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Actor Leslie Nielsen passed away today at a Ft. Lauderdale, Florida hospital, according to his agent John S. Kelly. He died of complications from pneumonia at the age of 84. Born on February 11, 1926, Nielsen is best known for his deadpan roles in spoof comedies such as "Airplane!" and "The Naked Gun" films, as well as "Forbidden Planet" (1956) and "The Poseidon Adventure" (1972). His agent sent out the following statement:
We are saddened by the passing of beloved actor Leslie Nielsen, probably best remembered as Lt. Frank Drebin in THE NAKED GUN series of pictures, but who enjoyed a more than 60 year career in motion pictures and television."
Mr. Nielsen, 84, died of complications of pneumonia in a hospital near his home in Fort Lauderdale, Florida, surrounded by his lovely wife and dear friends at 5:34pm EST today.
In lieu of flowers, the family requests donations in his name to the charity of your choice.
Nielsen appeared in over 100 films and over 1,500 TV programs during his career. Here are some classic Nielsen moments:
FRANCO and HATHAWAY to HOST OSCARS.
James Franco and Anne Hathaway will serve as co-hosts of the 83rd Academy Awards®, Oscar telecast producers Bruce Cohen and Don Mischer announced today. Both have previously appeared on the telecast but not in hosting capacities.
"James Franco and Anne Hathaway personify the next generation of Hollywood icons — fresh, exciting and multi-talented. We hope to create an Oscar broadcast that will both showcase their incredible talents and entertain the world on February 27," said Cohen and Mischer. "We are completely thrilled that James and Anne will be joining forces with our brilliant creative team to do just that."
Franco, who currently can be seen in "127 Hours," will be making his second appearance on an Oscar telecast. Hathaway will be making her fifth appearance on an Academy Awards telecast, and was recently seen in "Alice in Wonderland" and currently can be seen in "Love and Other Drugs."
Academy Awards for outstanding film achievements of 2010 will be presented on Sunday, February 27, 2011, at the Kodak Theatre at Hollywood & Highland Center, and televised live on the ABC Television Network. The Oscar presentation also will be televised live in more than 200 countries worldwide.
Paramount Pictures announced a sneak preview event for the biopic JUSTIN BIEBER: NEVER SAY NEVER, happening on February 9th:
Moviegoers across the U.S. and Canada may be among the first to experience the new 3D film, "JUSTIN BIEBER: NEVER SAY NEVER," at exclusive "sneak preview" screening events set for Wednesday, February 9th at 6pm at specially selected RealD® 3D equipped movie theaters across the country.
Each complete Sneak Preview Gift Pack is priced at $30.00 (plus shipping) and includes:
•One ticket to the movie sneak preview Wednesday, February 9th at 6pm
•A pair of limited edition purple "JUSTIN BIEBER: NEVER SAY NEVER" RealD® 3D glasses
•A souvenir VIP event lanyard
•Official "JUSTIN BIEBER: NEVER SAY NEVER" branded glow stick and bracelet
For event locations around the country, to purchase tickets, or to learn more about this exclusive event, please go to: JB3DPreview.com. Limit is 6 tickets per credit card transaction. Supplies are limited.
MICHELLE WILLIAMS is MARILYN.
London's The Daily Mail is currently obsessed with BBC Films' Marilyn Monroe movie MY WEEK WITH MARILYN, which just finished filming at Pinewood Studios with the Weinstein Company planning on distributing the movie stateside. The paper has a new interview with star Michelle Williams tying into the completion of filming with the actress talking at length about playing the iconic screen legend, Marilyn Monroe, with a new photo (below) from the movie accompanying that interview. "At a certain point, something else does take over. I don't quite feel myself these days," she told the paper. Co-starring Eddie Redmayne, Judi Dench, Julia Ormond, Dougray Scott, Dominic Cooper and more, the film focuses on Monroe's relationship with Colin Clark (Redmayne), a well-to-do British laborer on the set of her 1956 movie "The Prince and the Showgirl" with whom she had a romance.
Atlas Entertainment announced it is rebooting the beloved franchise, BUFFY THE VAMPIRE SLAYER, with Warner Bros. Pictures. Atlas' Charles Roven and Steve Alexander will produce the feature film alongside Doug Davison and Roy Lee of Vertigo Entertainment (The Ring, How to Train Your Dragon, The Departed). Whit Anderson is writing the script. "Buffy the Vampire Slayer" first appeared as a film in 1992, subsequently becoming a cult hit and spawning the wildly popular television series starring Sarah Michelle Gellar and David Boreanaz, among many others.
Creator Joss Whedon responded to the announcement, saying, "This is a sad, sad reflection on our times, when people must feed off the carcasses of beloved stories from their youths—just because they can't think of an original idea of their own, like I did with my Avengers idea that I made up myself."
Walt Disney Pictures has confirmed that Gore Verbinksi is now officially signed on for Disney's THE LONE RANGER. Verbinksi, who has worked with Johnny Depp on the first three "Pirates of the Caribbean" films and the upcoming "Rango," will re-team with the actor, currently attached to play the Lone Ranger's sidekick, Tonto. The Lone Ranger's origin story begins with a group of Texas Rangers chasing down a gang of outlaws led by Butch Cavendish. The gang ambushes the Rangers, seemingly killing them all. One survivor is found, however, by an American Indian named Tonto, who nurses him back to health. The Ranger, donning a mask and riding a white stallion named Silver, teams up with Tonto to bring the unscrupulous gang and others of that ilk to justice.
Mark Wahlberg has confirmed to MTV that he will play Nathan Drake in the David O. Russell-directed UNCHARTED: DRAKE'S FORTUNE video game adatptation and that Robert De Niro and Joe Pesci may have roles as well. Wahlberg told MTV he hopes to reteam with his "The Fighter" and "Three Kings" director next year. "The idea that he has is just insane," Wahlberg said about Russell. "So hopefully we'll be making that movie this summer." He added: "That's who he wants to write the parts for. I talked to Pesci about it and I know David's people have talked to [Robert De Niro]… I'm obviously in whatever David wants to do but the idea of it is so off the charts: De Niro being my father, Pesci being my uncle. It's not going to be the watered-down version, that's for sure." The story will allegedly have something to do with antiquities dealers in New York.
Gael Garcia Bernal will play boxing champ Roberto Duran in HANDS OF STONE, reports TheWrap. Al Pacino is also circling the role of boxing trainer Ray Arecel in the biopic. Jonathan Jakubowicz ("Secuestro Express") will write, direct and produce the project with Ben Silverman. The site says the film "will focus on the boxing champion and will tell the inside story of the 'No Mas' fight." In the closing seconds of the fight's last round, Duran turned his back to Leonard and quit, saying "no mas" ("no more"). Duran beat Leonard in an earlier welterweight championship bout. They would meet again in a 1989 middleweight championship fight in Las Vegas. Leonard won that fight in 12 rounds.
Until next week!
Tags: academy awards, Airplane!, Anne Hathaway, Buffy the Vampire Slayer, Gael Garcia Bernal, Hands of Stone, james franco, Joss Whedon, justin bieber, Justin Bieber: Never Say Never, Leslie Nielsen, Mark Wahlberg, Michelle Williams, My Week with Marilyn, Naked Gun, oscar, Uncharted: Drake's Fortune
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June 13, 2012
Justin Rowland
Duck Sports Authority
Four-star De La Salle linebacker Michael Hutchings is planning to make his decision in July and he wants to make it up to Oregon before his choice. That means the Ducks might have a chance, but only one chance, to make their case.The Rivals100 linebacker, ranked the No. 51 prospect in the nation, was recently in the Pacific Northwest visiting one of the Ducks rivals, and apparently they made a strong impression."Recently I went on a trip to Washington," Hutchings explained. "I was going to decide the first week in July or maybe a little earlier. I've kinda pushed it back just a little bit, maybe. The trip to Washington really opened my eyes. I should have a decision before too long." ...More... To continue reading this article you must be a member. Sign Up Now!
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subset: commoncrawl


