR rates vary widely, from about 40% to 100%.[23][Level of evidence 3iiiDiv]
There have been a number of randomized trials of imiquimod.[24,25,26,27,28,29] However, the designs of all of them make interpretation of long-term efficacy impossible. Most were industry-sponsored dose-finding studies, with small numbers of patients on any given regimen; and patients were only followed for 6 to 12 weeks, with excision at that time to determine histologic response.[Level of evidence 1iDiv] Therefore, although imiquimod is an FDA-approved treatment for superficial BCCs, some investigators in the field do not recommend it for initial monotherapy for BCC; some reserve it for patients with small lesions in low-risk sites who cannot undergo treatment with more established therapies.[23]
Carbon dioxide laser
This method is used very infrequently in the management of BCC because of the difficulty in controlling tumor margins.[30] Few clinicians have extensive experience with the technique for BCC treatment. There are no randomized trials comparing it with other modalities.
Treatment for Recurrent Basal Cell Carcinoma of the Skin
After treatment for BCC, patients should be followed clinically and examined regularly. Most recurrences occur within 5 years, but as noted above, about 18% of recurrences are diagnosed beyond that point.[2] Patients who develop a primary BCC are also at increased risk of subsequent primary skin cancers because the susceptibility of their sun-damaged skin to additional cancers persists.[31,32,33] This effect is sometimes termed field carcinogenesis. Age at diagnosis of the first BCC (<65 years), red hair, and initial BCC on the upper extremities appear to be associated with higher risk of subsequent new BCCs.[34]
Mohs micrographic surgery is commonly used for local recurrences of BCC. In a separate group within a randomized trial comparing excision to Mohs micrographic surgery for primary BCCs, 204 recurrent BCCs were randomly assigned to excision versus Mohs micrographic surgery. The recurrence rates were 8 out of 102 patients and 2 out of 102 patients, respectively, after a mean follow-up of 2.08 years (P = NS).[3][Level of evidence 1iiDii] There were more postoperative complications, including wound infections, graft necrosis, or bleeding in the excision group than the Mohs surgery group (19% vs. 8%, P = .021). As with primary tumors, the operative costs associated with Mohs surgery were higher than with excision (489.06 Euros vs. 323.49 Euros [P = .001]).
Treatment for Metastatic Basal Cell Carcinoma (or Advanced Disease Untreatable by Local Modalities)
Metastatic and far-advanced BCC is rare, and reports of systemic therapy are limited to case reports and very small case series with tumor response as the endpoint.[35][Level of evidence 3iiiDiv] Cisplatin, alone or in combination with other drugs, is the most commonly reported systemic therapy and appears to be associated with the best tumor-response rates.[36,37] A variety of other agents have been reported but have low-associated response rates, including cyclophosphamide, vinblastine, 5-FU, methotrexate, and doxorubicin.[36]
Since there is no standard therapy, clinical trials are appropriate if available. Because BCCs often exhibit constitutive activation of the Hedgehog/PTCH1-signaling pathway, Hedgehog pathway inhibitors are under investigation.[38] An orally administered Hedgehog pathway inhibitor (GDC-0449) has produced objective responses in patients with advanced or metastatic sporadic BCC,[39] and another topical inhibitor has produced objective responses in patients with nevoid basal cell carcinoma syndrome.[40][Level of evidence: 3iiiDiv]
Information about ongoing clinical trials is available from the NCI Web site.
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with basal cell carcinoma of the skin. 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.
Localized squamous cell carcinoma (SCC) of the skin is a highly curable disease.[1] There are a variety of treatment approaches to localized SCC, including excision, radiation therapy, cryosurgery, and electrodesiccation and curettage. Mohs micrographic surgery is a form of tumor excision that involves progressive radial sectioning and real-time examination of the resection margins until adequate uninvolved margins have been achieved, avoiding wider margins than needed.
There is little or no good-quality evidence that allows direct comparison of outcomes for patients with sporadic, clinically localized SCCs treated with local therapies. A systematic literature review found only one randomized controlled trial in the management of such patients, and that trial compared adjuvant therapy to observation after initial local therapy rather than different local therapies.[2] In that small single-center trial, 66 patients with high-risk, clinically localized SCC were assigned randomly, after surgical excision of the primary tumor (with or without radiation, depending on clinical judgment), to receive either combined 13-cis-retinoic acid (1 mg/kg orally per day) plus interferon-alpha (3 × 106 U subcutaneously 3 times/week) for 6 months or to observation.[3] In the 65 evaluable patients after a median follow-up of 21.5 months, there was no difference in the combined (primary) endpoint of SCC recurrence or second primary tumor (45% vs. 38%; hazard ratio = 1.13; 95% confidence interval [CI], 0.53–2.41), nor in either of the individual components of the primary endpoint.[3][Level of evidence 1iiDii]
Absent high-quality evidence from controlled clinical trials, the management of clinically localized cutaneous SCC is based upon case series and consensus statements from experts.[4] The commonly used treatments are listed below.
Treatment for Squamous Cell Carcinoma of the Skin
Surgical excision with margin evaluation
Excision is probably the most common therapy for SCC.[4] This traditional surgical treatment usually relies on surgical margins ranging from 4 mm to 10 mm, depending on the diameter of the tumor and degree of differentiation. In a prospective case series of 141 SCCs, a 4-mm margin was adequate to encompass all subclinical microscopic tumor extension in more than 95% of well-differentiated tumors up to 19 mm in diameter. Wider margins of 6 mm to 10 mm were needed for larger or less-differentiated tumors or tumors in high-risk locations (e.g., scalp, ears, eyelids, nose, and lips).[5] Re-excision may be required if the surgical margin is found to be inadequate on permanent sectioning.
Mohs micrographic surgery is a specialized technique used to achieve the narrowest margins necessary to avoid tumor recurrence, while maximally preserving cosmesis. In case series, it has been associated with a lower local recurrence rate than the other local modalities,[6] but there are no randomized trials allowing direct comparison.[2] This surgery is best suited to the management of tumors in cosmetically sensitive areas or for tumors that have recurred after initial excision (e.g., eyelid periorbital area, nasolabial fold, nose-cheek angle, posterior cheek sulcus, pinna, ear canal, forehead, scalp, fingers, and genitalia).[7,8]
Mohs micrographic surgery is also often used to treat high-risk tumors with poorly defined clinical borders or with perineural invasion. The method requires special training. The tumor is microscopically delineated, with serial radial resection, until it is completely removed as assessed with real-time frozen sections. Nevertheless, since the technique removes tumor growing in contiguity and may miss noncontiguous in-transit cutaneous micrometastases, some practitioners remove an additional margin of skin in high-risk lesions even after the Mohs surgical procedure confirms uninvolved margins.[4][Level of evidence: 3iiiDiv]
Radiation therapy is a logical treatment choice, particularly for patients with primary lesions requiring difficult or extensive surgery (e.g., nose, lip, or ears).[4,9] Radiation therapy eliminates the need for skin grafting when surgery would result in an extensive defect. Cosmetic results are generally good, with a small amount of hypopigmentation or telangiectasia in the treatment port. Radiation therapy can also be used for lesions that recur after a primary surgical approach.[10] Radiation therapy is avoided in patients with conditions that predispose them to radiation-induced cancers, such as xeroderma pigmentosum or basal cell nevus syndrome.
Although radiation therapy, with or without excision of the primary tumor, is used for histologically proven clinical lymph node metastases and has been associated with favorable disease-free survival rates, the retrospective nature of these case series makes it difficult to know the impact of nodal radiation on survival.[11,12][Level of evidence 3iiiDii]
This procedure is also sometimes called electrosurgery. A sharp curette is used to scrape the tumor down to its base, followed by electrodesiccation of the lesion base. Although it is a quick method for destroying the tumor, the adequacy of treatment cannot be assessed immediately since the surgeon cannot visually detect the depth of microscopic tumor invasion. Its use is limited to small (<1 cm), well-defined, and well-differentiated tumors.[4][Level of evidence: 3iiiDii]
Cryosurgery may be considered for patients with small, clinically well-defined primary tumors. It may be useful for patients with medical conditions that preclude other types of surgery. Contraindications include abnormal cold tolerance, cryoglobulinemia, cryofibrinogenemia, Raynaud disease (in the case of lesions on hands and feet), and platelet deficiency disorders. Additional contraindications to cryosurgery include tumors of the scalp, ala nasi, nasolabial fold, tragus, postauricular sulcus, free eyelid margin, upper lip vermillion border, lower legs, and tumors near nerves. Caution should also be used before treating nodular ulcerative neoplasia more than 3 cm in diameter, carcinomas fixed to the underlying bone or cartilage, tumors situated on the lateral margins of the fingers and at the ulnar fossa of the elbow, or recurrent carcinomas following surgical excision.
