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Original Article
Tumor response assessment by modified Choi criteria in localized high-risk soft tissue sarcoma treated with chemotherapy
Article first published online: 17 MAY 2012
DOI: 10.1002/cncr.27624
Copyright © 2012 American Cancer Society
Volume 118, Issue 23, pages 5857–5866, 1 December 2012
Additional Information
How to Cite
Stacchiotti, S., Verderio, P., Messina, A., Morosi, C., Collini, P., Llombart-Bosch, A., Martin, J., Comandone, A., Cruz, J., Ferraro, A., Grignani, G., Pizzamiglio, S., Quagliuolo, V., Picci, P., Frustaci, S., Dei Tos, A. P., Casali, P. G. and Gronchi, A. (2012), Tumor response assessment by modified Choi criteria in localized high-risk soft tissue sarcoma treated with chemotherapy. Cancer, 118: 5857–5866. doi: 10.1002/cncr.27624
Publication History
- Issue published online: 19 NOV 2012
- Article first published online: 17 MAY 2012
- Manuscript Accepted: 26 MAR 2012
- Manuscript Revised: 18 MAR 2012
- Manuscript Received: 9 JAN 2012
- Abstract
- Article
- References
- Cited By
- sarcoma;
- response assessment;
- Response Evaluation Criteria in Solid Tumors;
- Choi criteria;
- chemotherapy;
- prognosis;
- outcome
The objective of this study was to compare the prognostic relevance of Response Evaluation Criteria in Solid Tumors (RECIST) versus Choi criteria for the assessment of response in patients with high-risk soft tissue sarcoma of the extremities or trunk wall who received preoperative chemotherapy with or without radiotherapy in a phase 3 trial.
Patients received 3 cycles of preoperative epirubicin + ifosfamide with or without radiotherapy. The diagnostic concordance between RECIST and Choi criteria and their correlation with overall survival (OS) and freedom from progression (FFP) were evaluated in a univariate Cox regression model.
In 243 of 321 eligible patients, RECIST, Choi criteria, and histology were predictive for OS and FFP. In the subgroup of 69 patients who received chemotherapy alone and were evaluable by both RECIST and Choi criteria, Choi criteria were associated significantly with OS and FFP, whereas RECIST predicted only FFP, and the pattern of agreement observed between the 2 criteria was unsatisfactory. On a dichotomous scale, comparing objective response (complete and partial responses) and lack of response (stable and progressive disease) to preoperative chemotherapy according to RECIST and Choi criteria, only Choi criteria were predictive of OS and FFP, and fair agreement between RECIST and Choi criteria was observed. When lack of progression and progression were compared (complete and partial responses + stable disease vs progressive disease), both assessment criteria were significantly predictive of OS and FFP, and there was substantial agreement between the 2 criteria.
Response to chemotherapy with or without radiotherapy was associated with a better outcome in patients with high-risk soft tissue sarcoma. Choi criteria were better predictors than RECIST in patients who received preoperative chemotherapy alone. Cancer 2012. © 2012 American Cancer Society.
Response Evaluation Criteria in Solid Tumors (RECIST) are based on tumor size.1, 2 This is an added value in terms of their reliability (reproducibility), because size is relatively easy to measure. However, the introduction of molecular-targeted therapies has emphasized the limitations of RECIST in terms of their validity, because tumor response may be nondimensional, especially in an early phase.3-21 In these patients, tumor response is marked by changes in the tumor radiologic aspect and in its functional imaging.
Attempts to establish new response criteria have been undertaken. Choi criteria were conceived to assess tumor response in patients with advanced gastrointestinal stromal tumors who received treatment with imatinib, and the criteria were evaluated by computed tomography (CT) scans and were validated based on progression-free survival (PFS).22, 23 It is noteworthy that pathologic responses without any decrease in size were reported even in patients with solid tumors who received cytotoxic chemotherapy. Patients with myxoid liposarcoma who received trabectedin24, 25 and patients with osteosarcoma who received chemotherapy26-28 are examples among sarcomas.
We previously demonstrated that Choi criteria adapted to magnetic resonance imaging (MRI) correlated better with pathologic tumor response than RECIST in a series of 38 patients with high-grade soft tissue sarcomas who received preoperative chemotherapy with or without radiation therapy within a prospective phase 3 Italian Sarcoma Group/Spanish Sarcoma Group trial.29 The results of the trial recently were reported.30 Herein, we evaluate a comparison between RECIST and Choi criteria in eligible patients and correlate response to overall survival (OS) and freedom from progression (FFP).
From January 2002 and March 2007, a prospective, randomized study of preoperative chemoradiation therapy for localized, high-risk (high grade, deep, ≥5 cm in greatest dimension) soft tissue sarcoma of the extremities and trunk wall enrolled 321 eligible patients in Italy (10 sites) and Spain (9 sites).29 In this retrospective analysis, we included all patients who entered the study with measurable disease and completed the study protocol treatment; these patients were evaluated before and after treatment by MRI or CT. The current study was conducted on a total of 256 patients, including 143 patients who received neoadjuvant chemotherapy and radiotherapy and 113 patients who received neoadjuvant chemotherapy and adjuvant radiotherapy. Among the last group of 113 patients treated preoperatively only with chemotherapy, we selected the subgroup of patients who were fully evaluable for both RECIST (version 1)1 and Choi criteria.22 Table 1 reports the frequency distribution of RECIST, Choi criteria, and histology for the whole series of 256 patients as well as in the 113 patients who received only preoperative chemotherapy. Institutional review boards at each institution approved the trial, and signed informed consent was obtained for all patients.
|CT Only
|No. of Patients
|No. of Patients
|Choi criteriaa
|Synovial sarcoma
Patients received 3 cycles of epirubicin 120 mg/m2 plus ifosfamide 9000 mg/m2. Then, they underwent surgery within 4 to 6 weeks after the end of chemotherapy. Radiologic response was evaluated according to RECIST (version 1)1 and Choi criteria22 and was centrally reviewed.
Magnetic Resonance Imaging and Computed Tomography Techniques
Before surgery, MRI or CT studies were obtained at baseline and after chemotherapy with or without radiotherapy. The scans were collected from every center, and the images were centrally reviewed at Istituto Nazionale Tumori (Milano, Italy), by 2 expert sarcoma radiologists (A.M. for MRI, C.M. for CT) who were blinded to patient outcomes.