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Carry this color and show your support for breast cancer research. Learn more about the Vera Bradley Foundation for Breast Cancer.
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Topic Contents
- General Information About Plasma Cell Neoplasms
- Stage Information About Plasma Cell Neoplasms
- Treatment Option Overview for Plasma Cell Neoplasms
- Treatment for Amyloidosis Associated With Plasma Cell Neoplasms
- Treatment for Monoclonal Gammopathy of Undetermined Significance
- Treatment for Waldenström Macroglobulinemia (Lymphoplasmacytic Lymphoma)
- Treatment for Isolated Plasmacytoma of Bone
- Treatment for Extramedullary Plasmacytoma
- Treatment for Multiple Myeloma
- Refractory Multiple Myeloma
- Changes to This Summary (12 / 28 / 2012)
- About This PDQ Summary
- Get More Information From NCI
Plasma Cell Neoplasms (Including Multiple Myeloma) Treatment (PDQ®): Treatment - Health Professional Information [NCI]
This information is produced and provided by the National Cancer Institute (NCI). The information in this topic may have changed since it was written. For the most current information, contact the National Cancer Institute via the Internet web site at http://cancer.gov or call 1-800-4-CANCER.
Plasma Cell Neoplasms (Including Multiple Myeloma) Treatment
General Information About Plasma Cell Neoplasms
There are several types of plasma cell neoplasms. These diseases are all associated with a monoclonal (or myeloma) protein (M protein). They include monoclonal gammopathy of undetermined significance (MGUS), isolated plasmacytoma of the bone, extramedullary plasmacytoma, and multiple myeloma.
Incidence and Mortality
Estimated new cases and deaths from multiple myeloma in the United States in 2012:[1]
- New cases: 21,700.
- Deaths: 10,710.
Clinical Presentation and Evaluation
Table 1. 1. Clinical Presentation of Plasma Cell Neoplasms
|Plasma Cell Neoplasm
|M Protein Type
|Clinical Presentation
|MGUS = monoclonal gammopathy of undetermined significance.
|IgG kappa or lambda; or IgA kappa or lambda
|<10% plasma cells in bone marrow
|Asymptomatic, with minimal evidence of disease (aside from the presence of an M protein)[2]
|Isolated plasmacytoma of bone
|IgG kappa or lambda; or IgA kappa or gamma
|Solitary lesion of bone; <10% plasma cells in marrow of uninvolved site
|Asymptomatic or symptomatic
|Extramedullary plasmacytoma
|IgG kappa or lambda; or IgA kappa or gamma
|Solitary lesion of soft tissue; most commonly occurs in the nasopharynx, tonsils, or paranasal sinuses[3]
|Asymptomatic or symptomatic
|Multiple myeloma
|IgG kappa or lambda; or IgA kappa or gamma
|Often, multiple lesions of bone
Evaluation of patients with monoclonal (or myeloma) protein (M protein)
Idiotypic myeloma cells can be found in the blood of myeloma patients in all stages of the disease.[4,5] For this reason, when treatment is indicated, systemic treatment must be considered for all patients with symptomatic plasma cell neoplasms. Patients with MGUS or asymptomatic, smoldering myeloma do not require immediate treatment but must be followed carefully for signs of disease progression.
The major challenge is to separate the stable, asymptomatic group of patients who do not require treatment from patients with progressive, symptomatic myeloma who should be treated immediately.[6,7]
Patients with a monoclonal (or myeloma) protein (M protein) in the serum and/or urine are evaluated by some of the following criteria:
- Measure and follow the serum M protein by serum electrophoresis or by specific immunoglobulin assays; however, specific immunoglobulin quantification always overestimates the M protein because normal immunoglobulins are included in the result. For this reason, baseline and follow-up measurements of the M protein should be done by the same method.[8] Quantitative serum-free light chains may be helpful to follow response if an M protein is not apparent.
- Measure and follow the amount of M protein light chains excreted in the urine over 24 hours. Measure the total amount of protein excreted over 24 hours and multiply this value by the percentage of urine protein that is M protein, as determined by electrophoresis of concentrated urine protein. An easier, but less accurate, method uses a spot-urine protein electrophoresis.
- Identify the heavy and light chain of the M protein by immunofixation electrophoresis.
- Measure the hemoglobin, leukocyte, platelet, and differential counts.
- Sometimes, determine the percentage of marrow plasma cells. Be aware that marrow plasma cell distribution may vary in different sites.
- Measure serum-free kappa and lambda light chain. This is especially useful in cases of oligosecretory plasma cell dyscrasia or for following cases of light chain amyloidosis.[9]
- Take needle aspirates of a solitary lytic bone lesion, extramedullary tumor(s), or enlarged lymph node(s) to determine whether these are plasmacytomas.
- Evaluate renal function with serum creatinine and a creatinine clearance.
- Electrophoresis of concentrated urine protein is very helpful in differentiating glomerular lesions from tubular lesions. Glomerular lesions, such as those resulting from glomerular deposits of amyloid or light-chain deposition disease, result in the nonselective leakage of all serum proteins into the urine; the electrophoresis pattern of this urine resembles the serum pattern with a preponderance of albumin.
In most myeloma patients, the glomeruli function normally allows only the small molecular weight proteins, such as light chains, to filter into the urine. The concentration of protein in the tubules increases as water is reabsorbed. This leads to precipitation of proteins and the formation of tubular casts, which may injure the tubular cells. With tubular lesions, the typical electrophoresis pattern shows a small albumin peak and a larger light-chain peak in the globulin region; this tubular pattern is the usual pattern found in myeloma patients.
- Measure serum levels of calcium, alkaline phosphatase, lactic dehydrogenase, and, when indicated by clinical symptoms, cryoglobulins and serum viscosity.
- Obtain radiographs of the skull, ribs, vertebrae, pelvis, shoulder girdle, and long bones. Whole-body, low-dose, nonenhanced multidetector computed tomography and magnetic resonance imaging (MRI) are being evaluated as measures for therapy response monitoring.[10,11] MRI of the spine or long bones is more sensitive in detecting lytic lesions, but any prognostic or therapeutic value for this information remains to be determined.[11]
- Perform MRI if a paraspinal mass is detected or if symptoms suggest spinal cord or nerve root compression.
- If amyloidosis is suspected, perform a needle aspiration of subcutaneous abdominal fat and stain the bone marrow biopsy for amyloid as the easiest and safest way to confirm the diagnosis.[12]
- Measure serum albumin and beta-2-microglobulin as independent prognostic factors.[13,14]
- A high plasma cell labeling index (≥3%) or the presence of circulating myeloma cells are considered poor prognostic factors.[15]
These initial studies should be compared with subsequent values at a later time, when it is necessary to decide whether the disease is stable or progressive, responding to treatment, or getting worse.
As mentioned before, the major challenge is to separate the stable, asymptomatic group of patients who do not require treatment from patients with progressive, symptomatic myeloma who should be treated immediately.[6,7]
Monoclonal Gammopathy of Undetermined Significance (MGUS)
Patients with MGUS have an M protein in the serum without findings of multiple myeloma, macroglobulinemia, amyloidosis, or lymphoma and have fewer than 10% of plasma cells in the bone marrow.[2,16,17,18] Patients with smoldering myeloma have similar characteristics but may have more than 10% of plasma cells in the bone marrow.
These types of patients are asymptomatic and should not be treated. They must, however, be followed carefully since about 1% to 2% of MGUS patients per year will progress to develop myeloma (most commonly), amyloidosis, lymphoma, or chronic lymphocytic leukemia and may then require therapy.[18,19,20]
Virtually all cases of multiple myeloma are preceded by a gradually rising level of MGUS.[21,22,23]
Risk factors that predict disease progression include the following:
- An abnormal serum-free light chain ratio.
- Non-IgG class MGUS.
- A high serum M protein level (≥15 g/L).[24]
Isolated Plasmacytoma of Bone
The patient has an isolated plasmacytoma of the bone if the following are found:
- A solitary lytic lesion of plasma cells is found on skeletal survey in an otherwise asymptomatic patient.
- A bone marrow examination from an uninvolved site contains less than 10% plasma cells.[25,26,27]
When clinically indicated, MRI may reveal unsuspected bony lesions that were undetected on standard radiographs. MRI scans of the total spine may identify other bony lesions.[28]
Extramedullary Plasmacytoma
A patient has extramedullary plasmacytoma if the following are found:
- Isolated plasma-cell tumors of soft tissues, most commonly occurring in the tonsils, nasopharynx, or paranasal sinuses.
- Negative findings on skeletal x-rays and bone marrow biopsy.[29,30,31]
Multiple Myeloma
Multiple myeloma is a systemic malignancy of plasma cells that typically involves multiple sites within the bone marrow and secretes all or part of a monoclonal antibody.
Multiple myeloma is highly treatable but rarely curable. The median survival in the prechemotherapy era was about 7 months. After the introduction of chemotherapy, prognosis improved significantly with a median survival of 24 to 30 months and a 10-year survival rate of 3%. Even further improvements in prognosis have occurred because of the introduction of newer therapies such as pulse corticosteroids, thalidomide, bortezomib, and autologous and allogeneic stem cell transplantation, with median survivals of 45 to 60 months.[32,33,34]
Multiple myeloma is potentially curable when it presents as a solitary plasmacytoma of bone or as an extramedullary plasmacytoma. (Refer to the Isolated Plasmacytoma of Bone and Extramedullary Plasmacytoma sections of this summary for more information.)
Amyloidosis Associated With Plasma Cell Neoplasms
Multiple myeloma and other plasma cell neoplasms may cause a condition called amyloidosis. Primary amyloidosis can result in severe organ dysfunction especially in the kidney, heart, or peripheral nerves. Elevated serum levels of cardiac troponinsand brain natriuretic peptide are poor prognostic factors. A proposed staging system for primary systemic amyloidosis based on these serum levels requires independent and prospective confirmation.[35]
Stage Information About Plasma Cell Neoplasms
No generally accepted staging system exists for monoclonal gammopathy of undetermined significance (MGUS), isolated plasmacytoma of bone, or extramedullary plasmacytoma. Of the plasma cell neoplasms, a staging system exists only for multiple myeloma.
Multiple Myeloma
Multiple myeloma is staged by estimating the myeloma tumor cell mass on the basis of the amount of monoclonal (or myeloma) protein (M protein) in the serum and/or urine, along with various clinical parameters, such as hemoglobin and serum calcium concentrations, the number of lytic bone lesions, and the presence or absence of renal failure. Impaired renal function worsens prognosis regardless of stage.
The stage of the disease at presentation is a strong determinant of survival, but it has little influence on the choice of therapy since almost all patients, except for rare patients with solitary bone tumors or extramedullary plasmacytomas, have generalized disease.
International staging system
The International Myeloma Working Group studied 11,171 patients, of whom 2,901 received high-dose therapy and 8,270 received only standard-dose therapy.[1]
An International Staging System was derived and is shown below in Table 2 2.[1]
Table 2. 2. The International Staging System for Multiple Myeloma
|Median Survival (mo)
|Beta-2-microglobulin <3.5 mg/L and albumin ≥3.5 g/dL
|Beta-2-microglobulin <3.5 mg/L and albumin <3.5 g/dL or beta-2-microglobulin 3.5 mg/L to <5.5 mg/L
|Beta-2-microglobulin ≥5.5 mg/L
Genetic factors and risk groups
Genetic aberrations detected by interphase fluorescence in situ hybridization (FISH) may define prognostic groups in retrospective and prospective analyses.[2,3] Short survival and shorter duration of response to therapy have been reported with t(4;14)(p16;q32), t(14; 16)(q32;q23), cytogenetic deletion of 13q-14, and deletion of 17p13 (p53 locus).[2,3,4,5,6] The question of whether the choice of therapy based on FISH analysis can influence outcome must await further study in prospective trials.
Newer clinical investigations are stratifying patients with multiple myeloma into a so-called standard-risk group, which accounts for 75% of patients and has a median survival of 3 to 6 years, and a high-risk group, which has a median survival of less than 3 years.[2,3,4,5,6,7] (See Table 3 3 below.) This stratification, based on cytogenetic findings, has been derived from retrospective analyses and requires prospective validation.[7] Bone marrow samples are sent for cytogenetic and FISH analysis. Plasma cell leukemia has a particularly poor prognosis.[8]
Table 3. 3. Risk Groups for Multiple Myeloma
|Risk Group
|Cytogenetic Findings
|Disease Characteristics
|FISH = fluorescencein situ hybridization.
|Standard risk
|Has any of the following cytogenetic findings: (1) no adverse FISH or cytogenetics, (2) hyperdiploidy, (3) t(11;14) by FISH, or (4) t(6;14) by FISH.
|These patients most often have (1) disease that expresses IgG kappa monoclonal gammopathies and (2) lytic bone lesions.
|High risk
|Has any of the following cytogenetic findings: (1) del 17p by FISH, (2) t(4;14) by FISH, (3) t(14;16) by FISH, (4) cytogenetic del 13, or (5) hypodiploidy.
|These patients have (1) disease that expresses IgA lambda monoclonal gammopathies (often) and (2) skeletal-related complications (less often).
Treatment Option Overview for Plasma Cell Neoplasms
The major challenge in treating plasma cell neoplasms is to separate the stable, asymptomatic group of patients who do not require immediate treatment from patients with progressive, symptomatic myeloma who should be treated immediately.[1,2] Monoclonal gammopathy of undetermined significance or smoldering myeloma must be distinguished from progressive myeloma.
Asymptomatic Plasma Cell Neoplasms
Asymptomatic patients with multiple myeloma who have no lytic bone lesions and normal renal function may be initially observed safely outside the context of a clinical trial.[1,3,4] Increasing anemia is the most reliable indicator of progression.[4]
Symptomatic Plasma Cell Neoplasms
Treatment should be given to patients with symptomatic advanced disease.
Treatment should be directed at reducing the tumor cell burden and reversing any complications of disease, such as renal failure, infection, hyperviscosity, or hypercalcemia, with appropriate medical management. (Refer to the PDQ summary on Hypercalcemia for more information.)
Response criteria have been developed for patients on clinical trials.[5]
Current therapy for patients with symptomatic myeloma can be divided into the following categories:
- Induction therapies.
- Consolidation therapies, which are less applicable for the very elderly.
- Maintenance therapies.
- Supportive care, such as bisphosphonates. (Refer to the Adjuvant drugs section in the Pharmacologic Management section of the PDQ summary on Pain for more information.)
Treatment for Amyloidosis Associated With Plasma Cell Neoplasms
Standard Treatment Options for Amyloidosis Associated With Plasma Cell Neoplasms
Standard treatment options for amyloidosis associated with plasma cell neoplasms include the following:
|Stem cell rescue.
Two randomized trials showed prolonged overall survival (OS) with the use of oral chemotherapy with melphalan with or without colchicine versus colchicine alone.[1,2][Level of evidence: 1iiA]
As is true for all plasma cell dyscrasias, anecdotal responses for amyloidosis have been reported, as in the Southwest Oncology Group's trial (SWOG-9628 [NCT00002849])Translators: NCT # added after final markup, for dexamethasone alone and in combination, including thalidomide, cyclophosphamide, melphalan, bortezomib, and lenalidomide[3].[4,5,6,7,8]
Stem cell rescue
A randomized, prospective study of 100 patients with immunoglobulin amyloidosis light chain compared melphalan plus high-dose dexamethasone with high-dose melphalan plus autologous stem cell rescue.[9]
After a median follow-up of 3 years, median OS favored the nontransplant arm (56.9 months vs. 22.2 months; P = .04).[9][Level of evidence: 1iiA] The 24% transplant-related mortality in this series and others reflects the difficulties involved with high-dose chemotherapy in older patients with organ dysfunction.[9,10,11,12] A randomized trial confirming the benefit of autologous transplantation is not anticipated.[13]
An anecdotal series describes full-intensity and reduced-intensity allogeneic stem cell transplantation.[14]
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with primary systemic amyloidosis. 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.
Treatment for Monoclonal Gammopathy of Undetermined Significance
