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Original Article
Cushing syndrome secondary to ectopic adrenocorticotropic hormone secretion†
The University of Texas MD Anderson Cancer Center Experience
Article first published online: 15 MAR 2011
DOI: 10.1002/cncr.26029
Copyright © 2011 American Cancer Society
Volume 117, Issue 19, pages 4381–4389, 1 October 2011
Additional Information
How to Cite
Ejaz, S., Vassilopoulou-Sellin, R., Busaidy, N. L., Hu, M. I., Waguespack, S. G., Jimenez, C., Ying, A. K., Cabanillas, M., Abbara, M. and Habra, M. A. (2011), Cushing syndrome secondary to ectopic adrenocorticotropic hormone secretion. Cancer, 117: 4381–4389. doi: 10.1002/cncr.26029
- †
We thank Maude E. Veech from the Department of Scientific Publications, Sarah H. Taylor from the Tumor Registry, and Graciela M. Nogueras Gonzalez from the Division of Quantitative Sciences for their assistance with this article.
Publication History
- Issue published online: 16 SEP 2011
- Article first published online: 15 MAR 2011
- Manuscript Accepted: 18 JAN 2011
- Manuscript Revised: 28 DEC 2010
- Manuscript Received: 1 NOV 2010
Funded by
- National Institutes of Health. Grant Number: CA16672
- Abstract
- Article
- References
- Cited By
- paraneoplastic syndrome;
- adrenocorticotropic hormone;
- Cushing syndrome;
- neuroendocrine tumors;
- localization studies
Cushing syndrome (CS) secondary to ectopic adrenocorticotropic hormone (ACTH) secretion (EAS) has been described in association with a variety of tumors. The current experience with this syndrome was based on a few case series and individual case reports. Limited data were available about the tumors associated with CS-EAS in a cancer center setting. In this report, the authors have described their experience with CS-EAS at The University of Texas MD Anderson Cancer Center to further enhance the current understanding and management of this syndrome.
This was a retrospective review of 43 patients with CS-EAS who were diagnosed between 1979 and 2009 at The University of Texas MD Anderson Cancer Center.
Different neuroendocrine tumors were associated with CS-EAS. Twenty-one patients (48.9%) had tumors located in the chest cavity, with bronchial carcinoid and small cell lung cancer representing the 2 most common causes. The ACTH source remained occult in 4 patients (9.3%) despite extensive workup. Clinical presentation varied, and the classic features of CS were not evident in some patients. Death occurred in 27 patients (62.8%), and the median overall survival was 32.2 months. Major morbidities included new-onset or worsening hyperglycemia (77%), symptomatic venous thromboembolism (14%), and infections (23%).
In patients with CS-EAS who attended a comprehensive cancer center, tumors originating in the chest cavity were the leading tumors associated with this syndrome. The authors suspect that CS-EAS is under reported because of the atypical presentation in some patients. Thus, they suggest careful evaluation of patients with neuroendocrine tumors to avoid missing coexisting CS-EAS. Cancer 2011;. © 2011 American Cancer Society.
Cushing syndrome (CS) in association with nonpituitary tumors was reported initially in 1928, shortly before Harvey Cushing reported his eponymous clinical syndrome associated with basophilic pituitary tumors in 1932.1, 2 In the following 3 decades, multiple cases were reported in which adrenal hyperplasia was associated with various tumors, but the link between CS and ectopic adrenocorticotropic hormone (ACTH) secretion was not established until 1962.3
Our current understanding of CS associated with ectopic ACTH production is derived mainly from the published series from large institutions4-7 as well as literature reviews and individual case reports.8-12 On the basis of the available literature, it is estimated that CS secondary to ectopic ACTH secretion (CS-EAS) constitutes 8% to 18% of all causes of CS.8, 13, 14 Many different of tumors, most neuroendocrine in origin, reportedly are associated with this syndrome.11 These tumors are readily apparent in many patients, although some require a great deal of time and effort to localize.10, 12 There is some evidence that mortality is increased in patients who have CS-EAS compared with controls who do not have hypercortisolemia.15, 16 This excess mortality and morbidity may be caused in part by susceptibility to infection; however, prospective validation of these findings still is lacking.
The objective of the current review was to study our institutional experience with CS-EAS and to further our understanding of this clinical entity in a cancer center setting. To achieve this goal, we reviewed cases of CS to identify patients who had CS-EAS managed at our institution. We summarized their clinical features, diagnostic studies performed, long-term outcomes, and selected complications.
A retrospective review of patients with CS was undertaken at the University of Texas MD Anderson Cancer Center after we obtained local institutional review board approval. Patients were identified through an institutional tumor registry database and from additional departmental databases. Initially, we searched for all patients with CS; then, we individually reviewed all patients to identify those who had CS-EAS diagnosed based on clinical documentation and diagnostic studies. Clinical data were obtained through a review of the medical records.
For the purpose of this review, CS-EAS was defined as: 1) ACTH-dependent CS (plasma ACTH >15 pg/mL) in patients who had tumors that had a known association with ectopic ACTH secretion; or 2) ACTH-dependent CS with positive ACTH immunostaining of nonpituitary tumors; or 3) ACTH-dependent CS with inferior petrosal sinus sampling (IPSS) that suggested an ectopic source, as determined by a central:peripheral ACTH ratio <2 at baseline or <3 after corticotropin-releasing hormone (CRH) stimulation.
We also reviewed records to summarize important clinical and laboratory parameters associated with CS, including hypertension, hyperglycemia, and hematologic and electrolyte abnormalities. New-onset or worsening hypertension was defined as an elevated systolic blood pressure at presentation (>140 mm Hg) in patients without a prior history of hypertension or clinical documentation of uncontrolled hypertension in patients with a pre-existing diagnosis of hypertension that had been well controlled on antihypertensive medications. New-onset or worsening hyperglycemia was defined as a fasting blood glucose level ≥126 mg/dL in patients without a prior history of diabetes mellitus or clinical documentation of worsening glycemic control in the 3 months before the diagnosis of CS. White blood cell counts and differentials at presentation were studied and classified as follows: Leukocytosis was defined as a white blood cell count >11,000/mm3, neutrophilia was defined as a neutrophil count >7300/mm3, lymphopenia was defined as a lymphocyte count <1000/mm3, and eosinopenia was defined as an eosinophil count <40/mm3.
Hypokalemia was defined as a serum potassium level <3.5 meq/L at presentation or the need for potassium supplementation or potassium-sparing agents to normalize potassium. Alkalosis was defined as a serum bicarbonate level >30 meq/L at presentation.