Only patients who were studied using the same technique (MRI or CT) before and after treatment and whose radiologic studies were available on a Digital Imaging and Communications in Medicine (DICOM) file and loaded into a multimodality work place (ie, Picture Archiving and Communication System [PACS]; Syngo [Siemens Medical Solutions, New York, NY]; Leonardo [Siemens Medical Solutions]) at Istituto Nazionale Tumori were considered eligible for response evaluation by Choi criteria. The images had to be available in portal venous phase for CT scans (slice thickness 5 mm). For MRI, turbo-spin-echo (TSE) T2-weighted images and TSE T1-weighted images (slice thickness, 5 mm) followed by a contrast-enhanced TSE T1-weighted image were requested.
To evaluate MRIs, contrast-enhanced TSE T1-weighted images were evaluated before and after digital subtraction (by A.M.). All data sets were evaluated both qualitatively and semiquantitatively. The percentage of contrast enhancement was assessed as follows: on subtracted, contrast-enhanced, T1-weighted sequences, the radiologist (A.M.) measured the contrast enhancement of the tumor by manually drawing a region of interest around the margin of the whole lesion on sections taken every 5 mm, thus encompassing the entire tumor mass. Muscle was used as the reference tissue. The contrast enhancement measurements from all sections were added, and the average contrast enhancement for each lesion was calculated.
To evaluate CT scans, the radiologist (C.M.) measured CT attenuation values of the tumor lesion in Hounsfield units on CT images that were obtained during the portal venous phase. Two-dimensional regions of interest that included the entire lesion were drawn, and all axial slices encompassing the lesion were included. To accurately define the lesion, the radiologist manually edited the contours of the regions of interest on each axial slice. The volume of interest covering the whole lesion was defined as the sum of all 2-dimensional regions of interest. Both cystic and necrotic areas were included. The software semiquantitatively calculated the mean tumor density (in Hounsfield units), which was defined as the average of all pixels enclosed in the volume of interest.
The 2 radiologists retrospectively reviewed all MRI and CT images. The percentage of change in mean tumor density/contrast enhancement before and after treatment was computed for each lesion.
Tumor response was evaluated using RECIST and Choi criteria according to criteria defined for gastrointestinal stromal tumors and adapted to MRI.1, 22, 28 We applied Choi criteria to MRI, assuming that changes in contrast enhancement on subtracted, contrast enhanced, T1-weighted sequences would parallel the changes in density on CT scans, because both are markers of tumor vascularization. According to Choi criteria, a partial response (PR) was defined as a decrease ≥10% in tumor size or a decrease ≥15% in tumor density/contrast enhancement on CT/MRI studies; progression was defined as new lesions, an increase ≥10% in tumor size without meeting any criteria for a PR according to tumor density/contrast enhancement, or an increase ≥15% in tumor density/contrast enhancement.
Pathology Assessment
A retrospective, centralized pathologic review of pretreatment material was performed by a panel of Italian Sarcoma Group/Spanish Sarcoma Group pathologists with expertise in sarcoma to confirm diagnoses and histologic grading. A pathology review using World Health Organization criteria31 was carried out in 222 patients (71%). In the remaining 89 patients, the diagnosis made at the referral center was considered. For statistical analyses, patients were divided into 4 groups: undifferentiated pleomorphic sarcoma (formerly malignant fibrous histiocytoma) and spindle cell sarcoma not otherwise specified (Group 1), leiomyosarcoma (Group 2), synovial sarcoma (Group 3), and other (Group 4).
Statistical Analysis
In addition to the whole series of patients, we focused on the group of patients who received preoperative chemotherapy alone and were evaluable by both RECIST and Choi criteria. Responses according to RECIST and Choi criteria were investigated in terms of diagnostic concordance as well as the prognostic capability of their original ordinal measurement scale (3 categories). Subsequently, because of the small number of patients in this subgroup, RECIST and Choi criteria variables were dichotomized according to 2 different criteria and were investigated in terms of concordance and prognosis.
Concordance between dichotomous and ordinal variables was assessed by computing (unweighted) Cohen kappa statistics (κ) and weighed kappa statistics (κw), respectively.32 The kappa statistics (both unweighted and weighed) usually lie between 0 (absence of agreement) and 1 (absolute agreement), and negative values may be obtained for situations in which actual agreement is less than chance. Thus, as previously reported33 κw values were considered satisfactory if they were equal to or greater than 0.80, whereas values of κ were interpreted in a qualitative manner based on the report by Landis and Koch.34
To assess the association between the various response criteria and histology and clinical outcomes, we performed a survival analysis in terms of both OS and FFP, which we defined as the time elapsed from randomization to death and to the first evidence of recurrence, respectively. The patterns of OS and FFP were estimated using the Kaplan-Meier method.35 The prognostic role of each variable (univariate analysis) on OS and FFP was investigated using a Cox regression model.36 In this model, each regression coefficient represents the logarithm of the hazard ratio, which is assumed to be constant over time. Under the null hypothesis that a variable has no prognostic role on OS and FFP, the hazard ratio is expected to be 1.00. The hypothesis of a hazard ratio of 1.00 was tested using the Wald statistic. In the Cox regression model, histologic subtype was categorized in 4 dummy variables using undifferentiated pleomorphic sarcoma/spindle cell sarcoma not otherwise specified as the reference category. When RECIST and Choi criteria were considered on their original scale, 2 dummy variables were generated by using the putative better prognosis category (ie, PR) as the reference category.
The risk of local and distant recurrence after surgery was assessed using a competing risks approach.37 All statistical analyses were performed using SAS statistical software (version 9.2; SAS Institute, Inc., Cary, NC).
Figure 1 provides 2 examples of response according to Choi criteria evaluated with MRI and CT studies.
Clinical Outcome and Prognostic Value of RECIST, Choi Criteria, and Histology
Overall series of patients
In total, 243 of 256 patients who were included in this study were evaluable for response (13 were missing radiologic data). Fifty-five were evaluated by CT, and 188 were evaluated by MRI.
