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This information is produced and provided by the National Cancer Institute (NCI). The information in this topic may have changed since it was written. For the most current information, contact the National Cancer Institute via the Internet web site at http://cancer.gov or call 1-800-4-CANCER.
Fortunately, cancer in children and adolescents is rare, although the overall incidence of childhood cancer has been slowly increasing since 1975.[1] Children and adolescents with cancer should be referred to medical centers that have a multidisciplinary team of cancer specialists with experience treating the cancers that occur during childhood and adolescence. This multidisciplinary team approach incorporates the skills of the primary care physician, an orthopedic surgeon experienced in bone tumors, a pathologist, radiation oncologists, pediatric oncologists, rehabilitation specialists, pediatric nurse specialists, social workers, and others to ensure that children receive treatment, supportive care, and rehabilitation that will achieve optimal survival and quality of life. (Refer to the PDQ summaries on Supportive and Palliative Care for specific information about supportive care for children and adolescents with cancer.)
Guidelines for pediatric cancer centers and their role in the treatment of pediatric patients with cancer have been outlined by the American Academy of Pediatrics.[2] At these pediatric cancer centers, clinical trials are available for most types of cancer that occur in children and adolescents, and the opportunity to participate in these trials is offered to most patients/families. Clinical trials for children and adolescents with cancer are generally designed to compare potentially better therapy with therapy that is currently accepted as standard. Most of the progress made in identifying curative therapies for childhood cancers has been achieved through clinical trials. Information about ongoing clinical trials is available from the NCI Web site.
Dramatic improvements in survival have been achieved for children and adolescents with cancer. Between 1975 and 2002, childhood cancer mortality has decreased by more than 50%. For osteosarcoma, the 5-year survival rate has increased over the same time from 40% to 67% in children and adolescents.[1] Childhood and adolescent cancer survivors require close follow-up because cancer therapy side effects may persist or develop months or years after treatment. (Refer to the PDQ summary on Late Effects of Treatment for Childhood Cancer for specific information about the incidence, type, and monitoring of late effects in childhood and adolescent cancer survivors.)
Osteosarcoma occurs predominantly in adolescents and young adults. Review of data from the Surveillance, Epidemiology and End Results program of the NCI resulted in an estimate of 4.4 per million new cases of osteosarcoma each year in people aged 0 to 24 years.[3] The U.S. Census Bureau estimates that there will be 110 million people in this age range in 2010, resulting in an incidence of roughly 450 cases per year in children and young adults younger than 25 years. Osteosarcoma accounts for approximately 5% of childhood tumors. In children and adolescents, more than 50% of these tumors arise from the long bones around the knee. Osteosarcoma can rarely be observed in soft tissue or visceral organs. There appears to be no difference in presenting symptoms, tumor location, and outcome for younger patients (<12 years) compared with adolescents.[4,5] Two trials conducted in the 1980s were designed to determine if chemotherapy altered the natural history of osteosarcoma following surgical removal of the primary tumor. The outcome of patients in these trials who were treated with surgical removal of the primary tumor recapitulated the historical experience before 1970; more than half of these patients developed metastases within 6 months of diagnosis, and overall, approximately 90% developed recurrent disease within 2 years of diagnosis.[6] Overall survival for patients treated with surgery alone was statistically inferior.[7] The natural history of osteosarcoma has not changed over time, and fewer than 20% of patients with localized resectable primary tumors treated with surgery alone can be expected to survive free of relapse.[6,8,9]
Prognostic Factors
Pretreatment factors that influence outcome include site and size of the primary tumor and presence or absence of clinically detectable metastatic disease.[10] After administration of preoperative chemotherapy, surgical resectability and the degree of tumor necrosis influence outcome. In general, prognostic factors in osteosarcoma have not been helpful in identifying patients who might benefit from treatment intensification or who might require less therapy while maintaining an excellent outcome.
Primary site
The site of the primary tumor is a significant prognostic factor for patients with localized disease. Among extremity tumors, distal sites have a more favorable prognosis than proximal sites. Axial skeleton primary tumors are associated with the greatest risk of progression and death, primarily related to the inability to achieve a complete surgical resection.
Despite a relatively high rate of inferior necrosis following neoadjuvant chemotherapy, fewer patients with craniofacial primaries develop systemic metastases than do patients with osteosarcoma originating in the extremities.[19,20,21] This low rate of metastasis may be related to the relatively smaller size and higher incidence of lower grade tumors in osteosarcoma of the head and neck.
While small series have not shown a benefit from adjuvant chemotherapy for patients with osteosarcoma of the head and neck, one meta-analysis concluded that systemic chemotherapy improves the prognosis for these patients. Another large meta-analysis detected no benefit from chemotherapy for patients with osteosarcoma of the head and neck, but suggested that the incorporation of chemotherapy into treatment of patients with high-grade tumors may improve survival. A retrospective analysis identified a trend toward better survival in patients with high-grade osteosarcoma of the mandible and maxilla who received adjuvant chemotherapy.[18,22]
Radiation therapy was found to improve local control, disease-specific survival, and overall survival in a retrospective study of osteosarcoma of the craniofacial bones, which had positive or uncertain margins after surgical resection.[23][Level of evidence: 3iiA] Radiation-associated craniofacial osteosarcomas are generally high-grade lesions, usually fibroblastic, that tend to recur locally with a high rate of metastasis.[24]
In the German series, approximately 25% of patients with craniofacial osteosarcoma had osteosarcoma as a second tumor, and in 8 of these 13 patients, osteosarcoma arose following treatment for retinoblastoma. In this series, there was no difference in outcome for primary or secondary craniofacial osteosarcoma.[15]
Tumor size
Larger tumors have a worse prognosis than smaller tumors.[10,26] Tumor size has been assessed by the longest single dimension, by the cross-sectional area, or by an estimate of tumor volume; all have correlated with outcome. Serum lactate dehydrogenase (LDH), which also correlates with outcome, is a likely surrogate for tumor volume.
Presence of clinically detectable metastatic disease
Patients with localized disease have a much better prognosis than those with overt metastatic disease. As many as 20% of patients will have radiographically detectable metastases at diagnosis, with the lung being the most common site.[27] The prognosis for patients with metastatic disease appears to be determined largely by the site(s), the number of metastases, and the surgical resectability of the metastatic disease.[28,29]
Patients with multifocal osteosarcoma (defined as multiple bone lesions without a clear primary tumor) have an extremely poor prognosis.[32]
Adequacy of tumor resection
Resectability of the tumor is a critical prognostic feature because osteosarcoma is relatively resistant to radiation therapy. Complete resection of the primary tumor and any skip lesions with adequate margins is generally considered essential for cure. A retrospective review of patients with craniofacial osteosarcoma performed by the German-Austrian-Swiss osteosarcoma cooperative group reported that incomplete surgical resection was associated with inferior survival probability.[15][Level of evidence: 3iiB] For patients with axial skeletal primaries who either do not have surgery for their primary tumor or who have surgery resulting in positive margins, radiation therapy may improve survival.[11,35] In a European cooperative study, the size of the margin was not significant. However, having both the biopsy and resection at a center with orthopedic oncology experience conferred a better prognosis.[13]
Necrosis following induction or neoadjuvant chemotherapy
Most treatment protocols for osteosarcoma use an initial period of systemic chemotherapy prior to definitive resection of the primary tumor (or resection of sites of metastases for patients with metastatic disease). The pathologist assesses necrosis in the resected tumor. Patients with at least 90% necrosis in the primary tumor after induction chemotherapy have a better prognosis than those with less necrosis.[26] Patients with less necrosis (<90%) in the primary tumor following initial chemotherapy have a higher rate of recurrence within the first 2 years compared with patients with a more favorable amount of necrosis (≥90%).[36] Less necrosis should not be interpreted to mean that chemotherapy has been ineffective; cure rates for patients with little or no necrosis following induction chemotherapy are much higher than cure rates for patients who receive no chemotherapy.