Edema is common following treatment, especially around the periorbital region, temple, and forehead. Treated tumors usually exude necrotic material after which an eschar forms and persists for about 4 weeks. Permanent pigment loss at the treatment site is unavoidable, so the treatment is not well suited to dark-skinned patients. Atrophy and hypertrophic scarring have been reported as well as instances of motor and sensory neuropathy.
The management of SCC in situ (Bowen disease) is similar to good-risk SCC. However, since it is noninvasive, surgical excision, including Mohs micrographic surgery, is usually not necessary. In addition, high complete response (CR) rates are achievable with photodynamic therapy (PDT). In a multicenter trial, 229 patients (209 evaluated in the per-protocol/per-lesion analysis) were randomly assigned to receive PDT (methyl aminolevulinate + 570–670 nm red light; n = 91), placebo cream with red light (n = 15); or treatment by physician choice (cryotherapy, n = 77; topical 5-fluorouracil, N = 26).[13] The sustained complete clinical response rates at 12 months were 80%, 67%, and 69% in the three respective active therapy groups (P = .04 for the comparison between PDT and the two combined physician-choice groups).[13][Level of evidence 1iiDii] The cosmetic results were best in the PDT group. (For comparison, the CR rates at 3 months for PDT and placebo/PDT were 93% and 21%, respectively.)
Treatment for Recurrent Squamous Cell Carcinoma of the Skin
SCCs have definite metastatic potential, and patients should be followed regularly after initial treatment. Overall, local recurrence rates after treatment of primary SCCs ranged from about 3% to 23%, depending upon anatomic site.[6] About 58% of local recurrences manifest within 1 year, 83% within 3 years, and 95% within 5 years. The metastatic rate for primary tumors of sun-exposed skin is 5%; for tumors of the external ear, 9%; and for tumors of the lip, 14%. Metastases occur at an even higher rate for primary SCCs in scar carcinomas or in nonexposed areas of skin (about 38%).[6] About 69% of metastases are diagnosed within 1 year, 91% within 3 years, and 96% within 5 years. Tumors that are 2 cm or larger in diameter, 4 mm or greater in depth, or poorly differentiated have a relatively bad prognosis [14] and even higher local recurrence and metastasis rates than those listed.[6] Reported rates also vary by treatment modality, with the lowest rates associated with Mohs micrographic surgery, but at least some of the variation may be the result of patient selection factors; no randomized trials directly compare the various local treatment modalities.
Recurrent nonmetastatic SCCs are considered high risk and are generally treated with excision, often using Mohs micrographic surgery. Radiation therapy is used for lesions that cannot be completely resected.
As is the case with BCC, patients who develop a primary SCC are also at increased risk of subsequent primary skin cancers because the susceptibility of their sun-damaged skin to additional cancers persists.[15,16]
Treatment for Metastatic Squamous Cell Carcinoma (or Advanced Disease Untreatable by Local Modalities)
As is the case with BCC, metastatic and far-advanced SCC is unusual, and reports of systemic therapy are limited to case reports and very small case series with tumor response as the endpoint.[Level of evidence 3iiiDiv] Cisplatin-based regimens appear to be associated with high initial tumor response rates.[17,18] High response rates have also been reported with the use of 13-cis-retinoic acid plus interferon-alpha-2a.[19] Since there is no standard therapy, clinical trials are appropriate if available. Information about ongoing clinical trials is available from the NCI Web site.
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with squamous cell carcinoma of the skin. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
Actinic keratoses commonly appear in areas of chronic sun exposure, such as the face and dorsa of the hands. Actinic cheilitis is a related condition that usually appears on the lower lips.[1] These conditions represent early epithelial transformation that may eventually evolve into invasive SCC.
Actinic keratosis is a noninvasive lesion. The progression rate is extremely low. In a prospective study, the progression rate to SCC was less than 1 in 1,000 per year, calling into question the cost effectiveness of treating all actinic keratoses to prevent SCC.[2] Moreover, in a population-based longitudinal study, there was an approximately 26% spontaneous regression rate of solar keratoses within 1 year of a screening examination.[3] Therefore, studies designed to test the efficacy of any treatment for progression of actinic keratoses to SCC are impractical (or impossible). Nevertheless, a variety of treatment approaches have been reviewed.[4]
Treatment for Actinic Keratosis
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with actinic keratosis. 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.
Editorial changes were made to this summary.
Purpose of This Summary
This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the treatment of skin cancer. 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 Skin Cancer 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.
Permission to Use This Summary
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® Skin Cancer Treatment. Bethesda, MD: National Cancer Institute. Date last modified <MM/DD/YYYY>. Available at: http://cancer.gov/cancertopics/pdq/treatment/skin/HealthProfessional. Accessed <MM/DD/YYYY>.
Images in this summary are used with permission of the author(s), artist, and/or publisher for use within the PDQ summaries only. Permission to use images outside the context of PDQ information must be obtained from the owner(s) and cannot be granted by the National Cancer Institute. Information about using the illustrations in this summary, along with many other cancer-related images, is available in Visuals Online, a collection of over 2,000 scientific images.
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.
Contact Us
More information about contacting us or receiving help with the Cancer.gov Web site can be found on our Contact Us for Help page. Questions can also be submitted to Cancer.gov through the Web site's Contact Form.
Call 1-800-4-CANCER
For more information, U.S. residents may call the National Cancer Institute's (NCI's) Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237) Monday through Friday from 8:00 a.m. to 8:00 p.m., Eastern Time. A trained Cancer Information Specialist is available to answer your questions.
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The NCI's LiveHelp® online chat service provides Internet users with the ability to chat online with an Information Specialist. The service is available from 8:00 a.m. to 11:00 p.m. Eastern time, Monday through Friday. Information Specialists can help Internet users find information on NCI Web sites and answer questions about cancer.
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For more information from the NCI, please write to this address:
Search the NCI Web site
The NCI Web site provides online access to information on cancer, clinical trials, and other Web sites and organizations that offer support and resources for cancer patients and their families. For a quick search, use the search box in the upper right corner of each Web page. The results for a wide range of search terms will include a list of "Best Bets," editorially chosen Web pages that are most closely related to the search term entered.
There are also many other places to get materials and information about cancer treatment and services. Hospitals in your area may have information about local and regional agencies that have information on finances, getting to and from treatment, receiving care at home, and dealing with problems related to cancer treatment.
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The NCI has booklets and other materials for patients, health professionals, and the public. These publications discuss types of cancer, methods of cancer treatment, coping with cancer, and clinical trials. Some publications provide information on tests for cancer, cancer causes and prevention, cancer statistics, and NCI research activities. NCI materials on these and other topics may be ordered online or printed directly from the NCI Publications Locator. These materials can also be ordered by telephone from the Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237).
Last Revised: 2012-07-20
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Find us on:
39 Broadway, Suite 2700New York, NY 10006
1-800-GOL-IVER (Voice - Toll-free)212-668-1000 (Voice)212-483-8179 (FAX)
The American Liver Foundation (ALF) was formed in 1976 to promote and fund research on liver diseases -- hepatitis, liver cancer, pediatric liver disease, other liver diseases and injuries -- and to inform the public about these diseases. Research grants are awarded to physician, student and postdoctoral researchers, and prizes are presented for the best research projects. ALF sponsors postgraduate courses on liver disease diagnosis and management for physicians and other health professionals. A nationwide network of chapters and support groups exists to help patients and their families. ALF also sponsors a national organ donor program to increase public awareness of the continuing need for organs.
ALF publishes pamphlets and information sheets on liver diseases, liver functions, and preventive measures. Serial publications: Progress (newsletter), quarterly--news stories on ALF activities and liver research developments; and Liver Update (newsletter), semiannually--summarizes liver research for physicians. Videos: A Healthy Liver--A Happier Life; Foundations for Decision Making; Hepatitis B: Patient Information; and Hepatitis C, for healthcare professionals.
Tuesday, Jul 28, 2009
Language Assistance Available

