text:
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External Beam Radiation Therapy for Hepatocellular
Carcinoma: Potential of Intensity-Modulated and
Image-Guided Radiation Therapy
MARTIN FUSS,* BILL J. SALTER,*,‡TERENCE S. HERMAN,* and CHARLES R. THOMAS, Jr.*
*Department of Radiation Oncology, The University of Texas Health Science Center at San Antonio;‡and Cancer Therapy
and Research Center, San Antonio, Texas
External beam radiotherapy has historically played a minor
role in the primary treatment of hepatocellular carcinoma.
Although there is evidence for tumor response to external
beam radiotherapy and despite the fact that a radiation
dose–response relationship has been established, the
limited radiation tolerance of the adjacent normal liver
has prohibited wider use of radiation therapy in this
disease. Recent technological and conceptual develop-
ments in the field of radiation therapy—such as intensi-
ty-modulated radiation therapy, image-guided radiation
therapy, and stereotactic body radiation therapy—have
the potential to improve radiation treatments by con-
forming the delivered radiation dose distribution tightly
to the tumor or target volume outline while sparing
normal liver tissue from high-dose radiation. Image guid-
ance allows for a reduction of added (normal tissue)
safety margins designed to account for interfraction
patient and target setup variability, and stereotactic
targeting will further reduce residual target setup uncer-
tainty. Combining improvements in tumor targeting with
normal tissue sparing, radiation dose delivery will en-
able clinically effective and safe radiation delivery for
liver tumors such as hepatocellular carcinoma. This ar-
ticle reviews the role of radiotherapy for hepatocellular
carcinoma; presents modern radiation therapy modali-
ties and concepts such as intensity-modulated, image-
guided, and stereotactic body radiation therapy; and
hypothesizes about their future effect on primary treat-
ment alternatives.
noma (HCC) has been limited by the low radiation
tolerance of the surrounding liver. Radiation-induced
liver disease is commonly observed in patients treated
with doses of 30 to 35 Gy to the entire liver. However,
radiation doses required to achieve clinically relevant
local control rates range from approximately 50 Gy to
well in excess of 70 Gy for almost all solid tumors.
Whole-liver radiation for HCC with low radiation doses,
studied in cooperative group trials, has, consequently,
istorically, the use of external beam radiation ther-
apy for primary treatment of hepatocellular carci-
resulted in poor tumor control. As a result, radiation
therapy has been dismissed as a viable treatment alter-
native in the primary, curative treatment of HCC.
More recent clinical investigations indicate that a
partial volume of the liver can be irradiated with tumori-
cidal radiation doses if an adequate portion of normal
liver can be spared from high-dose exposure.1–4Techni-
cal means to accomplish such normal liver sparing re-
quire the use of so-called 3-dimensional conformal ra-
diotherapy techniques (3D-CRT). The most recent
software and hardware developments that further im-
prove on the concept of 3D-CRT include intensity-
modulated radiation therapy (IMRT) and image-guided
radiation therapy (IGRT). These new treatment modal-
ities for radiation therapy for HCC yield the promise of
delivering radiation doses that may allow the achieve-
ment of greater local tumor control while respecting the
acknowledged low radiation tolerance of the liver. These
developments, in turn, enable the development of new
treatment paradigms, such as stereotactic body radiation
therapy (SBRT), in which a single fraction or very few
fractions of radiation are delivered to confined target
volumes within the liver, with ablative intent.
This article reviews the critical issue of dose-limiting
radiation-induced liver toxicity, the established need for
high radiation doses to achieve local tumor control in
HCC, and the technical concepts of IMRT, IGRT, and
SBRT. We document the advantages of these new treat-
ment modalities and concepts by presenting representa-
tive cases of patients treated at the University of Texas
Abbreviations used in this paper: CT, computerized tomography;
D30, minimum dose that 30% of normal liver tissue is exposed to;
D50, minimum dose that 50% of normal liver tissue is exposed to;
3D-CRT, 3 dimensional-conformal radiotherapy techniques; HCC, he-
patocellular carcinoma; IGRT, image-guided radiation therapy; IMRT,
intensity-modulated radiation therapy; SBRT, stereotactic body radia-
tion therapy.
© 2004 by the American Gastroenterological Association
Page 2
Health Science Center at San Antonio/Cancer Therapy
and Research Center (San Antonio, TX).