Statistical Analysis
The primary analysis was to determine the overall survival (OS) of patients with CS-EAS. For OS, the time to death or censoring was calculated in months after the date of CS-EAS diagnosis. In the absence of death, survival was censored at the date of last known follow-up. Univariate Cox proportional hazards regression was used to model the association between sex and duration of OS. The Kaplan-Meier product-limit method was used to estimate median OS. Statistical analyses were performed using STATA/SE version 11 statistical software (Stata Corp., College Station, Tex).
Patient Characteristics
In total, 300 patients with CS were identified, including 43 patients with ACTH-dependent ectopic CS who had been diagnosed between 1979 and 2009. Patients' clinical features at presentation are summarized in Table 1.
|No. of Patients (%)
|17 (39.5)
|26 (60.5)
|Median age at diagnosis [range], y
|48 [19-75]
|Weight change
|Weight gain
|26/33 (79)
|Weight loss
|7/33 (21)
|Median BMI [range], kg/m2
|27.7 [19.1-54.9]
|New-onset or worsening hypertension
|35/41 (85)
|New-onset or worsening hyperglycemia
|30/39 (77)
|15/38 (39)
|21/36 (58)
|20/36 (56)
|18/33 (55)
|28/39 (72)
|23/35 (66)
Diagnostic Tests for CS
Results from a 24-hour urine free cortisol (UFC) test were available, and UFC levels were elevated in 30 patients. The median UFC level was 498 μg/24 hours (range, 71.7-12,515.0 μg/24 hours; upper reference value, 50 μg/24 hours). Random plasma ACTH levels were available in 42 patients. The median ACTH level at presentation was 182.5 pg/mL (range, 43-5900 pg/mL; upper reference value varied from 46 pg/mL to 52 pg/mL on different assays used during the review period). The ACTH value was not available at presentation in 1 patient who had a metastatic bronchial carcinoid tumor associated with a classic clinical presentation of CS and elevated cortisol.
Results from high-dose dexamethasone suppression tests (HDDSTs) were available for 16 patients, including 14 patients who had 8:00-AM serum cortisol values >5 μg/dL and 2 patients who had serum cortisol values <5 μg/dL after completing either 2-day or overnight HDDSTs. Cortisol levels in 8 patients after HDDST revealed a median 16.6% decrease (range, 2.8%-54.8% decrease) from baseline values.
The median change in peripheral plasma ACTH during an IPSS study (ACTH at 10 minutes after CRH injection compared with the baseline value) was 4.9% (range, 50%-81.5%). The change was <50% in 7 of 8 studies. In 1 patient, the increase was 81.5%, but the patient had a peak peripheral plasma ACTH level of 69 pg/mL and previously had no change in peripheral plasma ACTH after CRH injection during an earlier IPSS study.
Tumor Distribution and ACTH Source
Tumors associated with EAS were distributed as follows: 9 patients (21%) had bronchial carcinoid tumors, 9 patients (21%) had small cell lung carcinoma (SCLC), 5 patients (11.6%) had medullary thyroid carcinoma (MTC), 3 patients (6.9%) had thymic carcinoid tumors, 6 patients (14%) had gastroenteropancreatic neuroendocrine tumors (GEP-NETs), 4 patients (9.3%) had genitourinary tumors (2 prostatic NETs, 1 bladder NET, and 1 ovarian endometrioid carcinoma), 3 patients (6.9%) had widely metastatic NETs of unknown primary origin, and 4 patients (9.3%) had occult sources of ACTH despite extensive testing. Table 2 summarizes the tumors associated with CS-EAS in our series compared with other series in the English literature.
|No. of Patients (%)
|Liddle 1969,5 n = 104a
|Aniszewski 2001,4 n = 106
|Ilias 2005,6 n = 90
|Isidori 2006,7 n = 40
|Current Study, n = 43
|Combined Data, n = 383
|Bronchial carcinoid
|5 (4.8)
|26 (24.5)
|35 (38.9)
|12 (30)
|9 (21)
|87 (22.7)
|52 (50)
|12 (11.3)
|3 (3.3)
|7 (17.5)
|9 (21)
|83 (21.7)
|Thymic carcinoid
|11 (10.6)
|5 (4.7)
|5 (5.6)
|2 (5)
|3 (6.9)
|26 (6.8)
|2 (1.9)
|9 (8.5)
|2 (2.2)
|3 (7.5)
|5 (11.6)
|21 (5.5)
|14 (13.5)
|18 (17)
|8 (8.9)
|5 (12.5)
|6 (14)
|51 (13.3)
|Pheochromocytoma/ paraganglioma
|4 (3.8)
|3 (2.8)
|5 (5.6)
|1 (2.5)
|0 (0)
|13 (3.4)
|NET of unknown primary
|0 (0)
|7 (6.6)
|13 (14.4)
|2 (5)
|3 (6.9)
|25 (6.5)
|7 (6.7)
|17 (16)
|17 (18.9)
|5 (12.5)
|4 (9.3)
|50 (13.1)
|9 (8.7)
|9 (8.5)
|2 (2.2)
|3 (7.5)
|4 (9.3)
|27 (7)
Localization Studies
Several different localization studies were used, particularly in patients for whom the source of ACTH was not apparent at presentation.
Eight patients underwent IPSS, and the results provided further support for a diagnosis of EAS because of a lack of central-to-peripheral ACTH gradients in all 8 patients.
Twenty patients had 6-mCi indium-111 pentetreotide scans (octreoscans) obtained, including 8 patients who underwent this scan at least twice. Octreoscans identified the source of ACTH production in 12 patients (60% of those tested). This included 5 patients with bronchial carcinoid, 2 patients with medullary thyroid carcinoma, 3 patients with pancreatic NET, 1 patient with urinary bladder NET, and 1 patient with small bowel carcinoid. Octreoscans were negative in the remaining 8 patients (40%), including 4 patients who had an occult source of ACTH, whereas other imaging studies localized an ACTH source in the remaining 4 patients (1 patient with bronchial carcinoid, 2 patients with thymic carcinoid, and 1 patient with a widely metastatic NET of unknown primary origin).
[18F]fluoro-2-deoxy-D-glucose–positron emission tomography
Six patients had [18F]fluoro-2-deoxy-D-glucose–positron emission tomography (FDG-PET) scans obtained. The underlying tumor was observed on FDG-PET scans in 4 patients (SCLC, thymic carcinoid, bronchial carcinoid, and MTC in 1 patient each), whereas the scan was negative in 2 patients (1 with a bronchial carcinoid tumor and 1 with an occult ACTH source).
Pituitary imaging
Thirty-four patients had pituitary imaging studies obtained, with normal results in 31 patients (91%) and incidental pituitary abnormalities identified in 3 patients (9%). IPSS failed to localize ACTH secretion to the pituitary in 2 of these 3 patients with occult ACTH sources. In the third patient, an incidental, 0.3-cm pituitary microadenoma was identified on a magnetic resonance imaging (MRI) study, and she was diagnosed subsequently with an ACTH-producing bronchial carcinoid tumor.
