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To address the biological role of vimentin in the context of the living organism, we have introduced a null mutation of the vimentin gene into the germ line of mice. Surprisingly, animals homozygous for this mutation developed and reproduced without an obvious phenotype. Immunoblotting, immunofluorescence, and immunogold labeling analysis confirmed the absence of vimentin and of the corresponding filament network. Furthermore, no compensatory expression of another intermediate filament could be demonstrated. While these results leave open the question of the possible role of vimentin in unusual situations or pathological conditions, they show that a conspicuous developmental and cell-specific structure that is an integral part of the cytoskeleton can be eliminated without apparent effect on mouse reproduction and development.
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Found the same room at a different price? Tell us, and we'll offer to match it.
Hotel Locanda Salieri
Locanda Salieri features cosy guest rooms with beautiful views, and a small garden where you can enjoy a typical, Italian breakfast. Wi-Fi is free in all rooms. All rooms come with private bathrooms with hairdryer, air conditioning, Tv, direct telephone, jack for Internet and Free Wifi connection.

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Posted by sammie on Monday, September 5, 2011 at 9:53pm.
and i need the answer fast :\
Sir Ralph Lane.
Although he never went to North America, I think Sir Walter Raleigh should be considered the founder.
Sammie -- it looks like you need to read your book to find out if it considers Ralph Lane or Walter Raleigh the founder of Roanoke Colony.
ok cause my U.S history book says someone else but the school books can be wrong, and thank you so much to both of you :-)
Ms.Sue~~ i reed the book like 5 times and says 2 names.... and they weren't those names
Use the person in your book. If you read the Wiki article I linked, there were many men who could be considered the founder. Raleigh financed it. Other men came on two or more voyages to lead the colony.
oh ok, well i will put your men and the men in my book... cause i won't get points off for that cause i don't know so i will talk to my teacher about it :-)
and this question is weird to me: how were colony financed?
It's not weird. It cost money to sail across the ocean and establish a colony.
From the Wikipedia article:
"On March 25, 1584, Queen Elizabeth I granted Sir Walter Raleigh a charter for the colonization of the area of North America known as Virginia. This charter specified that Raleigh had seven years in which to establish a settlement in North America, or lose his right to colonization.[1]:9 Raleigh and Elizabeth intended that the venture should provide riches from the New World and a base from which to send privateers on raids against the treasure fleets of Spain."
oh ok, its maybe how i read it thats maybe why :-)
and thank you so much for the help you have given me, and used your time to helped me understand my worksheet! :-)
i need pennfoster answer text 007678
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Dental-Implants-01.com |
Immediate Load ImplantsImmediate load implants or same day implants are the most modern and faster approach in implant placement. They were developed to satisfy the patients' demand for shorter times of implant treatments. With immediate load implants the tooth restoration, temporary or permanent, can be attached (loaded) on the implant in the same day immediately after the implant is placed in the jawbone. Benefits of Immediate Load Implants | Same Day Implants
Traditional implant procedure is a two-stage process. The implant is placed during the first surgical procedure followed by several months of healing period, waiting for the implant to integrate with the jawbone. Then the implant is uncovered during a second surgical procedure, the abutment is placed on the implant and finally the restoration is cemented on the abutment. Immediate load implants made possible a single-stage surgery, eliminating the waiting osseointegration period and the second surgery. Dental implants have become a more patient-friendly treatment with the introduction of immediate load / same day implants. How immediate load implants workThe osseointegration process, meaning the bonding of implant to the jawbone, remains important also for immediate load implants. Research has shown that the osseointegration process is disturbed by the micro-movements of the implant inside the jawbone. For this reason dentists avoided to put any pressure (load) on the implant for several months in order to avoid these micro-movements that could cause problems to the integration in the bone. Another important factor is the amount of force put on the bone from the implant. When the implant is 'screwed' in the bone must not be loose but should also be not too tight to damage the bone. Immediate load implants were made possible when implant technology managed to control these factors. New techniques such as Teeth-in-an-hour that make use of radiographic CT-scans and computer 3D-imaging technologies allowed dentists to achieve implant placement with excellent precision. Special torque wrenches allow dentists to measure the amount of torque put on the implants at the time of placement. By using modern techniques the implant can be placed in healthy jawbone under ideal conditions that enable proper osseointegration even if the implant is under load. Restrictions of immediate load implantsImmediate load implants are recommended only for patients with healthy jawbone and excellent dental and general health. Immediate load implants are not suitable if there is any condition that could interfere with the osseointegration process. These include:
Some immediate load implants manufacturers provide specific treatment protocols that have to be followed. These protocols are very specific about when and how an implant can be immediately loaded successfully. Mini dental implants for immediate loadingIf the implants are going to be used for denture stabilization, a popular immediate load implant option are the mini dental implants. Main implants are narrower diameter implants that come in 1 piece (the abutment is already embedded in the body of the implant). They can be used for retaining the denture immediately after placement. Instant implants / Immediate implantsNormally an implant is placed in the position of an already lost tooth after the area has healed. Instant implants refer to a technique where a tooth is extracted and an implant is placed in the socket immediately after the extraction. The benefit is that with immediate implant placement the jawbone loss around the area of the extraction is prevented. Instant implants are an option only when the jawbone is healthy and there is no infection or inflammation in the area. With instant implants the patient can replace a doomed tooth with an implant and a crown in the same appointment, without having to live with the gap of a missing tooth not for a single day.
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Great minds think alike! I wrote my comments about pitching for the Texas Rangers in "Cheney defends Gitmo prison, torture…" before I read your article! How interesting is that?
Keep up the great work!
Charlie Couser
Go to Admin » Appearance » Widgets » and move Gabfire Widget: Social into that MastheadOverlay zone
Like all of you, I've watched the video of the shoe throwing incident several times. I have to say that I am totally impressed with the reflexes demonstrated by President Bush as he ducked twice to avoid the shoes flying not more than five inches over his head. The accuracy of the Iraqi journalist who pitched the shoes makes him a likely candidate to be recruited by the Texas Rangers. Can you imagine what a hurler he'd be throwing a ball instead of a shoe, and what an embarrassment to George Bush he'd be if he was a star on the team he used to own?
I know nothing about the intricacies of Iraqi shoe throwing technique, but certainly in this case our fast-shoe pitcher misjudged the strike zone by not anticipating the lightening fast double ducking by our nimble president.
If he'd aimed for the chest he would have hit him squarely in the noggin. My guess is the flying shoes probably zoomed across the room at between 20 and 30 mph.
A size 10 brogan could certainly do some damage.
The history and meaning of Arab shoe throwing is described on Wikipedia where the Bush incident is already memorialized:
In the Arab world, shoe flinging is a gesture of extreme disrespect. A notable occurrence of this gesture happened in Baghdad, Iraq in 2003. When U.S. forces pulled down a giant statue of Saddam Hussein during the 2003 invasion of Iraq, many Iraqi detractors of Hussein threw their shoes at the fallen statue.
This may be an ancient gesture from the Middle East; Psalms 60:8, speaking of some of the traditional enemies of Judah, says that "Moab is my washpot; over Edom will I cast out my shoe…."
The shoe represents the lowest part of the body (the foot) and displaying or throwing a shoe at someone or something in Arab cultures denotes that the person or thing is "beneath them." Showing the bottom of one's feet or shoes (for example, putting one's feet up on a table or desk) in Arab cultures is considered an extreme insult. Examples include Iraqi citizens smacking torn-down posters of Saddam Hussein with their shoes, and the depiction of President of the United States George H. W. Bush on a tile mosaic of the floor of the Al-Rashid Hotel's lobby, forcing all visitors entering the hotel to walk on Bush's face to enter the hotel.
During President George W. Bush's surprise visit to Iraq in December 2008, an Iraqi journalist threw his shoes at Bush during a press conference with Iraqi Prime Minister Nouri Kamel al-Maliki. President Bush later told reporters that he did not feel the incident was a "big deal" and that it "did not represent the Iraqi media as a whole." Reference
And we don't even know what the journalist deliberately stepped in before the news conference.
* IMages from Wikipedia Commons.
Hal Brown is a clinical social worker and former mental health center director who is mostly retired from his private psychotherapy practice. He writes on the psychopathology of public figures and other topics that pique his interest. He can be found online at www.stressline.com . He also publishes a website about his hometown of Middleboro, Massachusetts (aka Middleborough) called Middleboro Matters. Archive: of previous columns.
Read "additional for rules and guidelines for commenting on this column.
Great minds think alike! I wrote my comments about pitching for the Texas Rangers in "Cheney defends Gitmo prison, torture…" before I read your article! How interesting is that?
Keep up the great work!
Charlie Couser
As I said in another post on this site: Let's send that Iraqi shoe-thrower some shoes in appreciation. Maybe next time he won't miss. The idiot-in-chief doesn't even have the brains to know when he's been deeply insulted, and has no empathy for the people (both in the USA and Iraq) he's decimated. I hope there WAS dung on the shoes. Hopefully it splattered. I swear I'd spit at the idiot's feet if I ran into him.
It'll be an endless source of low humor.
Was the this reporter the sole hit-man, or were there others shoe-horned into the press box?
Should the reporter have stuck to his last at Bush's last Iraqi press conference?
Should his SS detail be given the boot for their slow response?
Was the reporter really being a heel to act that way? Couldn't he have quietly let out a giant sneaker?
Shouldn't they have shoed-away the press after the incident?
If the shoe fits, dodge it!
Doubtlessly the conspiracy buffs will rush to report that Frame 234 of the Zapbush video shows the President's brain splattered by the second shoe…which then magically ends up stuck in the Iraqi PM's left ear…while a pristine shoe was recovered from behind the grassy podium…and that experts have demonstrated that it is impossible for one thrower to make two well-aimed throws with a size 10 Mannlicher-Gucci in the time claimed.
Etc., etc., ad nauseam.
Most sincerely,
T. J. Flapsaddle
The President was lucky it wasn't a weapon. It could be a precursor to an actual attack to judge how the Secret Service would react. Does this make me a conspiracy buff or is it a practical analysis based on caution and safety?
It will probably be one of the last times Bush speaks outside of military bases.
Bush came into office in a hail of bottles, tomatoes, and eggs. Seems he'll leave in a hail of shoes. Is that an upgrade?