Radiation-Induced Liver Disease
Radiation-induced liver disease, or radiation hep-
atitis, is a common subacute radiation-induced symptom
of liver toxicity. The onset of radiation-induced liver
disease is observed 2 weeks to several months after liver
radiation. The clinical syndrome is composed of hepato-
megaly, ascites, and increased serum alkaline phospha-
tase and aminotransferase levels without jaundice. His-
topathologically, the picture is dominated by veno-
occlusive disease. Because of a lack of sufficient treatment
options for radiation-induced liver disease, liver failure
and death can occur. The occurrence of radiation-induced
liver disease has been closely related to the radiation dose
to the whole liver, with probabilities of 5% to 10% after
doses of 30 to 35 Gy.1,5–7The risk increases to 50% after
whole-liver exposure of 40 to 50 Gy. After partial liver
radiation, the mean liver dose has also been associated
with radiation-induced liver disease, with no cases ob-
served after mean doses ?31 Gy. The 5% and 50%
probabilities for radiation-induced liver disease were es-
timated to correspond with mean liver doses of 31 and 43
Gy, respectively, when radiation was delivered in 1.5-Gy
fractions twice daily.2For more conventional fraction-
ation regimens of once-daily 2-Gy fractions, the corre-
sponding mean liver doses for a 5% probability of radi-
ation injury are approximately 28 Gy. Similarly, the
volume of liver exposed to high radiation doses is a
strong predictor for the probability of radiation-induced
liver disease.2,5,6,8If less than a third of the liver is
exposed, doses as high as 100 Gy may be safely deliv-
Livers harboring primary tumors show a higher sus-
ceptibility for development of radiation-induced liver
disease.1,9The diagnosis of HCC has been correlated with
a significantly increased risk of radiation-induced liver
disease, and the increase in risk has been associated with
preexisting liver cirrhosis or hepatitis.1
It should be noted that data for liver radiation toler-
ance are often derived from series of patients treated by
combined-modality regimens, predominantly those in-
volving intra-arterial chemotherapy in combination with
external beam radiation. Although prospective data re-
searching the effect of such combinations on the proba-
bility of radiation-induced liver disease are lacking, there
is clinical evidence that combining bromodeoxyuridine
with radiation may result in a higher risk for radiation
injury in some patient cohorts.1
Radiation Dose–Response
Relationship in Hepatocellular
In general, radiographic response rates of HCC to
modern partial liver external beam radiotherapy are ap-
proximately 50% to 70%.10–13These results stand in
stark contrast to the disappointing response rates ob-
served after low-dose whole-liver radiation.14,15Al-
though prospective data on dose response in HCC are
lacking, several single-center experiences support a
strong dose-response relationship: doses ?50 Gy result
in improved tumor response rates10,16and prolonged
median survival.11,15,17It has been proposed that doses in
excess of 60 Gy should be used for radiotherapy for small
tumors when these are treated with curative intent.10
The potential need for even higher radiation doses in
the treatment of HCC is documented by the fact that in
a small autopsy series (7 patients), doses of 50 to 70 Gy
showed evidence of tumor regression, but not eradication
of the HCC.18Data for particle radiation therapy, spe-
cifically, proton radiation therapy, are not summarized in
this review because this topic will be presented and
discussed in a separate article in this issue.
Radiation Therapy: Background
To appreciate the advantages of IMRT, IGRT,
and SBRT over more conventional radiation therapy, an
understanding of the radiation therapy treatment-plan-
ning process is required. Modern radiation therapy is
always based on 3-dimensional image datasets (typically
computerized tomography [CT], but also magnetic res-
onance imaging and positron emission tomography or a
combination of ?2 imaging modalities), which are ac-
quired during what is typically referred to as the simu-
lation procedure. CT and magnetic resonance imaging
provide image data on anatomic abnormalities, whereas
positron emission tomography provides functional imag-
ing datasets that characterize the metabolic tumor activ-
Algorithms to co-register or "fuse" both anatomic and
functional image datasets may allow for a more accurate
determination of what the true biological target volume
is.19These image datasets are transferred into dedicated
radiation therapy–planning workstations. First, the tar-
get volume and organs at risk are delineated. The target
volume is delineated according to the concept of the
gross tumor volume, which is represented by the mac-
roscopically visible tumor. A clinical target volume is
created by adding regions of suspected, but not neces-
sarily visible, tumor extension to the gross tumor vol-
November Supplement 2004 INTENSITY–MODULATED AND IMAGE–GUIDED RT FOR HCCS207
Page 3
ume. Thus, a tumor volume for HCC radiotherapy may
include a margin of at least 1 to 2 cm of normal liver
tissue surrounding the visible tumor volume. For treat-
ment planning, additional safety margins accounting for
intrafraction target motion of the HCC with the liver
and interfraction variability of patient and target setup
must be added to the clinical target volume.