Cross-sectional body imaging
Chest imaging (computed tomography [CT] and/or MRI studies) localized the source of ACTH in 25 of 37 patients who had such imaging. These patients had their primary tumor located in the chest or lower neck and included 9 patients with bronchial carcinoid, 9 patients with SCLC, 4 patients with MTC, and 3 patients with thymic carcinoid. Abdominal imaging (CT and/or MRI) studies localized the source of ACTH or distant metastases to the abdomen in 9 of 32 patients who had such imaging studies.
Duration to ACTH Localization
The time to ACTH localization after CS diagnosis varied and ranged from 0 months to 118 months. The times to localization were as follows: Localization was observed at the time of diagnosis (within 1 month) in 32 patients (74.4%), and delayed localization (>1 month) was observed in 7 patients (16.3%) who had tumors that were localized after a median of 22 months (range, 6-110 months). The diagnoses of these patients were bronchial carcinoid tumors (4 patients), thymic carcinoid tumor (1 patient), bladder NET (1 patient), and 1 metastatic NET of unknown primary origin (1 patient).
Occult Source
In 4 patients (9.3%), the source of ACTH remained unknown despite extensive workup, and the patients were categorized with occult ACTH sources. Follow-up for these 4 patients ranged from 6 months to 118 months, and they had the following localization studies performed:
Pituitary imaging
Two patients had normal pituitary imaging studies, and 2 patients had images that suggested pituitary adenoma, but IPSS testing did not confirm adenomas as the source of ACTH. IPSS tests were done in all 4 patients, including 1 patient who underwent IPSS twice. Table 3 summarizes the biochemical profiles of these 4 patients.
|Patient No.
|Age at Diagnosis, y
|24-UFC, μg
|8 AM Cortisol After HDSST, μg/dL
|Pituitary MRI
|Central to Peripheral ACTH Ratio Before CRH Injectiona
|Central to Peripheral ACTH Ratio After CRH Injectiona
|Pituitary Surgery
|No adenoma (questionable)
|Yes, but no adenoma
|Suspicious 0.6-cm adenoma
|1.0 and 1.1
|1.5 and 1.1
|Yes, but no ACTH staining
|No adenoma
|Not done
|Suspicious 0.5-cm adenoma
|Not done
Chest and abdominal imaging
Chest and abdominal cross-sectional imaging scans were negative in all 4 patients.
FDG-PET scans
An FDG-PET scan performed for 1 patient was negative.
Octreoscans were negative in all 4 patients.
Surgical and medical options to control hypercortisolemia were individualized considering the variability in ACTH sources. Twenty-eight patients underwent surgery, including 7 patients who underwent bilateral adrenalectomy, 14 patients who underwent resection of their primary tumors (ACTH sources), and 7 patients who underwent combined bilateral adrenalectomy along with primary tumor resection.
Medical therapy to control cortisol overproduction, which consisted mainly of metyrapone and ketoconazole, was offered to 40 patients with variable success. Available data did not allow a meaningful assessment of the response duration or magnitude considering the variability of the clinical course and the frequent deaths experienced in this cohort.
Medical Complications
Infectious complications were documented in 10 patients (23.3%), including 5 patients with pneumonia alone, 2 patients with pneumonia and cellulitis, 2 patients with pneumonia and sepsis, and 1 patient with septicemia. Symptomatic venous thromboembolism (VTE) was documented in 6 patients (14%), including 4 patients with pulmonary embolism, 1 patient with unprovoked deep vein thrombosis of the axillary/subclavian veins, and 1 patient with symptomatic retinal vein thrombosis. Two patients with bronchial carcinoid died secondary to pulmonary embolism.
Death occurred in 27 patients, and the median OS duration was 32.2 months in all patients. There were no significant differences in median OS durations between men (32.2 months) and women (32.4 months; P = .714). The Kaplan-Meier curve for OS in all patients is illustrated in Figure 1. Progression of primary malignancies and systemic infections at the time of death were the leading causes of mortality, and 2 patients died from pulmonary embolism.
Cushing syndrome in association with nonpituitary tumors was described more than 8 decades ago, but our current knowledge is limited to retrospective reviews in part because of the rarity of this syndrome, its variability in clinical presentation, and the heterogeneity of underlying tumors associated with this syndrome. Tumors associated with ectopic ACTH production have been well documented in the medical literature mainly in case reports and case series from single institutions. It remains uncertain whether patients who attend comprehensive cancer centers differ from patients reported from other tertiary referral centers. To clarify this uncertainty, we summarized our experience with patients with CS-EAS who attended and were treated at a comprehensive cancer center and compared our findings with those from other case series at other major medical institutions. We identified a total of 300 patients with CS who attended and were treated in our institution, including 43 patients (14.3%) who had CS-EAS, a rate that is close to available reports in which CS-EAS constitutes 8% to 18% of all causes of CS.8, 13, 14 These estimates were derived mostly from major referral centers and probably are subject to referral bias.
The current body of literature reported the prevalence of clinical CS-EAS in 1.6% to 4.5% of patients with SCLC17-19 and biochemical abnormalities suggestive of CS or ectopic ACTH in as greater as 30% to 50% of patients with SCLC.20-22 Despite an extensive search of medical records, we identified only 9 patients who had SCLC-associated EAS-CS, and we could not reindentify previously reported cases of SCLC and CS published from our institution 2 decades ago.15 Therefore, we believe that our report underestimates the true prevalence of CS-EAS in patients with cancer.
Earlier reports have suggested that ectopic CS is more common in men, because initial cases of CS-EAS were often reported in patients with SCLC.17, 18 However, our report and some other more recent case series have estimated that men constitute between 40% and 50% of all patients with CS-EAS6-9 and represent only 6% to 26% of patients with Cushing disease.23-25
The median patient age at diagnosis was 48 years in our report. This falls within the range of mean ages at diagnosis (38-50 years) reported elsewhere.6-9
Clinically, weight gain was not universal in patients with CS-EAS, and weight loss was reported in 21% of patients in our series. This differs from the 10% of patients who reportedly lost weight in other series,6 and the discrepancy may be linked to the higher ratio of malignant tumors (especially SCLC) observed in our patients. The majority of patients in our series had new-onset or worsening hypertension or hyperglycemia, similar to what was observed in other reported series.6, 7 Conversely, leukocytosis was identified in only 39% of patients in our series; whereas neutrophilia, lymphopenia, and eosinopenia were identified in 55% to 58% of patients at the time of initial diagnosis. Hypokalemia was noted in 72% patients in our study, which is similar to the reported prevalence of 71% in the literature.6 UFC and plasma ACTH levels were elevated in all tested patients, suggesting ACTH-mediated CS; whereas serum cortisol levels remained elevated in 88% of patients after HDDST, suggesting EAS and similar to the rates of 90% and 91% of patients reported by Ilias et al6 and Isidori et al,7 respectively.