Damn sloppy response on the part of the Secret Service detail, to say the least!
I certainly hope Mr. Obama's SS detail is paying more attention.
Most sincerely,
T. J. Flapsaddle
Normal nimble
Clearly there was no pre-meditation. A spontaneous act of fury.
Watch Bush's eyes. He sees the raised shoe and ducks. Thrower makes same mistake second time, same result.
Just normal nimble.
Cashel Boylo
If you think about it, it's more proof Bush's macho image is a media lie. He ducked instead of using an arm to catch or deflect the shoe. This means his flight response is stronger than his fight response, making him more likely to run from a fight like a coward. Sure it's a stretch.
If you look at the video of the second shoe, it appeared to score a direct hit on the American Flag. Just a thought guys.
Maybe Bush shouldn't have ducked!
Bush protect the flag and what it should stand for?
It also seemed that the Iraqi prime minister Nuri Kamal al-Maliki reacted by trying to protect Bush by batting the second shoe away.
Jay Leno was joking last night that if the Iraqi journalist who threw the shoe is released from jail, MSNBC will have a job waiting for him.
If Bush were macho – the macho cowboy he pretends to be – he'd have caught a shoe and thrown it back!
Bush used to own a baseball team, the Texas Rangers. Not only that, he throws the first pitch every season.
If Bush knew anything about Arab cultures, he'd have done a counter insult by laughing and telling the reporter "you throw like a girl."


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Creamy Tomato-Basil Pasta with Shrimp
From strgzr2001 Report abuse
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Serves: 4
Yields: servings (2 cups each)
Total Time: 25 min
Prep Time: 15 min
Cook Time: 10 min
U.S. | Metric | Conversion chart |
- 3 cup(s) Farfalle (bow-tie pasta), uncooked
- 1/4 cup(s) KRAFT Sun-Dried Tomato Dressing, divided
- 1 pound(s) uncooked peeled deveined medium shrimp
- 1 cup(s) Fat-free reduced-sodium chicken broth
- 1/2 teaspoon(s) garlic powder
- 1/2 teaspoon(s) black pepper
- 4 ounce(s) (1/2 of 8-oz. pkg.) PHILADELPHIA Neufchatel Cheese, cubed
- 2 cup(s) Grape Tomatoes
- 1/2 cup(s) KRAFT Shredded Parmesan Cheese
- 8 piece(s) Fresh basil leaves, cut into strips
- COOK pasta as directed on package. Meanwhile, heat 2 Tbsp. dressing in large skillet on medium heat. Add shrimp; cook and stir 2 to 3 min. or until shrimp turn pink. Use slotted spoon to remove shrimp from skillet; cover to keep warm. Descard any drippings in skillet.
- ADD remaining dressing, broth and seasonings to skillet; cook 2 min. or until heated through. Add Neufchatel; cook and stir 2 to 3 min. or until melted. Stir in tomatoes; cook 1 min.
- DRAIN pasta. Add to ingredients in skillet. Stir in parmesan and half the basil; top with shrimp and remaining basil.
- Serving suggestion
Serve with a crisp mixed green salad tossed with you favorite dressing.
How to Purchase and Store Raw Shrimp Fresh shrimp should be firm, moist and translucent and should smell like the sea. Avoid those with black spots and any trace of ammonia odor. They can vary in color from grayish-green to pinkish-tan to light pink. Place in a bowl (if wrapped in plastic, punch a few holes in the plastic) and store in the coldest part of the refrigerator up to 1 day. How to Slice Large-Leafed Fresh Herbs Slice large-leafed herbs such as basil and mint, into thin strips by stacking several leaves on top of one another. Roll the stack lengthwise into a cylinder. Using a sharp knife, cut the cylinder crosswise to form fine shreds. This cut is called chiffonade. Be sure to use a sharp knife - a dull knife will bruise the leaves while cutting.
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For Kids by Kids
For Kids by Kids
Anne Farb
Director of Sales & Marketing
Developed for Kids, by Kids, Hyatt Regency Greenwich, New, Healthier Menu Offers
Fun, Fresh and Flavorful items
GREENWICH, CT (JULY 17, 2012) – The Hyatt Regency Greenwich today announced the launch of a new, innovative menu, "For Kids By Kids," which provides more nutritious, fresh and interactive offerings for children. The menu is grounded in Hyatt's industry-leading philosophy Food. Thoughtfully Sourced. Carefully Served. – promoting healthy people, a healthy planet and healthy communities – and has been developed in association with the Partnership for a Healthier America (PHA). As part of the roll out, separate from the PHA commitment, Hyatt Regency Greenwich will also offer a three- course organic menu for children developed exclusively by renowned food pioneer and chef, Alice Waters.
The "For Kids By Kids" menu was tasted, tested and approved by kids, including 11-year-old cooking enthusiast Haile Thomas, who is spearheading a campaign for healthy eating through her online cooking show, Kids Can Cook. Hyatt's food and beverage team worked with Haile and her peers to ensure offerings on the menu not only meet the brand's standards for nutrition and quality, but are also fun. Through their research, Hyatt learned that kids today have a greater level of sophistication in their taste preferences, but also enjoy items with which they can interact. To that end, new menu offerings will present a creative way for kids to engage with their food, such as customizing their own pasta dish and "shaking" their own salad.
With their new "For Kids By Kids" menu, Hyatt is making children's health a priority and strives to make the healthy choice, the easy choice for guests. Sample items from the new Hyatt Hyatt Morristown at Headquarters Plaza "For Kids By Kids," menu include:
- Breakfast: Top Your Own Taco, a whole wheat tortilla filled with scrambled eggs, cheese and fun toppings; Waffle Dipping Sticks with peanut butter, maple syrup and fruit sauces.
- Lunch: Shaken Chopped Salad with roasted chicken, vegetables, brown rice and yogurt basil dressing; Build Your Own Whole Wheat Sub Sandwich with turkey, lettuce, tomato, cheese on a whole wheat mini-sub. (These offerings are also available during dinner hours).
- Dinner: Natural Beef grilled and served with potatoes, roasted vegetables and garden salad; Vegetable and Sesame Rice Noodles with marinated tofu, corn, green beans, basil and cherry tomatoes.
Additionally, the menu developed by Alice Waters features a full organic meal offering including a salad, chicken entrée and a dessert. Another unique feature is that for children who prefer to choose the same meal as their parents, they have the option of ordering a half portion off the regular menu at half the price.
"We have made an industry-leading commitment to serving food and beverages that are good for our people, our planet and our communities. That is why we have transformed our children's menu and looked to experts such as Alice Waters, to help guide our offerings," said Shaheyrar Adil, General Manager at the Hyatt Regency Greenwich. "We look forward to welcoming our youngest guests to try our new "For Kids By Kids" menu."
"For Kids By Kids" further illustrates Hyatt's commitment to Partnership for a Healthier America, which will hold Hyatt accountable for continuously improving the nutritional profile of food menus at full-service managed Hyatt properties across the U.S. over the next ten years. Through this commitment, Hyatt's "For Kids By Kids" will offer fruits and vegetables as the default side item, make low-fat milk available with free refills, meet the most recent U.S. Dietary Guidelines for Americans, My Plate and PHA's standards and ensure food illustrations depict healthier options.
To add another layer of fun to mealtime, Hyatt will launch HyattFlavorJourney in September where kids and parents can learn more about "For Kids By Kids" and enjoy games and activities. Guests can use a QR code on their menu to link to the site.
Hyatt Regency Greenwich
1800 East Putnam Avenue
Greenwich, CT 06870
(203) 637-1234
Forward-Looking Statements
Forward-Looking Statements in this press release, which are not historical facts, are forward-looking statements within the meaning of the Private Securities Litigation Reform Act of 1995. These statements include statements about our plans, strategies, occupancy and ADR trends, market share, the number of properties we expect to open in the future, our expected capital expenditures, depreciation and amortization expense, interest expense and effective tax rate, estimates, financial performance, prospects or future events and involve known and unknown risks that are difficult to predict. As a result, our actual results, performance or achievements may differ materially from those expressed or implied by these forward-looking statements. In some cases, you can identify forward-looking statements by the use of words such as "may," "could," "expect," "intend," "plan," "seek," "anticipate," "believe," "estimate," "predict," "potential," "continue," "likely," "will," "would" and variations of these terms and similar expressions, or the negative of these terms or similar expressions. Such forward-looking statements are necessarily based upon estimates and assumptions that, while considered reasonable by us and our management, are inherently uncertain. Factors that may cause actual results to differ materially from current expectations include, among others, general economic uncertainty in key global markets, the rate and pace of economic recovery following economic downturns; levels of spending in business an leisure segments as well as consumer confidence; declines in occupancy and average daily rate; our ability to successfully execute and implement our organizational realignment and the costs associated with such organizational realignment; loss of key personnel, including as a result of our organizational realignment; hostilities, including future terrorist attacks, or fear of hostilities that affect travel; travel-related accidents; changes in the tastes and preferences of our customers; relationships with associates and labor unions and changes in labor law; the financial condition of, and our relationships with, third-party property owners, franchisees and hospitality venture partners; if our third-party owners, franchisees or development partners are unable to access the capital necessary to fund current operations or implement our plans for growth; risk associated with potential acquisitions and dispositions and the introduction of new brand concepts; changes in the competitive environment in our industry and the markets where we operate; outcomes of legal proceedings; changes in federal, state, local or foreign tax law; foreign exchange rate fluctuations or currency restructurings; general volatility of the capital markets; our ability to access the capital markets; and other risks discussed in the Company's filings with the U.S. Securities and Exchange Commission, including our Annual Report on Form 10-K, which filings are available from the SEC. We caution you not to place undue reliance on any forward-looking statements, which are made as of the date of this press release. We undertake no obligation to update publicly any of these forward-looking statements to reflect actual results, new information or future events, changes in assumptions or changes in other factors affecting forward-looking statements, except to the extent required by applicable laws. If we update one or more forward-looking statements, no inference should be drawn that we will make additional updates with respect to those or other forward-looking statements
Make a Reservation
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text:
Renault R26 - rear-end detail 28 February 2006
With the reduced cooling needs of the new V8, the R26 has narrower sidepods than its predecessor. It features wider flip-ups and gone are the R25's distinctive venting gills. The winglet (magnified) now has its supporting pillar (1) connected to its inner edge rather than centrally mounted as last year. This is to remove the pillar from the path of airflow passing towards the flip-up. The exhaust position (2) is much closer to the engine, with the exit now rearward, rather than outward, facing. The rear wing uses a central, inclined supporting pillar (3) and the main profile is now lower at its extremities than in the centre (4). Another tiny change is the endplates on the flip-ups (5) which are now no more than a small, vertical lip, reducing the drag generated by this element.