Standard Treatment Options for Monoclonal Gammopathy of Undetermined Significance (MGUS)
Standard treatment options for MGUS include the following:
|Watchful waiting.
Watchful waiting
Multiple myeloma, other plasma cell dyscrasia, or lymphoma will develop in 12% of patients by 10 years, 25% by 20 years, and 30% by 25 years.
All patients with MGUS should be kept under observation to detect increases in M protein levels and development of a plasma cell dyscrasia. Higher levels of initial M protein levels may correlate with increased risk of progression to multiple myeloma.[1,2] In a large retrospective report, the risk of progression at 20 years was 14% for an initial monoclonal protein level of 0.5 g/dL or less, 25% for a level of 1.5 g/dL, 41% for a level of 2.0 g/dL, 49% for a level of 2.5 g/dL, and 64% for a level of 3.0 g/dL.[1]
Treatment is delayed until the disease progresses to the stage that symptoms or signs appear.
Patients with MGUS or smoldering myeloma do not respond more frequently, achieve longer remissions, or have improved survival if chemotherapy is started early while they are still asymptomatic as opposed to waiting for progression before treatment is initiated.[3,4,5,6] Newer therapies have not been proven to prevent or delay the progression of MGUS to a plasma cell dyscrasia.[2]
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with monoclonal gammopathy of undetermined significance. 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.
Treatment for Waldenström Macroglobulinemia (Lymphoplasmacytic Lymphoma)
Refer to the Lymphoplasmacytic Lymphoma (Waldenström Macroglobulinemia) section in the PDQ summary on Adult Non-Hodgkin Lymphoma Treatment for more information.
Treatment for Isolated Plasmacytoma of Bone
Standard Treatment Options for Isolated Plasmacytoma of Bone
Standard treatment options for isolated plasmacytoma of bone include the following:
|Radiation therapy to the lesion.
|Chemotherapy (if the monoclonal [or myeloma] protein [M protein] increases and other evidence of symptomatic multiple myeloma occurs).
Radiation therapy
About 25% of patients have a serum and/or urine M protein; this should disappear following adequate radiation therapy to the lytic lesion.
The survival rate of patients with isolated plasmacytoma of bone treated with radiation therapy to the lesion is greater than 50% at 10 years, which is much better than the survival rate of patients with disseminated multiple myeloma.[1]
Most patients will eventually develop disseminated disease and require chemotherapy; almost 50% of them will do so within 2 years of diagnosis.[2,3] However, patients with serum paraprotein or Bence Jones protein, who have complete disappearance of these proteins after radiation therapy, may be expected to remain free of disease for prolonged periods.[2,4] Patients who progress to multiple myeloma tend to have good responses to chemotherapy with a median survival of 63 months after progression.[2,4]
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with isolated plasmacytoma 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.
Treatment for Extramedullary Plasmacytoma
Standard Treatment Options for Extramedullary Plasmacytoma
Standard treatment options for extramedullary plasmacytoma include the following:
|Radiation therapy to the isolated lesion with fields that cover the regional lymph nodes, if possible.[1,2]
|In some cases, surgical resection may be considered, but it is usually followed by radiation therapy.[2]
|If the monoclonal (or myeloma) protein (M protein) persists or reappears, the patient may need further radiation therapy. In some patients, the plasmacytoma may shrink, but not disappear, and the M protein persists. These types of patients should be followed closely. Surgery should be performed if the plasmacytoma is in a site where it can be removed easily (e.g., in the tonsil); the M protein may disappear from the blood or urine. In other cases, persistence or an increasing M protein may herald progression to multiple myeloma.
|Chemotherapy is required if the disease progresses and causes symptoms.
Patients with isolated plasma cell tumors of soft tissues, most commonly occurring in the tonsils, nasopharynx, or paranasal sinuses, should have skeletal x-rays and bone marrow biopsy (both of which should be negative) and evaluation for M protein in serum and urine.[1,2,3,4]
About 25% of patients have serum and/or urine M protein; this should disappear following adequate radiation.
Extramedullary plasmacytoma is a highly curable disease with progression-free survival ranging from 70% to 87% at 10 to 14 years after treatment with radiation therapy (with or without previous resection).[1,2,5]
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with extramedullary plasmacytoma. 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.
Treatment for Multiple Myeloma
Initial Evaluation
The initial approach to the patient is to evaluate the following parameters:
|Detection of a monoclonal (or myeloma) protein (M protein) in the serum or urine.
|Detection of more than 10% of plasma cells on a bone marrow examination.
|Detection of lytic bone lesions or generalized osteoporosis in skeletal x-rays.
|Presence of soft tissue plasmacytomas.
|Serum albumin and beta-2-microglobulin levels.
|Detection of free kappa and lambda serum immunoglobulin light chain.[1]
Treatment selection is influenced by the age and general health of the patient, prior therapy, and the presence of complications of the disease.[2]
Induction Therapy
The choice of induction therapy is unclear at the present time; however, the current basic categories include the use of steroids, thalidomide, and lenalidomide.
Several questions are raised when therapy is being chosen for a patient with symptomatic myeloma at first presentation, including the following:
|Is the patient eligible for a clinical trial? The sequence and combinations of new and older therapies can only be determined by prospective clinical trials.
|Is autologous stem cell transplantation (ASCT) a possible consolidation option for this patient? If so, alkylating agents should be avoided during induction therapy to avoid compromise of stem cell collection and to lessen leukemogenic risk.
|Does the patient have comorbidities? Age, organ dysfunction, and risk of cardiovascular and thrombotic complications would influence the choice of induction therapies as well as the choice of whether to consider consolidation therapies.
Induction therapy agents
Multiple therapeutic agents are available for induction therapy, either alone or in combinations.[3] These include the following:
- Steroids (e.g., dexamethasone and prednisone).
- Thalidomide.
- Lenalidomide.
- Bortezomib.
- Alkylating agents (e.g., melphalan and cyclophosphamide).
- Other cytotoxic drugs (e.g., vincristine, doxorubicin, and liposomal doxorubicin).
Clinical trials are needed to establish the regimens with the best efficacy and least long-term toxicity. (Refer to the Combination therapy section of this summary for a list of current clinical trials.)
Guidelines for choosing induction therapy
Until results become available, outside the context of a clinical trial, clinicians may choose induction therapy based on the following guidelines:
|In patients younger than 70 years, alkylators are avoided up front to avoid stem cell toxicity with subsequent risks for cytopenias, secondary malignancies, or poor stem cell harvesting if transplantation is considered for consolidation therapy.[4]
|Bortezomib or lenalidomide is combined with dexamethasone for at least 8 months or until best response if consolidation therapy is planned.[5,6] (Refer to the Lenalidomide and Bortezomib sections of this summary for more information.)
|The choice of bortezomib or lenalidomide is based on side-effect profile and route of administration.
|Patients with standard-risk disease, as defined in the Stage Information About Plasma Cell Neoplasms section of this summary, might receive induction therapy alone, followed by careful observation after best response.[11]
|Patients with high-risk disease might receive induction therapy until best response, followed by consolidation therapy with allogeneic or ASCT.[11]
These guidelines require validation by ongoing clinical trials; participation in clinical trials is the preferred choice, when possible.
Since the mid-1980s, dexamethasone has been administered at a dose of 40 mg orally for 4 consecutive days, which is the same schedule used with the vincristine plus doxorubicin plus dexamethasone (VAD) regimen.[12] Response rates of 60% to 70% in previously untreated patients appeared to be as high as those in patients treated with VAD.[12,13][Level of evidence: 3iiiDiv]
A prospective trial randomly assigned 488 patients older than 65 years to receive dexamethasone alone, melphalan plus dexamethasone, dexamethasone plus interferon-alpha, and melphalan plus prednisone (MP).
- With a median follow-up of 7.1 years, no difference was observed in overall survival (OS) (median survival times were 32 months–40 months).[14][Level of evidence: 1iiA]
- The patients on the dexamethasone-based arms had significantly more infections, glucose intolerance, gastrointestinal symptoms, and psychiatric complaints. (Refer to the PDQ summary on Gastrointestinal Complications for more information on gastrointestinal symptoms.)
There has never been a randomized trial comparing single-agent oral dexamethasone at a traditional high dose (40 mg a day for 4 days, repeated after 4 days off) with a lower dose (≤40 mg weekly). This issue of dexamethasone dose has been evaluated in two of the following prospective, randomized trials:
- In the context of melphalan, as evaluated in a National Cancer Institute of Canada trial (CAN-NCIC-MY7).
- Compared with standard-dose steroids, high-dose dexamethasone was associated with an increased risk of infection in the melphalan trial, but there was no difference in efficacy.[15]
- In the context of lenalidomide, as evaluated in an Eastern Cooperative Oncology Group trial (ECOG-E4A03).[5]
- The lenalidomide study questioned the safety and efficacy of high-dose dexamethasone.[5] (Refer to the Lenalidomide section of this summary for more information.)
Almost all ongoing clinical trials in the United States and Europe have implemented the low-dose dexamethasone schedule with or without other therapeutic agents.
Ten randomized prospective studies involving more than 4,500 patients have examined the introduction of thalidomide as induction therapy for previously untreated symptomatic patients with multiple myeloma.[16,17,18,19,20,21,22,23,24]
- All of the trials reported improved response rates with the introduction of thalidomide and no hematopoietic damage, allowing adequate stem cell collection when applicable or allowing combinations with other myelosuppressive agents.
- Only two of the ten randomized studies reported a survival advantage using thalidomide. In these trials, the patients older than 65 or 75 years at the 2-year follow-ups showed a 44- to 56-month median OS for MP plus thalidomide versus 28- to 30-month median OS for MP (P < .03 in both studies).[22,25][Level of evidence: 1iiA]
- A possible explanation is that these two trials used a lower dose of thalidomide than the other studies (100 mg vs. ≥200 mg), a lower dose of steroids (60 mg of prednisone vs. high-dose dexamethasone), and involved the use of alkylating agents.
As previously described in the section on corticosteroids, high-dose dexamethasone can complicate interpretation of clinical trials by worsening cardiopulmonary toxicity and deaths, especially in the context of thalidomide or lenalidomide, both of which are thrombogenic agents.
Factors that have been implicated to worsen the risk of DVT include the use of high-dose dexamethasone, concomitant erythropoietic growth factors, and concomitant doxorubicin, liposomal doxorubicin, or alkylating agents.[26,27]
Personal cardiovascular risk factors can also influence the rate of DVT. Various clinical trials have included different DVT prophylaxis measures, including aspirin (81 mg–100 mg a day), warfarin, or low molecular-weight heparin, but the validity of these measures has not been studied prospectively in a randomized study.[20,22,27,28,29]
Prospective electrophysiologic monitoring provides no clear benefit over clinical evaluation for the development of clinically significant neuropathy while on thalidomide.
|A prospective, randomized study of 351 relapsed patients compared lenalidomide, an analog of thalidomide, plus high-dose dexamethasone with high-dose dexamethasone plus placebo.[30]
|Similarly, another randomized, prospective trial (NCT00056160) of 353 previously treated patients favored the lenalidomide plus high-dose dexamethasone arm versus dexamethasone plus placebo.
|A prospective, randomized study (ECOG-E4A03) of 445 untreated symptomatic patients compared lenalidomide and high-dose dexamethasone (40 mg on days 1–4, 9–12, and 17–20, every 28 days) with lenalidomide and low-dose dexamethasone (40 mg on days 1, 8, 15, and 22, every 28 days).[5]
|A retrospective analysis of 353 patients who received lenalidomide and high-dose dexamethasone found that the 17% of the patients who experienced a thromboembolic episode had no decrease in OS or time to progression.[32][Level of evidence: 3iiiA]
Lenalidomide has substantially greater myelosuppression but less neuropathy than seen with thalidomide; however, both have the same tendency for DVT.[5,30,31,32] DVT prophylaxis with 81 mg of aspirin has been proposed, but randomized clinical trials have not confirmed any benefit for this recommendation.[29] Empirically, the greater the number of risk factors for DVT, the more intense the recommendation for prophylactic anticoagulation. (Refer to the Thalidomide section of this summary for more information about risk factors.) As a result of predominant renal clearance, lenalidomide doses need to be reduced in the setting of impaired renal function (creatinine clearance, 30–50: 10 mg per day; creatinine clearance, <30: 15 mg every other day; dialysis, 15 mg on day after dialysis).[33]
|A prospective, randomized trial (NCT00111319) of 682 previously untreated symptomatic patients who were not candidates for stem cell transplantation because of age (one-third of patients >75 years) compared bortezomib combined with melphalan and prednisone with melphalan and prednisone alone.[6]
|A prospective, randomized study of 669 patients with relapsing myeloma, who had been treated previously with steroids, compared intravenous bortezomib with high-dose oral dexamethasone.
|A prospective, randomized trial (NCT00103506) of 646 previously treated patients compared bortezomib plus pegylated liposomal doxorubicin with bortezomib alone.[38]
When bortezomib was incorporated with induction therapy, patients with unfavorable molecular cytogenetics did not show any difference in PFS or OS compared with patients with more favorable risk factors. The benefit from bortezomib appears to be maintained across risk groups, but not reproducibly in all studies.[39,40,41,42,43][Level of evidence: 3iiiD]
Because bortezomib is metabolized and cleared by the liver, it appears active and well tolerated in patients with renal impairment.[9,44,45] In a retrospective, nonrandomized comparison, bortezomib administered once weekly had significantly less grade 3 to 4 peripheral neuropathy (8% vs. 28%, P < .001) with no loss of efficacy compared with standard biweekly administration.[46]
Conventional-dose chemotherapy
The VAD regimen has shown activity in previously treated and in untreated patients with response rates ranging from 60% to 80%.[47,48,49,50][Level of evidence: 3iiiDiv]
- No randomized studies support the widespread use of this regimen in untreated patients.
- This regimen avoids early exposure to alkylating agents, thereby minimizing any problems with stem cell collection (if needed) and any future risks for myelodysplasia or secondary leukemia.
- Disadvantages include the logistics for a 96-hour infusion of doxorubicin and a low complete response rate.
- An alternative version of VAD substitutes pegylated liposomal doxorubicin for doxorubicin, eliminates the need for an infusion, and provides comparable response rates.[51,52][Level of evidence: 3iiiDiv]
Evidence is not strong that any alkylating agent is superior to any other. All standard doses and schedules produce equivalent results.[53] The two most common regimens historically have been oral MP and oral cyclophosphamide plus prednisone.[53,54,55]
Combinations, such as those used in EST-2479, of alkylating agents and prednisone, administered simultaneously or alternately, have not proven to be superior to therapy with MP.[56,57,58,59][Level of evidence: 1iiA]
A meta-analysis of studies comparing MP with drug combinations concluded that both forms of treatment were equally effective.[53][Level of evidence: 1iiA] Patients who relapsed after initial therapy with cyclophosphamide and prednisone had no difference in OS (median OS, 17 months) when randomly assigned to receive vincristine plus carmustine plus melphalan plus cyclophosphamide plus prednisone or VAD.[60][Level of evidence: 1iiA]
Combination therapy
Several national and international trials have been implemented to define the optimal combination regimens. Participation in these trials should be the preferred approach, when feasible. The combination regimens in these trials represent the most successful from numerous phase II reports during the last several years.