Imaging modalities such as dynamic magnetic resonance imaging (MRI) or positron emission tomography (PET) scanning are under investigation as noninvasive methods to assess response.[37,38,39,40,41,42]
Additional prognostic factors
Patients with osteosarcoma as a second malignant neoplasm, including those tumors arising in a radiation field, share the same prognosis as patients with de novo osteosarcoma if they are treated aggressively with complete surgical resection and multiagent chemotherapy.[43,44,45,46] Possible prognostic factors identified for patients with conventional localized high-grade osteosarcoma include the age of the patient, LDH level, alkaline phosphatase level, and histologic subtype.[26,47,48,49,50,51] A number of potential prognostic factors have been identified but have not been tested in large numbers of patients. These include the expression of HER2/c-erbB-2 (there are conflicting data concerning the prognostic significance of this human epidermal growth factor);[52,53,54] tumor cell ploidy; specific chromosomal gains or losses;[55] loss of heterozygosity of the RB gene;[56,57] Loss of heterozygosity of the p53 locus;[58] and increased expression of p-glycoprotein.[59,60] A prospective analysis of p-glycoprotein expression determined by immunohistochemistry failed to identify prognostic significance for newly diagnosed patients with osteosarcoma, although earlier studies suggested that overexpression of p-glycoprotein predicted for poor outcome.[61] In a large series, a delay of 21 days or more from the time of definitive surgery to the resumption of chemotherapy was an adverse prognostic factor.[62] Pathologic fracture at diagnosis or during preoperative chemotherapy does not have adverse prognostic significance.[63]
Syndromes Associated With Osteosarcoma
Rothmund-Thomson syndrome
Patients with Rothmund-Thomson syndrome have an increased risk of developing osteosarcoma compared with the general population. They also tend to develop osteosarcoma at a younger age.[64] Rothmund-Thomson syndrome, also called poikiloderma congenitale, is a rare autosomal recessive condition attributed to mutations of the RECQL4 helicase gene on 8q24. It is characterized by distinctive skin findings (e.g., atrophy, telangiectasias, pigmentation), sparse hair, cataracts, small stature, skeletal anomalies, and a significantly increased risk for osteosarcoma. There is no adverse prognostic significance for osteosarcoma in conjunction with Rothmund-Thomson syndrome.
Genetic diseases that predispose to osteosarcoma
Osteosarcoma is a malignant tumor that is characterized by the direct formation of bone or osteoid tissue by the tumor cells. The World Health Organization's histologic classification [1] of bone tumors separates the osteosarcomas into central (medullary) and surface (peripheral) [2,3] tumors and recognizes a number of subtypes within each group.
Central (Medullary) Tumors
Surface (Peripheral) Tumors
The most common pathologic subtype is conventional central osteosarcoma, which is characterized by areas of necrosis, atypical mitoses, and malignant osteoid tissue and/or cartilage. The other subtypes are much less common, each occurring at a frequency of less than 5%. Telangiectatic osteosarcoma may be confused radiographically with an aneurysmal bone cyst or giant cell tumor. This variant should be approached as a conventional osteosarcoma.[4,5]
Malignant fibrous histiocytoma (MFH) of bone is treated according to osteosarcoma treatment protocols.[13] MFH should be distinguished from angiomatoid fibrous histiocytoma, a low-grade tumor that is usually noninvasive, small, and associated with an excellent outcome with surgery alone.[14] One study suggests similar event-free survival rates for MFH and osteosarcoma.[13]
Extraosseous osteosarcoma is a malignant mesenchymal neoplasm without direct attachment to the skeletal system. Previously, treatment for extraosseous osteosarcoma followed soft tissue sarcoma guidelines,[15] though a retrospective analysis of the German Cooperative Osteosarcoma Study identified a favorable outcome for extraosseous osteosarcoma treated with surgery and conventional osteosarcoma therapy.[16]
Historically, the Enneking staging system for skeletal malignancies was widely used.[1] This system inferred the aggressiveness of the primary tumor by the descriptors intracompartmental or extracompartmental. The American Joint Committee on Cancer (AJCC) staging system for malignant bone tumors has updated this staging system, substituting compartmentalization with size (see Table 2).[2] The AJCC classification is as follows:
For the purposes of treatment, there are only two stages of high-grade osteosarcoma. Patients without clinically detectable metastatic disease are considered to have localized osteosarcoma. Patients in whom it is possible to detect any site of metastasis at the time of initial presentation by routine clinical studies are considered to have metastatic osteosarcoma.
For patients with confirmed osteosarcoma, in addition to plain x-rays of the primary site that include a single plane view of the entire affected extremity to assess for skip metastasis, pretreatment staging studies should include magnetic resonance imaging (MRI) and/or computed tomography (CT) scan of the primary site. Additional pretreatment staging studies should include bone scan, postero-anterior and lateral chest x-ray, and CT scan of the chest. Positron emission tomography (PET) using fluorine-18-fluorodeoxyglucose is an optional staging modality.[3]
Localized Osteosarcoma
Localized tumors are limited to the bone of origin. Patients with skip lesions confined to the bone which includes the primary tumor should be considered to have localized disease if the skip lesions can be included in the planned surgical resection.[4] Approximately one-half of the tumors arise in the femur; of these, 80% are in the distal femur. Other primary sites in descending order of frequency are the proximal tibia, proximal humerus, pelvis, jaw, fibula, and ribs.[5] Compared with osteosarcoma of the appendicular skeleton, osteosarcoma of the head and neck is more likely to be low grade [6] and to arise in older patients.
Metastatic Osteosarcoma
Radiologic evidence of metastatic tumor deposits in the lungs, other bones, or other distant sites is found in approximately 20% of patients at diagnosis, with 85% to 90% of metastatic disease presenting in the lungs. The second most common site of metastasis is another bone.[7] Metastasis to other bones may be solitary or multiple. The syndrome of multifocal osteosarcoma refers to a presentation with multiple foci of osteosarcoma without a clear primary tumor, often with symmetrical metaphyseal involvement. Multifocal osteosarcoma has an extremely grave prognosis.[5]
Successful treatment generally requires the combination of effective systemic chemotherapy and complete resection of all clinically detectable disease. Protective weight bearing is recommended for patients with tumors of weight-bearing bones to prevent pathological fractures that could preclude limb-preserving surgery.
Randomized clinical trials have established that both neoadjuvant and adjuvant chemotherapy are effective in preventing relapse in patients with clinically nonmetastatic tumors.[1,2] The Pediatric Oncology Group conducted a study in which patients were randomly assigned either to immediate amputation or amputation after neoadjuvant therapy. A large percentage of patients declined to be assigned randomly, and the study was terminated without approaching the stated accrual goals. In the small number of patients treated, there was no difference in outcome for those who received preoperative versus postoperative chemotherapy.[3] It is imperative that patients with proven or suspected osteosarcoma have an initial evaluation by an orthopedic oncologist familiar with the surgical management of this disease. This evaluation, which includes imaging studies, should be done prior to the initial biopsy, since an inappropriately performed biopsy may jeopardize a limb-sparing procedure.
Recognition of intraosseous well-differentiated osteosarcoma and parosteal osteosarcoma is important because these are associated with the most favorable prognosis and can be treated successfully with wide excision of the primary tumor alone.[4,5] Periosteal osteosarcoma has a generally good prognosis [6] and treatment is guided by histologic grade.[5,7]
Patients with localized osteosarcoma undergoing surgery and chemotherapy have a 5-year overall survival (OS) of 65% to 70%.[1] Complete surgical resection is crucial for patients with localized osteosarcoma; however, at least 80% of patients treated with surgery alone will develop metastatic disease.[2] Randomized clinical trials have established that adjuvant chemotherapy is effective in preventing relapse or recurrence in patients with localized resectable primary tumors.[2,3]
Patients with malignant fibrous histiocytoma (MFH) of bone are treated according to osteosarcoma treatment protocols, and the outcome for patients with resectable MFH is similar to the outcome for patients with osteosarcoma.[4] As with osteosarcoma, patients with a favorable necrosis (≥90% necrosis) had a longer survival than those with an inferior necrosis (<90% necrosis).[5] MFH of bone is seen more commonly in older adults. Many patients with MFH will need preoperative chemotherapy to achieve a wide local excision.[6]
The diagnosis of osteosarcoma can be made by needle biopsy, core needle biopsy, or open surgical biopsy. If limb sparing (removal of the malignant bone tumor without amputation and replacement of bones or joints with allografts or prosthetic devices) is contemplated, the biopsy should be performed by the surgeon who will do the definitive operation, since incision placement is crucial.