At a median follow-up of 62 months (range, 28-105 months), the probability of OS (Fig. 2A) and FFP for the overall series was 0.65 (95% Confidence Interval (CI), 0.58-0.71) and 0.54 (95% CI, 0.47-0.60), respectively. Recurrent disease developed in 114 patients, whereas 88 patients died after randomization. Among the 114 patients who relapsed after randomization, 17 developed a local recurrence, whereas 97 had distant metastases as the primary event either alone or concurrent with local recurrence. In univariate Cox regression analysis (Table 2), RECIST, Choi criteria, and histology were significantly predictive for both OS (Fig. 2B, 2C and 2D) and FFP.
|CT Only
|2.57 (1.33-4.96)
|2.84 (1.55-5.18)
|1.63 (0.61-4.41)
|1.88 (0.78-4.55)
|0.95 (0.54-1.69)
|1.09 (0.65-1.82)
|0.56 (0.24-1.34)
|0.60 (0.28-1.28)
|Choi criteriab
|6.89 (3.55-13.33)
|6.33 (3.33-12.04)
|6.85 (2.51-18.74)
|5.24 (2.05-13.39)
|1.94 (0.87-4.36)
|1.35 (0.61-2.99)
|3.18 (1.17-8.63)
|1.49 (0.55-4.03)
|2.78 (1.56-5.00)
|1.72 (1.02-2.93)
|2.83 (0.99-5.74)
|1.09 (0.51-2.33)
|Synovial sarcoma
|1.63 (0.93-2.86)
|1.13 (0.70-1.82)
|1.67 (0.69-4.01)
|0.94 (0.46-1.91)
|1.59 (0.88-2.88)
|1.10 (0.66-1.82)
|1.99 (0.81-4.91)
|1.09 (0.52-2.27)
Patients who received preoperative chemotherapy alone (113 patients)
Among the 113 patients who received chemotherapy alone, the 5-year probability of OS and FFP was 0.65 (95% CI, 0.55-0.74) and 0.51 (95% CI, 0.41-0.60), respectively. Recurrent disease was observed in 53 patients, whereas 39 patients died after randomization. Among the 53 patients who relapsed after randomization, 11 developed a local recurrence, whereas 42 had metastases as the primary event either alone or concurrent with local recurrence. In univariate Cox analysis (Table 2), RECIST were not associated with the 2 clinical outcomes. Conversely, Choi criteria maintained their predictive role for both OS and FFP, whereas histology was weakly associated only with OS.
Patients who received preoperative chemotherapy alone and were evaluable by both RECIST and Choi criteria (69 patients)
Population features
An unsatisfactory level of agreement between the 2 diagnostic criteria was observed with a κw statistic value of 0.46 (95% CI, 0.28-0.63). Overall, the probability of OS and FFP in this subset of patients was 0.67 (95% CI, 0.56-0.79) and 0.56 (95% CI, 0.44-0.69), respectively. Recurrent disease developed in 29 patients, and 24 patients died after randomization. Among the 29 patients who relapsed after randomization, 6 developed a local recurrence, whereas 23 had distant metastases as the primary event either alone or concurrent with local recurrence. The frequency distribution of the variable histology in this subset was: 1) undifferentiated pleomorphic sarcoma and spindle cell sarcoma not otherwise specified, n = 29 patients; 2) leiomyosarcoma, n = 14 patients; 3) synovial sarcoma, n = 12 patients; and 4) other histologies, n = 14 patients. The overall cumulative incidence of local recurrence and distant metastasis (±standard error) was 0.09 ± 0.03 and 0.35 ± 0.03, respectively (Fig. 3A).
Prognostic Value of RECIST, Choi Criteria, and Histology
Overall series of patients
In the univariate Cox analysis, with PR used as the reference category (Table 3), RECIST did not have any prognostic role in OS (Fig. 3B); and, for FFP, only the progressive disease (PD) category was associated significantly with outcome compared with the PR category. With Choi criteria, the considered comparisons (PD vs PR and stable disease [SD] vs PR) were associated significantly with OS (Fig. 3C). Conversely, only the comparison between PD and PR resulted significantly associated with FFP. Histology did not appear to be associated with the 2 considered clinical outcomes in this subset of patients (Fig. 3D).
|2.26 (0.77-6.88)
|2.85 (1.05-7.70)
|0.56 (0.22-1.45)
|0.48 (0.20-1.12)
|Choi criteriab
|6.85 (2.51-18.74)
|5.24 (2.05-13.39)
|3.18 (1.17-8.63)
|1.49 (0.55-4.03)
|1.68 (0.53-5.30)
|1.05 (0.40-2.77)
|Synovial sarcoma
|2.04 (0.64-6.45)
|0.99 (0.35-2.78)
|2.35 (0.82-6.70)
|0.81 (0.29-2.27)
RECIST and Choi Criteria on Dichotomous Scale
In evaluating RECIST and Choi criteria variables on a dichotomous scale, we compared responses to preoperative chemotherapy (ie, a PR according to RECIST and Choi criteria) with a lack of response (ie, SD + PD according to RECIST and Choi criteria) and observed fair agreement between the 2 diagnostic criteria with a κ statistic of 0.22 (95% CI, 0.10-0.34). Furthermore, when these variables were considered based on complementary dichotomization, that is, with versus without PD (ie, PR + SD vs PD according to RECIST and Choi criteria), we observed substantial agreement between the 2 diagnostic criteria with a κ statistic of 0.79 (95% CI, 0.16-1.00).
The prognostic role of both RECIST and Choi criteria also was explored by considering the 2 types of dichotomization mentioned above. For Choi criteria, both dichotomizations were significantly predictive for OS and FFP in the univariate Cox model; whereas, for RECIST, only the variable dichotomized as PR + SD versus PD was associated significantly with both clinical outcomes (data not shown).