- ECOG-E1A05: Bortezomib + dexamethasone versus lenalidomide + bortezomib + dexamethasone.[61]
- SWOG-S0777: Lenalidomide + dexamethasone versus lenalidomide + bortezomib + dexamethasone.
- EVOLUTION (NCT00507442) trial: Bortezomib + lenalidomide + dexamethasone versus bortezomib + cyclophosphamide + dexamethasone versus bortezomib + lenalidomide + cyclophosphamide + dexamethasone.
- U.S. Intergroup/Intergroupe Francais du Myélome trial (IFM): Lenalidomide + bortezomib + dexamethasone for three cycles; responders are then randomly assigned to five more cycles of lenalidomide + bortezomib + dexamethasone or high-dose melphalan + stem cell transplantation.
- ECOG-E1A06: Thalidomide + melphalan + prednisone versus lenalidomide + melphalan + prednisone.
Options for combination regimens:
|Bortezomib + dexamethasone (as demonstrated in ECOG-E1A05).[39,61]
|Lenalidomide + dexamethasone (as demonstrated in SWOG-S0777).[5,30,31]
|Bortezomib + lenalidomide + dexamethasone (as demonstrated in ECOG-E1A05, SWOG-S0777, EVOLUTION trial, and the U.S. Intergroup/IFM trial).[39,61,62]
|Bortezomib + cyclophosphamide + dexamethasone (as demonstrated in the EVOLUTION trial).[63,64]
|Bortezomib + lenalidomide + cyclophosphamide + dexamethasone (as demonstrated in the EVOLUTION trial).[65]
|Lenalidomide + cyclophosphamide + dexamethasone.[66]
|Bortezomib + melphalan + prednisone.[6]
|Bortezomib + liposomal doxorubicin +/- dexamethasone.[38,67]
|Melphalan + prednisone + thalidomide.[18,25]
|Melphalan + prednisone.[18,25]
Consolidation Chemotherapy
High-dose chemotherapy: Autologous bone marrow or peripheral stem cell transplantation
The failure of conventional therapy to cure the disease has led investigators to test the effectiveness of much higher doses of drugs such as melphalan. The development of techniques for harvesting hemopoietic stem cells, from marrow aspirates or the peripheral blood of the patient, and infusing these cells to promote hemopoietic recovery made it possible for investigators to test very large doses of chemotherapy.
Based on the experience of treating thousands of patients in this way, it is possible to draw a few conclusions, including the following:
- The risk of early death caused by treatment-related toxic effects has been reduced to less than 3% in highly selected populations.[68]
- Chemotherapy patients can now be treated as outpatients.
- Extensive prior chemotherapy, especially with alkylating agents, compromises marrow hemopoiesis and may make the harvesting of adequate numbers of hemopoietic stem cells impossible.[4]
- Younger patients in good health tolerate high-dose therapy better than patients with a poor performance status.[69,70,71]
- Upon review of eight updated trials encompassing more than 3,100 patients, at 10 years' follow-up, there was a 10% to 35% event-free survival (EFS) rate and a 20% to 50% OS rate.[72]
Single autologous bone marrow or peripheral stem cell transplantation
While some prospective randomized trials, such as the U.S. Intergroup trial SWOG-9321, have shown improved survival for patients who received autologous peripheral stem cell or bone marrow transplantation after induction chemotherapy versus chemotherapy alone,[73,74,75][Level of evidence: 1iiA] other trials have not shown any survival advantage.[76,77,78,79][Level of evidence: 1iiA]
Two meta-analyses of almost 3,000 patients showed no survival advantage.[80,81][Level of evidence: 1iiA]
Even the trials suggesting improved survival showed no signs of a slowing in the relapse rate or a plateau to suggest that any of these patients had been cured.[73,74,75,82] The role of ASCT has also been questioned with the advent of novel induction therapies with high complete-remission rates.[83,84]
Tandem autologous bone marrow or peripheral stem cell transplantation
Another approach to high-dose therapy has been the use of two sequential episodes of high-dose therapy with stem cell support (tandem transplants).[85,86,87,88,89]
|A meta-analysis of six randomized clinical trials enrolling 1,803 patients compared single autologous hematopoietic cell transplantation with tandem autologous hematopoietic cell transplantation.
|In a trial of 194 previously untreated patients aged 50 to 70 years, the patients were randomly assigned to either conventional oral melphalan and prednisone or VAD for two cycles followed by two sequential episodes of high-dose therapy (melphalan 100 mg/m2) with stem cell support.[75]
|Three different groups have compared two tandem autologous transplants with one autologous transplant followed by a reduced-intensity conditioning allograft from an HLA-identical sibling; treatment assignment was based on the presence or absence of an HLA-identical sibling. The results have been discordant for survival in these nonrandomized trials.
|A trial of 195 patients younger than 60 years with newly diagnosed myeloma randomly compared two tandem transplants with a single autologous stem cell transplant followed by 6 months of maintenance therapy with thalidomide.
High-dose chemotherapy: Allogeneic bone marrow or peripheral stem cell transplantation
In a registry of 162 patients who underwent allogeneic matched sibling-donor transplants, the actuarial OS rate was 28% at 7 years.[96][Level of evidence: 3iiiA]
Favorable prognostic features included the following:
- Low tumor burden.
- Responsive disease before transplant.
- Application of transplantation after first-line therapy.
Many patients are not young enough or healthy enough to undergo these intensive approaches. A definite graft-versus-myeloma effect has been demonstrated, including regression of myeloma relapses following the infusion of donor lymphocytes.[97,98,99,100]
Myeloablative allogeneic stem cell transplantation has significant toxic effects (15%–40% mortality), but the possibility of a potent and possibly curative graft-versus-myeloma effect in a minority of patients may offset the high transplant-related mortality.[100,101,102]
Further research is required to make allogeneic transplants less dangerous and to find methods for initiating an autoimmune response to the myeloma cells. Nonmyeloablative allogeneic stem cell transplant is under development.[103,104,105] Such strategies aim to maintain efficacy (so called graft-versus-tumor effect) while reducing transplant-related mortality.[106,107] The lower transplant-related mortality from nonmyeloablative approaches has been accompanied by a greater risk of relapse.[102] Given the lack of evidence so far that the high-risk patients benefit from allogeneic stem cell transplantation in this era of novel new agents, it remains debatable whether allogeneic stem cell transplantation should be offered in the first-line setting outside the context of a clinical trial.[102]
Maintenance Therapy
Myeloma patients who respond to treatment show a progressive fall in the M protein until a plateau is reached; subsequent treatment with conventional doses does not result in any further improvement. This has led investigators to question how long treatment should be continued.
|In a single study,[108] it was observed that maintenance therapy with MP prolonged the initial remission duration (31 months) compared with no maintenance treatment (23 months).
|Maintenance interferon-alpha therapy has been reported in several studies to prolong initial remission duration after conventional chemotherapy.[109,110,111,112] While the impact of interferon maintenance on disease-free survival and OS has significantly varied among trials, a meta-analysis of 1,543 patients treated on 12 trials randomizing between interferon maintenance and observation indicated that interferon maintenance was associated with improved relapse-free survival (27% vs. 19% at 3 years, P < .001) and OS (12% odds reduction, P = .04).[113] Toxic effects in this population may be substantial and must be balanced against the potential benefits in response duration.[114]
|A randomized study compared maintenance interferon with maintenance thalidomide in 103 previously untreated and treated patients who had at least a minimal response to induction chemotherapy with thalidomide, pegylated liposomal doxorubicin, and dexamethasone. With a median follow-up of 30 months, the thalidomide maintenance arm was better, with 2-year PFS of 63% versus 32% (P = .024) and a 2-year OS of 84% versus 68% (P = .03).[115][Level of evidence: 1iiA]
|In a trial of 556 previously untreated patients induced with thalidomide, doxorubicin, dexamethasone, and followed by high-dose melphalan with stem cell support, patients were randomly assigned to alpha interferon or to thalidomide maintenance. With a median follow-up of 52 months, there was no significant difference in median survival (P = .77) 60 months for interferon and 73 months for thalidomide.[24][Level of evidence: 1iiA]
|Maintenance therapy with interferon showed a benefit in PFS (46 months vs. 27 months, P < .025) and OS (75% vs. 50%, P < .01) in a randomized study of 84 patients following autologous bone marrow transplantation.[116][Level of evidence: 1iiA] A larger randomized trial of 805 patients showed no difference in PFS or OS with interferon given after peripheral stem cell transplantation or conventional chemotherapy.[117][Level of evidence: 1iiA]
|In a randomized trial, 269 patients with newly diagnosed myeloma were given maintenance thalidomide plus prednisolone versus prednisolone alone following both induction therapy and high-dose melphalan with ASCT. The trial showed a benefit in favor of the thalidomide arm after a median follow-up of 3 years: 3-year PFS, 43% versus 23% (P < .001); 3-year OS, 86% versus 75% (P = .004).[118][Level of evidence: 1iiA] As a result of these varying outcomes, further clinical trial results are required to determine whether there is a benefit of maintenance therapy.
|A study of 125 responding patients with first-line VAD induction who were randomly assigned to maintenance corticosteroids at 10 mg or 50 mg on alternate days showed improved PFS (14 months vs. 5 months, P = .003) and OS (36 months vs. 26 months, P = .05) for the patients receiving the higher-dose corticosteroids.[119][Level of evidence: 1iiA]
|In a larger trial by the National Cancer Institute of Canada (CAN-NCIC-MY7) of 585 patients treated with first-line MP, 292 patients were randomly assigned to pulse dexamethasone (40 mg a day for 4 days monthly) versus no maintenance.
|Two months after autologous transplantation, 597 patients younger than 65 years were randomly assigned to no maintenance, pamidronate, or pamidronate plus thalidomide.
|After autologous transplantation, 129 patients were randomly assigned to indefinite prednisone versus indefinite prednisone with 12 months of thalidomide.
Supportive care
Bisphosphonate therapy
|A randomized, double-blind study of patients with stage III myeloma showed that monthly intravenous pamidronate significantly reduced pathologic fractures, bone pain, spinal cord compression, and the need for bone radiation therapy (38% skeletal-related events were reported in the treatment group vs. 51% in the placebo group after 21 months of therapy, P = .015).[121][Level of evidence: 1iDiii] (Refer to the PDQ summary on Pain for more information on bisphosphonate therapy.)
|A double-blind, randomized, controlled trial with 504 patients with newly diagnosed multiple myeloma compared 30 mg of pamidronate to 90 mg of pamidronate and found there was no difference in skeletal-related events, but there was less osteonecrosis (2 events vs. 8 events) seen in the low-dose group.[122][Level of evidence: 1iDiv]
|A randomized comparison of pamidronate versus zoledronic acid in 518 patients with multiple myeloma showed equivalent efficacy in regard to skeletal-related complications.[123][Level of evidence: 1iDiii]
|Bisphosphonates are associated with infrequent long-term complications (in 3%–5% of patients), including osteonecrosis of the jaw and avascular necrosis of the hip.[124,125] (Refer to the PDQ summary on Oral Complications of Chemotherapy and Head/Neck Radiation for more information on osteonecrosis of the jaw.) These side effects must be balanced against the potential benefits of bisphosphonates when bone metastases are evident.[126] The optimal use and duration of bisphosphonates for bony involvement in myeloma have not been studied. Bisphosphonates are usually given intravenously on a monthly basis for 2 years and then extended at the same schedule or at a reduced schedule (i.e., once every 3–4 months), if there is evidence of active myeloma bone disease.[67,127]
Bone lesions
Lytic lesions of the spine should be radiated if any of the following are true:
|If they are associated with an extramedullary (paraspinal) plasmacytoma.
|If a painful destruction of a vertebral body occurred.
|If computed tomography or MRI scans present evidence of spinal cord compression.[128]
Back pain caused by osteoporosis and small compression fractures of the vertebrae responds best to chemotherapy. (Refer to the PDQ summary on Pain for more information on back pain.)
Extensive radiation of the spine or long bones for diffuse osteoporosis may lead to prolonged suppression of hemopoiesis and is rarely indicated.[129]
Bisphosphonates are useful for slowing or reversing the osteopenia that is common in myeloma patients.[121]
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with multiple myeloma. 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.
Refractory Multiple Myeloma
There are two main types of refractory myeloma patients:
- Primary refractory patients who never achieve a response and progress while still on induction chemotherapy.
- Secondary refractory patients who do respond to induction chemotherapy but do not respond to treatment after relapse.
A subgroup of patients who do not achieve a response to induction chemotherapy have stable disease and enjoy a survival prognosis that is as good as that for responding patients.[1,2] When the stable nature of the disease becomes established, these types of patients can discontinue therapy until the myeloma begins to progress again. Others with primary refractory myeloma and progressive disease require a change in therapy. (Refer to the Treatment for Multiple Myeloma section of this summary for more information.)
The myeloma growth rate, as measured by the monoclonal (or myeloma) protein-doubling time, for patients who respond to their initial therapy increases progressively with each subsequent relapse, and remission durations become shorter and shorter. Marrow function becomes increasingly compromised as patients develop pancytopenia and enter a refractory phase; occasionally, the myeloma cells dedifferentiate and extramedullary plasmacytomas develop. The myeloma cells may still be sensitive to chemotherapy, but the regrowth rate during relapse is so rapid that progressive improvement is not observed.
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with refractory multiple myeloma. 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.
Changes to This Summary (12 / 28 / 2012)
The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.
Treatment for Waldenström Macroglobulinemia (Lymphoplasmacytic Lymphoma)
An editorial change was made to this section.
This summary is written and maintained by the PDQ Adult Treatment Editorial Board, which is editorially independent of NCI. The summary reflects an independent review of the literature and does not represent a policy statement of NCI or NIH. More information about summary policies and the role of the PDQ Editorial Boards in maintaining the PDQ summaries can be found on the About This PDQ Summary and PDQ NCI's Comprehensive Cancer Database pages.
About This PDQ Summary
Purpose of This Summary
This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about treatment of plasma cell neoplasms (including multiple myeloma). 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).
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The lead reviewers for Plasma Cell Neoplasms (Including Multiple Myeloma) Treatment are:
- Steven D. Gore, MD (Johns Hopkins University)
- Mark J. Levis, MD, PhD (Johns Hopkins University)
- Eric J. Seifter, MD (Johns Hopkins University)
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.
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Some of the reference citations in this summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Adult Treatment Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations.
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National Cancer Institute: PDQ® Plasma Cell Neoplasms (Including Multiple Myeloma) Treatment. Bethesda, MD: National Cancer Institute. Date last modified <MM/DD/YYYY>. Available at: http://www.cancer.gov/cancertopics/pdq/treatment/myeloma/healthprofessional. Accessed <MM/DD/YYYY>.
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text:
Julius Thomas Adams Jr.
Position: DE-DT
Height: 6-3 Weight: 270 lbs.
Born: April 26, 1948 in Macon, GA
High School: Ballard
College: Texas Southern (school history)
Drafted by the New England Patriots in the 2nd round (27th overall) of the 1971 NFL Draft.
Weighted Career AV (100-95-...): 61 (892nd overall since 1950)
Relatives: Father of Keith Adams
1-time Pro Bowler (fine print)
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1979 Game Log: Regular Season · Playoffs · vs.