Surgical Removal of Primary Tumor
Surgical resection of the primary tumor with adequate margins is an essential component of the curative strategy for patients with localized osteosarcoma. The type of surgery required for complete ablation of the primary tumor depends on a number of factors that must be evaluated on a case-by-case basis.[7]
In general, more than 80% of patients with extremity osteosarcoma can be treated by a limb-sparing procedure and do not require amputation.[8] Limb-sparing procedures should be planned only when the preoperative staging indicates that it would be possible to achieve wide surgical margins. In one study, patients undergoing limb-salvage procedures who had poor histologic response and close surgical margins had a high rate of local recurrence.[9] Reconstruction after surgery can be accomplished with many options including metallic endoprosthesis, allograft, vascularized autologous bone graft, and rotationplasty. The choice of optimal surgical reconstruction involves many factors, including the site and size of the primary tumor, the ability to preserve the neurovascular supply of the distal extremity, the age of the patient and potential for additional growth, and the needs and desires of the patient and family for specific function, such as sports participation. If a complicated reconstruction delays or prohibits the resumption of systemic chemotherapy, limb preservation may endanger the chance for cure. Retrospective analyses have shown that delay in resumption of chemotherapy after definitive surgery is associated with increased risk of tumor recurrence and death.[10][Level of evidence: 1iiA]
For some patients, amputation remains the optimal choice for management of the primary tumor. A pathologic fracture noted at diagnosis or during preoperative chemotherapy does not preclude limb-salvage surgery if wide surgical margins can be achieved.[11] In two series, patients presenting with a pathologic fracture at diagnosis had similar outcomes to those without pathologic fractures at diagnosis, while in a third series, pathologic fracture at diagnosis was associated with a worse overall outcome.[12,13]; [14][Level of evidence: 3iiiA] If the pathologic examination of the surgical specimen shows inadequate margins, an immediate amputation should be considered, especially if the histologic necrosis following preoperative chemotherapy was poor.[15]
The German Cooperative Osteosarcoma Study performed a retrospective analysis of 1,802 patients with localized and metastatic osteosarcoma who underwent surgical resection of all clinically detectable disease.[16][Level of evidence: 3iiA] Local recurrence (n = 76) was associated with a high risk for death from osteosarcoma. Factors associated with an increased risk of local recurrence included nonparticipation in a clinical trial, pelvic primary site, limb-preserving surgery, soft tissue infiltration beyond the periosteum, poor pathologic response to initial chemotherapy, failure to complete planned chemotherapy, and performance of the biopsy at an institution different from the institution performing definitive surgery.
Not surprisingly, patients who undergo amputation have lower local-recurrence rates than patients who undergo limb-salvage procedures. There is no difference in OS between patients initially treated by amputation and those treated with a limb-sparing procedure. Patients with tumors of the femur have a higher local recurrence rate than patients with primary tumors of the tibia/fibula. Rotationplasty and other limb salvage procedures have been evaluated for both their functional outcome and their effect on survival. While limb-sparing resection is the current practice for local control at most pediatric institutions, there are few data to indicate that limb-salvage of the lower limb is substantially superior to amputation with regard to patient quality of life.
If complete surgical resection is not feasible or if surgical margins are inadequate, radiation therapy (RT) may improve the local control rate.[17,18]; [19][Level of evidence: 3iiA] While it is accepted that the standard approach is primary surgical resection, a retrospective analysis of a small group of highly selective patients reported long-term event-free survival with external-beam RT for local control in some patients.[20][Level of evidence: 3iiiA] RT should be considered in patients with osteosarcoma of the head and neck who have positive or uncertain resection margins.[21][Level of evidence: 3iiA]
Almost all patients receive intravenous preoperative chemotherapy as initial treatment. However, a specific standard chemotherapy regimen has not been determined. Current chemotherapy protocols include combinations of the following agents: high-dose methotrexate, doxorubicin, cyclophosphamide, cisplatin, ifosfamide, etoposide, and carboplatin.[22,23,24,25,26,27,28,29,30] A meta-analysis of protocols for the treatment of osteosarcoma concluded that regimens containing three active chemotherapy agents were superior to regimens containing two active agents.[31] The same meta-analysis concluded that regimens with four active agents were not superior to regimens with three active agents. The meta-analysis suggested that three-drug regimens that did not include high-dose methotrexate were inferior to three-drug regimens that did include high-dose methotrexate.
In certain trials, extent of tumor necrosis is used to determine postoperative chemotherapy. In general, if tumor necrosis exceeds 90%, the preoperative chemotherapy regimen is continued. If tumor necrosis is less than 90%, some groups have incorporated drugs not previously utilized in the preoperative therapy. This approach is based on early reports from Memorial Sloan-Kettering Cancer Center (MSKCC) which suggested that adding cisplatin to postoperative chemotherapy improved the outcome for patients with less than 90% tumor necrosis. With longer follow-up, the outcome for patients with less than 90% tumor necrosis treated at MSKCC was the same whether they did or did not receive cisplatin in the postoperative phase of treatment. Subsequent trials performed by other groups have failed to demonstrate improved event-free survival (EFS) when drugs not included in the preoperative regimen were added to postoperative therapy.[23,32]
The Children's Oncology Group performed a prospective randomized trial in newly diagnosed children and young adults with localized osteosarcoma. All patients received cisplatin, doxorubicin, and high-dose methotrexate. One-half of the patients were randomly assigned to receive ifosfamide. In a second randomization, one-half of the patients were assigned to receive the biological compound muramyl tripeptide-phosphatidyl ethanolamine encapsulated in liposomes (L-MTP-PE) beginning after definitive surgical resection. The addition of ifosfamide did not improve outcome. The addition of L-MTP-PE produced improvement in EFS, which did not meet the conventional test for statistical significance (P = .08), and a significant improvement in OS (78% vs. 70%; P = .03).[33][Level of evidence: 1iiA] There has been speculation regarding the potential contribution of postrelapse treatment, although there were no differences in the postrelapse surgical approaches in the relapsed patients. The appropriate role of L-MTP-PE in the treatment of osteosarcoma remains under discussion.
Osteosarcoma of the Head and Neck
Osteosarcoma of the head and neck occurs in an older population compared to osteosarcoma of the extremities.[21,34,35,36,37,38] In the pediatric age group, osteosarcomas of the head and neck are more likely to be low or intermediate grade than tumors of the extremities.[39,40] All reported series stress the need for complete surgical resection.[21,34,35,36,37,38,39,40][Level of evidence: 3iiiA] Osteosarcoma of the head and neck has a higher risk for local recurrence and a lower risk for distant metastasis than osteosarcoma of the extremities.[34,37,38,41] The probability for cure with surgery alone is higher for osteosarcoma of the head and neck than for extremity osteosarcoma. Primary sites in the mandible and maxilla are associated with a better prognosis than other primary sites in the head and neck.[36,37,41] When surgical margins are positive, there is a trend for improved survival with adjuvant radiation therapy.[21,37][Level of evidence: 3iiiA] There are no randomized trials to assess the benefit of chemotherapy in osteosarcoma of the head and neck, but several series suggest a benefit.[34,42] Chemotherapy should be considered for younger patients with high-grade osteosarcoma of the head and neck.[39,40]
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with localized osteosarcoma and localized childhood malignant fibrous histiocytoma of bone. 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.
Approximately 20% to 25% of patients with osteosarcoma present with clinically detectable metastatic disease. For patients with metastatic disease at initial presentation, roughly 20% will remain continuously free of disease, and roughly 30% will survive 5 years from diagnosis.[1]
The lung is the most common site of initial metastatic disease.[2] Patients with metastases limited to the lungs have a better outcome than patients with metastases to other sites or to the lungs combined with other sites.[1,3]
The chemotherapeutic agents used include high-dose methotrexate, doxorubicin, cisplatin, high-dose ifosfamide, etoposide, and in some reports, carboplatin or cyclophosphamide. High-dose ifosfamide (17.5 grams per course) in combination with etoposide produced a complete (10%) or partial (49%) response in patients with newly diagnosed metastatic osteosarcoma.[4] The addition of either muramyl tripeptide or ifosfamide to a standard chemotherapy regimen that included cisplatin, high-dose methotrexate, and doxorubicin was evaluated using a factorial design in patients with metastatic osteosarcoma (n = 91).[5] There was a nominal advantage for the addition of muramyl tripeptide (but not for ifosfamide) in terms of event-free survival (EFS) and overall survival (OS), but criteria for statistical significance were not met.