In this study on neoadjuvant chemotherapy for high-risk soft tissue sarcoma (with or without preoperative radiotherapy and with or without 2 additional cycles of adjuvant chemotherapy), tumor response to preoperative chemotherapy with or without radiotherapy was associated with a better outcome. However, Choi criteria, extended to MRI, exhibited a better prognostic role than RECIST (Table 2). In fact, the outcome of patients who had SD according to RECIST was identical to the outcome of patients who had a PR. Conversely, in the subgroup of 69 patients who received preoperative chemotherapy alone and were evaluable by both RECIST and Choi criteria, Choi criteria were better prognosticators than RECIST (Table 3), with most patients who had SD according to RECIST (72%) were classified with PRs according to Choi criteria; furthermore in 2 patients, PD according to RECIST was classified as a PR according to Choi criteria. A trend toward a better outcomes was observed in patients who had a PR according to RECIST compared with those who had PD; however, paradoxically, those who had SD according to RECIST fared better than those who had a PR. Conversely, patients who had a PR according to Choi criteria had a trend toward better survival compared with patients who had PD and SD. The comparison between response to preoperative chemotherapy (ie, complete response + PR, according to both RECIST and Choi criteria) and lack of response (ie, RECIST/Choi criteria SD + PD) indicated that responders according to Choi criteria had better outcomes than nonresponders, whereas responses according to RECIST were not correlated significantly either with OS or FFP compared with nonresponses. Conversely, lack of progression (CR + PR + SD) according to RECIST was correlated with better outcomes compared with PD according to RECIST, similar to what was observed with Choi criteria. In brief, several patients with SD according to RECIST had a PR according to Choi criteria, and this correlated favorably with the outcome. Overall, histology had a significant prognostic role for both OS and FFP: undifferentiated pleomorphic sarcoma was the histotype with the most favorable outcome, and leiomyosarcoma had the worst. Consistently, undifferentiated pleomorphic sarcoma had a higher response rate than leiomyosarcoma according to Choi criteria.
This analysis has some limitations. First, it is an unplanned subgroup analysis. Second, the number of patients was small, because they had to be evaluable by both RECIST and Choi criteria, and those who also received preoperative radiotherapy are at least less meaningful, because the local effect of radiation therapy does not necessarily have any major systemic impact. The main limitation is that this trial did not have a control arm of patients who did not receive adjuvant therapy. Therefore, it cannot settle the long-lasting issue of the efficacy of adjuvant therapy in soft tissue sarcoma.38-41 If the efficacy were nil, then there could not be any correlation in principle between the tumor response and the outcome. Conversely, detecting some correlations, as we did, does not mean that adjuvant chemotherapy is effective (because of the potential selection bias, which theoretically could lead independently to both a tumor response and a better outcome).
We previously demonstrated that Choi criteria were better predictors of pathologic response than RECIST in a subgroup of patients who were treated on this study.28 At the time, we still lacked data on patient outcomes. Currently, although we have data only in a limited number of patients, we can state that Choi criteria also are better than RECIST in predicting survival. Unfortunately, we could not study pathologic responses in all patients because of differences in tumor sampling between participating centers.
In the current study, we made an effort to refine the way we assess nondimensional responses. Choi criteria are complex for use in daily routine practice, because they require postprocessing assessment by dedicated software with the help of a radiologist in the segmentation of lesions. In addition, they allow for only semiquantitative evaluation. Thus, perfusion and diffusion MRI and CT studies, dynamic contrast-enhanced ultrasound studies, and PET scans also are planned in our new ongoing trial to better describe tumor tissue changes and for the evaluation of quantitative parameters and radiologic-pathologic correlations.
In our series, patients with SD according to RECIST fared better than those who had a PR according to RECIST. It is noteworthy that most SD according to RECIST corresponded to a PR according to Choi criteria. This indicates that nondimensional, or minor, responses brought about a better outcome than dimensional responses, which we also were able to confirm by combining RECIST and Choi criteria. This is intriguing, although the small number of patients, of course, is a limiting factor for any further speculation. However, the patients received 3 cycles of preoperative chemotherapy; thus, major responses actually are fast responses, and they may correspond to the most aggressive tumors. In these patients, chemotherapy may have exerted a limited prognostic impact overall. The value of such a hypothesis will require further assessment.
It is noteworthy that, in terms of the shortcomings of tumor response with targeted agents, PFS often is advocated as a suitable indicator of antitumor activity. However, in our series of 166 patients, 7 patients who were classified with PD according to RECIST had a PR according to Choi criteria, and 2 patients who were classified with SD according to RECIST had PD according to Choi criteria. In other words, using Choi criteria would result in a different assessment of PD and, thus, would change the estimated PFS.
In our study, patients with leiomyosarcoma fared worse than patients who had other histotypes. This result correlated with the responses defined according to Choi criteria, in which leiomyosarcoma is the histotype with the lowest percentage of responses and the highest progression rate. It is noteworthy that Choi criteria again were better predictors than RECIST. These results suggest that chemosensitivity may have an impact on patient outcomes, possibly in combination with the natural history of each histotype. In particular, it is believed that leiomyosarcomas are less sensitive to ifosfamide if they are sensitive at all to this drug.
In conclusion, currently, there is much discussion about tumor response criteria in solid tumors. There is a trend toward nondimensional criteria, especially when molecularly targeted agents are used. Our current analysis suggests that tumor response to chemotherapy may benefit from newer criteria. Further work is needed to refine criteria for nondimensional assessment of tumor responses.
No specific funding was disclosed.
The authors made no disclosures.
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Trudy Rubin: No one has coherent long-term solution to ISISStory | Nov 24, 2014 | 5:35 AMIf there was ever an issue that required politics to stop at the water's edge, it's the fight against ISIS. With its Mideast land grab, its growing army of Western volunteers, and its global aspirations, ISIS threatens U.S. security interests and must be...
War-weary Darfuris see grim future with or without U.N. peacekeepersStory | Nov 24, 2014 | 6:24 AMBy Khalid Abdelaziz TABIT, Sudan (Reuters) - Caught in a forgotten war between rebels and government forces and beset by bandits who roam the lawless roads, villagers in Darfur say their lives can scarcely get any worse if Sudan insists on...

subset: commoncrawl


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(617): View more from Massachusetts
Why don't you ever send me any naked pics
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Why don't you ever send me any naked pics
You bet me 100 dollars that the Raiders would win the super bowl this year. I have it on tape.
My teachers should feel privileged to see me this morning, after the amount of alcohol I consumed last night.
today he pulled me aside to show me a lawn mower that he drew above his pubes. I saw his pubes in all their glory. Right there. In spanish class. Hola.
just got super drunk mixing jägermeister with my lyme disease meds. even if my face goes paralyzed, at least i got smashed from it.