text:
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David Ubben @davidubben Good sentiment. Poor word choice. T.J. Moe on playing Alabama: "its our opportunity to be an Iowa State of last year" http://*******/VKug1b
Followed by:
David Ubben @davidubben
Just a hunch, but I don't think Missouri intended on leaving the Big 12 so it could become Iowa State, "Giant Killer" storyline aside.
Ubben looks like a troll might as well act like one.
Man suffers only because he takes seriously what the gods made for fun.
― Alan Wilson Watts
Ubben ticks me off sometimes, but that doesn't bother me much.
I sort of laugh at all of it, but it's almost like he goes out of his way with comments like that, backhanded compliments, etc.
Not really that big of a troll...honestly I'd take it as just normal reporting - Mizzou on the other hand can go suck an egg. I'm glad they're enjoying their new friends in the SEC.
I don't see anything wrong with what he said. I'm guessing Missouri's goal was to be a "giant" not a "giant killer"
If ISU beats Kansas State on Satruday Ubben will have to be put on suicide watch...
Good times on Hawkeyenation.com after the 2010 Wisconsin Game!
He makes a valid point. Iowa State is a bottom half team that is trying to climb up to the top half by upsetting highly ranked teams.
Mizzou hasn't been in that position for several years now. Yes he should want to beat Alabama but his comments make it seem like Mizzou is going to be the bottom team in the SEC and they need to upset the big guys to start to move up.
Like Ubben said, Mizzou shouldn't have the feeling that it left the Big 12 to sit beside Ole Miss or Kentucky in the SEC standings.
From the link it sounds like Moe was referring to someone taking down a highly rated team to shake up the BCS. Ubben made the A-hole connection. He is a first class doosh.
Why is he covering Mizzou, again?
he gets our fans talking every time he makes a comment, he is doing his job...its unbelievable how thin skinned some of our fans can be!
Originally Posted by PabloDiablo
From the link it sounds like Moe was referring to someone taking down a highly rated team to shake up the BCS. Ubben made the A-hole connection. He is a first class doosh.
Why is he covering Mizzou, again?
Mizzou is his alma mater
read this post quickly - it might not last long
MU has to actually win a game to be called a "Giant Killer"
Besides, Alabama will win by 40 so MU can suck on that. Screw Ubben too.
Would love to see Missery beat Bama. Just to shake things up. Possibly give West Virginia a shot at the title. At least til the last week of the season
Originally Posted by Gorm
If ISU beats Kansas State on Satruday Ubben will have to be put on suicide watch...
Naw, he'll just write an article about how badly Kansas State played and how they beat themselves.
Originally Posted by Cyballz
Mizzou is his alma mater
Correct, it's also in the SEC. Which last time I checked, isn't the Big 12.
I don't think it's thin skinned to ask for a little respect from the guy who is supposed to cover all the teams in our conference for a major sport news outlet.
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The San Diego region has made strides toward water independence by securing diverse water supplies, the San Diego County Grand Jury said in a new report.
After making seven visits to water-treatment and distribution centers and reviewing numerous related documents, the grand jury said the San Diego County Water Authority is on the right track with projects involving water reclamation, desalination and enhanced storage capacity.
In the past decade, the water authority has invested $2 billion on upgrades such as pipeline and canal lining, construction of the Olivenhain Dam, expansion of the San Vicente Dam and creation of the Twin Oaks Valley Water Treatment Plant, said the agency's assistant general manager, Dennis Cushman.
It also recently agreed to buy desalinated water from the Poseidon plant in Carlsbad, which is slated to come online in 2016. And the city of San Diego is pursuing plans to purify 15 million gallons of recycled wastewater per day.
The grand jury urged the water authority to move ahead with its projects, and to pursue a second desalination plant — at Camp Pendleton — and plan for more than its current goal of a six-month emergency supply of water.
The multipronged strategy is meant to buffer the region against the kind of water shortages that arose in 1990, Cushman said. At the time, drought and cutbacks by the county's predominant water wholesaler — the Metropolitan Water District — harmed business and agricultural operations.
The water authority vowed to diversify its water portfolio. Now the San Diego region relies on the Metropolitan Water District for 45 percent of its water, and the authority aims to trim that to 30 percent by 2020.
"The story that the grand jury is recognizing is how far we've come," Cushman said.