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How to Work a Room, Revised Edition: Your Essential Guide to Savvy Socializing
Harper Paperbacks | 2007 | ISBN: 0061238678 | 336 pages | PDF | 1,5 MB
This is the fully revised and updated edition of the ground–breaking self–help book on improving communicating and socializing skills in business and life. How To Work A Room lays down the fundamentals for savvy socializing, whether at a party, a conference, or even communicating online. RoAne clearly shows how to overcome the five roadblocks that keep most people from making new contacts; mix chutzpah and charm to start and end conversations smoothly; know when to use humor––and when not to; and follow simple rules of etiquette. Incorporating years of feedback from hundreds of presentations, as well as anecdotes from around the globe, RoAne keeps How To Work A Room fresh and on target. New chapters include: strategies starting, maintaining, and exiting conservations; and advice on commutating effectively in today's tech driven world
[Fast Download] How to Work a Room, Revised Edition: Your Essential Guide to Savvy Socializing
Getting St Done: The Art of Feeling Good about Doing Nothing, Faster
Krankenversicherung: Zahlen, Daten, Fakten. Gesetzlich und privat, Versicher
101 Fallen auf dem Weg zur eigenen Immobilie
How to Use Twitter for Business
International Business, Sustainability and Corporate Social Responsibility
Organisatorische Gestaltung in der Post Merger Integration
Management Teams: Why they succeed or fail, Third Edition
The Frontiers of Project Management Research
Lords of Finance: The Bankers Who Broke the World
Central Banks in the Age of the Euro: Europeanization, Convergence, and Powe
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How To Write A Business Plan, 7 Edition(2339)
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Business Plans Handbook, vol.22(1959)
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50 Best Jobs for Your Personality(1713)
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Creating a Portfolio like Warren Buffett(1696)
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Risk and Portfolio Analysis: Principles (1616)
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"Interview Secrets Exposed" by Gavin F. (1377)
The Intelligent Investor: The Definitive(21887)
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text:
Local Settings Environment Variable??My question is this, i am making an app portable that leaves its appdata in the !if "${REDIRECTUSERPROFILE}" = "TRUE" IfFileExists "$DATADIR\UserProfile\*.*" +2 CreateDirectory "$DATADIR\UserProfile" ; create directory for portable user profile System::Call 'Kernel32::SetEnvironmentVariableA(t, t) i("USERPROFILE", "$DATADIR\UserProfile").r0' ; set new user profile folder StrCmp "$0" "0" ProfileError Goto ProfileDone ProfileError: MessageBox MB_ICONEXCLAMATION|MB_OK "Can't set environment variable for new Userprofile!$\nLauncher will be terminated." Abort ProfileDone: !endif
Oh yeah the environment variable for local settings is this i think "%userprofile%\local settings\application data" is there another one? and how would i add this to my script to get it to save in my "data" folder? ( categories: )
What's the full path ofWhat's the full path of where your files end up? In the root of C:\ or some subfolder? It ends up in a folder...it ends up in a folder in the C:\Ares, instead of it being put in my "data\ares" folder. An eye for an eye makes the whole world blind. Not sure. It sounds likeNot sure. It sounds like it's checking for the existence of %userprofile%\Application Data\ or %userprofile%\Local Settings\Application Data\, and if it doesn't exist it's defaulting to C:\Ares. Try creating $DATADIR\UserProfile\Application Data\ or $DATADIR\UserProfile\Local Settings\Application Data\ Alright ill try those and tell u how it goesill try those in a bit and tell u if they work. An eye for an eye makes the whole world blind. Nope they didnt workI dont know but everything i try doesnt work. Im gonna check my script and make sure i didnt make an error or something. An eye for an eye makes the whole world blind. |


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Event Details
Date(s) & Time(s)::
June 8, 2013 at 7:30 PM until 9:30 PM
Location: Unitarian Church, 5310 Old Mill Rd. Fort Wayne, IN 46807
Phone: 260-744-1867
Email: email@example.com
Link: http://www.uufortwayne.org
Event Description
The Dave Latchaw Trio will explore through collective improvisation several jazz standards such as All the Things You Are, Autumn Leaves, Green Dolphin Street and more.
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House Architecture Rifa G'07 / Villalba, Rudolph, Vila, López, Canén, Apolant, Martinez
Architects: Leandro Villalba, Nicolás Rudolph, Omar Vila, Joaquín López, Pablo Canén, Patrick Apolant, Sebastián Martinez
Location: Punta del Este, Uruguay
Area: 168.0 sqm
Year: 2014
Photographs: Nicolás Rudolph, Courtesy of Pablo Canén y Joaquín López
Rifa House / Andrés Varela Cruces + Elías Martínez Ojeda + Ignacio de Souza López + Joaquín Mascheroni Fleitas
Architects: Andrés Varela Cruces + Elías Martínez Ojeda + Ignacio de Souza López + Joaquín Mascheroni Fleitas
Location: Montevideo, Uruguay
Architects Consultant Team: Arq Alvaro Gentini, Arq Fernando García Amen
Area: 215 sqm
Year: 2013
Photographs: Elías Martinez Ojeda
Rovira House / Marcelo Daglio
Architects: Marcelo Daglio
Location: Punta del Este, Uruguay
Area: 332.0 m2
Year: 2010
Photographs: Trucco – Tricanico
Oil Factory / Marcelo Daglio Arquitectos
Architects: Marcelo Daglio Arquitectos
Location: Maldonado, Uruguay
Collaborators: Pablo Jaime, Ariel Sosa
Constructor: Pedro Baubeta
Landscaper: Roberto Mulieri
Area: 514.0 sqm
Year: 2012
Photographs: Courtesy of Marcelo Daglio Arquitectos, Carli Angenscheidt
La Pedrera Block House / Gualano + Gualano Arquitectos
Architects: Gualano + Gualano Arquitectos
Location: La Pedrera, Uruguay
Project Area: 96 sqm
Photographs: Courtesy of Marcelo Gualano
Parador Penitente / gualano + gualano arquitectos
Architects: gualano + gualano arquitectos – Marcelo Guanlano, Martín Gualano
Location: Lavalleja, Uruguay
Project Area: 400 sqm
Photographs: Courtesy of gualano + gualano arquitectos
Ibiray House / Oreggioni Prieto
Architects: Oreggioni Prieto
Location: Punta Carretas, Montevideo, Uruguay
Project Team: Lucho Oreggioni, Sonia Prieto, Fernanda Ríos
Project Area: 172 sqm
Project Year: 2010
Photographs: Leonardo Finotti
Marabajo / Nicolás Campodonico
Architects: Nicolás Campodonico
Location: La Pedrera 27004, Uruguay
Area: 415.0 sqm
Year: 2006
Photographs: Gustavo Sosa Pinilla, Nicolas Campodonico
La Solana Stable / Nicolas Pinto da Mota
Architects: Nicolas Pinto da Mota
Location: Soriano, Uruguay
Associated Architect: Victoria Maria, Falcón
Design Team: Matías Cosenza, Tadeo Itzcovich, Agustín Aguirre
Project Area: 240 sqm
Project Year: 2013
Photographs: Eduardo Moras
Mystic Hill / FDS Arquitectos
Architects: FDS Arquitectos
Location: Lavalleja, Uruguay
Architect In Charge: Facundo de Souza, Matias Keuroglian
Year: 2012
Photographs: Jose Pampin
Schandy House / Gualano + Gualano: Arquitectos
Architects: Gualano + Gualano: Arquitectos
Location: Montevideo, Uruguay
Site Management: Nicolás Percovich
Structures: Alberto Catañy
Project Area: 450 sqm
Project Year: 2012
Photographs: Elías Martínez
Buenos Mares House / RDR Arquitectos
Architects: RDR Arquitectos
Location: José Ignacio, Uruguay
Team: Ignacio Dahl Rocha, Bruno Emmer, Susana Barra, Nicolas Adrien, Ovidio Lagos
Area: 900.0 m2
Year: 2009
Photography: Cristóbal Palma / Estudio Palma
House Booth / Marcelo Daglio Arquitectos
Architects: Marcelo Daglio Arquitectos
Location: Punta Ballena, Maldonado, Uruguay
Architect In Charge: Marcelo Daglio
Collaborators: Jimena Cáceres, Pedro Baubeta
Landscape Planner: Elena Artagaveytia
Area: 360 sqm
Year: 2009
Photographs: Courtesy of Marcelo Daglio Arquitectos
Venice Biennale 2012: Panavision / Uruguay Pavilion
Panavision, the Uruguay exhibit for the 13th Venice Biennale, features the works of the new generation of Uruguayan architects, using their Pavilions as a common ground, a place rather than an exhibit, where the focuses, approaches, tools, worries, emphasis and strategies of these practices converge. More details from the curators after the break:
Venice Biennale 2012: Uruguayan pavilion presents 'Panavision'
Uruguay has been invited to be one of the Latin American countries participating in the 2012 Venice Biennale. Located in a former warehouse of the Biennale, which has belonged to the Uruguayan State since 1960, the Uruguayan pavilion will present their curatorial proposal, Panavision – an exhibition that will feature six diverse and emergent Uruguayan practices that will not exhibit their work, but rather their practices as a way to spark a discussion on contemporary Uruguayan architectural agenda.