Apparently i just threw up in the bathroom, i told them i just blew my nose. i don't think they believe me...
My head weighs 7 pounds. i know this because i spent the majority of the night passed out in the bathroom, using the scale as a pillow.
For some reason I have a hard time believing getting drunk and recreating a movie about singing transvestites is ever very far from a situation you're in.
You have to stop getting hammered and preaching about that mission trip to Haiti.
I just woke up to find the whole kitchen sick had been converted into a gravity bong.
I cannot believe I said bareback movement...
Just started taking liver support pills. Welcome to Senior year.
At this point I will cuddle anything to prevent from dying alone
the scent of your tears make me crave pizza
That awkward moment when the guy you hooked up on spring break invites you over for dinner to meet his parents and you say yes because the first rule of college is never turn down a free meal.


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British town council votes to ban all Israeli goods, in defiance of Labor policy
IDF official: 3 months after Gaza war Hamas still rehabilitating military hierarchy
EU Representative: Time running short on Gaza reconstruction
Netanyahu: There is an effort to undermine the Jews' right to their own state
South Africa's Zuma welcomes Abbas, says Israeli settlements undermining 2-state solution
Peres slams 'Jewish state bill' as maneuver for 'transient' political purposes
With government's fate uncertain, Netanyahu seeks commitment from haredim for next coalition
Widow of slain rabbi blames internal haredi discord for Jerusalem synagogue terror attack
Green groups demand environment minister
Infant mortality rates higher in Arab population
Smartphones are keeping your children awake
Hookah smokers are inhaling benzene
Effective drugs for carriers of hepatitis C not included in health basket
Tech Talk: The best keyboard apps available for smartphones
Elbit Systems developing bus with supercapacitator fast-charging system
Zion Tech: Israeli start up Dogiz helps dogs and owners socialize
Zion Tech: Our Israeli start-up of the week aims to make air pollution visible
The Lion's share
Get your gobble on: Thanksgiving in Tel Aviv
5th annual Hullegeb Festival celebrates Ethiopian culture
A man of leisure
Maccabi Tel Aviv on a roll as unbeaten CSKA comes to town
Another back-breaking loss for Jerusalem
Ga'ash, ESRA team up for golf tournament
Casspi making best of second stint as a King
Amid extreme winter weather, rescue workers save two hikers from floodwater near Dead Sea
Netanyahu after foiled terror plot: Hamas challenges existence of Jews, Israel
Orthodox leaders condemn US rabbi for anti-Arab rhetoric
US haredim seek to share kollels' 'burden'
Polish town plans to turn Jewish cemetery into apartment complex
Divided US Jews largely silent on 'Jewish state bill'
South African court bans BDS protests inside Woolworths
Is the price of watermelons relevant to Iran's nuclear crisis?
ISIS says its flag will wave over Jerusalem, even if the Jews don't like it
Iranian Police: 200,000 people in the country are alcoholics
WATCH: Syrian child preacher says stop chasing half-naked women, look to your 72 virgins
Pope: Don't close door on dialogue with Islamic State
Awakening to our nightmare
'But is it good for the Jews?'
New opportunities for Israel in Europe
Home demolitions?
We aren't crying wolf
Wishful doing
Cinema of reconciliation
On the volcano's edge
Knowledge, power and abuse
Moshe Hogeg's secret formula for success
Letters to the Editor: Fearless Publishing
Taiwan reaches out
Moving beyond politics
Grapevine: The history of Hansen Hospital
Less rioting, but more transportation delays
This week in Jerusalem
Taking Shape
Wading Through Widowhood: A museum by moonlight
Grapevine: Tel Aviv baby boom
Running for Afikim
Obama: Helping terror go nuclear
On incitement, lots of talk but little action
To finally look behind the news
Recognizing Palestine – anomalies and ambiguities
שְתִיקָתוֹ שֶל בָּרוּך
שָרִים מִקוֹל הַלֵב
50 שָנִים לְאַנְדַרְטַת הַנֶגֶב
Har Nof in flames
A voice from India
Happily Eva After: When the going gets tough...
Book Review: Written from his heart
Frontlines Podcast: The Iranian regime is 'doomed'
The weavers of dreams
Stock up on fish
Top 10 things to do: November 28-December 4
Casting a high-concept net
Pourquoi une loi sur l'Etat-nation?
Pour ou contre des élections anticipées?
Une horreur injustifiable
Une brèche dans la démocratie
Une petite fille juive du nord de Londres
Rétrospective en noir et blanc pour la ville d'Or
L'unité : notre seule planche de salut
Daniel Oren, maestro d'Israël, d'Italie et d'ailleurs !
Arad n'a pas encore jeté l'éponge
Le pot de chocolat liégeois par qui le scandale arrive
Le dernier kibboutz
La course aux étoiles
De Maxime Hauchard à Abou Abdallah Al-Faransi, itinéraire d'un Français parti faire le Djihad
On n'invite pas un pyromane à éteindre un incendie
Tuer l'EI dans l'œuf
Le mont du Temple et la guerre sainte de l'islam
L'Occident et l'Iran jouent les prolongations
La liste des organisations terroristes qui dérange
Les « Israéliens » de Kampala
Les attentats du lundi 10 novembre vus par la presse française
Netanyahou s'adresse à la communauté francophone
Christian priest speaks out strongly in favor of Jewish state law
Hispanic Evangelicals among Israel's greatest supporters
Christians United for Israel Chairman John Hagee says Obama is anti-Semitic
Temple Mount: Common ground between Jews and Christians
Pope Francis condemns Palestinian violence
KKL Belgium Donates Portable Bomb Shelter to Kiryat Gat
KKL-JNF Awards 2014 Blumberg Prize
Exploring the Ilanot Botanical Garden and the Vickar Observation Point
Cornerstone Laid for Sports Rehab Park at Meir Hospital
Mexican Politician and Business Leader Miguel Aleman Velasco Visits KKL-JNF in Jerusalem
International Conference in Sde Boker: Combating Desertification Together
Rehabilitation of the Lower Jordan: Bringing the River Back to Life
Central America Celebrates Independence at the Rabin Center
In his Footsteps: Heritage Excursions in Memory of Yitzhak Rabin
Cleanup Day Activities in Central Israel
International Cleanup Day: Cleaning Together in Northern Israel
KKL-JNF's Eyes in the Forest - The Horshim Forest Green Patrol
Israel Today and Tomorrow: KKL France Mission Visits Israel
Start-up Israel: KKL Italy November Mission Learns about Israel's Past and Future
KKL-JNF and Desert Agriculture Latin American Diplomats visit the Negev
A Successful Annual Fundraising Event for KKL Milan
Living Green in Israel: the Contest and the Winners
Addressing Climate Change Conference
Nurturing the Foresters of the Future
Saving the Sabras
11.27.2014 | 5 Kislev, 5775
Prime minister to Channel 1: I'll be running again in next election
Not all bleak for Netanyahu
China's moves: US decline, or balance in Asia?