text:
The Blick Studio Sketchbox Table Easel is a
Compare the quality, design, features, and workmanship of Blick Studio Easels with any major brand and we're sure you'll agree we measure up with the best — at a much more affordable price. Plus, we stand behind every easel with our unbeatable 100% satisfaction guarantee.
® Blick and Blick Studio are registered trademarks.


text:
Posted on 1/2/2013
Rebecca Thompson
Over the age of 55? Join the Piedmont Plus Senior Games as they kick off the 2013 games!
The kick-off event will be held on January 25 from 10am – Noon, at the Hanes Hosiery Rec Center (501 Reynolds Blvd.). This event is FREE and open to the public.
Participants will be able to take part in Senior Games events. Artists will have the opportunity to create their very own works of arts and crafts. It's a great time of fellowship, fun and fitness.
Entry forms for the 2013 Games will be given out during this event. Can't make the event? Entry forms will be available in all recreation centers and at the Senior Games office.
Click here to view kick-off flyer.
For more information, please contact Chuck Vestal at 336-727-2325 or visit www.WePLAY.ws.
201 North Chestnut Street
Winston-Salem, NC 27101
Copyright © 2016 Forsyth County | Contact the Webmaster | Site Map


text:
Survivorship Care Guidelines for Patients Living With Multiple MyelomaThe NLB identified the most significant needs of patients diagnosed with multiple myeloma as bone health, health maintenance, mobility and safety, sexual dysfunction, and renal health. They then developed a survivorship care plan to assist healthcare providers and patients with multiple myeloma, their partners, and their caregivers to identify these needs.
Maintaining Bone Health in Patients With Multiple Myeloma
About 90% of individuals with myeloma will develop osteolytic bone lesions from increased osteoclastic and decreased
osteoblastic activity. Supportive care targeting bone disease is an essential adjunct to antimyeloma therapy. In addition, the maintenance of bone health in patients with multiple myeloma can significantly improve quality of life
Routine Health Maintenance in Patients
Living With Multiple MyelomaPatients with multiple myeloma are at risk for illnesses experienced by the general population and at additional risk for illnesses related to multiple myeloma and its treatment. Therefore, the NLB has developed practice recommendations to meet the particular needs of adult patients with multiple myeloma using evidence-based recommendations for screening and disease prevention, as well as nursing experience.
Mobility and Safety in the Multiple Myeloma SurvivorAlthough mobility challenges vary among survivors of myeloma, patients have an increased risk of impaired mobility because of side effects of therapy and the pathology of the disease, as well as other factors (e.g., increasing age). Health maintenance increasingly is becoming a part of the cancer control continuum, and nurses have the opportunity to help survivors of multiple myeloma optimize their functional mobility and safety, thereby preserving quality of life.
Sexual Dysfunction in Multiple MyelomaIn this article, members of the NLB present evidence-based practice recommendations that have been developed for promoting dialogue and assessment, education,
and management practices among patients with multiple myeloma and their healthcare providers and partners.
Renal Complications in Multiple Myeloma and Related DisordersKidney dysfunction is a common clinical feature of symptomatic multiple myeloma. Some degree of renal insufficiency or renal failure is present at diagnosis or will occur during the course of the disease and, if not reversed, will adversely affect overall survival and quality of life. The NLB has developed practice recommendations for screening renal function, identifying risk and environmental factors, selecting appropriate therapies and supportive care measures.