subset: commoncrawl


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Icon - Black (In Stock)
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100% Recycled Polyester
Acrylic Backing With Teflon® Finish
400,000 Double Rubs (cotton duck)
11.5 ounces per linear yard
No Repeat (Pattern is woven up the roll and suitable for railroading)
Icon is part of the Del Mar/Icon Collection. For more information about specifications and available colors, click here to download the Del Mar/Icon sample card.
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text:
By the way, I couldn't add the skip function.
I'm sorry to make you tolerate frustration to see how things going
on every time.
[How to play GROW game series]
Drag panels in your selected order.
Items you drag will grow and grow with each turn.
You will complete the game when all panels' level is max.
They effect each other as they grow.
So you have to think about the dragging order.


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Dining Al Fresco
Larimer Square
1430 Larimer St.
Denver, CO 80202
Larimer Square
1430 Larimer St.
Denver, CO 80202
Sure, you could fight your way into a one-square-foot patio space at Avanti Food & Beverage—but we'd recommend adding a little luxury to your outdoor dining experience. Swanky eateries including Rioja, TAG, and Bistro Vendome extend their fresh-air seating areas into the street during this traffic-stopping evening, creating an outdoor foodie's paradise that stretches throughout Larimer Square. Pick your favorite restaurant (10 have signed on so far), make a reservation, and enjoy LoDo's communal Edison-bulbed back deck.
—Photo courtesy of Jacey McDaniel
- Category:
- Culinary
- Date:
- Jul 22, 2017 5 p.m. - 10 p.m.
- Cost:
- Prices vary.


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Tim Jones
Rebellion "proud" of AvP violence
Rebellion told us that Aliens vs Predator's violence is something the studio's "proud of," but that a high level of gore was "essential" for the reboot.
Tim Jones headlines
AvP Special Edition DLC available to all "soon after release"
The four day one DLC maps only available in the Aliens vs Predator Special Edition will be openly available soon, Rebellion told VG247 today, adding that you should "watch this space" for further content.
Rebellion says PC community helped with the development of AvP
Rebellion's head of design, Tim Jones, has told IncGamers that the PC community helped with the development of Aliens vs Predator, and that the support of said community pushed the team to "deliver everything [it] can with AvP". "The PC community is the grass roots that drive us to deliver everything we can with AvP," […]
Rebellion thinks it's "great" that more than one Alien game is coming
Rebellion's Tim Jones has told D'Toid that he thinks it's terrific that more Alien games are in the works, even if it's not being made by the firm, apparently. "As a life-long Aliens fan, I think it's terrific that Sega is publishing more than one Aliens game in the near future," he told the site. […]
Aliens and Predators still relevant, say Sega and Rebellion
Aliens and Predators may have been de rigueur back in the 80s, but they're just as relevant now as they ever were, AvP dev Tim Jones told us at GamesCom. "I think it's still very much relevant to the younger audience," said the Rebellion man. "The comics and graphic novels still sell well, and the […]
AvP multiplayer reveal "later this year," class system dropped?
Rebellion's told Gamespot that a first look at AvP multiplayer will happen this year. Comforting. "Our multiplayer reveal will be happening later this year," said art head Tim Jones. "Suffice to say that you will able to play as all three species and there are some great game modes that make the most of each […]
Tim Jones latest
AvP Special Edition DLC available to all "soon after release"
Rebellion says PC community helped with the development of AvP
Rebellion thinks it's "great" that more than one Alien game is coming
AvP multiplayer reveal "later this year," class system dropped?


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Unmatched Direct Selling Law Expertise
The environment in which the MLM and direct selling industry must operate has put a premium on effective legal counsel. Direct selling and MLM companies must strategically and tactically prepare for this environment. Such preparation demands a breadth and depth of experience from your attorney in all aspects of corporate operations, as well as in the law of direct selling and multilevel marketing.
The legal services we provide extend far beyond the specific laws surrounding the MLM and direct selling industry. Indeed, our comprehensive legal services are designed to help you successfully navigate the expansive labyrinth of federal, state and international statutes and regulations, as well as the confusing world of contracts, litigation, labor and other law associated with domestic and international business.
Additional services extend beyond what clients typically expect from their attorney, and can help companies achieve their business objectives, ensure their long-term existence and, ultimately, save them money.
The Legal Audit essentially takes and presents a direct selling or MLM company with a legal photograph, or perhaps more precisely, a CAT scan of the legal inner-workings of its organization and operation. To the extent that deficiencies are discovered, the Legal Audit also furnishes clients a prognosis and a remedial course of action.
General Counsel At Your Service(SM) provides direct selling and MLM companies with an attorney for across-the-board, long-term legal support to address the diverse panoply of legal issues that regularly arise in the course of business.