These planning target volume safety margins result in
the irradiation of normal tissues that are at risk for
radiation-induced toxicity, but they are necessary to en-
sure a high probability (typically ?90% or 95%) of
exposing the target volume to the prescribed radiation
dose for each day of a prolonged treatment course. Safety
margins for radiotherapy for liver tumors may be as large
as 2 to 3 cm and can expand the volume of tissue that
will be treated by a factor of ?2. Subsequently, a treat-
ment plan is created by designing customized radiation
fields that treat the entire planning target volume. For
so-called conventional radiotherapy approaches, oppos-
ing anterior and posterior fields are typically used,
whereas 3D-CRT approaches aim to reduce the amount
of normal tissue exposed by adding at least an additional
lateral or oblique field. To further reduce high-dose
exposure of normal tissues, as many as 7 fields may be
used in 3D-CRT. The dose distribution resulting from
such approaches is a function of field overlap, with 2
opposing fields creating a somewhat cylindrical region of
high dose (Figure 1A) and the addition of more fields
causing the effectively delivered high-dose region to
better conform to the outline, or shape, of the target
volume (Figure 1B). Often, the optimal treatment plan is
developed through a series of trial-and-error iterations of
field angles and field weightings, also referred to as
forward planning. In summary, normal-tissue sparing can
be accomplished by better conforming the resulting ra-
diation dose distribution to the outline of the planning
target volume, by reducing the need for excessively large
safety margins, or both.
Intensity-Modulated Radiation
IMRT is distinctly different from conventional
radiation and 3D-CRT in 2 ways. First, the radiation
fields (or ports) used are divided into smaller field seg-
ments, or pencil beams, each of which can be individu-
ally assigned radiation intensity, or fluence. The fluence
of the beam is modulated, and thus, instead of delivering
an almost homogeneous dose profile over 1 large radia-
tion field, the resulting delivered dose represents a highly
complex map of varying radiation intensities from large
numbers of small beamlets. Second, computed IMRT
treatment planning uses an inverse treatment-planning
approach. Inverse planning differs from forward-plan-
Figure 1. Schematic display of
beam entry portals for (A) con-
ventional radiotherapy (anteri-
or/posterior and posterior/ante-
rior) and (B) 3D-CRT (anterior/
posterior and posterior/anterior
plus perpendicular lateral field).
The resulting dose distribution
(blue, 100% of the dose equals
60 Gy; red, 90%; yellow, 70%;
and green, 50% isodose lines)
evidences the dose cylinder
generated by conventional ra-
diotherapy and the compara-
tively significant
sparing with the addition of a
lateral field in 3D-CRT. Please
note that for this schematic,
field entry angles were not opti-
mized to spare the spinal cord
as an organ at risk. Doses were
delivered homogeneously over
each treatment port (mid figures
show homogeneous dose inten-
sity; dose intensity is rendered
in shades of red).
S208 FUSS ET ALGASTROENTEROLOGY Vol. 127, No. 5
Page 4
ning approaches in that the physician, instead of defining
the radiation fields to be used, basically defines the
desired radiation dose distribution. In effect, the physi-
cian defines the goals rather than the means to accom-
plish the requirements and then uses a computerized
optimization system to determine the best way to ac-
complish the stated goals. Requirements for the desired
dose distribution are typically entered into a computer in
numerical form and include the prescribed dose to the
target volume and the allowed radiation exposure of
organs at risk. The computer-based optimization proce-
dure subsequently derives a treatment plan that will
enable the delivery of an acceptable treatment. Theoret-
ically, the optimizer identifies the best radiation plan
from a set of literally millions of alternatives in a "solu-
tion space."