The distribution of tumors associated with CS-EAS is summarized in Table 2. Looking at the combined data from multiple series in Table 2, it appears that bronchial carcinoid and SCLC tumors are the 2 most common causes of EAS and represent approximately 44.4% of all cases. Thus, chest imaging represents the most important diagnostic test in patients who have ACTH-dependent CS with negative pituitary imaging or IPSS results suggestive of EAS.
IPSS is a very helpful tool for ruling out pituitary sources of ACTH with very high sensitivity and specificity13; however, the wider use of this procedure still is limited by the potential risk for serious complications and the availability of experienced neuroradiologists. After combining our data with 3 other reports,4, 6, 7 we observed that 37 of 38 patients with occult CS-EAS who had IPSS studies had no central/peripheral gradient suggestive of a nonpituitary source for ACTH secretion. However, this assumption should be viewed in the light of retrospective series in which false-negative IPSS results were observed in approximately 6.5% of patients with Cushing disease.26, 27 Conversely, octreoscans localized the sources of ACTH in only 12 of 20 patients (60%) in our series, a rate that is close to other reports in the literature that indicated limited sensitivity for octreoscans in patients with CS-EAS.6, 7 The use of FDG-PET is not established in the diagnosis and management of CS-EAS, although it is used often to stage and assess lung malignancies. Scattered reports have suggested the incidental finding of carcinoid tumors by using FDG-PET scans,28-30 with sensitivity of 75% to detect bronchial carcinoid tumors that measure 1 to 8 cm.31 The combination of FDG-PET with CT imaging reportedly enhanced the localization of bronchial carcinoid tumors.32 In the current series, FDG-PET localized ACTH sources in 4 of 6 patients (with SCLC, MTC, bronchial carcinoid, and thymic carcinoid tumors) in whom the primary tumor also was observed on less-expensive cross-sectional imaging studies. In the fifth patient, an FDG-PET scan was negative, as were all other imaging studies, at the time of diagnosis. With long-term follow-up, this patient had a 1-cm bronchial carcinoid tumor identified on a chest CT study 28 months after her initial diagnosis. In the sixth patient with an occult ACTH source, an FDG-PET scan was negative, similar to the other diagnostic studies. In 11 patients (25.6%), the diagnosis of the source of ACTH production was either delayed for >6 months or remained unknown after exhaustive workups. This finding is compatible with the overall experience reported in the literature, especially among patients with occult ACTH sources, as indicated in Table 2. Considering the complex nature of this disease, we suggested an algorithm for ACTH source localization (see Fig. 2).
Multiple questions remain unanswered regarding the association between infections and other medical complications previously reported in patients with CS. The association between CS and a predisposition to infection has been reported since the description of Cushing disease in 1932 by Harvey Cushing, who noted that patients with the syndrome were left with a definite susceptibility to infection.2 Ever since that report, retrospective evidence has accumulated to support the assumption of a higher risk of infection associated with hypercortisolemia.15, 16, 33 We also observed an increased risk of infection in our series, but the lack of a good control group and the nature of retrospective data reviews may have affected the accurate assessment of the strength of this association between CS and infections.
The likelihood of VTE in association with CS has been debated; and, to date, the true prevalence has not been well established.34 It has been well documented that patients who have CS with altered coagulation-factor profiles, including elevated levels of coagulation factors II, V, VIII, IX, XI, and XII, are compatible with an increased risk of thrombosis.35 Despite the lack of quality evidence, a recent review suggested a risk of VTE in patients with CS of close to 2% in patients who did not undergo surgery and approximately 4% after surgery.36 It is unclear whether patients with CS-EAS have a higher risk of VTE compared with patients who have CS secondary to other causes. The finding that ectopic CS is associated with underlying malignancy theoretically may put these patients at greater risk for VTE compared with other CS patients. Still, our finding of 6 episodes of VTE (14%) is close to what was reported by others, who also combined prospective follow-up with retrospective analysis.34
The median OS in our series was 32.2 months, and we observed no effect of sex on survival. In our series, death occurred in 27 of 43 patients (62.8%) during follow-up, a death rate that was much higher than the reported rate of 21% (19 of 90 patients) in the National Institutes of Health series, which included fewer patients with SCLC (3.3% of all patients).6 Nevertheless, our findings are similar to those published by Isidori et al,7 who reported that 25 of 40 patients (62.5%) died during follow-up; those authors noted deaths among 17.5% of patients with SCLC, which was close to our rate of 21%. Although CS with an occult ACTH source can lead to significant morbidity, OS is better in such patients than in patients who have apparent malignant sources of ACTH, including SCLC and MTC.4, 8
The heterogeneity of underlying tumors as well as the retrospective nature of our current study limited our ability to assess the effect of cortisol-lowering therapy on clinical outcomes, and especially on infections and death. We speculate that lowering cortisol levels before attempting curative treatments (surgery or chemotherapy) may reduce the mortality and morbidity associated with CS and, in particular, may reduce the rates of opportunistic infections. Prospective investigations of this syndrome are needed to fill the gaps in our knowledge related to CS-EAS and its effect on cancer-related therapy.
In conclusion, CS-EAS is a relatively uncommon clinical syndrome that accompanies a wide variety of tumors. Patients may not have obvious CS, because their clinical presentation may be masked by symptoms of the underlying tumor. Thus, the diagnosis can be challenging, and the source of ACTH production can be difficult to identify. In addition, the true prevalence of this syndrome probably has been underestimated in the current retrospective review. This syndrome is associated with significant morbidity and mortality, which may be related in part to the expected increased incidence of infectious and thrombotic complications. Patients with NETs need to be assessed carefully for CS-EAS. Prospective studies are needed to clarify the true prevalence of this syndrome in cancer patients and its clinical complications.
Supported in part by the National Institutes of Health through a grant to The University of Texas MD Anderson Cancer Center (Cancer Center Support Grant CA16672).
The authors made no disclosures.
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Hitting The Ground Running
It's no secret that Ohio State had struggles moving the ball on the ground against Youngstown State.…
Every week, Fantasy Football Expert Rusty Reeves predicts a heaping handful of players who will decline in the coming weeks. They should be downgraded at least one tier. Chicago Bears QB Jay Cutler …Read More
The top 30 teams in college football after Week Thirteen...Read More
Finding just the right present for that special someone can be a challenge, so we've compiled a wide variety of hunting, fishing and outdoor gifts that you—or Santa—can deliver this Christmas.Read More
There have been so many great basketball players in the Atlantic Coast Conference since 2000, but which have been the very best? We break down the Player of the Century, Best Coach, Best Freshman, and…Read More
The story of the first Thanksgiving is filled with folklore and legend. But what's the real story? Here are 10 commonly believed myths about the First Thanksgiving debunked.Read More
It's no secret that Ohio State had struggles moving the ball on the ground against Youngstown State.…

subset: commoncrawl


text:
Definition of Twitard
- an extreme fan of the fiction series Twilight.