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Sesame Sauce Recipes
Mirchi Ka Salan Recipe
I just learned how to make a variant of mirchi ka salan by Sheerin Auntie, who came to visit us during winter break week. This version is made with only white sesame seeds and originated from the region of Lucknow (Lakhnau) where Abbi, my husband Lulu's late grandfather was born. The previous version was taught by Baji (Lulu's late grandmother); they lived in Hyderabad where mirchi ka salan is made with peanut, fresh coconut and sesame.
The sesame seed variant is quite a bit milder. The sesame seeds are blended into a thick paste (tahini), then added to cumin-flavored oil (baghar). Whole chile peppers are cooked in the sesame mixture until softened. A drizzle of lemon juice finishes the dish. It's as simple as that. Prior to cooking the mirchi ("chiles" in Urdu), I had to be brave and estimate the level of spiciness of the peppers. If the heat is too fiery, you could cut a longitudinal slit and remove the seeds and more of the sesame sauce will enter in the cavity of the chiles for a milder taste.
Full Recipe...
Khatta Recipe: Indian Sesame and Tamarind Sauce
Khatta is an Indian condiment that is generally served as an accompaniment to khichdi (coral lentil basmati rice). Unlike raita (Indian yogurt sauce) or chutneys, khatta has a thin consistency. Toasted sesame seeds are ground into a thick paste (tahini) and mixed with green chiles and tamarind. The sauce is then diluted with water and mixed with thinly sliced onions. The finishing touch is the usual top layer of baghar, which consists of fried garlic, cumin seeds, curry leaves and dried chiles.
The recipe was provided by Lulu's aunt, Sheerin Auntie, who is an amazing, gifted cook. Love is the most important ingredient that is required in any dish, and she has it in boundless quantities. She has agreed to teach me several Indian dishes that I've been wanting to learn, and of course, I'll share them with you once I know them well. Thank you, Sheerin Auntie for teaching me so many valuable lessons, culinary and otherwise.
Full Recipe...


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Our Tweet
The Mirage 2 builds on the platform of the original, strapping on a streamlined upper for a little more get up and go.
(View Men's Mirage 2 and Women's Mirage 2)
Big Updates
- Redesigned Upper: By using fewer overlays, Saucony gave the Mirage 2 a sleeker design and enhanced fit.
Road Test
The original Mirage offered a smooth, stable ride that got rave reviews. Saucony didn't mess with success in this latest version, keeping the mid/outsole unchanged from the original Mirage. Our testers couldn't tell a difference in the ride of the new Mirage, and they still appreciate the shoe's near-effortless heel-to-toe transition.
Or should we say midfoot-to-toe transition? While the Mirage will accommodate a heel striker, it's really designed for the runner who lands with a midfoot or even forefoot strike. Think again if you're expecting this shoe to be a Kinvara with a little pronation control. The ride of the Mirage is firmer, and it has a couple ounces on the Kinvara (though the Mirage is by no means a beefy shoe).
There were no surprises in the ride of the Mirage 2 – a good thing – but testers had mixed feelings about the new upper design. On the positive side, most testers preferred the overall fit, which is a little more snug than the original Mirage but never constricting. They also liked that the medial side of the upper is more supportive, working in concert with the midsole technology to keep the foot properly aligned. On the flip side, a few testers found the shoe to fit a little too loose in the midfoot, and several wondered if the tighter mesh knit of the new design would be as breathable as the mesh on the original.
Overall, this shoe will continue to appeal to runners who are looking for a daily trainer that will help ease them into more of a midfoot strike, and stick by them on race day as well. It's almost certain that the Mirage fan base will be getting bigger with this latest update.
Runners Say
"The reduced volume in the shoe fits my foot much better than the original Mirage." – Lauren
"The Mirage 2 deserves to be considered along with other minimum support shoes including the Mizuno Elixir and Asics Gel DS Trainer." – Matt
"The low-to-the-ground, responsive feel is what I look for in a shoe that can do mixed duty for training and longer races." – Daniel


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Family Constellations was developed by Bert Hellinger during his observation of Zulu tribes. It is an effective way to transform what is holding you back so that you can live your life from your greatest potential. They uncover and dissolve the blockages affecting your relationships, finances, profession, and health so you are free to live the fulfilling life you were really meant to live.
You are about to embark on a soul journey. Are you ready?
Some of the Benefits of Family Constellations:
- Improving your relationships (parents, partner, children, colleagues, etc.)
- Turning your past into a source of strength
- Acquiring a healing inner image of your family
- Freeing you and your descendants from invisible burdens
- Transforming your blockages and self-sabotage
- Increasing your empathy, love, and compassion for yourself and others
- Opening your heart to love
This powerful soul work assists in creating positive shifts in:
- Relationships
- Success in life
- Recurring emotions (depression, fear, anxiety, sadness, feeling unworthy or unrooted, blockages, stagnation etc.)
- Achieving life goals
- Finances
- Unexplained symptoms
- Health
- Self-sabotage
- Infertility
- Addictions etc.
"A miracle is a shift in perception", says The Course of Miracles. That is exactly what begins to happen after Family Constellations. However, that is only the beginning.
Date: Saturday, August 18 & Sunday, August 19 - option to attend for Saturday only or entire weekend.
Cost: $95 for Saturday only; $175 for Saturday and Sunday *pre-registration required by August 16.
Debra Franklin, LCSW
As a Licensed Clinical Social Worker and 30 years of experience, Debra provides psychotherapeutic services for adults, couples, families, adolescents, and children individually and in groups in Ellenville, NY. In Connecticut and New York, she offers workshops and training for psychotherapists in "Heart Path Therapy" that she developed. She integrates approaches from her training in ancient shamanic practices, inner child work, Family Constellations, conscious communication, Reiki, guided imagery, and energy psychology.
She has helped hundreds of people move beyond emotional challenges including depression, anxiety, and relationship difficulties. She empowers people to become joyfully inspired to find and fulfill their higher spiritual life's purpose or mission. See progressivepsychotherapy.com for more information.


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The injected form of sumatriptan is used to treat
cluster headaches. Self-injection kits are available
so that you can give yourself the shot. Nasal and oral sumatriptan are also
You can take zolmitriptan as a pill (by mouth) or use
it as a nasal spray.
Triptans (sometimes referred to as
5-HT-1 receptor agonists) shrink the blood vessels in the brain, which may
relieve pain by reducing pressure from
inflammation that can occur with cluster headaches.
Triptans may also affect certain brain chemicals that regulate pain.
These drugs are used to quickly stop cluster headache pain.
A shot of sumatriptan works very well to stop a cluster headache. When injected soon after a cluster headache starts, sumatriptan can stop headache pain within 15 minutes.1
Nasal and oral sumatriptan and zolmitriptan all work to stop cluster headaches. But they may not work as quickly or as well as a shot of sumatriptan.
All medicines have side effects. But many people don't feel the side effects, or they are able to deal with them. Ask your pharmacist about the side effects of each medicine you take. Side effects are also listed in the information that comes with your medicine.
Here are some important things to think about:
Call 911 or other emergency services right away if you have:
Call your doctor right away if you have:
Common side effects of this medicine include:
See Drug Reference for a full list of
side effects. (Drug Reference is not available in all systems.)
It is
important that you do not use triptans daily to treat or prevent
cluster headaches. Overuse of triptans can cause you to have more headaches
when the medicine wears off. These are called
rebound headaches. If you feel like you need to use
triptans often, talk to your doctor. He or she may have you try a different
Medicine is one of the many tools your doctor has to treat a health problem. Taking medicine as your doctor suggests will improve your health and may prevent future problems. If you don't take your medicines properly, you may be putting your health (and perhaps your life) at risk.
There are many reasons why people have trouble taking their medicine. But in most cases, there is something you can do. For suggestions on how to work around common problems, see the topic Taking Medicines as Prescribed.
If you are pregnant, breast-feeding, or planning to get pregnant, do not use any medicines unless your doctor tells you to. Some medicines can harm your baby. This includes prescription and over-the-counter medicines, vitamins, herbs, and supplements. And make sure that all your doctors know that you are pregnant, breast-feeding, or planning to get pregnant.
Follow-up care is a key part of your treatment and safety. Be sure to make and go to all appointments, and call your doctor if you are having problems. It's also a good idea to know your test results and keep a list of the medicines you take.
Complete the new medication information form (PDF)(What is a PDF document?) to help you understand this medication.
CitationsCapobianco DJ, Dodick DW (2006). Diagnosis and
treatment of cluster headache. Seminars in Neurology,
26(2): 242–259.
Last Revised:
May 14, 2012
Healthwise Staff
Medical Review:
Anne C. Poinier, MD - Internal Medicine & Colin Chalk, MD, CM, FRCPC - Neurology
This information does not replace the advice of a doctor. Healthwise, Incorporated disclaims any warranty or liability for your use of this information. Your use of this information means that you agree to the Terms of Use. How this information was developed to help you make better health decisions.
To learn more visit Healthwise.org
© 1995-2012 Healthwise, Incorporated. Healthwise, Healthwise for every health decision, and the Healthwise logo are trademarks of Healthwise, Incorporated.