The treatment for malignant fibrous histiocytoma (MFH) of bone with metastasis at initial presentation is the same as the treatment for osteosarcoma with metastasis. Patients with unresectable or metastatic MFH have a very poor outcome.[6]
Lung Metastases Only
Patients with metastatic lung lesions as the sole site of metastatic disease should have the lung lesions resected if at all possible. Generally, this is done following administration of preoperative chemotherapy. In approximately 10% of patients, all lung lesions disappear following preoperative chemotherapy.[3] Complete resection of pulmonary metastatic disease can be achieved in a high percentage of patients with residual lung nodules following preoperative chemotherapy. The cure rate is essentially zero without complete resection of residual pulmonary metastatic lesions.
For patients who present with primary osteosarcoma and metastases limited to the lungs and who achieve complete surgical remission, 5-year EFS is approximately 20% to 25%. Multiple metastatic nodules confer a worse prognosis than one or two nodules, and bilateral lung involvement is worse than unilateral.[1] Patients with peripheral lesions may have a better prognosis than those with central lesions.[7] Patients with fewer than three nodules confined to one lung may achieve a 5-year EFS of approximately 40% to 50%.
Bone Only or Bone With Lung Metastasis
The second most common site of metastasis is another bone that is distant from the primary tumor. Patients with metastasis to other bones distant from the primary tumor experience roughly 10% EFS and OS.[1] In the Italian experience, of the patients who presented with primary extremity tumors and synchronous metastasis to other bones, only 3 of 46 patients remained continuously disease-free 5 years later.[8] Patients who have transarticular skip lesions have a poor prognosis.[9]
Multifocal osteosarcoma is different from osteosarcoma which presents with a clearly delineated primary lesion and limited bone metastasis. Multifocal osteosarcoma classically presents with symmetrical, metaphyseal lesions, and it may be difficult to determine the primary lesion. Patients with multifocal bone disease at presentation have an extremely poor prognosis. No patient with synchronous multifocal osteosarcoma has ever been reported to be cured, but systemic chemotherapy and aggressive surgical resection may achieve significant prolongation of life.[10,11]
When the usual treatment course of preoperative chemotherapy followed by surgical ablation of the primary tumor and resection of all overt metastatic disease (usually lungs) followed by postoperative combination chemotherapy cannot be used, an alternative treatment approach may be used. This alternative treatment approach begins with surgery for the primary tumor, followed by chemotherapy, and then surgical resection of metastatic disease (usually lungs). This alternative approach may be appropriate in patients with intractable pain, pathologic fracture, or uncontrolled infection of the tumor when initiation of chemotherapy could create risk of sepsis.
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with metastatic osteosarcoma and metastatic childhood malignant fibrous histiocytoma of bone. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
Approximately 50% of relapses occur within 18 months of therapy termination, and only 5% of recurrences develop beyond 5 years.[1,2,3,4] In 564 patients with a recurrence, patients whose disease recurred within 2 years of diagnosis had a worse prognosis than did patients whose disease recurred after 2 years. Patients with a good histologic response to initial preoperative chemotherapy had a better overall survival (OS) after recurrence than did poor responders.[1] The probability of developing lung metastases at 5 years is 28% in patients presenting with localized disease.[5] In two large series, the incidence of recurrence by site was as follows: lung only (65%–80%), bone only (8%–10%), local recurrence only (4%–7%), and combined relapse (10%–15%).[4,6]
Patients with recurrent osteosarcoma should be assessed for surgical resectability, as they may sometimes be cured with aggressive surgical resection with or without chemotherapy.[7,6,8,9,10,11] Control of osteosarcoma following recurrence depends on complete surgical resection of all sites of clinically detectable metastatic disease. If surgical resection is not attempted or cannot be performed, progression and death are certain. The ability to achieve a complete resection of recurrent disease is the most important prognostic factor at first relapse, with a 5-year survival rate of 20% to 45% following complete resection of metastatic pulmonary tumors and a 20% survival rate following complete resection of metastases at other sites.[4,6,11,12]
The role of systemic chemotherapy for the treatment of patients with recurrent osteosarcoma is not well defined. The selection of further systemic treatment depends on many factors, including the site of recurrence, the patient's previous primary treatment, and individual patient considerations. Ifosfamide alone with mesna uroprotection, or in combination with etoposide, has shown activity in as many as one-third of patients with recurrent osteosarcoma who have not previously received this drug.[13,14,15,16] Cyclophosphamide and etoposide have activity in recurrent osteosarcoma as does the combination of gemcitabine and docetaxel.[17,18,19] The Italian Sarcoma Group reported rare objective responses and disease stabilization with sorafenib in patients with recurrent osteosarcoma.[20] Peripheral blood stem cell transplant utilizing high-dose chemotherapy does not appear to improve outcome. High-dose samarium-153-ethylenediaminetetramethylene phosphonic acid (EDTMP) coupled with peripheral blood stem cell support may provide significant pain palliation in patients with bone metastases.[21,22,23,24] Toxicity of samarium-153-EDTMP is primarily hematologic.[25][Level of evidence: 3iiDiii]
Lung Only Recurrence
Repeated resections of pulmonary recurrences can lead to extended disease control and possibly cure for some patients.[12,26] Survival for patients with unresectable metastatic disease is less than 5%.[6,27] Five-year event free survival (EFS) for patients who have complete surgical resection of all pulmonary metastases ranges from 20% to 45%.[4,11,12]; [28][Level of evidence: 3iiiA] Factors that suggest a better outcome include fewer pulmonary nodules, unilateral pulmonary metastases, longer intervals between primary tumor resection and metastases, and tumor location in the periphery of the lung.[4,5,6,29,30] Resection of metastatic disease followed by observation alone results in low OS and disease-free survival. A high percentage of patients with pulmonary nodules identified in only one lung who underwent staged bilateral thoracotomy were found to have palpable nodules in both lungs that were not visualized on a computed tomography scan. This suggests that patients with unilateral nodules may benefit from bilateral exploration.[29]
Recurrence With Bone Metastases Only
Patients with osteosarcoma who develop bone metastases have a poor prognosis. In one large series, the 5-year EFS rate was 11%.[31] Patients with late solitary bone relapse have a 5-year EFS rate of approximately 30%.[31,32,33,34] For patients with multiple unresectable bone lesions, samarium-153-EDTMP with or without stem cell support may produce stable disease and/or relief of pain.[25]
Local Recurrence
The postrelapse outcome of patients who have a local recurrence is quite poor.[35,36,37]
Two retrospective, single-institution series reported 10% to 40% survival following local recurrence without associated systemic metastasis.[38,39,40,41] The survival for patients with local recurrence and either prior or concurrent systemic metastases is poor.[40] The incidence of local relapse was higher in patients who had a poor pathologic response to chemotherapy in the primary tumor and in patients with inadequate surgical margins.[35,39]
Second Recurrence of Osteosarcoma
The Cooperative Osteosarcoma Study group reported on 249 patients who had a second recurrence of osteosarcoma. The main feature of therapy was repeated surgical resection of recurrent disease. Of these patients, 197 died, 37 were alive in complete remission (24 after a third complete response and 13 after a fourth or subsequent complete response). Fifteen patients remain alive who did not achieve surgical remission, but follow-up for these patients was extremely short.[42]
Treatment Options Under Clinical Evaluation for Recurrent Osteosarcoma
Clinical trials (phases I and II) are appropriate for patients with unresectable metastatic disease and should be considered. Information about ongoing clinical trials is available from the NCI Web site. Examples of these trials include the following:
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with recurrent osteosarcoma and recurrent childhood malignant fibrous histiocytoma of bone. 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.
General Information About Osteosarcoma and Malignant Fibrous Histiocytoma (MFH) of Bone
Added Isakoff et al. as reference 14.