Hanegbi heads to Myanmar for highest-level visit in 35 years
Former ambassador to the US Oren may enter politics on list Kahlon is drafting
MK calls on PM to destroy homes of Jews who murdered Arab teen
Netanyahu: Hamas leaders are legitimate targets, no one is invincible
Kahlon indicates comeback with new 'framework'
'Israel no better than Chelm for providing electricity to Palestinian companies that boycott it'
Manhattan borough president shows solidarity with Israel visit
Ministers and MKs urge Netanyahu to pound Hamas
Right-wing MKs call to investigate Balad party, ban it from Knesset after Qatar trip
Diplomacy & Politics
03/20/2014 00:28
US Secretary of State John Kerry (R) and Defense Minister Moshe Ya'alon.
(photo credit:REUTERS)
Defense Minister Moshe Ya'alon found himself apologizing for the second time in recent weeks for harsh comments made about the US government. In a phone conversation with US Secretary of Defense Chuck Hagel on Wednesday night, Ya'alon said that his comments "were not intended to express opposition, criticism or offense to the United States," adding that maintaining strong ties with the United States is Israel's utmost priority. Ya'alon expressed his appreciation for the close relationship Israel shares with the United States, and emphasized his full commitment to cooperation between the two nations. Hagel thanked Ya'alon for his clarification, acknowledging that some of the comments may have been taken out of context. Prime Minister Binyamin Netanyahu already began his efforts at damage control earlier in the day.Hours after senior US officials slammed Ya'alon for his latest criticism of American policy, Netanyahu told the Knesset on Wednesday the US remained Israel's greatest ally."We also appreciate the very high security and intelligence cooperation, including during the incident with the Iranian arms ship [the Klos C, which the Israel Navy seized on March 5]," Netanyahu said.US Secretary of State John Kerry phoned Netanyahu on Wednesday to protest Ya'alon's comments, stopping short of calling for his resignation, State Department spokeswoman Jen Psaki said."Clearly his comments were not constructive," Psaki told reporters at her daily briefing. "It is certainly confusing to us."Psaki added that Kerry does not believe Ya'alon's comments "reflect the view of the government of Israel."Ya'alon was quoted by Haaretz as saying at a Tel Aviv University event on Monday that America's aid to Israel needed to be "seen in proportion," and that it was not a one-way street."It isn't a favor America is doing, it's in their interest," he said. "They get quality intelligence and technology.
We invented [the] Iron Dome [anti-rocket system]. The wings of the F-35 stealth fighter – we invented. We invented the Arrow [anti-ballistic missile system]."Ya'alon's comments and other remarks he made critical of US foreign policy triggered withering criticism from a senior US official."We were shocked by Moshe Ya'alon's comments, which seriously call into question his commitment to Israel's relationship with the United States," a senior administration official told The Jerusalem Post on Tuesday night. "Moreover, this is part of a disturbing pattern in which the defense minister disparages the US administration, and insults its most senior officials."Ya'alon, in his speech at Tel Aviv University, said that in light of the US's policies in the Middle East, with China and with Russia, it has developed an image in the world of "feebleness.""The moderate Sunni camp in the area expected the United States to support it, and to be firm, like Russia's support for the Shi'ite axis," Ya'alon said. "I heard voices of disappointment in the region. I was in Singapore and heard disappointment about China getting stronger and the US getting weaker. Look what's happening in Ukraine, where the United States is demonstrating weakness, unfortunately."Ya'alon criticized the US for showing weakness globally."If you sit and wait at home, the terrorism will come again," he said. "Even if you hunker down, it will come.
This is a war of civilizations. If your image is feebleness, it doesn't pay in the world. Nobody will replace the United States as global policeman. I hope the United States comes to its senses. If it doesn't, it will challenge the world order, and the United States is the one that will suffer."On Iran, Ya'alon said that "comfortable Westerners prefer to put off confrontation. If possible to next year, or the next president. But in the end it will blow up." The US was being out-negotiated by Iran, and that "on this matter we have to behave as though we have nobody to look out for us, but ourselves," he said.The US official told the Post that "given the unprecedented commitment that this administration has made to Israel's security, we are mystified why the defense minister seems intent on undermining the relationship."The comments came two weeks after Ya'alon was criticized for saying in a private conversation that Kerry's diplomatic efforts stemmed from an "incomprehensible obsession" and "a messianic feeling." The State Department demanded an apology for those comments, which Ya'alon delivered at the time, at Netanyahu's insistence.Sources in Ya'alon's office said that he discussed the latest incident with the prime minister on Wednesday, and that the defense minister would clarify his comments to the Americans.Meanwhile, Ynet quoted sources close to Ya'alon as saying that some in the Obama administration were "trying to hurt" the defense minister's "legitimacy and his great popularity."One source said that "the Americans are calling him a 'hard nut to crack' and an 'extremist,' but in actuality he is standing firm facing what he identifies as a danger to the state and the security of its citizens."
JPost.com Staff contributed to this report.
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- Product Information
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Light up anyone's birthday with more than candles thanks to our Flashing Happy Birthday LED Blinkies! These Happy Birthday pins make great party favors and will let the birthday boy or girl know everyone is sending them plenty of birthday love on their big day! Each of these light up Happy Birthday blinkies has 4 LEDs, 1 red, 1 green, 1 yellow, and 1 blue, for maximum visibility on that special day. Use the butterfly connector on the back of the Happy Birthday pins to attach them practically anywhere and let the birthday fun begin! Please note the butterfly connectors may create small holes in the garments they are attached to. These light up Happy Birthday blinkies come with CR927 batteries included and installed and the batteries can be replaced. Our Flashing Happy Birthday LED Blinkies are sold by the dozen and come individually packaged in a clam shell.