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After a slow start to the 2012 season, starter Doug Mathis has hit his stride. The 29 year old right hander is 5-3 for the PawSox after his tremendous outing in Buffalo on Thursday. The former Texas Rangers pitcher handcuffed the Bisons for 6 innings, scattering three hits en route to a 5-0 victory.Making his twelfth appearance in a PawSox uniform, Mathis scattered three hits, walked one and struck out three. He obviously felt pleased after his latest start. "It was a good game to get through. I actually didn't feel too good early in the game. In the bullpen, warming up for the game was terrible. In the first couple of innings I got lucky. I had some line drives hit right at some guys. After that, I found a little groove and I felt pretty good."
Mathis got the win while highly touted Mets prospect, Matt Harvey took the loss. Harvey is also 5-3, with two of the losses coming at the hands of the PawSox. "He was throwing the ball great. He was throwing the ball better than I was at the start of the game. We ended up getting to him in the sixth, with two outs. I was very impressed with him. Even though he ended up with the loss, it was one of the better-pitched games I've seen all year in this league."
Mathis struggled out of the blocks in April. He is a veteran and talked about the psychology of not letting it get to him and snowball. "Obviously, you want to get off to a fast start, but you realize as you get older, it isn't always how you start, it's how you finish. I would rather be a guy that finishes strong than start strong and fade down the stretch. The first couple of weeks, I was terrible. I've been working hard, working with Rich (Sauveur). It's all you can do to try to get back into it."
With the exception of Alex Wilson and Junichi Tazawa, this is a veteran pitching staff. Mathis says that working with guys like Justin Germano and Brandon Duckworth is a pleasure. "It helps because a lot of us are similar pitchers. Myself, Duck and Germano, we're not overpowering by any means. We do similar things out there. We feed off each other and talk about various things. When guys are throwing well, you want to go out there and continue it. Even though you're on the same team, you want to be competitive with your teammates." Mathis doesn't confine his praise to just the starting rotation. He likes the Pawtucket bullpen and thought that Mark Melancon set a great example for his younger teammates when he was optioned to the PawSox. "Mark was great when he came down here. Great attitude. He obviously pitched well while he was hee. He was one of the more dominant relievers in the league. He embraced his situation. He didn't feel sorry for himself. That fed off onto others, as well. Garrett Mock is throwing well. Alex Wilson has been good. I think that pretty much everybody is doing the job. That's the reason that we've been doing so well. Without a bullpen like ours, we wouldn't be doing so well. Our starters wouldn't have as many wins. Having a strong staff and a strong bullpen goes hand in hand."
Thanks to Doug Mathis, the PawSox are strong and deep on the mound.


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|Results of the 2018 herring ageing exchange
using samples from the first and fourth quarters of the 2017 NEFSC commercial samples.(A) Agreement plot, showing the ages attained by each reader. A small amount of noise was added to the data to improve visibility of overlapping data points.
(B) Age-frequency table, showing each reader's ages.
Numbers in the shaded boxes indicate agreement between the two ages. Numbers above this diagonal indicate fish which were given higher ages by the Canadian age reader; those below the shaded boxes were given higher ages by the U.S. age reader. Total age frequencies are given by age for both readers. (C) Results summary, indicating results for the U.S. reader relative to each age for the Canadian reader.
|A. Agreement Plot
B. Age-Frequency Table
C. Results Summary


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There's a Vook, a Nook, and a Que. There's a handful of Kindles and Sonys -- and something Cool-ER. And don't forget Alex!
The supply of electronic readers -- gadgets that let you read books, newspapers, and magazines -- is exploding, with Amazon.com, Sony, Barnes & Noble, and a host of publishers either entering the business or strongly considering it.
But where's the demand? Readers of books, physical or virtual, are hardly a growth market; the audience for literary works has long been declining, at an accelerating pace in recent decades.
Even more ridiculous than the profusion of e-book readers is a lawsuit filed by a Silicon Valley startup over one of them. Spring Design, a Cupertino, Calif.-based company, is suing Barnes & Noble over its Nook device. Both the Nook and Spring Design's hastily introduced Alex have dual screens, and Spring claims that Barnes & Noble "misappropriated" its design after the companies met in the spring of this year.
Even if Spring proves its allegations, so what? Being a pioneer in the e-book market strikes me as a poor prize indeed.
Take Amazon.com, maker of the Kindle. By one bullish Wall Street estimate, Amazon might sell 2.7 million Kindles next year. But even at those numbers, spottings of Kindles in the real will remain scarce. Unlike Apple's ubiquitious iPods and iPhones, sightings of celebrities toting Kindles are few and far between.
Indeed, the most successful e-reader may prove to be the iPhone, not the Kindle. Amazon smartly hedged its bets by introducing a software version of the Kindle that runs on the iPhone. And as netbooks get smaller and cheaper, it's hard to see why people would load their backpacks and purses with separate devices.
The Kindle may end up finding a niche, especially on college campuses where it might replace a heavy, expensive load of textbooks. But niches don't make for big markets. And as Spring Design and Barnes & Noble are likely to find out if their lawsuit drags on, only big markets are worth fighting over.