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Well, I hope I don't come off as an absolute ogre here, but I think this is the sort of basic technique that all Photoshoppers rely upon on a regular basis, and you would benefit greatly from experimenting on your own to create this imagery, rather than following a tutorial. Teach a man to fish is one thing, but point him toward a river is another.
There are probably easily a dozen ways to achieve this particular effect. I think you ought to be able to come up with at least two at the newbie level.
Edit: Furthermore, throwing oneself into the river is how all the amazing guys here come up with their original awesome advanced techniques to share with others. You must never be afraid to hurl yourself into the water, head first! It's not as if you'll break your neck on a rock. Okay, I've ridden that metaphor into the ground now.


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Part of the problem is people are just running the install.cmd directly. I did say to open a command prompt (cmd.exe) first with admin privileges. However I will change the code to run by clicking on it.
absolutely you did great job
and i check everyword you says
run in "cmd"as "admin"。。。
i open the "install.cmd" check the lines can't tell whats wrong...
i guess because im not english system?


text:
Lalique Collection by ET2
With a historic craftsman look in a contemporary design, the Lalique Collection by ET2 brings high style into any home. Bronze stem finishes end in the homeowner's choice of glass shades. Rich light cascades through flower-like petals of glass shades to fill a chosen space. These pieces come with the matching bulbs.


text:
Five months after a movie theater massacre in suburban Denver shocked the nation, Colorado's Gov. John Hickenlooper now says "the time is right" for state lawmakers to consider gun control measures.
The Democratic governor has until now resisted calls to review state gun laws after the shootings in Aurora. Hickenlooper upset some in his party when he said last summer that stricter laws would not have prevented the massacre.
In an interview with The Associated Press Wednesday, Hickenlooper said enough time has passed since the tragedy and that the legislative session in January would be an appropriate time to take up a debate gun control measures.
Former neuroscience student James Holmes is charged with killing 12 people and wounding 70 in the July movie shootings.
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If you believe that any of the comments on our site are inappropriate or offensive, please tell us by clicking "Report Abuse" and answering the questions that follow. We will review any reported comments promptly.powered by Disqus


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Package:Portage (Funtoo)
Portage is the official package manager of Funtoo Linux. Daniel Robbins maintains a slightly different version from upstream Gentoo Linux, with support for mini-manifests and other features.
Portage Commands
Portage Specifications
The latest progress and changes related to EAPI/PMS and Portage can often be found in the Gentoo Council meeting logs, which are listed on the Gentoo Council page.
The latest PMS specification to be approved by the Gentoo Council is available: eapi-3-approved-2010-01-18. The PMS specification is an attempt to codify the inner workings of Portage, and is authored by Ciaran McCreesh and Stephen Bennett as a Gentoo-hosted project.
Portage Profiles
Portage uses profiles to define settings for various architectures and types of Funtoo/Gentoo systems. See the Portage Profiles page for detailed information on how Portage handles profiles.
Portage Variables
Portage's behavior can be controlled by a number of configuration settings other variables that can be defined within the ebuild itself. In addition, a number of these variables are defined for the ebuild automatically by Portage. These variables are now documented on their own page: Portage Variables.
Multiple ABI Support
Portage contains support for multiple ABIs (Application Binary Interfaces) co-existing on the same system. This functionality has been extensively documented and has been moved to its own page: Multiple ABI Support.
Ebuild Functions
An ebuild developer has the ability to define Ebuild Functions that define steps to perform during a particular part of the ebuild lifecycle. These steps are now documented on their own page: Ebuild Functions.
Funtoo Portage Development
The Funtoo Core Team is currently working on a general-purpose plug-in system so that the GNU info file regeneration, news update display, and scanning of files that need updating in /etc can be pulled out of the official Portage emerge code. In addition, this plug-in system will allow other types of things to be hooked into various phases of emerge. This will allow various new plug-ins to be developed and used on systems, such as periodic security checks, etc.
Add support to portage, so that when an ebuild is merged, the /var/db/pkg entry contains a list of all currently-installed versions of all ebuilds upon which that ebuild RDEPENDs. This, combined with a comprehensive set of past USE settings (may need to implement this too,) can be used to detect when an ebuild needs to be rebuilt. This could help to address issues like those in Gentoo Bug 167662 and allow easier implementation of support for things like perl-cleaner. Currently, perl-cleaner doesn't detect that vim uses perl and moving from -ithreads to ithreads causes vim to die, so it needs to be manually rebuilt.
Add support for portage to understand which version of a particular app is the "active" version that it was built against, and record this information in /var/db/pkg. This can help to implement perl-cleaner-like support in Portage.
Funtoo Features/Changes
In the thin-manifest branch, Funtoo changes have been isolated into the following commits:
e5a6649e094eb7230aa8f56d97fe303f77b158e9 preserve bindist through use expansion 5a092fdae8afbff679350dc5d8818e10ab35fd80 safetydance feature 16887ddce712da8b61887f9bce70e19b95e75c25 core funtoo git-sync implementation 2c6e2b427a2aa179b61667caf89497818ec34ae2 run pwconv and grpconv after emerge completes to ensure /etc/shadow and /etc/gshadow are valid. ea565da9ab5f54580f66814a17aca39d8e568732 funtoo-specific man page changes c8f130fa4b332d87f2202ddaf0222b89018914d0 Funtoo config file changes. This includes stuff related to rsync as well as /lib/firmware dba5a350e16043a6ff6281ea80fc02c8f56efd4f remove emerge-webrsync -- not supported in funtoo 0d9dda7b2b3165b268545e3e8eb44aa8d3c20a57 small ebuild.sh fix to not source any stray directories 8500043b3075d26c77a7ec1b8c2745373ca0c3b5 disable warning for use of *, -* in KEYWORDS 86ed81605e73b8b6d6b06fc60a9a0bc0c13ee429 protect firmware as well as modules e7b6512e582fbcd9af0eb82c617549b101c8ae97 slashbeast's localpatch feature 5af34ad9334310c0926e52d9e1801ee170e12184 simplify path setting in ebuild.sh by using getpath() function 42789a70184343008c4cb1fe20bc4398e881d285 remove bin/ebuild-helpers/sed
These commits do not yet include the unified-path/funtoo-profile 1.0 patches.
In Funtoo stable/current Portage
- emerge --sync from git
- If a git-based Portage tree is already in place, emerge --sync will run "git pull" to update the underlying Portage tree. If one is not in place, the contents of the SYNC variable will be used as the remote URI from which to clone a git tree (2.2). In addition, SYNC_USER and SYNC_UMASK (defaulting to root and 022) can be used to define the user account to use for cloning/syncing, as well as the umask to use. (2.2).
- Sed Wrapper Symlink and PATH fix
- The Funtoo version of Portage has replaced the BSD-only sed wrapper with a symlink. This will eventually be deprecated. The sed wrapper was a way to provide BSD systems with a "sed" command that could be used inside ebuilds that worked similarly to GNU sed. A PATH fix has been applied so that /bin/sed will be detected first anyway.
- mini-manifest
- Funtoo's Portage supports a special mode of operation where Manifests only contain digests for distfiles and not for files in the Portage tree. This is to eliminate redundant digests since git already provides SHA1 digests. This feature is currently enabled by adding "mini-manifest" to FEATURES in /etc/make.conf but the intention is to eventually move it to a repo-specific option (note: this has now been done, as "thin-manifest" functionality has been integrated into recent versions of Portage, and is being beta tested in Funtoo.) Funtoo provides a special "mini-manifest" tree that is smaller than the full-size Portage tree, and is intended to be used with the mini-manifest feature.
- preserve bindist through USE filtering
- Normally, anything not in an ebuild's IUSE is stripped from the USE passed to ebuild.sh. This patch allows "bindist" to not be stripped, so it can be used as a means to disable pre-merge sanity checks that may exist in pkg_setup() and pkg_pretend() but will not otherwise affect the resultant build. If "bindist" will affect some functionality in the package, then it should be added to an ebuild's IUSE. This patch allows pkg_setup() and pkg_pretend() to look for "bindist", which indicates that the ebuild is being built for release, typically in an automated fashion, and thus runtime sanity checks that might otherwise run can be optionally skipped. This check is used by the udev-160-r1.ebuild to see if we should fail if we are merging udev on a system where the kernel will not support it. In Metro, this is not a big deal, but on a real production system, merging the udev on an incompatible system will render the kernel inoperable.
- safetydance FEATURE
- A new FEATURE setting is used by Funtoo's udev ebuild called "safetydance" which can be used to manually bypass sanity checks. This is an alternative to the "bindist" approach above. udev-160 in Funtoo Linux supports both approaches and Metro sets "safetydance" by default.
- GLEP 55 removal
- Some code to support GLEP 55 has been removed.
- new metadata format (experimental)
- Some tweaks to ebuild.sh have been made so that it is easier to support new metadata formats in the future.
- xz-utils auto-dependency
- There are several ebuilds in the Gentoo Portage repository that use .xz files but do not explicitly depend on xz-utils. A workaround has been added to ebuild.sh to add this dependency to metadata automatically if a .xz file exists in SRC_URI. This change is not yet in the official Portage sources but is being used on the Funtoo side when generating our git-based Portage trees.