We were friends until I discovered that she was a Twitard.
Last edited on May 30 2010. Submitted by Anonymous on May 29 2010.
|Add a definition for this slang term
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|Definitions include: Someone that can be used
|Definitions include: an attractive man.
|Definitions include: "comfortable".
|Definitions include: Shoes
|Definitions include: some location extremely far away.
|Definitions include: form of address for a person, usually female.
|Definitions include: acronym for "to the best of my knowledge."
|Definitions include: an invitation to let something proceed, as when bull-riding and requesting the gate be opened.
|Definitions include: a man who is successful with women.
|Definitions include: very good, excellent; "cool"; "awesome".
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Wholesale African Decor
Showing 1-12 of 68
|Savannah Complete Bath Decor
Decorate your bath like a designer in mere minutes; all you need is this all-in-one set! Luscious jungle print peps up any powder room with matching bath accessories. Set includes: shower curtain, 12 ...
|Categories: New Arrivals, Wholesale African Decor, Bath Sets, Shower Curtains
|Artisan Deco Bowl And Balls
Instantly create a striking centerpiece anywhere and add a dash of tribal flair! Striking tribal carvings add textural interest to a trio of decorative balls and matching wooden bowl. For decorative p...
|Categories: New Arrivals, Bowls, Home Decor, Wholesale African Decor
|Zebra Stripe Lamp
Striking stripes of black and white add adventurous appeal to this jug-shaped lamp, tastefully topped with a white fabric shade. Adds a wild little touch of Africa wherever it is placed! Polyresin wit...
|Categories: Lamps, Zebra Prints, Wholesale African Decor
|Flock O Flamingos Decor
Sunny tropics and sandy beaches spring to mind at the very sight of this fabulous flock of bright pink flamingos. Metal-art statue is a colorful confection that no discerning decorator will want to do...
|Categories: New Arrivals, Flamingos
|Temple Solar Water Fountain
Graceful Asian fountain has the authentic look of hand-hewn stone; a dramatic addition to your outdoor decor! Place this dual powered fountain anywhere you please: Solar panels for cord-free enjoyment...
|Categories: New Arrivals, Water Fountains
|Nantucket Tall Storage Cabinet
You'll find a thousand uses for this fashionable organizer, from the bathroom to the living room and beyond! Sleek louvered styling and bright white finish let this handsome shelf brighten most any de...
|Categories: New Arrivals, Cabinets
|Playful Dolphins Accent Table
Enhance your decor with a statuary table of incomparable artistry! Lovingly sculpted column base perfectly captures a dolphin pair's light-hearted joy and exuberant grace as they play amongst the foam...
|Categories: Dolphins, Tables, Accent Tables
|Solar Crystal Buttefly Decor
Butterflies on parade create a lovely glittering cascade! This unique decoration adds delight day and night, as it dances in the sunny breeze or the gentle glow of its very own solar light. Weight 0.7...
|Categories: New Arrivals, Wind Chimes
|Florentine Fireplace Screen
A warm, rustic finish and ornate scrollwork give this metal screen the look of a timeless Italian treasure, graciously keeping stray sparks and fireplace embers at bay. A handsome enhancement for any ...
|Categories: New Arrivals, Fireplace Screens
|Mini Oil Warmer Trio
Attractive ceramic decorative oil warmers beautify most any decor, brightening the room with twinkling light and a subtle hint of fragrance. Weight 1 lb. Tealight candle and oil not included. Set incl...
|Categories: New Arrivals, Oil Warmers
|Moroccan Tower Candle Lantern
Tall, elegant and impressive, this graceful bronze candle lamp is a stunning focus piece for your decor. Add a stately candle to shed an entrancing amber glow. An imaginative accessory! Sturdy base le...
|Categories: New Arrivals, Lanterns, Candle Lanterns, Moroccan Lanterns
|Noble Elephant Wall Decor
Indulge your wild side when you dress up a dull room with this lifelike sculptural plaque! Lovingly detailed re-creation of Nature's gentle giant is a breathtaking addition to any area. Hole on back f...
|Categories: New Arrivals, Elephants
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text:
Circuit Breakers - Automotive
Automotive circuit breakers provide a resetable and reusable alternative over standard fuses for circuit protection, and can altogether replace fuses and fusable links in most applications. Circuit breakers come in 3 types: Type 1 are auto resettable, and once tripped, will attempt to reset the circuit, or 'cycle', as the internal elements of the breaker cool down. Type 2 (trip and hold) are called modified reset, and will remain tripped until the power is removed from the breaker. Type 3 circuit breakers are manual resettable, and require that a button or lever be pushed in order to reset the breaker. We carry thermal circuit breakers from the leaders in the transportation market, Cooper Bussmann and Carling Technologies. Our circuit breaker selection include the following: ATC and Mini style breakers, which can replace traditional fuses in many applications. High Amperage weatherproof breakers for higher current protection from 50 to 150 amps. The famous Bussmann 'Short Stop' brand, a workhorse in 12 and 24 volt circuit protection from 5 to 50 amps. Panel mount circuit breakers with 1/4" quick connections for mounting into panels with the amperage printed on the reset button. Use the links below to view our entire selection of 12 volt and 24 volt circuit breakers.
Bussmann 'Short Stop' Circuit BreakersShort Stop Bussmann DC circuit breakers for automotive and marine use. 5 amps to 50 amps capacity. Available in Type 1, Type 2, and Type 3 versios.
High Amp Circuit BreakersHigh Amp Waterproof Circuit Breakers for providing protection to high power electrical wire feeds. Breakers available from 50 amps to 150 amps.
Panel Mount Circuit BreakersPanel mount thermal circut breakers are engineered for automotive, marine, and RV use.10-30 amp sizes Connections via 1/4 Inch quick connect terminals.
ATC Circuit BreakersATC Circuit Breakers ATC fuse replacement circuit breakers available in type 1 auto reset, Type 2 modified reset, and type 3 manual reset.
MINI Circuit BreakersMINI Circuit Breakers. Available in type 1 auto reset and type 2 modified reset versions. Can replace MINI fuses in many electrical applications.
Mid-Range Circuit BreakersCooper Bussman brand mid-range power circuit breakers for new and replacement circuits. 30 to 50 amp capacity. Connections made using #10 studs.
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14 gauge Blue SXL Automotive Wire 100ft. Spool
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text:
I've been thinking about intention lately. How often do we find ourselves slipping into "automatic thinking" ? What does our window of aspiration look like and how do we frame it?