The practices representing the young generation of architects for the 2012 Uruguayan pavilion are the following:
Outdoor Food Court In Centenario Town / Jaf Architecture + Design
Architects: Jaf Architecture + Design
Location: Centenario, Uruguay
Client: Municipality of Durazno
Project Year: 2012
Project Area: 99.0 sqm
Photographs: Javier Villasuso Multimedia
Vivace Music Brings World Class WSDG Studio to Uruguay
Vivace Music, an elegant, high-end recording studio, has debuted in the heart of Montevideo, the ¨Switzerland¨ of Latin America. Acoustically superb, and aesthetically unique, studio details are highlighted by rare wood elements such as doors, window trim, flooring and custom furniture built with recycled wood acquired from ancient wooden casks originally used for the leather tanning industry, (one the multiple activities of studio co-owner Luis Cesio). Designed by Walters-Storyk Design Group to accommodate the full spectrum of Latin, jazz, pop, rock and world music production, Vivace establishes a new standard of high-quality audio production for South America. More images and their description after the break.
UY House / Estudio Joselevich & Ana Rascovsky
Architects: Estudio Joselevich & Ana Rascovsky
Location: José Ignacio, Uruguay
Completion: 2011
Area: 590 sqm
Collaborators: Fernanda Torres, Tamara Caplan Estudio Joselevich
Photographers: Courtesy of Estudio Joselevich & Ana Rascovsky


text:
A House Not Meant to Stand
A House Not Meant to Stand
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A House Not Meant to Stand
is the last play written by
Tennessee Williams
Tennessee Williams
Thomas Lanier "Tennessee" Williams III was an American writer who worked principally as a playwright in the American theater. He also wrote short stories, novels, poetry, essays, screenplays and a volume of memoirs...
. It was produced during the 1981–82 season at the
Goodman Theatre
Goodman Theatre
The Goodman Theatre is a professional theater company located in Chicago's Loop. A major part of Chicago theatre, it is the city's oldest currently active nonprofit theater organization...
Chicago is the largest city in the US state of Illinois. With nearly 2.7 million residents, it is the most populous city in the Midwestern United States and the third most populous in the US, after New York City and Los Angeles...
Gregory Mosher
Gregory Mosher
Gregory Mosher is a long time director and producer of stage productions – at the Lincoln Center and Goodman Theatres, on and off-Broadway, at the Royal National Theatre, and in the West End. He is also a film and television director, producer, and writer...
and published for the first time in 2008 by New Directions. with a foreword by
Gregory Mosher
Gregory Mosher
Gregory Mosher is a long time director and producer of stage productions – at the Lincoln Center and Goodman Theatres, on and off-Broadway, at the Royal National Theatre, and in the West End. He is also a film and television director, producer, and writer...
and an Introduction by Thomas Keith.
A Gothic Comedy
, the play is set during the Christmas holiday in the deteriorating
Pascagoula, Mississippi
Pascagoula, Mississippi
Pascagoula is a city in Jackson County, Mississippi, United States. It is the principal city of the Pascagoula, Mississippi Metropolitan Statistical Area, as a part of the Gulfport–Biloxi–Pascagoula, Mississippi Combined Statistical Area. The population was 26,200 at the 2000 census...
house of Cornelius and Bella McCorkle, who have just buried their eldest son, a gay man Cornelius banished from the home years earlier. During a raging storm, heavy drinker Cornelius, who once had political aspirations, tries to get Bella, who suffers from mild dementia, to disclose where she concealed the considerable amount of money she inherited from her grandfather, who accumulated his wealth by making and selling
Moonshine is an illegally produced distilled beverage...
. When she refuses to cooperate, her husband threatens to have her institutionalized, just as he did their daughter Joanie. Coming to her rescue is their negligent youngest son Charlie, who has returned home with his zealously religious pregnant fiancée Stacey in tow.
The play is derived from a one-act titled
Some Problems for the Moose Lodge
(published in 2011 in
The Magic Tower & Other One-Act Plays
) that was staged—together with
A Perfect Analysis Given by a Parrot
The Frosted Glass Coffin
—under the umbrella title
Tennessee Laughs
by the Goodman Theatre in 1980. Director Gary Tucker and Goodman artistic director Gregory Mosher urged Williams to expand it into a full-length play. The playwright returned to his home in
Key West
Key West
Key West is an island in the Straits of Florida on the North American continent at the southernmost tip of the Florida Keys. Key West is home to the southernmost point in the Continental United States; the island is about from Cuba....
and began working on what was now called
A House Not Meant to Stand
, a title suggested by a production assistant on
Tennessee Laughs
. Williams called it a "Southern Gothic spook sonata," a deliberate reference to an
August Strindberg
August Strindberg
Johan August Strindberg was a Swedish playwright, novelist, poet, essayist and painter. A prolific writer who often drew directly on his personal experience, Strindberg's career spanned four decades, during which time he wrote over 60 plays and more than 30 works of fiction, autobiography,...
play known as
The Ghost Sonata
The Ghost Sonata
The Ghost Sonata is a play in three acts by Swedish playwright August Strindberg. Written in 1907, it was first produced at Strindberg's Intimate Theatre in Stockholm on January 21, 1908. Since then, it has been staged by such notable directors as Max Reinhardt, Olof Molander, Roger Blin, and...
in its English translation. The crumbling house was a
A metaphor is a literary figure of speech that uses an image, story or tangible thing to represent a less tangible thing or some intangible quality or idea; e.g., "Her eyes were glistening jewels." Metaphor may also be used for any rhetorical figures of speech that achieve their effects via...
for contemporary society, while the characters were drawn from the Williams family, notably his father Cornelius, his aunt Belle, his paternal grandfather, and his brother Dakin. The play opened in late April 1982 at the Goodman, where it did respectable business through the end of May.
Time (magazine)
Time is an American news magazine. A European edition is published from London. Time Europe covers the Middle East, Africa and, since 2003, Latin America. An Asian edition is based in Hong Kong...
, calling it "a rich collection of scarred characters," said it was the best play Williams had written in a decade.


text:
Northwest Paddle Surfers is your source for Everything SUP (Stand Up Paddle) in the Pacific Northwest! Register for SUP lessons, tours, and rentals at one of our Greater Seattle waterfront locations. We are located in Kirkland on Lake Washington at both Juanita Beach Park and Marina Park. At Juanita Beach Park, we have kayaks as well. There you can also try PaddleFlow™ Yoga. We also have rentals within Lake Chelan State Park in North Central Washington. Check out our Events Calendar for a thorough list of races, expos, and demo days in the Puget Sound region and beyond. Check out our Online Store for the latest NWPS apparel and accessories.
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itracMEDIA Selected as Official Supplier of Marketing CRM Software Solutions for Drees Homes
"America's Best Builder" embraces innovative marketing channels to strengthen leadership position
TORONTO, ONTARIO--(Marketwire - Oct. 28, 2008) - itracMEDIA, a leading developer of email marketing software and CRM technology, has been selected as official supplier of marketing CRM software solutions used by Online Sales Counsellors with Drees Homes, "2008 America's Best Builder" as recognized by Builder Magazine.
"We conducted a thorough assessment of CRM software solutions within the real estate marketing industry and itracMEDIA is hands-down the best solution available," said Aaron C. Tackett, National Sales Director, M.I.R.M., C.S.P. "Their technology is superior and they have a proven success ratio. Our Online Sales Counsellors are really excited about the opportunity to use their product."
A Toronto-based marketing CRM software company, itracMEDIA's innovative technology is relied on by over 45 of North America's top developers, comprising almost 250 separate development projects. Specializing in real estate e-marketing, itracMEDIA's email marketing CRM software enables developers to captures leads, identify hot prospects and conduct lead scoring while saving time and boosting overall sales.
"We're ecstatic to be working with market leader Drees Homes to help boost their CRM requirements," said Justin Parker, itracMEDIA's co-founder and Managing Partner. "It was a rigorous selection process; they are extremely methodical when selecting a best-of-breed partner and we are honoured itracMEDIA is their e-marketing company of choice."
Each of Dress Homes' ongoing developments now has its own website. Through user sign-in on the website, itracMEDIA's technology tracks a potential buyer's site usage, monitoring which pages are viewed, how long they are on the site, the number of times that person returns and much more. itracMEDIA then transforms this information into a unique lead scoring system that provides proven insight into top-line prospects.
"In the end, Drees Homes' decision came down to our outstanding lead scoring analytics," explained itracMEDIA's Justin Parker. "Our software has enabled their Online Sales Counsellors to focus on key leads and conversion prospects. Real estate is a highly competitive and challenging industry, and Drees Homes has continued to succeed in spite of current market conditions. This partnership provides them with another tool to make them even more competitive in the future."
itracMEDIA Inc. is a leading developer of email marketing CRM software that helps generate lead scoring and conversion. Their solutions help increase web traffic; deliver targeted, automated e-marketing messages; track prospect behaviour, activity and interest; maximize traffic conversion; and measure campaign results.
Headquartered in Fort Mitchell, Kentucky, Drees Homes is prolific developer of new homes throughout the United States. Recently named "2008 America's Best Builder" by Builder Magazine, they were bestowed this award thanks to their operational stability, excellence in design and construction, customer satisfaction and community service.
For more information, please contact
itracMEDIAJustin Parker
Managing Partner
(416) 364-9444
Email: email@example.com
Website: www.itracmedia.com


text:
Cincinnati leads 2-1 (as of 8/21)
Game 1: Monday, August 19 | ||
Arizona | 3 | Final |
Cincinnati | 5 | |
Recap »Boxscore » |
Game 2: Tuesday, August 20 | ||
Arizona | 5 | Final |
Cincinnati | 2 | |
Recap »Boxscore » |
Game 3: Wednesday, August 21 | ||
Arizona | 7 | Final |
Cincinnati | 10 | |
Recap »Boxscore » |
Game 4: Thursday, August 22 | ||
Arizona | 1 | Final |
Cincinnati | 2 | |
Recap »Boxscore » |
Diamondbacks 7
(65-60, 29-34 away)
Reds 10
(72-55, 39-21 home)
Coverage: FSOH
7:10 PM ET, August 21, 2013
Great American Ball Park, Cincinnati, Ohio
CINCINNATI -- Shin-Soo Choo got the Reds offense going early and they opened up a big lead.
They needed every bit of it against the Diamondbacks.
Choo went 4-for-5 with a homer and three RBIs to spark Cincinnati's offensive outburst in a 10-7 win over Arizona on Wednesday.
The Reds opened an 8-0 lead through four innings, but had to hold on tight at the end.