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|Thread Tools
|Display Modes
For The Glory Of The City
Join Date: Sep 2002
Location: Kansas City
Casino cash: $13868
The GOP's media cocoon
A long-simmering generational battle in the conservative movement is boiling over after last weeks shellacking, with younger operatives and ideologues going public with calls that Republicans break free from a political-media cocoon that has become intellectually suffocating and self-defeating.
GOP officials have chalked up their electoral thumping to everything from the countrys changing demographics to an ill-timed hurricane and failed voter turn-out system, but a cadre of Republicans under 50 believes the partys problem is even more fundamental.
The party is suffering from Pauline Kaelism.
Kael was The New Yorker movie critic who famously said in the wake of Richard M. Nixons 49-state landslide in 1972 that she knew only one person who voted for Nixon.
Now, many young Republicans worry, they are the ones in the hermetically sealed bubble except its not confined to geography but rather a self-selected media universe in which only their own views are reinforced and an alternate reality is reflected.
Hence the initial denial and subsequent shock on the right that the country would not only reelect President Barack Obama but do so with 332 electoral votes.
What Republicans did so successfully, starting with critiquing the media and then creating our own outlets, became a bubble onto itself, said Ross Douthat, the 32-year-old New York Times columnist.
The right is suffering from an era of on-demand reality, is how 30-year-old old think tanker and writer Ben Domenech put it.
Citing Kael, one of the most prominent Republicans in the George W. Bush era complained: We have become what the left was in the 70s insular.
In this reassuring conservative pocket universe, Rasmussen polls are gospel, the Benghazi controversy is worse than Watergate, Fair and Balanced isnt just marketing and Dick Morris is a political seer.
Even this past weekend, days after a convincing Obama win, it wasnt hard to find fringes of the right who are convinced he did so only because of mass voter fraud and mysteriously missing military ballots. Like a political version of Thelma and Louise, some far-right conservatives are in such denial that theyd just as soon keep on driving off the cliff than face up to a reality theyd rather not confront.
But if the Fox News-talk radio-Drudge Report axis is the most powerful force in the conservative cocoon, technology has rendered even those outlets as merely the most popular destinations in the choose-your-own-adventure news world in which consumers are more empowered than ever.
Facebook and Twitter feeds along with email in-boxes have taken the place of the old newspaper front page, except that the consumer is now entirely in charge of what he or she sees each day and can largely shut out dissenting voices. Its the great irony of the Internet era: People have more access than ever to an array of viewpoints, but also the technological ability to screen out anything that doesnt reinforce their views.
The Internet amplifies talk radio and cable news, and provides distribution for other sources like Newsmax, said Trey Grayson, 40, the former Kentucky secretary of state and the current head of Harvards Institute of Politics. Then your friends, who usually agree with you, disseminate the same stories on Facebook and Twitter. And you assume that everyone agrees with you!
Grayson continued: Its very striking for me living in Cambridge now. My Facebook feed, which is full of mostly conservatives from Kentucky, contains very different links to articles or topics than what I see in Cambridge. It is sort of the reverse up here. They dont understand how anyone would eat Chick-fil-A, watch college sports or hold pro-life views.
Social media has made it easier to self-select, added 45-year-old GOP strategist Bruce Haynes. Who do you follow on Twitter, who do you friend on Facebook? Do they all look the same and say the same things? If so, youve created a universe for yourself that is wedded to its own self-fulfilling prophecies.
Like Grayson, Haynes and many of the approximately two-dozen young Republicans interviewed for this story noted that Democrats have their own self-reassuring echo chambers.
What worries Republicans, though, is that their Kaelism may be harder to overcome in the short term.
Unfortunately, for us Republicans who want to rebuild this party, the echo chamber [now] is louder and more difficult to overcome, said Grayson.
Thats partly because of the difference between the two cocoons in the two parties.
First, the Al Sharptons and Rachel Maddows of the left dont have the same influence as their counterparts on the right. There are as many, if not more, NPR-oriented liberals as MSNBC devotees on the left; the Democratic media ecosystem is larger and more diverse.
Further, and more importantly, the Democratic Party has a leader in Obama who for over four years has sought to appeal to a majority of Americans for the obvious political reasons.
Being a Democrat means being identified with Barack Obama, not Ed Schultz and Martin Bashir, said Douthat, citing two liberal MSNBC hosts.
Conversely, for nearly six years, since President Bushs second term went south, Republicans have been effectively without a leader. And into that vacuum has stepped a series of conservative figures whose incentives in most cases are not to win votes but to make money and score ratings by being provocative and even outlandish.
Their bottom line is their main goal, but that doesnt mean theyre serving the population that buys their books, said Domenech.
And this, say next-generation Republicans, is where cocoonism has been detrimental to the cause.
The tension between the profit- and ratings-driven right call them entertainment-based conservatives and conservatives focused on ideas (the thinkers) and winning (the operatives) has never been more evident.
The latter group worries that too many on the right are credulous about the former.
Dick Morris is a joke to every smart conservative in Washington and most every smart conservative under the age of 40 in America, said Douthat. The problem is that most of the people watching Dick Morris dont know that.
The egghead-hack coalition believes that the entertainment-based conservatives create an atmosphere that enables flawed down-ballot candidates, creates a cartoonish presidential primary and blocks needed policy reforms, and generally leave an odor on the party that turns off swing voters.
It even fosters an atmosphere in which theres a disconnect with the ostensible party leaders.
Consider: In the fall of the past two presidential campaigns, those in the conservative cocoon were talking about, respectively, the Rev. Jeremiah Wright and Obama as a black radical, and the seemingly impeachment-worthy scandal surrounding the deaths of U.S. officials in Libya. Meanwhile, on the actual campaign trail, John McCain and Mitt Romney showed little interest in even mentioning either topic.
And the entertainers power isnt just with gullible grass-roots activists who are likely to believe whatever nefarious rumor about Obama is forwarded to them in an e-mail chain its with donors, too.
Outside of Washington, New York and state capitals, the big conservative givers are as likely to have read Ed Kleins Obama book and seen Dinesh DSouzas documentary 2016, and generally parrot whatever they just heard on Fox News as the old lady stuffing envelopes at county GOP headquarters.
One of the reasons the entertainment complex has the influence they do is because the people who are supposed to be responsible figures in the party, those who fund the campaigns, have bought into this apocalyptic world view, said Douthat.
More than a few Republicans said it was such donors whom Romney was trying to impress when he infamously riffed about the 47 percent, a variation of the makers-versus-takers world view that has become popular in the conservative cocoon (Rush Limbaugh has called Obama Santa Claus since Election Day).
The tension between entertainers and operatives-thinkers may have come into sharpest relief in the prolonged, and for many Republicans, painful 2012 GOP primary. The thinkers and the operatives cringed at the umpteen debates and carnival-like procession of candidates with little chance of landing in the Oval Office.
Look at Newt Inc., [Herman] Cain and [Michele] Bachmann, sighed Haynes. Whats the purpose of entering a presidential primary anymore?
Suggesting the incentives for getting in the race now owe as much to fame as to winning the job, Haynes added: If that market didnt exist, what would our primary look like?
The sexual harassment scandal around Cain offered a vivid example of the different goals of the two groups. To the entertainment-based right, it was a great opportunity to rally the faithful against a purportedly liberal media targeting a black conservative. It touched almost every erogenous zone for the likes of Rush Limbaugh. But for the operatives and thinkers, the story threatened to tarnish the GOP with a sex scandal and make a martyr out of a marginal figure they were already cringing over before POLITICO reported the harassment charges.
Long after the primary ended, the entertainment-based right was still promoting figures that many in the GOP believe are harmful to the partys brand. Take Donald Trump, who made regular appearances on Fox & Friends all year and delighted in pushing the discredited idea that Obama wasnt born in America. Why energize black voters and turn off moderates broadly by elevating a buffoonish figure questioning the presidents legitimacy? Because its good box office. (To be sure, other nonpartisan outlets, including POLITICO, not to mention Romney himself, did their share of enabling Trump).
Its like a weird version of identity politics for people who like trash culture and reality TV, said Douthat of Trump.
This same financial-political tension also arose two years ago in one of the most high-profile GOP Senate primaries in the country between Grayson and Rand Paul. Senate Republican Leader Mitch McConnell, worried that his hand-picked candidate wasnt getting equal time on Fox to make his case, called Fox President Roger Ailes to ask that Grayson get similar treatment as the oft-interviewed Paul, according to a source familiar with the call. Ailes, who consulted on McConnells first Senate race, had tough news for his old friend: Paul was just a better draw.
Some younger conservatives worry that the effects of cocoonism are just as evident after the race as before and not only in the disbelief that Obama won. The knee-jerk reaction by some on the right to Romneys poor performance with Hispanics has been to simply say that all will be well with the party if they pass an immigration bill and elevate Cuban-American Sen. Marco Rubio (R-Fla.).
But to many next-generation Republicans, this smacks of tokenism and is more than a tad patronizing.
They just want to put a sombrero on the Republican elephant, said one Latino GOP operative, who didnt want to be identified discussing such a sensitive topic.
Similarly, Haynes fretted that the mistake Republicans are going to make is thinking this is a demographic and political problem and not a social and cultural problem. You cant fix this with Orca (the Romney campaigns ill-fated GOTV software) or iPad apps or to some extent even running Hispanic candidates.
To young Republican strategists and writers, a fundamental shift of how the party communicates is required. That doesnt mean delegitimizing hugely popular and powerful outlets on the right, but rather transcending them.
Communicating to the countrys changing demographics and outside of the Fox News echo chamber is a strategic imperative, said GOP operative Phil Musser, 40.
The rise of conservative media has been one of the best things to ever happen to the conservative movement. It has helped us reach new voters, has helped with voter persuasion and even motivation, said GOP strategist Todd Harris, 41. But with all the positives, there is this fact: If all you did was watch and read the conservative media, you were probably pretty shocked at what happened Tuesday. Theres a huge and ever-growing segment of the vote that Republicans just arent talking to and in some cases didnt even know existed.
The good news, say the young Republicans, is that theres hope for them to appeal more widely. They look no further than to 2004, when liberals were in disbelief that America had reelected George W. Bush. Jesusland was the name of the famous map of the country showing where Bush had won.
But instead of inveighing against the purported theocracy the country had become, Obama and his aides began to plot how they could appeal to a broad coalition of voters.
Younger Republicans are confident that they, too, will take over the party and reorient it to accommodate a more tolerant country.
I expect that in the years to come, a class of young and up-and-coming Republican practitioners will exert a greater degree of influence on how the partys outreach to key groups is handled and ensure that the tone and tenor of our message is reflective of todays society, said Jon Downs, 35, a Republican media consultant.
But these Republicans know a degree of self-examination is required.
In some communities, like with African-Americans, its simply unacceptable to be a Republican. This is a cultural phenomenon, said Haynes. Who do you go to church with, who do you send your kids to school with? Are enough Republicans socially and culturally engaged with folks who dont look like themselves?
Or, as Domenech put it: Conservatives may be content to stay in a bubble and yell about Benghazi, but it doesnt help the cause in the long term.
Whats needed, he said, is to develop new institutions that will engage conservatives on the issues that the broader country is focused on.
He cited the much-buzzed-about piece in The Atlantic earlier this year about whether women can have successful careers and devote ample attention to child-rearing as a conversation conservatives should have gotten in on.
We need to play the long game on how people engage in culture and society, Domenech said. Conservatives and the right generally have a lot to say, but its going to require more than a place to discuss the latest campaign or the New Black Panthers.
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Great thread tl/dnr-eckshun!!!
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I live in a Republican cocoon, I guess. It's called a nice county where people have good jobs and nicely landscaped yards.
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The Trump campaign and Black Lives Matter movement are perfect for each other. Both sides filled with easily led and angry nitwits convinced they are victims~
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I knew Obama would win based on the polls and all the info coming out. If Romney had followed up the first debate shellacking with a second debate shellacking of Obama we might have a different story. He just didn't have enough momentum to keep it going.
I am surprised that people could continue to vote for him though. High unemployment, very slow recovery, dismal housing market, continuing wars, and little traction on policies (even when he had his majority). Outside of Obamacare he didn't seem to do anything. Besides blatantly buying votes with his amnesty a few weeks ago.
Repubs blew their chance by being too ideological and inflexible. First rule of a negotiation is that you determine what your sticking points are and then give up the less important issues to gain what you REALLY want. Let's be honest, an election is just a very large negotiation. They showed little resolve to give up even the minutest of details.
I know this thread wasn't directed at me as I'm not a Republican (or Democrat) but I do live in Texas so I see the conservative, insular mindset all the time. For the record, I also don't watch Fox News.
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I personally just wish the R's would accept the fact that they're sticking to dramatically changing public views on many of the social issues. When choosing between the giant douche and the shit sandwich, people grab onto those issues when making a decision on a candidate and ignore a lot of the other stuff. It may not be right, but it's the truth.
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We must reject the idea that every time a law's broken, society is guilty rather than the lawbreaker. It is time to restore the American precept that each individual is accountable for his actions. President R. Reagan
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And then there's abortions and gay marriage.
People can never really tell who has the best plan for the country. But they can tell when one guy wants to tell their gay friend that they can't get married and their friend who was raped that they should've been forced to keep the kid.
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Trouble ahead and in our road. Entitlement issues also played a large part in this election, as well as skin color. Need to put all these secondary issues behind us and focus on the real issue or there won't be any good options for anyone.
We must reject the idea that every time a law's broken, society is guilty rather than the lawbreaker. It is time to restore the American precept that each individual is accountable for his actions. President R. Reagan
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Federal student loans are available to most students regardless of income and provide a range of repayment options. A loan is money that you must repay with interest under varying terms and conditions. While it is important to be cautious of irresponsible borrowing, loans are considered an integral part of a student's Financial Aid package. Please carefully review the different types of loans available below and consider each one as a viable option for financing a college education.
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How do I apply for a Loan?
Complete a Direct Loan Entrance Counseling: click here. *Required of all students NEW to Concordia Complete a Loan Agreement (MPN): click here. Complete a Direct Loan Exit Counseling: click here. Manage your loans: click here. Loan Consolidation: click here. First-Time Borrowers on or after July 1, 2013: click here.
Summary: Federal loan program for parents of dependent undergraduate students. Federal legislation permits graduate students to borrow through the PLUS (Parent Loans for Undergraduate Students) Loan program.
Manage your loans: click here.
Complete the Direct PLUS Loan Application. Sign Master Promissory Note.
Go to www.studentloans.gov. "Sign In" then "Request a PLUS loan." Parents MUST sign in using their own FAFSA PIN (Parent PLUS only).
If you were initially declined for the PLUS loan you can either obtain an endorser (cosigner), or choose to appeal the reason you were declined.
Call the Direct Loan Servicing Center for instructions at 800-557-7394 or select "Appeal Credit Decision" once logged into www.studentloans.gov. You will receive an answer regarding your appeal within 7-10 business days of all required documentation for the appeal being received.
If you elect to use an endorser, you must start by having the endorser get their own Federal Student Aid PIN. Once the endorser's PIN is active, they will log into the StudentLoans.gov site and select "Endorse a PLUS Loan." The endorser must pass a credit check. If approved, they will be asked to note how much they are willing to endorse. The PLUS loan amount cannot exceed what the endorser is willing to guarantee. Finally, the parent borrower signs the Federal Direct PLUS a Loan Agreement (MPN). The endorser does not sign the promissory note.
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Summary: Bank-funded education loan for undergraduate and graduate students. Generally used to supplement the Federal Direct Stafford loan.