Recurrent Osteosarcoma and MFH of Bone
Added Qi et al. as reference 19.
Added text to state that the Italian Sarcoma Group reported rare objective responses and disease stabilization with sorafenib in patients with recurrent osteosarcoma (cited Grignani et al. as reference 20).
This summary is written and maintained by the PDQ Pediatric Treatment Editorial Board, which is editorially independent of NCI. The summary reflects an independent review of the literature and does not represent a policy statement of NCI or NIH. More information about summary policies and the role of the PDQ Editorial Boards in maintaining the PDQ summaries can be found on the About This PDQ Summary and PDQ NCI's Comprehensive Cancer Database pages.
Purpose of This Summary
This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the treatment of osteosarcoma and malignant fibrous histiocytoma of bone. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.
Reviewers and Updates
This summary is reviewed regularly and updated as necessary by the PDQ Pediatric Treatment Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).
Board members review recently published articles each month to determine whether an article should:
Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.
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text:
Amateurs Wanted 22Favorites [+]
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Running Time: 121 minutes
Studio Name: Net Video Girls
Series: Amateurs Wanted
Categories: Amateur Gonzo High Definition
Description: Once we saw her puffy pussy we knew we were in for a good time! Alli - Black haired beauty with an all natural rack! Kira - Tiny frame, little titties, but a big hunger for dick! Lex - Amateur babes has an awesome ass and she eats cum! Selena - Nothing hotter than watching that dick disappear down her throat!
4 Scenes from Amateurs Wanted 22
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subset: commoncrawl


text:
BLUE Wilderness® Wild Delights Chicken & Turkey Recipe For Adult Cats
Because cats love meat, BLUE Wilderness Wild Delights Meaty Morsels Chicken & Turkey goes a step beyond our protein-rich Wilderness recipe and boasts two tasty meats for your feline to enjoy. Tender, delectable chunks of real chicken and succulent turkey are accompanied by a rich gravy, making this a true feline favorite.
- Chicken and turkey provide readily digestible protein and essential amino acids
- A 100% grain-free formula eliminates any source of gluten which can trigger allergic reactions in some cats
- No chicken or poultry by-product meals means a more wholesome diet
ALWAYS Starts with Protein-Rich CHICKEN
- NO Chicken (or Poultry) By-Product Meals
- NO Corn, Wheat or Soy
- NO Artificial Flavours or Preservatives
Guaranteed Analysis
|Crude Protein
|9.0% min
|Crude Fat
|4.0% min
|Crude Fiber
|1.5% max
|82.0% max
|0.1% min
Nutrition Statement
BLUE Wilderness Wild Delights Chicken & Turkey Formula In Gravy Food for Cats is formulated to meet the nutritional levels established by the AAFCO Cat Food Nutrient Profiles for maintenance.
Feeding Guidelines
Feeding Instructions
Feed 3 cans per 6 to 8 lbs. body weight per day.
Refrigerate unused portion.
Fresh Water
Be sure to have a clean bowl of cool, fresh water available at all times.
Note: Individual cat's requirements may vary due to age, breed, environment, and activity level. Adjust food as required to maintain optimal body condition, and ask your veterinarian if you are unsure.
Calorie Content:
914 Kcals/kg, 78 Kcals/can.


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Kyra Sedgwick may seem every bit the supportive wife as she's accompanied real-life husband Kevin Bacon along their amazingly successful red carpet run this year.
But onscreen Sedgwick's personality is about to change after signing onto the indie-film "Chlorine" with Vincent D'Onofrio, according to the Hollywood Reporter.
Sedgwick's new role will be that of a New England family matriarch with more interest in putting on the right appearances than truly taking care of her home. The chilly exterior pushes her husband (D'Onofrio) into making a bad real estate decision.
The indie script by writer-director Jay Alaimo sounds like the perfect vehicle for Sedgwick who continues to pull in the award hardware for her role TNT's "The Closer." As for D'Onofrio, who is leaving USA Network's "Law & Order: Criminal Intent," hose him down and have a change of clothes nearby -- he'll be ready with the required angst. Looking forward to the fireworks.
This is the second time around for "Chlorine" which originally was set for Ray Liotta and Demi Moore. But that picture plan was scuttled due to Hurricane Katrina and scheduling.


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8501.0 - Retail Trade, Australia, May 2010
Previous ISSUE Released at 11:30 AM (CANBERRA TIME) 01/07/2010
|Page tools: Print Page Print All RSS Search this Product
The latest ABS figures show that retail sales rose 0.2% in May, seasonally adjusted, compared with a rise of 0.6% the previous month.
Clothing, Footwear & Other Personal Accessory Retailing (1.7%) and Department Stores (1.0%) recorded the largest increases in May followed by Cafes, Restaurants & Takeaway Food Services (0.8%), Other Retailing (0.3%) and Food Retailing (0.2%). Sales fell in Household Goods Retailing (-1.4%).
New South Wales (0.9%) and Victoria (0.2%) recorded increases in sales in May. Sales decreased in the other states and territories: South Australia (-0.9%), the Australian Capital Territory (-0.6%), the Northern Territory (-0.4%), Western Australia (-0.3%), Queensland (-0.2%), Tasmania (-0.1%).
Trend turnover grew 0.2% in May 2010. This follows a 0.2% rise in both April 2010 and March 2010.
In original terms, turnover increased 0.6% in the twelve months to May 2010.
Further information is available in Retail Trade, Australia (cat no. 8501.0)
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I maintain this isn't a "real" game. I think somebody, somewhere was taking the piss until publisher Majesco actually took the bait, is actually releasing it, and now it's all gotten a little awkward.
Babysitting Mama is a babysitting game for the Wii, where you cram a Wii Remote inside a baby and...do babysitting stuff. You'd hope that meant tell it lecherous stories, let it stay up after 10 and eat chocolate cookies for dinner, but sadly, it just means...whatever is on this trailer.
That Wii Remote cramming sequence is going to give me nightmares.
It'll be out next month on the Wii.


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"So," the question invariably begins when I whip out the Samsung Galaxy Tab (hereafter to be referred to as the gTab), "is it better than the iPad?" "Better," however, is the wrong adjective when addressing the inevitable and ultimately false equivalency between the two.
Why a false equivalency? Aren't they both tablet PCs?
gTab fits in your pocket. iPad doesn't. So choosing between the two really comes down to a question of posture and location.
Forget the stupid spec comparison between gTab and iPad. It's all about logistics. gTab has already sold 600,000-plus worldwide (even though Apple sold one million iPads in the U.S. alone in its first month of availability, gTab sales are still impressive) because it is a MOBILE device — you can keep it in an inside breast jacket pocket (suit or outerwear), and is a supplementary to a non-smart flip phone. If you already have an Android phone, a gTab is ridiculously redundant.
By comparison, iPad is a PORTABLE device — you need a bag to carry it around — and it can act as a laptop replacement.
Even though both tablets perform much of the same functions, similar to the truer equivalency between iPhone and an Android phone, their size differences and, by extension, how and how often they are accessed, means gTab and iPad will be used in completely different ways.
I've been "wearing" gTab for nearly two weeks, and all comparisons boil down to this: gTab fits in your pocket.
A Giant Android Phone
First, remember how cynics called the iPad an over-sized iPod Touch? We all know now what an absurd assertion that was. But the "just a larger version of…" comparison is more precise for the Samsung Galaxy Tab and the company's four Galaxy cellphones (Verizon's Fascinate, AT&T's Captivate, Sprint's Epic and T-Mobile's Vibrant).
Other than size, there is only one other major difference between gTab and its Galaxy cousins — the gTab has no phone. Android 2.2 Froyo runs the same on the gTab as it does on a phone, and it contains the same 1 GHz Hummingbird processor — similar the Apple shared iPhone/iPad OS 4.2 and 1 GHz processor.
But unlike iPad, gTab's browser defaults to the mobile optimized version of Web sites such as CNN, The New York Times and ESPN, just like a cellphone. And gTab actually lags in its lauded inclusion of cameras — the rear imager is just 3.2 MP, not the 5 MP on the Galaxy phones, and there's no HD video recording. (Anyone who doesn't think the next-gen iPad II won't have the same 5 MP/HD camera array on the iPhone 4 plus a front FaceTime camera raise your digits.)