"It was the epitome of a full moon," Reds manager Dusty Baker said. "We were riding easy 8-0, then all the sudden it was 8-4. A lot of stuff happened. Those guys (Diamondbacks) didn't give up.
The Reds opened up a six-game lead over Arizona in the race for the National League's second wild-card spot.
Cincinnati remained third in the NL Central, but moved to 2 1/2 games behind first-place Pittsburgh, which lost at San Diego.
Mike Leake allowed four runs in the fifth inning, but was dominant in his other five innings for first win in his past five starts.
Leake (11-5) allowed six hits and four runs with no walks and three strikeouts while the Reds were building an 8-0 lead.
"I was mixing and matching and keeping them off balance," Leake said. "Two pitches got me. Sometimes that happens. Fortunately, we had an eight run lead. It ended up being a stressful game."
The Diamondbacks added three runs against the Cincinnati bullpen before Aroldis Chapman finished for his 32nd save and first career two-inning save.
Baker was forced to take Jonathan Broxton out of the game in the eighth inning with soreness in his elbow. Broxton spent five weeks on the disabled list, returning on Aug. 6.
"It was disheartening to go get Broxton," said Baker, who went to his closer Chapman an inning early. "I went out with (pitching coach) Bryan Price. BP said, `He's done."
The umpire asked Baker, whom he wanted and he indicated that he wanted Chapman. That answer prevented Baker from making a double-switch with the pitcher's spot due up third in the bottom of the eighth.
"That's the first time I've ever experienced something like that," Baker said. "I was so worried about Broxton."
Todd Frazier and Brandon Phillips added RBI singles in the eighth, giving the Reds their highest run total since winning 11-0 at San Francisco on July 22.
Frazier fought off a tough pitch and had a hit that landed out of the reach of shortstop Didi Gregorius.
"It was an ugly swing with good results," Baker said.
Frazier was as surprised as anyone the ball fell for a hit.
"It's crazy," Frazier said. "I was talking to (Wil) Nieves at the plate about what a game it was. We were laughing at each other. It's humbling. It's weird. It's confusing at times.
"No matter what you get a W at the end, you're happy. I don't know what I was doing man. I was confused. He (Brad Ziegler) has a nasty slider. It started two feet behind me and I thought that's going to come back in. I kind of jumped out of the way. My body did its own thing and away it went."
Choo hit Brandon McCarthy's second pitch of the game 337 feet down the left field line, where the ball appeared to hit the lens of a TV camera just inside the foul pole.
The homer was Choo's 16th of the season, his sixth leadoff homer of the season and 11th of his career.
The Reds had four straight two-out hits to open up a 4-0 lead in the second. Leake lofted a ground-rule double down the right field line that bounced into the netting above the visitor's bullpen to drive in one run, and Choo drove in two more with a single to center.
Chris Heisey added an RBI double and Devin Mesoraco made it 7-0 with a two-run single up the middle through a drawn-in Arizona infield to knock McCarthy (2-8) out of the game after a season-low 2 1/3 innings.
He allowed eight hits and a season-high seven runs with one walk and two strikeouts while slipping to 0-5 in his past seven starts.
Choo narrowly missed hitting his second home run of the game leading off the fourth inning, settling for a double off the top of the left field wall and scoring on Joey Votto's single.
The Diamondbacks broke through against Leake with four runs in the fifth. Pinch-hitter Jason Kubel delivered a two-run single and Adam Eaton followed on Leake's next pitch with his second homer of the season, a 367-foot drive into the visitors' bullpen.
Prado added a run-scoring single off J.J. Hoover in the seventh and Gerardo Parro led off the eighth with his ninth homer, a fly ball off Jonathan Broxton that hit the top of the left field wall and bounced back onto the field before the umpires ruled it a homer after a 3:02 replay delay.
"We played our tails off," Arizona manager Kirk Gibson said of his offense. "They did a heck of a job."
Chapman pitched more than one inning for the first time this year. He also struck out in his first major league at-bat.
"He has to work on his bunting," Baker said. "We let him swing away. He's a good athlete. He can swing the bat and is probably one of our fastest players. We hoped that he would hit one in the gap so people could see it."
Game notes
Chapman struck out in the eighth in his first career plate appearance. ... Broxton, who missed almost two months this season with an elbow injury, walked off the field with a Reds trainer after facing two batters in the eighth. ... Cincinnati LHP Tony Cingrani is scheduled to make his regular start on Sunday despite leaving Tuesday's game in the fourth inning with a lower back strain. ... Reds RHP Johnny Cueto, who's on his third stint on the disabled list with a strained muscle behind his right shoulder, played catch Wednesday, the first time he's thrown since going on the DL on June 29. ... RHP Trevor Cahill (4-10), who snapped a six-game losing streak with a win in Pittsburgh in his previous start, is Arizona's scheduled starter in Thursday's series finale against RHP Mat Latos (12-4).
Photo Wire
CINCINNATI, OH - AUGUST 21: Mike Leake #44 of the Cincinnati Reds pitches against the Arizona Diamondbacks during...
(Photo by Joe Robbins/Getty Images)Regular Season Series
Scoring Summary
1st | S Choo homered to left (346 feet). | 0 | 1 | |
2nd | M Leake hit a ground rule double to deep right, D Mesoraco scored, Z Cozart to third. | 0 | 2 | |
2nd | S Choo singled to center, Z Cozart and M Leake scored. | 0 | 4 | |
3rd | C Heisey doubled to deep left, B Phillips scored, J Bruce to third. | 0 | 5 | |
3rd | D Mesoraco singled to center, J Bruce and C Heisey scored. | 0 | 7 | |
4th | J Votto singled to center, S Choo scored. | 0 | 8 | |
5th | J Kubel singled to right, W Nieves and A Pollock scored. | 2 | 8 | |
5th | A Eaton homered to right (378 feet), J Kubel scored. | 4 | 8 | |
7th | M Prado singled to center, T Campana scored, A Eaton to third. | 5 | 8 | |
8th | G Parra homered to left (379 feet). | 6 | 8 | |
8th | M Davidson grounded into fielder's choice to shortstop, D Gregorius out at second, W Nieves to third, W Nieves scored, M Davidson to second on throwing error by second baseman B Phillips. | 7 | 8 | |
8th | T Frazier singled to center, Z Cozart scored, S Choo to second. | 7 | 9 | |
8th | B Phillips reached on infield single to shortstop, S Choo scored, T Frazier to third, J Votto to second. | 7 | 10 | |
View complete Play-By-Play |
Game Information
Stadium | Great American Ball Park, Cincinnati, OH |
Attendance | 23,297 (55.1% full) - % is based on regular season capacity |
Game Time | 3:46 |
Weather | 83 degrees, partly cloudy |
Wind | 5 mph |
Umpires | Home Plate - Chris Conroy, First Base - Will Little, Second Base - Gary Darling, Third Base - Jerry Meals |
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text:
Ozzie Guillen says Mark Buehrle truly is an ace despite an underwhelming fastball.
Mark Buehrle, Chicago White Sox vs. Tampa Bay, 5-0, July 23, 2009.
Left-handed pitcher Mark Buehrle was 13-9 with a 3.59 ERA for the White Sox in 2011.
Following a perfect game in his last start against the Tampa Bay Rays, Chicago White Sox pitcher Mark Buehrle threw five perfect innings against the Twins in Minneapolis and retired the first 17 batters to set a major league record with 45 outs in a row.
But in the sixth, Buehrle walked Alexi Casilla to end his streak. He was charged with five runs in Chicago's 5-3 loss.


text:
MP 2.03.07 | Cytoreductive Surgery and Perioperative Intraperitoneal Chemotherapy for the Treatment of Pseudomyxoma Peritonei, Peritoneal Carcinomatosis of Gastrointestinal Origin, and Peritoneal Mesothelioma |
Medical Policy | ||
Section Medicine |
Original Policy Date 6/27/05 |
Last Review Status/Date Reviewed with literature search/10:2012 |
Issue 10:2012 |
Return to Medical Policy Index |
Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract. Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage. Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.
Peritoneal carcinomatosis from non-ovarian malignancies has long been regarded as a terminal disease with limited survival. In an attempt to prolong survival, aggressive locoregional therapy, such as combining cytoreductive surgery with perioperative intraperitoneal chemotherapy, has been used.
Pseudomyxoma peritonei
Pseudomyxoma peritonei is a clinicopathologic entity characterized by the production of mucinous ascites and mostly originates from epithelial neoplasms of the appendix. As the tumor grows, the narrow lumen of the appendix becomes obstructed and subsequently leads to appendiceal perforation. The neoplastic cells progressively colonize the peritoneal cavity and copious mucin production builds up in the peritoneal cavity. Appendix tumors causing pseudomyxoma peritonei range from a benign pathologic appearance (disseminated peritoneal adenomucinosis) to malignant pathologic findings (peritoneal mucinous carcinomatosis), with some intermediate pathologic grades. Clinically, this syndrome ranges from early pseudomyxoma peritonei, fortuitously discovered on imaging or during a laparotomy performed for another reason, to advanced cases with a distended abdomen, bowel obstruction, and starvation. The conventional treatment of pseudomyxoma peritonei is surgical debulking repeated as necessary to alleviate pressure effects. However, repeated debulking surgeries become ever more difficult due to progressively thickened intra-abdominal adhesions, and this treatment is palliative, leaving visible or occult disease in the peritoneal cavity. (1)
Colorectal cancer and peritoneal carcinomatosis
Peritoneal dissemination develops in approximately 10–15% of patients with colon cancer, and despite the use of increasingly effective regimens of chemotherapy and biologic agents in the treatment of advanced disease, peritoneal metastases are associated with a median survival of 6 to 7 months.