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WOW I didn't expect this poem. It's like an ambush, there's no time to hide from the relentless theme - You do not exist. I am reminded of a story Joseph Campbell told. He had been studying Hindu scriptures in the original language for over four years when he went to India the first time. He thought he could easily talk with the gurus as one of them, but the first one he met showed him he was a rank novice. Where are you, Joseph Campbell, the wise man asked, between thoughts? Professor Campbell was speechless, as am I! (Report) Reply
Anthony Di'anno
Where Are You?
You are not your body.
It functions without You.
You can not be a soul if it's living inside You.
You are not the beliefs that You make up.
They are merely the difference between You drinking from a full or a half empty cup.
Look for your self.
How can You resist?
You will soon find out,
You do not really exist.
Anthony Di'anno's Other Poems
Read this poem in other languages
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Poet's Notes about The Poem
Comments about this poem (Where Are You? by Anthony Di'anno )
Daniel Brick (4/11/2014 6:08:00 AM)
Alookh (matin) (9/17/2013 8:59:00 AM)
WOooow! this one is one the best songs ive read in this website! ! ! ! i truly believe in it! ......life is like a bubble in a mirage of a dream! ! ! ! ! .......LIKEEEE ;) (Report) Reply
Victoria Donnelly (4/22/2013 10:25:00 AM)
love the note........I imagine more often than not we look for our perceived self in others..... (Report) Reply
Sally Plumb Plumb (4/10/2013 7:51:00 AM)
Yasmeen Khan (4/7/2013 11:00:00 AM)
quest for self...It reminds me of The Hollow Men by Eliot (Report) Reply
David Wood (4/2/2013 3:12:00 PM)
I like your style of poetry it makes mine rather dull (Report) Reply
Frank James Davis (3/31/2013 12:29:00 AM)
Whether or not I truly exist, I perceive parameters within which I can operate.
The gift of self-awareness allows me to choose; prods me to act; therefore, I very closely approach am-hood.
An invigorating offering, Anthony! (Report) Reply
Smoky Hoss (3/30/2013 4:17:00 PM)
A very interesting, and rather intriguing poem... I like it! ! ! (Report) Reply
Valerie Dohren (3/25/2013 8:18:00 AM)
A question that has long been asked and speculated upon - an interesting write Anthony. (Report) Reply
Diane Hine (3/25/2013 6:23:00 AM)
Or maybe you're a different you every fraction of a second - how would we know? I love these mind-twisting poems! (Report) Reply
Babatunde Aremu (3/25/2013 4:16:00 AM)
This is highly philosophical and deep. A very nice poem that keeps me thinking about my real self. Kudos. (Report) Reply
Ellias Aghili (3/25/2013 3:45:00 AM)
so true. we all are sinking in the current life and daily problems. we need something Superior. we need humanity to be survive in our lives. well done (Report) Reply
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Great Wall Motor in talks to enter India - SIAM official
MUMBAI/NEW DELHI (Reuters) - Great Wall Motor Co (601633.SS) is in talks to open a plant in India, a move that would make it the first Chinese carmaker to operate in the country without a partner.
"They are meeting industry. They are meeting government. They are meeting suppliers," Vishnu Mathur, director general of the Society of Indian Automobile Manufacturers - a lobby group, told Reuters in an interview on Monday.
Great Wall (2333.HK), which sells its sport-utility vehicles and pick-up trucks in other emerging markets such as Russia and South Africa, is not yet present in India's booming SUV market, one of a few bright spots in the local automotive industry.
China's eighth-largest car maker, which sent a delegation to India last week, is targeting 2016 to start manufacturing in India, Mathur said, adding Great Wall executives met SIAM representatives last week.
Great Wall was not available to comment.
Passenger utility vehicle sales, helped by subsidies on diesel fuel, rose 62 percent in the April-November period, while car sales rose 1.3 percent.
New entrants will compete with market leader Mahindra and Mahindra (MAHM.NS) and Tata Motors (TAMO.NS). Also, Italian carmaker Fiat FIA.MI said last week it would launch Jeep, an SUV brand controlled by U.S. subsidiary Chrysler, in late 2013.
While India has attracted billions of dollars investment from overseas manufacturers, such as Ford (F.N), General Motors (GM.N) and Toyota (7203.T), Chinese carmakers have yet to make significant inroads.
Chinese group SAIC Motor Corp (600104.SS) cut its stake in GM's Indian operations to 9 percent in October, from 50 percent.
A slowdown in India's car market over the past 18 months has raised fears of overcapacity, with sales expected to grow 1-3 percent in the financial year that ends in March.
Great Wall, China's largest car maker without a foreign partner, aims to more than double annual sales by 2015 by targeting more overseas markets, its chairman said last month.
(Additional reporting by Fang Yan in BEIJING; Editing by Dan Lalor)
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Secretary of Defense
Donald H. Rumsfeldand Deputy Secretary of Defense
Paul Wolfowitzhave no public or media events ontheir schedules.
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text:
New answers tagged gender
In a play the gender role that matters most is the 'characters' because they are conveying or telling the story to the audience to understand. In fact some actors are not too good for a specific character so you get someone who suits that character you want. Thank you.
If the author is good the language used, the syntax, and the way situations are approached should reflect the narrator's background. The "Voice" is distinctive for every one, and should be directly related to gender, age, culture and experiences. "Other than the point of view of the narrator, how does the gender and age of a narrator affect the ...
In my opinion, it is heavily dependent on the story in question. Most of the times I've read books narrated by a female, young or otherwise, they seem to take on the role of a memoir - not so much a way of taking me to a whole new world, but rather allow me to relate to the person telling the story. I'm recalling the book "The Girl Who Owned a City". Even ...
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Managed IT Services Sales Consultant
VMG Recruiting has partnered with our client to grow their new practice division as an Information Technology Service Consultant (ITSC-Managed IT Services,). Our client is focused on enabling the success of small and medium-sized businesses through the effective use and ...