Doing vs. Being | Acting vs. Reacting | Ideal vs. Real |
Intention leads to quantum creativity because for many people, creativity restores order. Some of the most important things that we do in life come from our creativity, which invokes possibilities of new beginnings.
The human condition causes individuals to make flawed assumptions that people do not change. But those of us have done deep self-exploration, know that we get to make a choice to be even better today than the day before. Read the rest of this entry »


text:
Letter: Seats on the train
Thursday 12 August 1999
Should not Railtrack perhaps spend slightly less on superstructure and slightly more on infrastructure?
Alternatively, might not Railtrack consider charging for such spectator sports in future? There are enough pigeons (and rats) at Paddington to guarantee an endless supply of players.
Reading, Berkshire
'At times I thought he was me'film
Review: One Direction, Fourmusic
Review: The World of Ice and Firebooks
Film More romcom than S&M
Review: The Imitation Gamefilm
Comedy...to show her mastectomy scars
TVNetflix gets cryptic
TV review A moving film showing kids too busy to enjoy their youth
Books Not even a Man Booker prize could save Richard Flanagan from a nomination
Arts & Ents blogs
- 1 'Not suppost to cry': 9-year-old lists the worst things about being a boy
- 2 To help fuel their propaganda machine against the poor, our government has now decided to redefine the word 'welfare'
- 3 Woman opens professional cuddling shop – gets 10,000 customers in first week
- 4 Lana Del Rey rape video: Marilyn Manson denies involvement in shocking leaked footage
- 5 Kenya bus attack: Al-Shabaab militants kill 28 non-Muslims who failed to recite Koran
Lee Evans announces his retirement from comedy on The Jonathan Ross Show
Iggy Azalea responds to Eminem rape lyrics: 'I'm bored of old men threatening young women'
Beyoncé '7/11' music video: Star bounces on bed in low-fi homage to viral video
Angelina Jolie confirms retirement from acting: 'I've never been comfortable on-screen'
Lana Del Rey rape video: Marilyn Manson denies involvement in shocking leaked footage
Rochester by-election: Ukip gains second MP as Tory defector Mark Reckless holds seat
'Beast of Bolsover' Dennis Skinner takes Ukip MP Mark Reckless to task moments after he is sworn in
Rochester by-election: Labour MP Emily Thornberry resigns after posting white van and England flags tweet
France 'blocks' Russian sailors from boarding a warship
Revealed: How the world gets rich – from privatising British public services
Myleene Klass: Ed Miliband 'strikes back' by comparing UK's need for Labour's mansion tax to Hear'Say track
WIN a trip for two to Cuba
Follow Simon Calder's journey in Cuba, and enter our competition to win a trip for two to Cuba
Rainbow list 2014: The LBGT people who make a real difference
Introducing our annual celebration of the lesbian, bisexual, gay, and transgender people who make a real difference
2014 WISE Summit
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Build yourself a brighter future
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Expertly tailored
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Enter the latest Independent competitions
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Business videos from commercial thought leaders
Watch the best in the business world give their insights into the world of business.


text:
orthognathousLine breaks: or|thog¦nath¦ous
Pronunciation: /ˌɔːθəɡˈneɪθəs , ɔːˈθɒɡnəθəs /
Definition of orthognathous in English:
(Especially of a person) having a jaw which does not project forwards and a facial angle approaching a right angle.
Definition of orthognathous in:
- US English dictionary
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Word of the day ingratiate
Pronunciation: ɪnˈɡreɪʃɪeɪt
bring oneself into favour with someone through flattery…


text:
Starts a concern for Bruins as Stanley Cup Final continues
Jun 20, 2013, 8:57 PM EST
Both the Boston Bruins and Chicago Blackhawks have, respectively, had their share of good starts in this Stanley Cup Final, and a pair of bad ones.
And it seems the two teams have alternated good starts and bad starts from one game to the next.
On Wednesday, the Blackhawks got on the scoreboard first and ultimately went on to win Game 4 by a final of 6-5 in overtime.
Should it surprise anyone that this series is tied 2-2, as it shifts back to Chicago for Game 5 on Saturday.
But as the series continues and the final prize grows even closer on the horizon, this aspect has triggered more focus. A slow start at this juncture could be the difference between a Stanley Cup championship and being the runner-up.
"I think if there's one thing in this series so far, they've definitely had the better starts. That's an area where we keep talking about having a better start," said Bruins head coach Claude Julien, as per CSNNE.com.
"They've had the advantage on us in that department, and we're working on hopefully having some better starts.
"There's a maximum of three games left. Hopefully we get better starts in those games."
- ethanmacleod1685 - Jun 20, 2013 at 10:06 PM
Terrible writing, especially in the writing !
- ethanmacleod1685 - Jun 20, 2013 at 10:06 PM
- ethanmacleod1685 - Jun 20, 2013 at 10:07 PM
- endusersolutions2013 - Jun 20, 2013 at 10:11 PM
Only seems relevent for games 3 and 4. Hawks were down in the 1st and came back. Hawks owned the 1st period and start of the 2nd with a huge disparity on both SOG and BLK against, but infortunately encountered "Stonewall Rask", scoring nothing.
- hockeyflow33 - Jun 20, 2013 at 11:15 PM
Be honest, how drunk were you when you wrote this?
- comeonnowguys - Jun 21, 2013 at 1:51 PM
Cocaine is a hell of a drug.
- ryanw822 - Jun 21, 2013 at 1:14 AM
All b/c its an off day doesnt mean you have to write some horrible filler article about the series. Sometimes less is more. And in this case, doing nothing would have been more.
You dont have to worry about us forgetting that the Cup Final is going on because of a 2-day break.
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text:
Mario Sounds
For us every day Mario fanatics the classic Super Mario Sounds will always hold a special place in our hearts. A lot of these downloads are in their original midi format and sound exactly like they do in the game!
In this collection there is Mario background music as well as sound effects such as Jumping, shooting fireballs etc. If you have a Mario sound that isn't listed here please get in contact with us!
Nes Sounds
Super Nes Sounds
Nintendo 64 Sounds
Nintendo Gamecube Mario Sounds
Nintendo Wii Mario Sounds
November 24, 2014
8 awesome Super Mario World Facts!
November 17, 2014
Mario 64 facts, easter eggs and cut content bits!
December 5, 2013
The importance of casinos in 007: Legends on the Wii
©2006 - 2014 mariomayhem.com
We are in no way affiliated with Nintendo, Nintendo of America, or any other mentioned companies. Super Mario Bros. , character names and all Mario Sprites are copyrights of Nintendo Co. Ltd.


text:
Their result for The Revised R you addicted to sex Test ...
Congratulations! You scored ###%!