Malignant mesothelioma is a relatively uncommon malignancy that may arise from the mesothelial cells lining the pleura, peritoneum, pericardium, and tunica vaginalis testis. In the U.S., 200-400 new cases of diffuse malignant peritoneal mesothelioma (DMPM) are registered every year, accounting for 10-30% of all-type mesothelioma. (2) DMPM has traditionally been considered as a rapidly lethal malignancy with limited and ineffective therapeutic options. (2) The disease is usually diagnosed at an advanced stage and is characterized by multiple variably sized nodules throughout the abdominal cavity. As the disease progresses, the nodules become confluent to form plaques, masses, or uniformly cover peritoneal surfaces. In most patients, death eventually occurs as a result of locoregional progression within the abdominal cavity. In historical case series, treatment by palliative surgery, systemic/intraperitoneal chemotherapy, and abdominal irradiation results in a median survival of approximately 12 months. (2)
Surgical cytoreduction in conjunction with hyperthermic intraperitoneal chemotherapy is designed to remove visible tumor deposits with intraperitoneal chemotherapy to address remaining microscopic disease. By delivering chemotherapy intraperitoneally, drug exposure to the peritoneal surface is increased some 20-fold compared to systemic exposure. In addition, prior animal and in vitro studies have suggested that the cytotoxicity of mitomycin C is enhanced at temperatures greater than 39 degrees Celsius.
Cytoreductive surgery (CRS) consists of peritonectomy procedures and multivisceral resections, depending on the extent of intra-abdominal tumor dissemination. (3) The surgical procedure may be followed intraoperatively by the infusion of hyperthermic chemotherapy, most commonly mitomycin C. Inflow and outflow catheters are placed in the abdominal cavity, along with temperature probes to monitor the temperature. The skin is then temporarily closed during the chemotherapy perfusion, which typically runs for 1 to 2 hours. This procedure is referred to as hyperthermic intraperitoneal chemotherapy (HIPEC). Other methods of intraperitoneal chemotherapy include early postoperative intraperitoneal chemotherapy (EPIC).
Cytoreductive surgery and perioperative intraperitoneal chemotherapy for the treatment of pseudomyxoma peritonei may be considered medically necessary.
Cytoreductive surgery and perioperative intraperitoneal chemotherapy for the treatment of diffuse malignant peritoneal mesothelioma may be considered medically necessary.
Cytoreductive surgery and perioperative intraperitoneal chemotherapy is considered investigational for peritoneal carcinomatosis from colorectal cancer.
Policy Guidelines
The coding for this overall procedure would likely involve codes for the surgery, the intraperitoneal chemotherapy, and the hyperthermia.
There is no specific CPT code for the surgical component of this complex procedure. It is likely that a series of CPT codes would be used describing exploratory laparotomies of various components of the abdominal cavity, in addition to specific codes for resection of visceral organs, depending on the extent of the carcinomatosis.
Intraperitoneal Chemotherapy
CPT code 96446 identifies "chemotherapy administration into the peritoneal cavity via indwelling port or catheter." When performed using a temporary catheter or performed intraoperatively, the unlisted code 96549 (unlisted chemotherapy procedure) would be reported.
CPT code 77605 identifies, "Hyperthermia, externally generated; deep."
Benefit Application
BlueCard/National Account Issues
Cytoreduction and intraperitoneal hyperthermic chemotherapy is a specialized procedure and may be offered at limited centers. Therefore, out of network referral may be requested.
Pseudomyxoma peritonei
A retrospective, multicenter cohort study evaluated the toxicity and prognostic factors after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) and/or early postoperative intraperitoneal chemotherapy (EPIC), for diffuse peritoneal disease from malignancies of multiple different histologic origins. (4) The study included 1,290 patients from 25 institutions who underwent 1,344 procedures between 1989 and 2007. HIPEC was performed in 1,154 procedures. Postoperative mortality was 4.1%. The principal origin of peritoneal carcinomatosis was pseudomyxoma peritonei in 301 patients. Exclusion criteria were perioperative chemotherapy performed greater than 7 days after surgery and the presence of extra-abdominal metastases. Median overall survival (OS) for patients with pseudomyxoma peritonei was not reached (median OS for all patients was 34 months).
Elias and colleagues report a large case series treating pseudomyxoma peritonei with CRS and intraperitoneal chemotherapy. (5) Their multicenter study included 301 patients treated between 1993 and 2007. Complete CRS was achieved in 219 patients (73%), and hyperthermic intraperitoneal chemotherapy was performed in 255 (85%). The primary tumor site was the appendix in 91% of patients, the ovary in 7%, and the origin was unknown in 2%. Tumor histology was disseminated peritoneal adenomucinosis in 51%, intermediate in 27%, and peritoneal mucinous carcinomatosis in 22%. Postoperative mortality was 4% and morbidity, 40%. Mean follow-up was 88 months. The 1-, 3-, and 5-year OS rates were 89.4%, 84.8%, and 72.6%, respectively. The 10-year survival rate was 54.8%. Median survival had not yet been reached but will be longer than 100 months. The disease-free survival (DFS) rate was 56% at 5 years, and the median duration of DFS was 78 months. A multivariate analysis identified 5 prognostic factors: the extent of peritoneal seeding (p=0.004), the center (p=0.0004), the pathologic grade (p=0.03), gender (p=0.02), and the use of hyperthermic intraperitoneal chemotherapy (p=0.04). When only the 206 patients with complete CRS were considered, the extent of peritoneal seeding was the only significant prognostic factor (p=0.004).
Vaira and colleagues report their experience managing pseudomyxoma peritonei with cytoreduction and hyperthermic intraperitoneal chemotherapy in a single institution in 60 patients, 53 of whom had final follow-up data. (6) The postoperative morbidity rate was 45%; no postoperative deaths were observed. The primary tumor was appendiceal adenocarcinoma in 72% of patients and appendiceal adenoma in 28%. Approximately one-half of the patients with adenocarcinoma had received previous systemic chemotherapy. Five- and 10-year OS were 94% and 85%, respectively, and 5- and 10-year DFS were 80% and 70%, respectively. Significant differences in improved OS were observed in patients who experienced complete surgical cytoreduction (p<0.003) and in those with histologic type disseminated peritoneal adenomucinosis versus those with peritoneal mucinous carcinomatosis (p<0.014).
Chua and colleagues report the long-term survival of 106 patients with pseudomyxoma peritonei treated between 1997 and 2008 with cytoreductive surgery and intraperitoneal chemotherapy. (7) Sixty-nine percent of patients had complete cytoreduction. Seventy-three patients had disseminated peritoneal adenomucinosis, 11 had peritoneal mucinous carcinomatosis, and 22 had mixed tumors. The mortality rate was 3% and the severe morbidity rate was 49%. The median follow-up was 23 months (range: 0–140 months). The overall median survival was 104 months with a 5-year survival rate of 75%. PFS was 40 months with 1-, 3-, and 5-year PFS rates of 71%, 51%, and 38%, respectively. Factors influencing survival included histopathologic type of tumor, with the best survival in patients with disseminated peritoneal adenomucinosis and the worst in patients with peritoneal mucinous carcinomatosis (p=0.002), and completeness of cytoreduction (p=0.002).
In 2008, Elias and colleagues reported the results of 105 consecutive patients with pseudomyxoma peritonei treated between 1994 and 2006 with CRS and hyperthermic intraperitoneal chemotherapy. (1) The primary tumor was the appendix in 93 patients, ovary in 3, urachus in 1, pancreas in 1, and indeterminate in 7. Tumor histology was disseminated peritoneal adenomucinosis in 48% of patients, intermediate in 35% and peritoneal mucinous carcinomatosis in 17%. At the end of surgery, 72% of patients had no visible residual peritoneal lesions. Postoperative mortality was 7.6% and morbidity, 67.6%. Median follow-up was 48 months, and 5-year OS and DFS were 80% (95% confidence interval [CI]: 68–88%) and 68% (95% CI: 55–79%), respectively. Two factors were identified on multivariate analysis that had a negative influence on DFS: a CA 19.9 level greater than 300 units/mL and nondisseminated peritoneal adenomucinosis tumor histology.
Yan and colleagues conducted a systematic review on the efficacy of CRS and intraperitoneal chemotherapy for all relevant studies from 1996 to 2006. (8) There were no randomized controlled trials (RCTs) or comparative studies. Ten studies were included (with a total of 863 patients) and were observational without control groups. Two of the studies had relatively long-term follow-up of 48 and 52 months, and the remaining studies had median follow-up times of less than 3 years (range: 19-35 months). Median survival across all studies ranged from 51 to 156 months. One-, 2-, 3-, and 5-year survival rates varied from 80–100%, 76–96%, 59–96%, and 52–96%, respectively. Overall mortality rates varied from 0-18% and morbidity from 33–56%.
Peritoneal carcinomatosis from colorectal cancer
Reviews from 2009 and 2010 (3, 9, 10) summarize the experience in the literature for treatment of colorectal peritoneal carcinomatosis with CRS and hyperthermic intraperitoneal chemotherapy (HIPEC), some of which is included in the section below. There has been an RCT with a second publication after 8 years of follow-up, (11, 12) one comparative study, (13) and numerous observational studies. Across studies, overall median survival after CRS and hyperthermic intraperitoneal chemotherapy in patients with peritoneal dissemination from colon cancer has ranged from 13 to 63 months (median: approximately 18 months). The study that showed 63 months survival (14) may be explained by the use of more contemporary chemotherapeutic regimens in the treatment of advanced stage colon cancer compared to prior studies in which previous standard therapy was used. (3) For comparison, published studies reporting the outcome after systemic treatment of metastatic colon cancer with polychemotherapy with or without biologic agents range from 14.8 months to 22.6 months (median: 19.2 months). (3)
A single institution study was undertaken that randomly assigned 105 patients with peritoneal carcinomatosis to receive standard treatment with systemic chemotherapy (fluorouracil and leucovorin) and palliative surgery, if necessary (i.e., treatment of bowel obstruction), or to a second arm consisting of aggressive cytoreduction and intraperitoneal chemotherapy followed by standard systemic chemotherapy. (12) Patients with other sites of metastases, i.e., lung or liver, were excluded. The cytoreductive procedure consisted of stripping the parietal peritoneum and resection of infiltrated viscera, if possible. Most often, resection of the gall bladder, parts of the stomach, and spleen were performed. The greater omentum was also routinely removed. At the completion of resection, the presence of residual tumor was assessed. Hyperthermic mitomycin C was then administered intraperitoneally for 90 minutes. The most important complications were small bowel leakage and abdominal sepsis, but a total of 24% of patients suffered from severe or life-threatening complications, such as heart failure, arrhythmias, or renal failure. A total of 8 patients (16%) died as the result of treatment at 30 days. The main endpoint was survival, measured from the time of randomization to death from any cause. After a median follow-up of 21.6 months, 20 of 51 patients in the standard therapy group were still alive compared to 30 of 54 patients in the cytoreduction group. Median survival in the control group was 12.6 months compared to 22.4 months in the cytoreduction group. Subgroup analysis revealed that survival was particularly poor among patients with either residual tumor measuring greater than 2.5 mm or in patients with tumor involvement in 6 or more regions in the abdomen. In these groups, median survival was only approximately 5 months, compared to 29 months in patients with no residual tumor.