And it ain't so good as a camera. gTab is too large and awkward to wield as a snap-and-shooter, even with its giant viewfinder. Even if you managed to quickly whip it out, it's got a slow shutter, there's no zoom, and its images are hazy, often bleached and mostly lack color, contrast and detail, all less impressive than results from the higher resolution cameras/video recorders on Samsung's Galaxy smartphones.
But did we mention it fits in your pocket?
The Comparison
gTab's only functional equivalency with iPad is movie viewing. gTab's screen is a wide 600 x 1024 pixels, nearly the exact aspect ratio as most widescreen movies. At 768 x 1024 pixels, iPad's 9.7-inch screen, is less oblong, so widescreen movies are displayed letterboxed. As a result, despite its screen being three inches smaller, widescreen movies on the gTab are nearly the same size as they are on the iPad (extra credit if you can identify what film the still image in the comparative picture is from).
In all other apps — Web surfing, map viewing, office app usage (word processing, spreadsheets, presentations, et al), iPad's more copious, squarer screen is "better."
But did we mention gTab fits in your pocket? As such, gTab works "better" as a music player since you don't have to string a headphone cable into your backpack (I don't have an music on my iPad — it's too inconvenient to use as a music player).
Excuse Me While I Whip This Out
I used gTab — which surprisingly doesn't weigh down a suit jacket pocket — more like I'd use a cellphone. Over the last two weeks, I've whipped out gTab to check the time. I've whipped it out to check email. I've whipped it out to Web surf to fill line-waiting time or play a game. I've whipped it out for pedestrian navigation and other location-based activities. I've whipped it out for standing subway-riding e-reading. I whipped it out and used in portrait mode.
Once inside home or office, the jacket came off and the gTab inaccessible for whipping-out. For serious work — article writing, photo processing, spreadsheet reviewing (yes, reviewers, when they do product forecasts, look at spreadsheets), Scrabble playing (no Android version yet), trip-planning, reading-room (ahem) e-reading and movie watching, supplemental Web surfing while TV watching — I picked up the iPad, holding it in landscape mode.
In other words, I used gTab vertically — holding in portrait mode while standing and wandering about outside. I used iPad horizontally — in landscape mode when was sitting indoors.
So, there is no "better." Your tablet choice depends entirely in which posture and location you more often find yourself.


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Tens of Thousands Remain Powerless, Homeless in Hurricane Isaac's Aftermath
Tens of thousands of people are powerless and thousands remain in emergency shelters nearly a week after Hurricane Isaac swamped the Gulf Coast with a deluge. President Barack Obama met victims on Monday while officials assessed the damage which might cost over $2 billion.
The fading remnants of Isaac have moved east but about 125,000 people were still without power and at least 2,600 people remained in emergency shelters due to floodwaters in Louisiana on Monday.
The National Weather Service has warned that scattered thunderstorms this week might cause frequent lightning and heavy downpours in southeastern Louisiana and southern Mississippi.
Heat index values are likely to range between 100 and 105 degrees, possibly higher in some locations, putting at risk especially those without power. "We need everyone to take their risk of heat stroke seriously," said Bruce D. Greenstein, Louisiana Department of Health and Hospitals secretary. "This is a serious condition that can kill you."
The Pearl River, along the Mississippi state line, was reported to have reached over 5 feet above the flood mark on Tuesday, prompting authorities to warn people to keep away from the area, CNN reported. More flood warnings were in effect Tuesday for parts of the Mississippi coast, where rivers north of Pascagoula and Gulfport were running high.
Obama visited St. John the Baptist Parish, which bore the brunt of Isaac, and met federal, state and local officials on Monday, a day ahead of the Democratic National Convention in North Carolina. He also met residents and heard their stories. "There has been enormous devastation in St. John's Parish," said the president, who was preceded by GOP challenger Mitt Romney who surveyed damaged areas last Friday, a day after the Republican National Convention concluded in Florida.
Louisiana Gov. Bobby Jindal's office said the Louisiana National Guard in St. Tammany Parish had 253 members ready to assist with security and evacuations near the Pearl River with 22 high-water vehicles, 23 Humvees and 21 boat teams.
Inspectors from the Federal Emergency Management Agency or FEMA were assessing the damage. Residents of nine Louisiana parishes with heavy damage have been approved to apply for grants for temporary housing and home repairs, and to cover uninsured property losses from the storm.
According to disaster modeler AIR Worldwide, Isaac may have caused up to $2 billion in insured onshore losses.
Meanwhile, oil operations that had been interrupted along the Gulf Coast were coming back on line, according to Reuters.
Southern Baptist Disaster Relief feeding units were serving 225,000 meals a day in Louisiana and Mississippi, according to Baptist Press.
"I think this truly shows what the Great Commission is all about as far as reaching out to our own communities in our area," said Tom Long, the southeast region coordinator for Louisiana Baptist Disaster Relief. "Then the support we have as Southern Baptists from all across our convention, the gathering together of our workers and teams, has been tremendous. No matter what kind of problem may come up, we're able to respond and respond quickly."
Isaac came exactly seven years after Hurricane Katrina, which left at least 1,836 people dead.


text:
contemporary facility offers an extensive menu of cutting-edge hair and nail
care services, the highest quality skin and body care treatments and extensive
product lines.
Satori's team of expert stylists, colorists, technicians and estheticians are continually provided with advanced education in the latest techniques and product technology.
We provide customized client education to help you navigate what services and products best enhance your life. When you leave Satori, you'll feel beautiful, acquire techniques, product knowledge, and have fun in the process.
With our fun, interactive shopping experience that encourages you to try before you buy and a spa party area designed for gatherings, Satori creates a sense of community. It's a great place to connect with friends and be pampered at the same time.


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Students in Lakeland College's music department will take the road as the concert choir participates in its annual spring tour.
The week culminates with a homecoming concert on Sunday, April 13, at 3 p.m. in the Bradley Theatre on Lakeland's main campus. That performance is free and open to the public.
This year's repertoire includes a wide variety of music from many historical periods, genres and styles. Pieces include "Domine, Ad Adjuvandum Me Festina" by G.B. Martini, "Five Hebrew Love Songs" by Whitacre, "Lass Dich Nur Nichts Nicht Dauren" by Johannes Brahms, "Salmo 150" by Ernani Aguiar and "Cantique de Jean Racine" by Gabriel Faure. The program also includes a gospel song, hymns, folk songs, movie music and a pop song.
The Lakeland Singers will join the choir on the program. This small, auditioned group will sing "To Love You," written by Andra Moran and Josh Elson and arranged by Lakeland College student Jacob Nault.
The annual tour takes Lakeland students to various churches around the Midwest. This year's tour includes the following performances:
- April 10 – Glenview United Methodist Church, 727 Harlem Ave., Glenview, Ill., 7 p.m.
- April 11 – St. Paul's United Church of Christ, 1260 Leonard Point Road, Oshkosh, Wis., 7 p.m.
- April 12 – St. Peter's UCC, 166 W. Dekora St., Saukville, Wis., 7 p.m.


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Summit County brewers, ranchers would be impacted by proposed FDA regs
In January 2011, President Obama signed into law the Food & Drug Administration's Food Safety Modernization Act, which aims to protect the U.S. food supply by shifting to a more proactive strategy to avoid contamination and foodborne illness across the country. As part of the act, on Oct. 25, 2013, the FDA proposed new regulations regarding the manufacturing, process, packing and holding of food for animals, regulations that small brewers across the country are fighting hard to amend.
But wait, why would regulating animal feed have an impact on craft brewing? The answer lies not in the beer, but, basically, in the trash. When crafting those tasty ales and lagers, brewers start with tons and tons of malted barley and other grains. When the malt is boiled during mashing, enzymes convert the starches in the grain into sugars, creating a liquid called wort. The wort is strained off and sent on its way to meet up with yeast and become alcohol, but the remaining part of the grain — dubbed spent grain, mostly barley husks with a bit of residual sugar — becomes a byproduct of the brewing process.