Their Analysis (Vertical line = Average)
They scored 19% on sexpoints, higher than 3% of your peers.
All possible test results
Not Sexual
You are not very sexual. Your to embarised to do diffrent things. Read more
Likes Sex
You like sex. You've had sex but not as much as you probobly want to. Probobly havn't tried everything you wanted to though. Read more
Very into Sex
You love sex and willing to do anything. You've did just about anything. Probobly willing to do just anything to have sex now arn't you? Read more
Tests others are taking
Shoelace3618 / m / Straight
The Sex With Your Best Friend Test
meeeeekathecat26 / f / Straight
darryl864 / m / Gay
Topsy-Turvical48 / m / Straight
dtotin53 / m / Straight
More tests we think you'll like
Taken 2118 times.
The PROGRESSIVE ROCK music Test
Hi! And welcome to my Progressive Rock music Test. I'll be using advanced logic and knowledge to determine if this music appeals to your tastes and yo...
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The How 'L Word' Are You? Test
Do you watch Showtime's Hit Series "The L Word". Of course you do. How into this show are you? Let's find out!
Taken 216 times.
The SANRIO/HELLO KITTY KNOWLEDGE Test
Hi! And welcome to my SANRIO/HELLO KITTY KNOWLEDGE Test. I'll be using advanced logic and knowledge to determine how well you know your Sanrio charac...
Taken 25884 times.
The Sexuality Test
Gals and guys often fantasise about sex with the same gender...even if they dont admit it:) So, do you?
Taken 55070 times.
The Are you gay bi or straight? Test
This is the ultimate and most accurate test one could ever take in this area. This test is for boys, but if you're a girl and you feel you REALLY want...
Taken 5173 times.
The would you take me out in public Test
Hi! And welcome to my would you take me out in public Test. I'll be using advanced logic and knowledge to determine your true nature. ...yep, I'm too ...
Taken 17654 times.
The Which DOORS song are you? Test
Find out which Doors song comes closest to describing the real you
Taken 1525 times.
The Dog Facts Test
This is my first test and it contains 50 questions of various facts about dogs. Each question is scored 2 points so there is a possible 100 points. ...
Taken 3570 times.
The Sidekick One Question Test
The world is divided into leaders and sidekicks. You are no leader or you wouldn't be here taking tests, instead you'd be starting a war, like a good responsible leader should. So let's see which...
Taken 26633 times.
The Which Wife are You Test
This test is to show which kind of wife you are, or will be (if that is your thing). Remember to answer honestly, otherwise any future spouses out th...
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text:
With little children, it is obvious that we need to act as their prefrontal cortex because we know that they aren't capable of inhibiting their impulses. We keep them close when we're near the street and make sure not to leave sweets sitting around where they will have trouble resisting them.
Before I correct my kids, I have to ask myself if what they said is only bothering me because it's the truth.
Plenty of good parenting happens by instinct, and instinct is essential in parenting. But that's when I realized that not all of the parenting instincts we have are the parenting instincts we want to have.
Children who feel liked, cherished and enjoyed want to behave well because they naturally want to please us. When they sense tension between their parents, or have no tools for managing frustration, their behavior can take a turn for the worse.
You are your child's ally, the one who will chart the course for her development. Therefore, it is important to guide her toward positive solutions.
Why is it OK to be openly clueless"as a parent, but not openly confident? Is it all a backlash against Tiger Moms and Helicopter Parents? Whatever the case, it seems that it is not acceptable to openly strive for competence in the most important role that we will ever have.
Anyone can tell you that discipline is a messy business. Not even the best of parents could possibly get it right all the time. However, part of what complicates the process of teaching our kids to behave is that parents bring a lot of their own baggage to the table.
Moving towards our kids is so important -- even more so in those moments when we feel it's the last thing we want to do.
With the December 1 trial date tentatively set for Minnesota Vikings running back Adrian Peterson for charges of reckless or negligent injury towards his 4-year-old son when he whipped him with a switch last May, child discipline will again be part of the national conversation. When does punishment go too far?
Do you have an overly active, creative brain? Do you struggle to focus on any one thing long enough to get traction to take the idea to its fullest potential? This can be a serious problem that at best is exhausting and at worst is paralyzing.
People like Bill O'Reilly call upon people to raise themselves up while helping keep a foot on their necks.
I started treating him like my buddy rather than a nuisance. I gave him the responsibility that he deserved, was capable of and wanted. I stopped pushing him to the side in the chaos of everyday life and slowed down to spend time with him.
Coming as close as we did to losing our marriage, we learned to truly care for and appreciate each other to a degree that we may not have experienced otherwise.
I'm learning how to weather these changing seasons as a parent. I'm not a new mom, I'm not really even a veteran mom. But, I'm becoming the mom my children need today.
Most children would rather learn -- often through play -- than eat. It doesn't take much food, or time, to fill a 4-year-old's belly. So if you want her to be more involved in what happens at the dinner table, try to make it more welcoming.
Since I'd snapped at her, we decided I should get a timeout. I congratulated myself on the creative parenting while she paused at the door. Her eyes were wet. "I won't close it," she said. "I don't want you to be scared."


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Azarenka Press Conference
Azarenka Press Conference
November 26: The Daily Zap
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Azarenka Press Conference
Victoria Azarenka talks about defeating Maria Sharapova in the semifinals at Day 12 from the 2012 U.S. Open tennis championships.
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November 26: The Daily Zap
Recap all the action from a 13-game night in the NBA.
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November 26: Top 10
Count down the very best plays from an action packed 13-game Wednesday night in the NBA.
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Nightly Notable: Tyson Chandler
Tyson Chandler set season highs with 17 points and 25 rebounds.
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Grizzlies vs. Lakers
Marc Gasol (19 points, 11 rebounds) leads the Grizzlies to a 99-93 victory over the Lakers
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Jabari Parker End of Game
Jabari Parker congratulates his teammatesa after their ninth win of the season.
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Soda Springs Condos
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Up to the Misty Mountains
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We've been camping on the fringe of town and it's starting to get cold. It's expected to get as low as -15 degrees by the end of the week which should be interesting!
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A drive through the high country.
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Originally published Wednesday, August 8, 2012 at 1:34 PM
IRS discouraged fraud detection in ID program
The Internal Revenue Service has been looking the other way instead of rooting out fraud when people apply for taxpayer identification numbers, Treasury Department investigators said Wednesday, exposing a shortfall with both financial and national security implications.
Associated Press
The Internal Revenue Service has been looking the other way instead of rooting out fraud when people apply for taxpayer identification numbers, Treasury Department investigators said Wednesday, exposing a shortfall with both financial and national security implications.
A member of Congress who sits on the House's tax-writing committee responded to the report by calling on IRS Commissioner Douglas Shulman to resign, claiming the IRS is helping illegal immigrants defraud the government.