An editorial on this randomized trial commented that while this study shows that CRS and HIPEC with systemic chemotherapy nearly doubles survival compared to systemic chemotherapy alone, it does not show how much of this benefit is derived from the surgery and how much from the HIPEC, (15) and in a letter to the editor, Markman points out that the reported survival benefit may be primarily related to the cytoreduction, with added chemotherapy only contributing to increased morbidity. (16) Finally, new targeted systemic treatment options have emerged for colon cancer, specifically cetuximab and bevacizumab, which offer additional palliative options for colon cancer, whereas the chemotherapy used in the randomized trial is no longer considered standard.
Aside from the issues of the trial methodology, the results of the trial present complicated risk benefit questions that are not adequately addressed. If the main rationale for CRS is to provide a curative option, data regarding disease recurrence would be important. It is not known whether the survivors in either group are alive with or without disease. If the main rationale for the therapy is palliation in terms of prolonging life or relieving specific symptoms (e.g., related to ascites or bowel obstruction), it is important to determine the quality of life associated with the 10-month improvement in median survival. Quality-of-life data were not reported in this randomized trial; however, the high incidence of major complications, and the reported mean length of hospitalization of 29 days suggest that this aggressive surgical approach has a significant impact on quality of life. Quality of life was addressed in a separate case series of 64 patients undergoing CRS and intraperitoneal chemotherapy. (17) The Functional Assessment of Cancer Therapy - Colon (FACT-C), activities of daily living, the brief pain inventory, and depression scales comprised the quality-of-life instruments used. A total of 48 patients completed the assessment prior to and at a mean of 12 days after surgery; 16 of the original 64 patients did not complete the survey either due to death (n=11) or missed appointments. By 6 months' follow-up, only 39 patients were available, either due to death or continuing dropout. Among the respondents, the overall quality of life decreased significantly from baseline to postsurgery but improved to greater than baseline at 3 months. However, these data are difficult to interpret without a control group and owing to the large number of dropouts due to death.
The randomized study (12) reported an 8-year follow-up of all patients still alive until 2007. (11) This update had a minimum follow-up of 6 years for all patients (median: 94 months; range: 72–115 months). During the follow-up, 1 patient crossed over from the standard arm to the hyperthermic intraperitoneal chemotherapy arm after recurrent disease at 30 months after randomization (the standard arm being systemic chemotherapy only and the hyperthermic intraperitoneal chemotherapy arm including systemic chemotherapy, CRS, and HIPEC). At the time of this long-term follow-up, in the standard arm, 4 patients were still alive, 2 with disease and 2 without disease, and in the HIPEC arm, 5 patients were still alive, 2 with disease and 3 without disease. Disease-specific survival was reported as 12.6 months in the standard arm and 22.2 months in the HIPEC arm (p=0.028), and progression-free survival (PFS) was 7.7 months in the standard arm and 12.6 months in the hyperthermic intraperitoneal chemotherapy arm (p=0.02).
A retrospective, multicenter cohort study evaluated the toxicity and prognostic factors after CRS and HIPEC and/or EPIC, for diffuse peritoneal disease from malignancies of multiple different histologic origins. (4) The study included 1,290 patients from 25 institutions who underwent 1,344 procedures between 1989 and 2007. HIPEC was performed in 1,154 procedures. Postoperative mortality was 4.1%. The principal origin of peritoneal carcinomatosis was colorectal adenocarcinoma in 523 patients. Exclusion criteria were perioperative chemotherapy performed greater than 7 days after surgery and the presence of extra-abdominal metastases. The overall median survival for patients with a colorectal primary was 30 months. Independent prognostic indicators in multivariate analysis were institution, histologic origin of the tumor, completeness of CRS, extent of carcinomatosis, and lymph node involvement.
Elias and colleagues compared 48 patients in the French Multicentric Database with peritoneal carcinomatosis arising from colon cancer who received palliative systemic oxaliplatin or irinotecan-based chemotherapy to 48 patients who underwent additional cytoreduction and HIPEC. (14) The chemotherapeutic regimen and the duration of systemic chemotherapy were comparable in both groups. The results showed a significant improvement of long-term survival after complete macroscopic cytoreduction followed by HIPEC compared to systemic treatment alone. The median survival was 23.9 months in the control group versus 62.7 months in the HIPEC group. The 5-year survival rates were 13% and 51%, respectively.
vanLeeuwen and colleagues reported on the experience in a Swedish series of 103 patients treated between 2003 and 2006. (18) This study was to explore factors associated with postoperative morbidity and survival. While postoperative mortality in this center was less than 1%, postoperative morbidity was 56%. Tumor type and optimal cytoreduction influenced survival. In this uncontrolled series, at 2 years, OS was estimated at 72% and DFS was 34%.
Glehen and colleagues reported on a retrospective multi-institutional case series involving 28 institutions and 506 patients. (19) The study population consisted of patients with peritoneal carcinomatosis related to colorectal cancer who underwent the procedure between 1987 and 2002. Patients with extra-abdominal metastases were excluded. A variety of protocols for intraperitoneal operative chemotherapy were used; mitomycin C was the most common. Some patients also received intraperitoneal chemotherapy in the early postoperative procedure, sometimes after a prior operative infusion. In the early postoperative setting, fluorouracil was most common. A total of 20 patients (4%) died postoperatively. Major complications occurred in 116 patients (22.9%); digestive fistula was the most common major complication, occurring in 8.3% of patients, and was the cause of death in the 7 of the 20 patients who died. At a mean follow-up of 53 months, the morbidity and mortality rates were 22.9% and 4%, respectively, with a median survival of 19.2 months. Subgroup analysis of outcomes based on the completeness of resection reported that patients with complete resection of macroscopic disease had a median survival of 32.4 months compared to only 8 months in those cases for which complete resection was not possible. The completeness of resection was the most significant prognostic indicator. The overall recurrence rate was 73.3%, with peritoneal recurrences noted in 41.9% of patients. The authors concluded that these results echoed those reported in small case series.
Peritoneal mesothelioma
A 2011 systematic review by Baratti and colleagues searched the PubMed literature from 1979-2010 for studies on the clinical management of diffuse malignant peritoneal mesothelioma (DMPM). (2) The review included 14 studies with a total of 427 patients; 289 of whom underwent CRS with HIPEC, EPIC in 2, or both in 106. Series that included patients with well-differentiated or low-grade types of mesothelioma were excluded. All of the included series were prospective non-randomized observational case-series studies without control groups. Mean patient age ranged from 49 to 55.7 years. All of the centers used peritonectomy procedures and multivisceral resections to remove all visible disease. HIPEC protocols varied widely among institutions in terms of technique, drugs, carriers, timing and temperature. Operative mortality and morbidity were reported in 11 mono-institutional series. Operative death rates ranged from 0% to 10.5%. Overall, it occurred in 11 of 373 assessable patients (3.1%). In a multi-institutional series, mortality was 2.2%. Severe and life-threatening complications were analyzed. Morbidity varied from 20 to 41%. For the patients who underwent CRS and HIPEC, median overall survival ranged from 29.5 to 92 months. It was not reached in 3 series, being longer than 100 months in one. The 1-, 2-, 3-, and 5-year overall survival rates varied from 43% to 88%, 43% to 77%, 43% to 70%, and 33% to 68%, respectively. In 4 series, median PFS ranged from 7.2 to 40 months.
The largest series in the systematic review was from an international registry study, for which 401 patients (99%) had complete follow-up. (20) Of the 401 patients, 92% received HIPEC. Reasons for not receiving HIPEC included EPIC being given instead, intraoperative hemodynamic instability, and reason unclear. The median and 1-, 3-, and 5-year survival were 53 months, 81%, 60%, and 47%, respectively.
The review acknowledges the possibility of patient selection bias as an explanation for the superior survival noted with aggressive treatment over more conventional treatment modalities, since patients with poor performance status are generally excluded from CRS and HIPEC. The authors conclude that, even in the absence of controlled data, the evidence suggests that the use of CRS and HIPEC in the treatment of DMPM should be the benchmark against which other treatments should be evaluated.
A retrospective, multicenter cohort study evaluated the toxicity and prognostic factors after CRS and HIPEC and/or EPIC, for diffuse peritoneal disease from malignancies of multiple different histologic origins. (4) The study included 1,290 patients from 25 institutions who underwent 1,344 procedures between 1989 and 2007. HIPEC was performed in 1,154 procedures. Postoperative mortality was 4.1%. Principal origin of tumor was peritoneal mesothelioma in 88 patients. Exclusion criteria were perioperative chemotherapy performed greater than 7 days after surgery and the presence of extra-abdominal metastases. Median survival for the patients with mesothelioma was 41 months. Independent prognostic indicators in multivariate analysis were institution, origin of peritoneal carcinomatosis, completeness of CRS, extent of carcinomatosis, and lymph node involvement.
National Comprehensive Cancer Network (NCCN) Guidelines and National Cancer Institute (NCI) Physician Query Database (PDQ)
NCCN clinical practice guidelines in oncology for colon cancer (v.1.2013) consider the treatment of disseminated carcinomatosis with cytoreductive surgery and perioperative hyperthermic intraperitoneal chemotherapy to be investigational and do not endorse such therapy outside of a clinical trial. (21)
NCCN guidelines that specifically address the treatment of appendiceal tumors, pseudomyxoma peritonei and peritoneal mesothelioma are not identified.
Two randomized Phase III trials were identified and are outlined in the following paragraphs.
A Phase III randomized study of systemic chemotherapy with versus without intraperitoneal chemohyperthermia in patients undergoing surgery for peritoneal carcinomatosis originating from colorectal cancer is of unknown status (NCT00769405). Primary outcome is OS. Secondary outcome measures include recurrence-free survival (RFS), treatment toxicity, morbidity from surgical complications, and prognostic factors of survival. Expected enrollment is 264, with a trial start date of February 2008.