The brewery has no use for the spent grain, and it would all end up in the landfill were it not for a long-standing relationship between brewers and the farmers and ranchers in their respective communities. As it turns out, the spent grain is a great food supplement for all manner of livestock, from cows and buffalo to pigs and chickens. The wet mash is highly palatable to animals, and the processed grains are easier for them to digest. Because of this, natural alliances have formed whereby the breweries unload their detritus and the ranchers get tons and tons of tasty leftovers for their herds.
Proposed regulations
The government wants to intervene in this symbiotic relationship to ensure that the grain is handled properly and doesn't introduce contaminants into the food supply, which is an honorable goal, but conforming to the regulations would be a huge hurdle to brewers.
"What they would like to do is see more standardized process on how our spent grain gets to the ranchers and farmers," said Steve Kurowski, with the Colorado Brewers Guild. "What they want to do so far would make it very expensive and cumbersome for brewers to adhere to the rules they want to put in place."
The spent grain would have to be dried out and packaged, following very precise handling guidelines laid out by the FDA. For the majority of Colorado's small craft breweries, the cost to process the grain would be prohibitive.
"It would make most of the grain that gets used in brewing go to the landfill, rather than going to these farmers and ranchers," Kurowski said. "They want this spent grain to be packaged and done so in a way that requires a lot of equipment and a very expensive process to do."
The crux of the issue is that there's no current evidence that the way the grain is being handled is a detriment to the food supply.
"Brewers' grains have been used as cattle feed for centuries, and the practice is generally considered safe," the Brewers Association said in a statement released in late March. "We ask the FDA to conduct a risk assessment of the use of spent brewers' grain by farmers prior to imposing expensive new regulations and controls."
Local grain chain
Dave Simmons, head brewer at Pug Ryan's Brewing Co. in Dillon, said the brewery has partnered with a number of ranches and farms in the past, but its current spent grain bill is mostly split between Cripple Creek and Aspen Canyon ranches north of town. Simmons said the brewery gives away its grain, rather than selling it, which is typical of most brewers in the High Country, and as long as the relationship keeps working for both sides, he's happy to continue it.
"For us to get rid of this grain is a pain in the ass — the few times we've had to do that — especially with our expansion and how much we're producing right now and how much spent grain we're putting out," Simmons said.
The ranchers pick up the grain from the brewery, so all Simmons and his crew have to do is make it available. He said if the new legislation passes in its current form, the brewery would no longer be able to afford to provide the grain to the ranchers and it would just go in the trash.
"With this new regulation, one of the options that they want you to take is either you're going to have to dry it out, package it and then sell it that way, if that's what you're doing, or you're going to have to get a whole different Dumpster and go to the landfill and pay for that disposal," he said. "We're not going to dry our grain and package it, that's not going to happen, that's way too many man hours and machinery to even try to tackle that."
The Breckenridge Brew Pub has had a steady relationship with Ed Campling, a rancher near Fairplay, for the past eight years, and Jimmy Walker, head brewer, said the brewery has passed along its spent grain to one rancher or farmer or another for the past 24 years.
"The grain we get from Breckenridge we use for just about everything," Campling said. "We've fed buffalo, horses, calf, bulls — everything eats it, and they all do well on it. It's a supplement that we've used for years."
Aside from a 5-gallon bucket or two that gets picked up by locals for chicken feed, Campling is the solitary beneficiary of Breck's grain, Walker said.
"We pick up about a ton of grain a week. That supplements all of our feed," Campling said. "When we first started doing this, I was concerned about how (the livestock) were going to handle it, but the second or third trip out there, they run you over for it, everybody. We've never had any problems with it."
Campling said if the legislation goes through unaltered and Breckenridge cuts off the grain supply, he won't be able to raise as much livestock as he does now. Walker said without Campling clearing out the grain, not only would the Dumpster fill up, but the brewery would need more people to mash out, or finish the process, for each batch of beer.
"Like every Waste Management dumpster, it's like 6 feet in the air, so we'd have to lift a trash can full of wet, spent grain — which probably weighs a couple hundred pounds — we'd have to lift that like 6 feet in the air, so it would make it freaking impossible," Walker said. "The way it is now, it's a low trough, like a feeding trough, so now one person can mash out. If we had to put it in the Dumpster, it would take two people and twice as long. And it would all end up in a landfill instead of cutting feeding costs for cow feed."
Hot-button topic
Alan Simons, head brewer at Backcountry Brewery in Frisco, said his spent grain is picked up by a rancher and trucked an hour away to Hartsel, where it is shared with a couple of other small ranches. He said the issue of dealing with spent grain is an important enough topic that it was addressed in a presentation by Michael Pollan, author of "The Omnivore's Dilemma," at the recent Craft Brewers Conference in Denver.
"He talked about what kind of makes us advanced as humans, being able to cook food and the process of breaking down vegetables and grains, making it easier to consume," he said. "The example he gave is a gorilla spends eight hours a day chewing and digesting food. (With spent grain), they don't have to process the food, the rancher doesn't and the animal doesn't. It's easier for them to digest, it's easier to chew."
Some larger breweries have figured out alternative ways to dispose of their spent grain, Simons said. Alaskan Brewing Co., for example, just built a boiler that runs on spent grain, but purchasing a piece of equipment like that is out of the reach of most small craft breweries.
"There's other options, but for it to be feasible and economical, being able to produce enough grain to be able to produce enough fuel to do that, you have to be much bigger than our local guys," he said.
Cooperation between brewers and their local farmers and ranchers provides the most economical and mutually beneficial way to dispose of brewing byproducts, and heavy intervention from the Brewers Association, letter-writing campaigns by individual breweries and the support of Congressional figures is working toward maintaining those relationships.
"Even if any of this does come about, it's not going to be until 2015, 2016," Simmons said. "We're just going to have to wait and see what happens with that. We've voiced our opinion and we're part of the Colorado Brewers Guild, people looking out for our small breweries. We have to see how that legislation plays out."
Start a dialogue, stay on topic and be civil.
If you don't follow the rules, your comment may be deleted.


text:
Rockies Recap: Rockies 9, Giants 7
Rockies recap
Rockies 9, Giants 7
At Scottsdale
At the plate:Clint Barmes held a lumber party, going 4-for-4 with four RBIs. He finished a home run shy of the cycle. Barmes will open the season as the starting second baseman. "I am at my best when I stay loose and relaxed. I have been able to keep that approach and stay through the ball," said Barmes, who his hitting .467 this spring.
On the mound:Franklin Morales rebounded from an atrocious outing with a sharp performance. He commanded a fastball that ranged from 88 to 92 miles per hour, allowing just three hits over four innings. "I had better location with my fastball, and had good balance and concentration. You know what, I never was down over the last game. I need to stay in control and try to win a job."
Jason Hirsh was smashed for three runs in the sixth, his fastball lacking zip as it reaches the glove. He improved when his slider came into play, but didn't get a lot of cheap outs. Hirsh is working to increase his mound tempo because he has a habit of working slowly. "It was progress, but not what I wanted," Hirsh said. As it stands today, Morales and Greg Smith are slight leaders in the race for the fifth rotation spot, followed by Josh Fogg and Hirsh. Reynolds should benefit from more Triple-A seasoning, and Matt Belisle is still in the mix. He will make his debut Sunday.
In the field:Making a strong early push to land a bench job, Matt Murton has gotten good jumps and made a strong throws in both corner outfield spots. Jonathan Herrera, a walking web gem, made a sensational diving play at third base. He's been playing all over given the injuries to Garrett Atkins, Ian Stewart and Jeff Baker. Yes, folks, Christian Colonel kept his streak alive. He has appeared in every spring game, including the B game and exhibition against Mexico. Dexter Fowler made a spectacular grab, running approximately 50 yards to track down a ball in the gap in the ninth inning.
Up next: The Rockies host the Padres in Tucson. Smith, Greg Reynolds and Belisle, in his spring debut, are scheduled to pitch. Todd Helton will start tomorrow and hit in the third spot in the lineup. Chris Young will start for San Diego.