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|Mark Bittman's Ginger Chicken is a dish that's easy, delicious, and healthy!
Of course if you know me, you already know I made a few changes to Mark Bittman's recipe. I used my favorite Baby Bella (Crimini) mushrooms instead of Shitakes (which made the recipe a lot more budget-friendly.) I also increased the sauce ingredients just a bit and substituted Stevia in the Raw Granulated Sweetener for sugar. I also used small red chiles to season the oil but didn't keep them in the dish, which made it much less spicy.
Mark Bittman's Ginger Chicken
(Makes about 4 servings, recipe adapted from The Best Recipes in the World.)
Sauce Ingredients:
1-2 T soy sauce
1 T or slightly more Thai Fish Sauce (I like Three Crabs Fish Sauce)
2 tsp. Stevia in the Raw Granulated Sweetener, Splenda, or sugar
black pepper to taste
2 -3 T fresh lime juice
2 small red dried chiles
2 T peanut oil
2 shallots or one very small red onion, sliced thin, slices cut in fourths
1 T minced garlic
1 T grated ginger root
(Minced garlic in a jar or pureed ginger root in a jar will work in this recipe)
2 boneless, skinless chicken breasts cut in 1/2 inch pieces (be careful to keep them small)
about 1 cup sliced fresh Baby Bella Mushrooms (or use Shitake mushrooms if you'd like)
1/4 cup sliced green onions
Add shallots or onions and stir-fry 2 minutes. Add garlic and ginger and cook just a few seconds, then add chicken and stir fry until all chicken has turned opaque and no pink remains, about 5 minutes. Add mushrooms and scallions and cook a few minutes more, until the mushrooms have released their liquid and it has evaporated.
Add the combined sauce mixture to the wok and cook 2-3 minutes, until sauce is slightly thickened. Taste, add salt if desired, and serve hot.
South Beach Suggestions:
This dish is great for the South Beach Diet, any phase, as long as you substitute Stevia in the Raw Granulated or Splenda for the sugar. (Even if you use sugar, the amount of sugar in a serving would be very minimal. For phase two or three, this would taste great with Brown Rice with Cashews and Herbs.
Nutritional Information?
I chose the South Beach Diet to manage my weight partly so I wouldn't have to count calories, carbs, points, or fat grams, but if you want nutritional information for a recipe, I recommend entering the recipe into Calorie Count, which will calculate it for you.
More Tasty Ideas with Chicken:
(Recipes from other blogs not always South Beach Diet friendly; check ingredients.)
General Tso's Chicken ~ Appetite for China
Forbidden City Chicken ~ Kalyn's Kitchen
Chicken and Broccoli Stir Fry with Oyster Sauce ~ Cookin' Canuck
Grilled Fusion Chicken ~ Kalyn's Kitchen
Szechwan Chicken Stir Fry ~ Barbara Bakes
(Want even more recipes? I find these recipes from other blogs using Food Blog Search.)
Blogger Disclosure:
Posts may include links to my affiliate account at Amazon.com, and Kalyn's Kitchen earns a few cents on the dollar if readers purchase the items I recommend, so thanks for supporting my blog when you shop at Amazon!


text: These shoes are clean and in overall good condition. The uppers and heels are in good condition. The back left shoe is lightly scuffs, bottom edges of the heels have some scratches and there are light toe impressions. The outsoles show moderate signs of use. The insoles are clean. RETURN POLICY: Shoes may be returned in the condition received. They must be in the original box and/or packaging with the security tag attached.


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Tanzania is loosing over 70bn/- annually due to tax evasion by charcoal businesses despite the fact that they negatively impact on the environment.
This was said yesterday by Dr Felician Kilahama, who is the Director of Forestry and Beekeeping in the Ministry of Tourism and Natural Resources when explaining the challenges facing the forestry sector.
He said the government loses a lot of money in this area due to negligence in arresting the culprits, adding that there is a need to reverse the worsening situation.
Dr Kilahama said tax evasion has resulted in the lack of some social services to members of the public by the government because financial problems.
"This is a substantial amount of money, and if fully collected, would help improve various social economic activities," he added.
It is estimated that between 15, 000 to 40,000 sachets of charcoal enter Dar es Salaam city alone daily and an equally combined amount goes into the other major cities towns in the country.
A survey conducted by this paper in Dar es Salaam recently shows that Temeke District is leading in for charcoal demand followed by Ilala and Kinondoni.
Speaking to this paper in the city forestry development stakeholder Juma Mwakikoti said charcoal use can be minimised if there is alternative source of energy such as natural gas and solar power.
Many ordinary people cannot afford alternative energy at their homes and instead end up using charcoal.
"The cost of installing alternative energy is high. That is why many people find it difficult to rely on it," he said.
He pointed out that few people can afford to purchase Liquefied Petroleum Gas (LPG) hence continue using charcoal for cooking.
"The price of a cylinder of LPG (30kg) was 20,000/- two years ago, but now it has jumped to 50,000/-. How can an ordinary person buy gas?" he queried.
The only was out is for the government and perhaps donors agencies to increase funding in alternative energy supply, he said.
If alternative energy could get enough support it would help to reduce deforestation, he said.
He also called on the government to promote the use of LPG, by adopting favourable fiscal, social and environmental policies.
The government has to build the capacity of stakeholders especially at the community level, implement environmental management plans, improve awareness for the stakeholders to understand forest and land laws and institute village by-laws to regulate the use of natural resources, he said.


text:
|Watari Ninja
|Wandering Ninja (Watari ninja)
|Appears in
|Clan Data
The Wandering Ninja (Watari ninja) is a small group of missing-nin led by Hōki. Most of the members wear masks to hide their identities.
This group had for a long time wandered from place to place to seek out techniques to copy. At some point, Hōki decided that his clan needed some place to settle. To that end he went to the Land of Birds disguised as "Mōsō", became chief adviser to the land's daimyō, Ōwashi, and eventually assassinated Ōwashi.
Plot overview
The new daimyō, Sagi (who was later revealed to really be Sagi's twin sister, Toki), took the guise of the Cursed Warrior in order to avenge her father. Mōsō sent his assistant and the daimyō's childhood friend Chishima to Konoha for help, a task Neji Hyūga, Naruto Uzumaki, and Tenten are assigned to. After the team of Konoha ninja figured out that the real threat was the Watari ninja, the members Hokushin and Nagare proceed to follow and attack the foreign ninjas. They were both defeated by Kakashi Hatake, who had come to assist the Konoha ninja. Naruto defeated Hōki with Naruto Uzumaki Combo. Hōki was then handed over to Toki, and Naruto requested that he be forced to repent for what he had done.
Despite having "copied" many techniques, many of the clan's techniques were just weaker copies of the actual technique. For example, Hōki's "Summoning Technique" was activated by a projector. Also, he used strings to make it appear that the enemy was caught in the Nara clan's Shadow Imitation Technique. In fact, Hokushin was effortlessly defeated by Kakashi.


text:
This web presentation contains the
audio and slides
of a lecture given at the Fields Institute on July 7, 2010
as part of the Theme Weeks on Emergence and Spread of Drug Resistance.
Listen to audio presentation:
Ogg Vorbis format
(downloadable too; right-click to download)
MP3 format
(downloadable too; right-click to download)
You may browse the slides
in the presentation (a browser capable of displaying PNG graphics
is required).
Or, you may download a higher-resolution printer-ready
in PDF format
(requires Acrobat Reader).
Shown: slide
large size.
Previous Slide
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Switch to small size


text:
WiFi Shoot! WiFi Direct
by nothing inc
Download this app if: you want to transfer files directly to another device.
Developer Notes
WiFi Shoot it is the first app in the Google Play to use the WiFi Direct technology to wirelessly transmit photos, videos and any file directly between two Android devices!
If you're having any problems email me your device model and what you tried to do to make it work that I'll reply as fast as...
With A Bullet — WiFi Shoot makes sending files directly to a device a snap. Really useful for when my friends like a song I own, or want pictures that I just took of us.