Non-citizens without Social Security numbers have to get ID numbers from the IRS to claim tax refunds. Their applications for ID numbers are processed at an IRS center in Austin, Texas.
J. Russell George, the Treasury Department's inspector general for tax administration, said investigators looking into the application process found "an environment which discourages employees from detecting fraudulent applications."
Instead, IRS employees were encouraged to process as many ID applications as possible, George said in his report. In addition, investigators learned that the IRS had quit using successful fraud-detection measures in processing the applications.
"There is a potential that erroneous tax refunds are going to non-qualifying individuals, allowing them to defraud the federal government of billions of dollars," investigators wrote in the report.
Once ID numbers are obtained fraudulently, they can be used for other deceptions. When first introduced in 1996, the ID numbers were supposed to be used only for taxes. But investigators found they're now being used in several states to get driver's licenses.
Almost 3 million tax returns seeking $6.8 billion were filed last year using IRS ID numbers rather than Social Security numbers. Investigators said they couldn't put a number on how many of those returns may have been fraudulent.
At issue are the documentation requirements for verifying the identity of those who apply for an ID number. Unlike applications for a passport or a Social Security number, applicants for the ID number weren't required to submit certified copies of their birth certificate or other identification.
IRS managers had been aware of the problem since at least 2002, but failed to take sufficient action, investigators said. Tax examiners at the agency also complained to investigators they had little to no training in how to root out fraudulent applications.
IRS officials responding to the report said they already had taken action to address the problem. In June, the agency started requiring original or certified documents until new rules can be developed for 2013.
"Our leadership moved quickly and aggressively to address issues that were identified," IRS spokeswoman Michelle Eldridge said.
Treasury investigators said the IRS has agreed to adopt seven of their nine recommendations for correcting the problem and is still considering the other two.
In a letter to Shulman calling for his resignation, Rep. Sam Johnson, R-Texas, cited investigators' findings that people sought $4.2 billion in refundable child tax credits last year using IRS ID numbers.
"The commissioner and certain IRS officials are essentially aiding and abetting illegal immigrants and others in fraudulently receiving tax refunds courtesy of the American taxpayer," Johnson said in a statement.
IRS officials declined to comment on Johnson's letter.
Follow Josh Lederman on Twitter at http://twitter.com/joshledermanAP
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Tracey Edmonds
Legendary songwriter Babyface. Iconic comedian Eddie Murphy. Hall of Fame football GOD Deion Sanders. If there's anyone qualified to write the official Gold Digger Bible, it's Tracey Edmonds.
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My wife and I went to Dubai a few years back (March 2002) and we had a good time there (check out the trip report on http://gardkarlsen.com/dubai.htm ). The other day I talked to a guy who had lived in Dubai for for a year in 2002 and he said that he could hardly recognize the place when he returned in 2005. I see that they have been building like crazy over the years so I guess a lot will change there.
But I have also gotten the impression that Dubai is becoming more of an expensive destination. Or is my impression totally wrong? Is Dubai still an affordable destination? When we went there is 2002 we stayed in Bur Dubai and we ate at many local places in town and we only went out to places like Jumeirah on day trips. I did find quite a lot of good offers in the malls and I came home with stuff like shoes, squash rackets...even a surround sound amplifier Is it still a shopping paradise?
http://gardkarlsen.com - trip reports and pictures
Is Dubai an affordable destination?
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I was fortunate enough to stay with friends during my November trip, so I can't comment on hotel prices. However, I found that most other expenses seemed pretty reasonable-souvenirs, meals dining out. As in other cities, there were a range of prices. Some foods in grocery stores were more expensive, but on the whole pretty decent. Some electronics were a great deal, like Ipods.
I would think that a trip sooner rather than later would be best-I can only see prices starting to climb as quickly as the construction is growing!
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Hotel prices have gone up but that is balanced in new places opening, Dubai is a major destination for shoppers ( bulk shopping ) from many places in Africa and that market does not go for high end hotel prices, so you can still find reasonable priced good accommodation. Eating out there are plenty of places to get snacks and one of th geat things is the variety of snacks and food you can get from alkl over the world.
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As a tourist coming to Dubai for a vacation for a week or so, it probably isn't any more expensive than anywhere else you would go after all that is what vacations are for right?
After living here for the last 12 years I can tell you everything is expensive, the traffic unbearable and depending on where you are staying, so is the noise of the constant construction.
If you can overlook all of that, Dubai is a beautiful place and definetly has changed since 2002. Heck, it's changed since 2005.
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Facebook app flaws create Trojan download risk
Grey-hat hacker Unu has discovered cross-site scripting vulnerabilities involving Facebook applications, of a type that might be used to distribute Trojan horse malware or launch other hacking attacks. The Romanian hacker - well known for identifying security flaws in the websites of banks, security firms and the UK parliament …
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What a coincidence
" developed by a former project engineer at Microsoft . . ."
Nuff said
Maybe it's just me...
...but this whole idea of giving the login details of one site to various other sites, just so you can play "does my bum look big in this?" or some other pointless waste of time, has always seemed like asking for trouble.
Failbook does it again
When will the sheeple ever learn?
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It's a holiday of hugs in Blue's Room! Open your arms to everyone you APPRECIATE in this Hug Day play date filled with dance, heart-art, stories, pretend, and of course, hugs!
Joe's Clues
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Blue, Joe and all their friends are celebrating the things that make them happy. Will you help Joe find Blue's Clues to figure out what makes Blue happy? You'll be happy you did!
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Click Here for Articles About Carly Rae Jepsen
VIDEO: Carly Rae Jepsen's New Single 'This Kiss'
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Below, check out the brand new music video by Carly Rae Jepsen performing This Kiss from School Boy/Interscope Records!
The single "This Kiss" has so far climbed to #86 on the Billboard Hot 100. "This Kiss" is also featured on the soundtrack to the film Fun Size released this past weekend and has also recently made it into the top 50 in national mainstream pop radio airplay.
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A Trip To The Berlin Wall Changed My Perspective – Bruce Rants
After standing where the Berlin Wall once stood I learned a lot about how walls of brick and stone are easier to topple than walls made of prejudice and hate.
After standing where the Berlin Wall once stood I learned a lot about how walls of brick and stone are easier to topple than walls made of prejudice and hate.
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There is something special and unique about the first Friday the 13th of the year. Make sure you are celebrating it in the right way.
Wouldn't it be great if we could change "the rules" so we could all win? We already do that now in youth sports and we're raising a generation of certificate holding crybabies. Sometime your best effort just isn't good enough, it's called life and the connections of California Chrome need to be remember the name of another famous horse and be " Real Quiet".
Will there be a triple crown winner in today's Belmont Stakes? Bruce tells you how the race will unfold.


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