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In April 1920, Harlow Shapley and Heber D. Curtis debated "The Scale of the Universe" in the main auditorium of Smithsonian's Natural History Museum in Washington, DC. In April 1995, 75 years after the "Great Debate", Donald Lamb (Chicago) and Bohdan Paczynski (Princeton) will debate "The Distance Scale to Gamma-Ray Bursts" in the same auditorium. Martin Rees (Cambridge) will moderate.
These pages are still under construction. Information will be updated here frequently. A reasonably complete set of pages should exist by 15 January 1995. These pages are unofficial and do not represent the opinions, beliefs, or standards of any organization. Although every attempt has been made to be accurate, please use the information below only at your own risk. Information presented here is subject to change without prior notice and, unless otherwise noted, is for private educational purposes only and not for general distribution. Ticket availability is not guaranteed.
Harlow Shapley Heber D. Curtis
Published version of the 'Great Debate.' This is a reprint of the texts of Great Debate published in 1921 in the Bulletin of the National Research Council by Shapley and Curtis.
The 'Great Debate:' What Really Happened by Michael Hoskin, editor of the Journal for the History of Astronomy. This is a reprint of an article appearing in the Journal for the History of Astronomy discussing reality and myths about the 1920 event. The article includes text from the actual notes used by Shapley and slides used by Curtis.
A long bibliography for the 1920 Great Debate. This collection of over one hundred articles and books was compiled by Robert W. Smith, a historian working at the Smithsonian National Air and Space Museum.
A short bibliography for the 1920 Great Debate. Five key books and articles about the Great Debate.
Lesson Plans for teaching undergraduates about the Great Debate. Lessons available for introductory undergraduate and advanced undergraduate.
A Glossary of terms used in the Great Debate.
What the Great Debate was, how it was resolved, and why it was important.
A subjective abstract in three short paragraphs.
A limited supply of tickets are still available for this event as of the last update of this page. Tickets are free but should be requested in writing to the address given below.
The distance scale to gamma-ray bursts (GRBs) is as uncertain today as the distance scale to spiral nebulae was in 1920. Evidence appears to be mounting that GRBs occur in our Galaxy, but conflicting evidence also appears to be mounting that GRBs occur at cosmological distances. Therefore, at this debate, Lamb and Paczynski will publicly disagree, and each display evidence and reasoning on why one distance scale should be preferred over the other.
Address to write for free tickets, if still available. This page also contains details of when and where the 75th anniversary debate will be held.
The 1995 Debate Program including introductory review lectures.
A short bibliography for the 1995 debate.
Some of these articles are highly technical in nature.
A Glossary of terms likely to be used in the 1995 debate.
What this debate is about, how it will likely be resolved, and why it is
Might some of your friends or colleagues be interested in attending? If so,
you might consider downloading and posting this
postscript poster about the `Diamond Jubilee' debate in 1995.
Electronic correspondence should be directed to
Robert Nemiroff at the Internet address: firstname.lastname@example.com
A subjective abstract in three short paragraphs.
What this debate is about, how it will likely be resolved, and why it is
Might some of your friends or colleagues be interested in attending? If so, you might consider downloading and posting this postscript poster about the `Diamond Jubilee' debate in 1995.
Electronic correspondence should be directed to Robert Nemiroff at the Internet address: firstname.lastname@example.com


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Originally published March 1, 2014 at 8:00 PM | Page modified March 2, 2014 at 11:30 AM
Oil trains return to Northwest in big way
Regulators working with the rail industry can make oil trains even safer.
Special to The Seattle Times
The Pacific Northwest is a long way from the Oil Patch. But the Oil Patch is coming to us by train, ready or not.
The reason is hydraulic fracturing, the technology that injects water, sand and chemicals into rock formations to unlock oil and gas. The biggest fracking play is the Bakken formation in North Dakota, Montana and southern Canada. Relatively high crude prices make these ventures profitable.
These new oil fields tend to be far from pipelines, so railroads are moving the oil to refineries and terminals on the coasts.
The Sightline Institute, a think tank that focuses on environmental issues, calculates that 11 refineries or terminals are operating, under construction or planned in Washington and Oregon that can handle oil by rail. Three are already built.
In the past, most of the oil coming to the Northwest was from Alaska. In the future, trains could be bringing 700,000 barrels or more per day here and traveling through the region's most populous cities.
Sightline policy director Eric de Place says the key issue is the ''aggregate effects" of all these projects on environmental and safety risks, not the individual proposals.
Those dangers were most highlighted by the derailment and explosion last July of a runaway oil train in Lac-Mégantic, Quebec, which killed 42 and incinerated much of the town center.
Some other derailments have followed, even though major railroads have a good safety record in moving oil and other hazardous materials. The Lac-Mégantic disaster happened on a 510-mile.
Still, Todd Paglia, executive director of the environmental group ForestEthics, wrote in a Seattle Times op-ed, "Neither the federal government nor the state of Washington is remotely prepared for what is already in our state, let alone what may be coming."
Meanwhile, members of the Washington Legislature want the state Department of Ecology to improve its disaster planning. Democrats propose requiring energy companies to disclose their routes and how much oil they are sending by rail.
But stopping the process is impossible. Because of America's voracious appetite for fossil fuels, including a desire to export the oil bounty from fracking, that train has left the station.
Once, trains were the way oil traveled. At its peak, in 1943, rail carried 162 million barrels. By the early 1960s, the volume had fallen to 5 million barrels because of the construction of pipelines.
Although not necessarily safer, pipelines were much cheaper.
Fracking has given railroads a new advantage. Unlike the old "elephant fields" of the past, America's new oil plays are often far from pipelines. Fracked wells tend to deplete quickly, so constant drilling is required to keep output going. This makes it chancy for pipeline companies to make the heavy investment necessary to build new networks.
Rail is economical
Rail, on the other hand, is flexible and can reach many places more economically and quickly. As a result, railroads in the United States and Canada have experienced a boom in transporting oil.
Another potential business is transporting tar-sands oil from Alberta. This heavy crude is difficult to move by pipeline, requiring it to be diluted. At the terminal on the other end, this distillate must be removed. The cost advantage may go to rail.
Class 1 railroads, the largest carriers, are investing heavily in tank cars, and also increasing capacity and safety. The Association of American Railroads, the leading industry trade group, is calling for stringent new car designs and phasing out older models.
Gus Melonas, spokesman for the BNSF, the major railroad carrying Bakken oil to the Northwest, told me that the company is investing in new track, carrying out more inspections and buying 5,000 of the newest, safest tanker cars.
However, one complication for the railroads is that leasing companies and rail customers own most of the 92,000 tank cars used to transport oil in North America.
The BNSF sends between one-and-a-half and 2 oil trains per day to the Puget Sound region. Trains going through downtown Seattle travel at 25-miles-per-hour or less.
Sightline estimates that if all the refineries and terminals are built, all railroads could be operating 11 trains per day through the Northwest.
Melonas said the "northern tier" of the BNSF, which includes the former Great Northern and Northern Pacific railroads, has not seen a fatality as a result of a hazardous materials accident since 1981.
Even so, a December collision in North Dakota involving a 100-car oil train caused a fire and led to a partial evacuation of evacuation of Casselton, a small town west of Fargo.
Proper testing
Last month, federal regulators required shippers to properly test and classify oil coming from Bakken before it is loaded on trains.
This cuts to a critical problem with some fracked oil: It is more explosive than traditional light sweet crude.
Regulators working with the rail industry can make oil trains even safer.
Also, the fracking revolution risks being oversold. It depends on relatively high energy prices and heavy capital investment. It causes heavy environmental damage. Even with fracking, U.S. production last summer was 7.5 million barrels per day, still below the 9.6 million when America reached peak production in 1970.
But as long as Americans keep up their love affair with driving, as long as fossil fuels and highways are subsidized while transit is starved and climate-change causing carbon isn't taxed, rail will be moving oil.
Rail can also move people. America once enjoyed the finest passenger train system in the world. It could again.
Until these responses to climate change and the externality costs of oil happen, we're left with the mordant wit of the social critic James Howard Kunstler.
He jokes about environmentalists attending a rally, then getting in their SUVs to drive home.
You may reach Jon Talton at firstname.lastname@example.com
About Jon Talton
Jon Talton comments on economic trends and turning points, putting them into context with people, place and the environment in the Pacific Northwest
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