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Tire Technician - Rent - A -Tire
Founded in 1996, Rent-A-Tire and Rent A Wheel started with one store in California. Since its modest beginning, the company is now the largest Rent-To-Own Custom Wheel and Tire Retailer in the nation with over 120 stores across 15 states and growing. Our customers can expect ...
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Dallas - Transportation
Assistant Manager - Rent - A - Tire
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HireLive is a national career service company specializing in Sales, Retail and Management Career Fairs, and has more than a decade of experience in connecting job seekers with industry leading companies that are ...
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Residential Outside Sales Representative - TXU Energy
Energy Future Holdings Corp., formerly TXU Corp., is a Dallas-based, privately held energy company with a portfolio of competitive and regulated energy subsidiaries. TXU Energy, Luminant and Oncor, EFH's primary businesses, serve the high-growth Texas electricity market. TXU ...
Non Commission Security Officers
We are looking for professional, motivated individuals to provide customer service while providing security to Class A High Rise Buildings in the Dallas/Ft. Worth area. Full-time as well as Part-time and Flex Officer positions are IMMEDIATELY available.
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Seeking collectors with experience and knowledge of medical collections to collect payment from self pay patient's onsite at client hospital facility. The successful candidate will be customer service orientated. We are at the hospitals 24 hours per day 7 days per week. Our ...
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Currently seeking English/Spanish bilingual candidates with experience assisting individuals with government programs such as, but not limited to, Medicaid, SSI, TANF, County Indigent and Crime Victims. The successful candidate will have experience in positions such as ...
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Canada-based distributor buys Cheektowaga warehouse
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- David Bertola
- Buffalo Business First Reporter- Buffalo Business First
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Meyers Transportation Services, a trucking company based in Belleville, Ont., has acquired an 80,000-square-foot warehouse in Cheektowaga to expand and streamline operations.
Terms of the transaction were not disclosed.
President Jacquie Meyers said the fourth-generation, family-owned business bought the building at 40 Sonwil Drive in June from Livingston International Inc. Her great-grandfather started the company in 1927.
"Our process has been streamlined a lot because we had a smaller warehouse in the Tonawanda area, so we were able to consolidate two warehouses and trucking," said Meyers of the Cheektowaga location which is called Meyers Distribution International. "For us, it was a perfect acquisition that lets us be more efficient and provide more services."
Two warehouses and a trucking business – Niagara Logistics Services, a small company that runs between Buffalo and Toronto – also were consolidated into the Sonwil Drive operation.
She said Meyers Transportation will do more cross-docking, where loads are delivered to the Cheektowaga warehouse before being rerouted to a final destination.
Meyers Transportation has a fleet of 250 trucks that cross the Canadian border daily. The new warehouse will be used to consolidate deliveries from multiple points across the United States, she said, then cross the Canadian border. The same thing happens in reverse as orders will be consolidated in Toronto for shipment to the Cheektowaga warehouse, where pallets will be unloaded and shipped to the appropriate destinations.
The company has 400 full- and part-time employees, including 26 in Cheektowaga who were Livingston workers and will remain after the acquisition.
David Bertola covers small business, energy and marketing
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* * * * *
Theatre to Go, Inc. begins season two as
Artists in Residence at Trinity Episcopal Church in Melrose, Mass.
Auditions for
The Trading Post
by Larry Ketron
directed by Alex Lucchesi
Sunday and Monday, November 23, 24, 2014 at 7:00 PM
Callbacks (as needed) on Monday, December 1, 2014 at 7:00 PM
Read-through scheduled for Wednesday, December 3rd!
Show runs February 6, 7, 13 - 15, 2015
The Merry Wives of Windsor
by William Shakespeare
Directed by Barbara Fulchino
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Theatre To Go, Inc., Attn: Staffing, P.O. Box 1502, Wakefield, MA 01880.
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TTG is also encouraging technical staff who would like to join our ranks to please contact us for an opportunity to "play" in our new space!
Any questions regarding our productions, or for general information, please email firstname.lastname@example.com.
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New campaign aims to help 50 million kids whose births were never registered
Development agencies push to have more children registered at birth to help ensure they are educated and have medical care.
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In Pakistan, 15-year-old Shahida's mother wanted her to get married, but she resisted.
Shahida longed to stay in school.
The child won that battle because she possessed a document that 50 million children do not: a certificate of birth registration. It offered proof of her age. If her parents forced the marriage, they could be charged and imprisoned.
Around the world, children who have not been registered are "invisible," says Mother to Child, a new report from the development agency Plan International, celebrating its 75th anniversary Tuesday.
Children without proof of age are more vulnerable to recruitment into armed struggles or forced labour, and their oppressors are less likely to be prosecuted. Congolese warlord Thomas Lubanga, who denied he recruited child soldiers as young as 9, was found guilty last week by the International Criminal Court.
"He said they only looked young," says Rosemary McCarney, president and CEO of Plan Canada. "With birth certificates and legal identity, he could not say that."
The lack of identity ripples throughout a child's life. Without it, a child may not be able to enrol in school, get inoculations, vote, or get a driver's licence or passport. Without proof of identity, reunification is much more difficult for families scattered by war or natural disaster.
In South Asia, only 36 per cent of children are registered at birth. Even where birth registration is mandated, heads of household who are required to register children (usually male) may be absent or unwilling.
In some countries there is deeply rooted resistance to identity cards.
"In Rwanda, the genocide was based on racial identity," McCarney says. "Registration identified you as Hutu or Tutsi. We're overcoming a generation of fear."
In India, up to 90 per cent of children with disabilities don't have birth certificates.
But there are success stories.
In Kenya, mobile phone networks set up for banking are being used to text a child's name and birth to Nairobi. After mobile units were introduced in Mozambique, parents now travel one kilometre to register their children instead of 75 kilometres.
In partnership with UN organizations, and after lobbying local and state governments, Plan has registered some 40 million children.
In India last week, McCarney met a group of street kids who sleep at Nizamuddin railway station in Delhi. Plan community workers keep an eye on them. When the children introduced themselves, they gave their names and added: "I think I am 9" or "I think I am 6." To McCarney, that child looked closer to 4.
During its anniversary celebrations, Plan is focusing on these children with no legal status, says McCarney. "We want to spotlight children who don't know when their birthdays are."
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