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Ga. – Freshman Abi
LeRoy (Dublin, Ga.) of the GC softball team was
awarded the Bobcat Athlete of the Week after her six games this
past week.
LeRoy went 12-for-22 (.545) this past weekend with two triples, scoring seven runs and knocked in five.
The freshman's best performance was against Eckerd College when she went 3-for-4 with a triple, two runs, and a pair of RBI.
LeRoy's pitching performance was impressive as well, spending 18 2/3 innngs in the circle for the Bobcats while allowing just seven runs (2.64 ERA) and striking out 12 batters.
Bobcat softball will return to the diamond against No. 14 Flagler College, for a doubleheader, Sunday, Feb. 17. at 12:00 p.m.
The Georgia College Department of Athletics, two-time winners of the PBC Commissioner's Cup, sponsors 11 varsity athletic programs at the NCAA Division II level. As a Division II program, Bobcat Athletics prides itself on balancing the life of the student-athlete, evidenced by the teams' multiple appearances in post-season competition as well as documented academic success and community-service involvement. Sign up at www.twitter.com/BobcatSports and www.facebook.com/gcbobcats for up-to-the-minute reports, and visit www.GCBobcats.com for more information, and to nominate your favorite former Bobcats and Colonials to the GC Athletics Hall of Fame.
LeRoy Named Bobcat Athlete of the Week
Ga. – Freshman Abi
LeRoy (Dublin, Ga.) of the GC softball team was
awarded the Bobcat Athlete of the Week after her six games this
past week.