A Phase III randomized pilot study of standard systemic therapy with versus without cytoreduction surgery and hyperthermic intraperitoneal mitomycin C in patients with advanced limited peritoneal dissemination of colon adenocarcinoma is ongoing. (NCT01167725) Primary outcome is OS. Secondary outcomes include PFS, quality of life, toxicity burden of these regimens, survival according to patient's peritoneal surface tumor genotype, and comparisons of circulating tumor cells in patients treated with these regimens. Expected enrollment is 340, and estimated primary completion date is May 2014.
Practice Guidelines and Position Statements
In 2007, the Society of Surgical Oncology issued a consensus statement on cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the management of peritoneal surface malignancies of colonic origin. (22) Their recommendation is that patients with peritoneal carcinomatosis without distant disease, in whom complete cytoreduction is possible, undergo hyperthermic intraperitoneal chemotherapy prior to systemic therapy. As of September 2012, an updated consensus statement has not been identified.
Pseudomyxoma peritonei
Several case studies and a systematic review on the use of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy have been published. Although no randomized trials or comparative studies have been published, the data have shown consistent, long-term DFS and OS with the use of this technique as compared to historic controls. Therefore, cytoreductive surgery and hyperthermic intraperitoneal chemotherapy may be considered medically necessary for this indication.
Peritoneal carcinomatosis from colorectal cancer
Numerous studies with different levels of evidence support the safety and feasibility of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy, and existing data suggest a possible improvement in long-term survival of select patients. However, prospective randomized trials are needed to compare best available systemic therapy with and without cytoreductive surgery and hyperthermic intraperitoneal chemotherapy to determine the exact effects of each step, which are currently unknown. An ongoing Phase III trial (NCT00769405) addresses this question of how much of the survival benefit is derived from the cytoreduction and how much from hyperthermic intraperitoneal chemotherapy, as patients will be randomly assigned to hyperthermic intraperitoneal chemotherapy or no hyperthermic intraperitoneal chemotherapy after complete cytoreductive surgery. Therefore, cytoreductive surgery and hyperthermic intraperitoneal chemotherapy is considered investigational for this indication.
Peritoneal mesothelioma
The conventional treatment of peritoneal mesothelioma (diffuse malignant type) has resulted in a median survival of approximately 12 months. Although the data on the use of cytoreductive surgery and perioperative intraperitoneal chemotherapy consists of non-randomized case series without control groups, they have shown a significant prolongation of survival ranging from 29.5 to 92 months. Therefore, cytoreductive surgery and hyperthermic intraperitoneal chemotherapy may be considered medically necessary for this indication.
- Elias D, Honore C, Ciuchendea R et al. Peritoneal pseudomyxoma: results of a systematic policy of complete cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Br J Surg 2008; 95(9):1164-71.
- Baratti D, Kusamura S, Deraco M. Diffuse malignant peritoneal mesothelioma: systematic review of clinical management and biological research. J Surg Oncol 2011; 103(8):822-31.
- Glockzin G, Ghali N, Lang SA et al. Results of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis from colorectal cancer. J Surg Oncol 2009; 100(4):306-10.
- Glehen O, Gilly FN, Boutitie F et al. Toward curative treatment of peritoneal carcinomatosis from nonovarian origin by cytoreductive surgery combined with perioperative intraperitoneal chemotherapy. Cancer 2010; 116(24):5608-18.
- Elias D, Gilly F, Quenet F et al. Pseudomyxoma peritonei: a French multicentric study of 301 patients treated with cytoreductive surgery and intraperitoneal chemotherapy. Eur J Surg Oncol 2010; 36(5):456-62.
- Vaira M, Cioppa T, de Marco G et al. Management of pseudomyxoma peritonei by cytoreduction + HIPEC (hyperthermic intraperitoneal chemotherapy): results analysis of a twelve-year experience. In Vivo 2009; 23(4):639-44.
- Chua TC, Yan TD, Smigielski ME et al. Long-term survival in patients with pseudomyxoma peritonei treated with cytoreductive surgery and perioperative intraperitoneal chemotherapy: 10 years of experience from a single institution. Ann Surg Oncol 2009; 16(7):1903-11.
- Yan TD, Black D, Savady R et al. A systematic review on the efficacy of cytoreductive surgery and perioperative intraperitoneal chemotherapy for pseudomyxoma peritonei. Ann Surg Oncol 2007; 14(2):484-92.
- Maggiori L, Elias D. Curative treatment of colorectal peritoneal carcinomatosis: current status and future trends. Eur J Surg Oncol 2010; 36(7):599-603.
- Rampone B, Schiavone B, Martino A et al. Current role of hyperthermic intraperitoneal chemotherapy in the treatment of peritoneal carcinomatosis from colorectal cancer. World J Gastroenterol 2010; 16(11):1299-302.
- Verwaal VJ, Bruin S, Boot H et al. 8-year follow-up of randomized trial: cytoreduction and hyperthermic intraperitoneal chemotherapy versus systemic chemotherapy in patients with peritoneal carcinomatosis of colorectal cancer. Ann Surg Oncol 2008; 5(9):2426-32.
- Verwaal VJ, van Ruth S, de Bree E et al. Randomized trial of cytoreduction and hyperthermic intraperitoneal chemotherapy versus systemic chemotherapy and palliative surgery in patients with peritoneal carcinomatosis of colorectal cancer. J Clin Oncol 2003; 21(20):3737-43.
- Mahteme H, Hansson J, Berglund A et al. Improved survival in patients with peritoneal metastases from colorectal cancer: a preliminary study. Br J Cancer 2004; 90(2):403-7.
- Elias D, Lefevre JH, Chevalier J et al. Complete cytoreductive surgery plus intraperitoneal chemohyperthermia with oxaliplatin for peritoneal carcinomatosis of colorectal origin. J Clin Oncol 2008; 27(5):681-5.
- Levine EA. The randomized trial of cytoreductive surgery with hyperthermic intraperitoneal chemoperfusion: what it does and does not tell us. Ann Surg Oncol 2008; 15(10):2633-5.
- Markman M. Intraperitoneal hyperthermic chemotherapy as treatment of peritoneal carcinomatosis of colorectal cancer. Letter to the editor. J Clin Oncol 2004; 22(8):1527.
- McQuellon RP, Loggie BW, Fleming RA et al. Quality of life after intraperitoneal hyperthermic chemotherapy (IPHC) for peritoneal carcinomatosis. Eur J Clin Oncol 2001; 27(1):65-73.
- van Leeuwen BL, Graf W, Pahlman L et al. Swedish experience with peritonectomy and HIPEC. HIPEC in peritoneal carcinomatosis. Ann Surg Oncol 2008; 15(3):745-53.
- Glehen O, Kwiatkowski F, Sugarbaker PH et al. Cytoreductive surgery combined with perioperative intraperitoneal chemotherapy for the management of peritoneal carcinomatosis from colorectal cancer: a multi-institutional study. J Clin Oncol 2004; 22(16):3284-92.
- Yan TD, Deraco M, Baratti D et al. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for malignant peritoneal mesothelioma: multi-institutional experience. J Clin Oncol 2009; 27(36):6237-42.
- National Comprehensive Cancer Network (NCCN). Colon cancer. 2013. Available online at: http://www.nccn.org/professionals/physician_gls/PDF/colon.pdf. Last accessed September, 2012.
- Esquivel J, Sticca R, Sugarbaker P et al. Cytoreductive surgery hyperthermic, intraperitoneal chemotherapy in the management of peritoneal surface malignancies of colonic origin a consensus statement. Society of Surgical Oncology. Ann Surg Oncol 2007; 14(1):128-33.
Codes |
Number |
Description |
See Policy Guidelines section |
197.6 |
Secondary malignant neoplasm of retroperitoneum and peritoneum |
ICD-9-CM Procedure | No specific code for cytoreductive surgery; coding would be based on what is excised. | |
99.85 | Hyperthermia for treatment of cancer | |
ICD-10-CM (effective 10/1/13) | C78.6 | Secondary malignant neoplasm of retroperitoneum and peritoneum |
ICD-10-PCS (effective 10/1/13) | No specific code for cytoreductive surgery; coding would be based on what is excised. | |
DWY38ZZ | Radiation oncology, anatomic regions, other radiation, abdomen, hyperhthermia | |
DWY68ZZ | Radiation oncology, anatomic regions, other radiation, pelvic region, hyperhthermia |
Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy
Hyperthermic Intraperitoneal Chemotherapy
Intraperitoneal Hyperthermic Chemotherapy
Policy History
Date |
Action |
Reason |
06/27/05 |
Add policy to Medicine section, Oncology subsection |
New policy |
04/17/07 | Replace Policy | Policy updated with literature search through February 2007; no changes in policy statement. Reference numbers 6–9 added |
06/12/08 | Replace policy |
Policy updated with literature search, reference numbers 10 and 11 added. Policy statement unchanged.
06/11/09 | Replace policy | Policy updated with literature search, reference numbers 11 through 13 added. Policy statement unchanged |
10/08/10 | Replace policy | Policy updated with literature search; Rationale and Background sections revised extensively. Policy statement added that cytoreduction and hyperthermic intraperitoneal chemotherapy for the treatment of pseudomyxoma peritonei may be considered medically necessary; investigational policy statement clarified to specify that the indication considered is peritoneal carcinomatosis from colorectal cancer. The term, "pseudomyxoma peritonei" was added to the policy title. References 1-8, 10-12, and 17 added; reference 18 updated |
10/04/11 | Replace policy | Policy updated with literature search. References 2, 4 and 20 added; references renumbered. Title changed to include peritoneal mesothelioma. Policy statement added that cytoreductive surgery and perioperative intraperitoneal chemotherapy for the treatment of peritoneal mesothelioma may be considered medically necessary. Use of the term "hyperthermic" changed to "perioperative" in the title and policy statements to include early postoperative intraperitoneal chemotherapy. Use of the term "cytoreduction" changed to "cytoreductive surgery" to be more specific. |
10/11/12 | Replace Policy | Policy updated with literature search. No references added. No change to policy statements. |