text:
Check out our Citroen GT Concept photo gallery
with HQ pics.
Last update in GT Concept gallery: 2014-06-15
Giant 30-inch rims, which first appeared on the 19_19 concept, over the next ten years can merge into mass-produced cars.
Citroen starts to develop the newest flagship sedan. The AutoExpress edition writes that Citroen CEO Linda Jackson told them about the 'ideal' time for the release of such flagship.
The DS3 Crossback from Citroen has been caught in the snow. Get a chance to have a sneak peak at the 1st PSA Group product constructed on the innovated CMP platform.
The French brand Citroen confirmed that the official premiere of the re-skiing C4 Cactus will take place on October 26, 2017.
Citroën presented the newest-gen C3 almost 1 year ago. It looks like the automaker is almost ready to reveal its crossover counterpart.
The innovated C3 Picasso from Citroën is going to prove that MPVs should not always be shaped as a refrigerator and have a bland outlook.
We select only big size citroen gt concept photos
for our photogallery.


text:
simonshack wrote:I sometimes wonder - after almost half-a-decade of analyzing the 9/11 imagery, just why it took such a long time or me (or anyone) to notice the atrocious crassness of it. There are mysteries aplenty in this world, but this particular mystery (why I didn't fully grasp the evident bogusness of the entire pool of 9/11 imagery) has had me scratching my head for a long while. I now realize that this was all part of the 9/11 plotters' plan.
Back in 2007, I made my very first 9/11 imagery analysis: The Grand TV Illusion. Of course, I wasn't quite content with it: the poor quality video resolution at hand left me wondering if I had pushed too far my interpretation of the given visuals. Perhaps I was just looking at standard video artifacts - caused by digital conversions/compressions?
Luckily, in 2010, the very stupid 9/11 perpetrators decided to release higher-resolution versions of their horrid digital animations. The below HQ frame of this CNN shot is from the NIST-FOIA batch of imagery released in 2010. (Huh? Have you ever asked yourself why NIST would have been sitting on/archiving this 9/11 image pool ? Wouldn't the TV networks have that material stored in their archives? )
Anyways, the below image was supposedly shot from a "static camera" placed in the CNN's Penn Plaza building... How anyone can still believe these are real/genuine images by a broadcast-quality CNN camera is quite beyond me. Note the <<<clear masking line>>> around WTC1:
source video: http://www.youtube.com/watch?v=u88I0jZ8xYo
Here's a frame of the collapse of WTC2 - supposedly from the same "static camera" placed in the CNN's Penn Plaza building". All I have done here is to apply a brightness/contrast filter to highlight the absurd, pitch black cartoon-outlines around the buildings (and other problems):
source video: http://www.youtube.com/watch?v=OjKyHn8pxGo
The 2 above images naturally lead to the following simple and logical conclusion:
NOT ONLY WAS THE IMAGERY OF AN AIRPLANE IMPACTING THE WTC SHOWN ON TV a digital animation, ALSO THE WTC COLLAPSES were digital animations.
Equinox wrote:
Originally sourced--- CNN Sept. 11, 2001 8.48 - 9.29am@ 22.08 Minutes
Re- Released--- NIST FOIA: WPIX Dub5, Clip 15
photos credited to William Nunez (director/writer/producer) http://www.imdb.com/name/nm0638035/
source of image: http://rvision.daydreamlabs.com/user/50 ... 6778578227
Some "9/11 eyewitness" apparently captured this wonderful, lucky shot. He snapped a pic JUST as "Flight 175" emerged from that building. That's Poolitzer Prize material, folks!
This other shot also depicts "Flight 175 - as it explodes". Hence, it is evidently (and supposedly) immediately successive to the shot.
This "William Nunez" claims he snapped these pictures with a $15 disposable Kodak camera.)
This claim is completely unbelievable. This claim is offensive to any photographer's intelligence.
Bond analyst Will Nuñez had gone to his corner newsstand and bought a $14.99 disposable Kodak, hoping to record the smoking tower out his office window "for history's sake," he says. "I remembered an incident back in the thirties when a plane had hit the Empire State Building, and I was always impressed by photos in encyclopedias." Instead, from his perch on the thirty-second floor of One State Street Plaza, he captured the plane's breathtaking blur out his office window, quite unintentionally. In his shot, a colleague, standing before a vast picture window, looks on in silhouette, next to an innocuous baseball trophy, its tiny batter poised on a two-handled loving cup. The plane had streaked by with such speed, Nuñez had not even realized he had caught it on film until he finally got around to developing the roll a week or two later.
- David Friend, Watching the World Change: The Stories Behind the Images of 9/11, Farrar, Straus and Giroux, New York, p. 13.
Hereby, I challenge any engineer specialized in crash physics to explain what we see in the 4 below videos.
How does this aluminum airliner penetrate the steel structure of the WTC without a single part shearing off?
SHOT 1: Credited to "Michael Hezarkhani"---
SHOT 2: Credited to "Luc Courchesne"---
SHOT 3: Credited to "Evan Fairbanks"---
SHOT 4: Credited to "Jennifer Spell"---
To be sure, this is a still completely unresolved issue to this day. NOT ONE individual contending that these are REAL videos has ever tackled this basic issue in any sort of scientific, peer-reviewed manner. Peer-reviewed? Yes well, that is a common requirement for any thesis/analysis to be deemed valid by our planet's scientific community.
lux wrote:Found a few more:
There are copies of all the CLUES, YOUTUBE VIDEOS, AND GIFS.. on my hard drive. In case anything gets lost, copies of videos are also being re-uploaded to you tube being re-uploaded I'm also sharing on face-book.
Rudy Algera wrote:@ Equinox at 12:32 above
In the top photo, directly beneath the yellow Kodak camera, isn't there something odd about the row of 7 black windows in the building on the right hand side? Shouldn't they be brown, not black - the same as in the photo underneath it showing the same building?
Could someone with better eyesight than I have look carefully and compare these two photos, and especially the rows of windows?
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