Complicating matters is the fact that IMRT comes in
a variety of distinctly different "flavors." The most com-
monly used systems differ from one another mainly in
the manner in which the resulting treatment plan is
actually delivered. The 2 core classes of treatment deliv-
ery associated with IMRT are rotational treatments in
which the radiation dose is delivered in a slice-by-slice or
continuous helical fashion and so-called static field de-
livery, which uses a number of radiation fields that
intersect at the tumor volume. Although the advantages
of 1 modality over the others are the subject of ongoing
scientific debate, all methods of IMRT delivery have
been proven effective in the delivery of conformal radi-
ation treatments.
Inverse planning is an integral component of IMRT
treatment planning. The term refers to the definition of
treatment plan characteristics, or parameters, and the use
of computers to derive a corresponding solution by using
optimization algorithms. Treatment parameters are typ-
ically entered numerically and include at least the pre-
scription target radiation dose and dose limits for organs
at risk. The importance of sparing organs at risk may be
set by a binary function (organ at risk vs. critical organ
at risk) or by using sliding-bar techniques to emphasize
the risk reduction for the occurrence of radiation-related
toxicity. The numerical parameters entered during in-
verse planning can actually include or consist of tumor-
control probability and normal tissue complication prob-
ability data: this effectively drives the optimizer to find
a solution optimized for the 2 ultimate outcome mea-
sures. Although such approaches are already technically
feasible, the lack of proven, clinically reliable tumor-
control probability and normal tissue complication prob-
ability parameters prohibits current use. With an in-
creasing body of data being generated on volumetric
organ and target radiation exposure and prospective and
retrospective assessments of associated tumor control and
toxicity rates, such data will likely be available soon.
Since its clinical inception in 1994, IMRT has been
documented to be capable of creating and delivering
superior dose distributions to a variety of solid tumors,
including primary and secondary brain tumors, head and
neck cancer, and prostate cancer. Experience with IMRT
in the treatment of upper abdominal cancer is limited,
with reports referring to treatment of gastric cancer,
pancreatic cancer, hepatobiliary tumors, and primary and
secondary liver tumors.20–23
Figures 1 and 2 depict the typical radiation field
configuration and resulting dose distributions from con-
ventional opposing beam radiation therapy (Figure 1A),
3D-CRT with an additional lateral field (Figure 1B),
5-field static-field IMRT (Figure 2A), and sequential
tomotherapeutic IMRT (Figure 2B). It can be seen from
the figures that the dose profile is homogeneous over each
field in conventional radiation therapy and 3D-CRT,
whereas static-field and tomotherapeutic IMRT deliver
highly complex, nonhomogeneous dose matrices. For
inverse IMRT planning, the parameters of the tomo-
therapeutic IMRT treatment plan that was actually de-
livered for this HCC with an inferior vena cava thrombus
were used to create the static field IMRT plan, whereas
planning for conventional radiation therapy and 3D-
CRT followed established forward-planning procedures.
By using an inverse-planning IMRT system (Corvus;
Nomos Corp., Cranberry Township, PA), the prescrip-
tion dose for these exemplary calculations was entered as
the desired target goal dose. Also required was entry of
the percentage of the target volume allowed to receive
lesser doses (typically set to no more than 3%), the
minimum dose to be received by the target volume
(typically at least 95% of the prescribed dose), and the
allowed maximum target dose (approximately 110%).
Similarly, dose limits for organs at risk, percentages of
organs at risk allowed to receive more than the specified
dose limit, and the minimum and maximum allowed
doses to organs at risk were entered into a template
(Figure 3). In addition to these dose parameters, the
pencil-beam dimension, the degree of intensity modula-
tion (steps of 10%, effectively resulting in 11 intensity
levels), and gantry rotation (here 340°; rotation from
350° to 10°) for tomotherapy or the number and field
angles for static-field IMRT delivery were specified.
IMRT plans were subsequently optimized by using a
dose–volume histogram-driven simulated annealing
approach. Figure 4 represents dose–volume histograms
for the computed conventional radiotherapy, 3D-CRT,
static-field IMRT, and sequential tomotherapeutic
IMRT plans. All plans were normalized for comparison
November Supplement 2004INTENSITY–MODULATED AND IMAGE–GUIDED RT FOR HCC S209
Page 5
so that 95% of the planned target volume was encom-
passed by the prescription 100% isodose (60 Gy). Al-
though this normalization guarantees that the respective
target volumes were all exposed to the prescribed doses,
the resulting plans differ significantly in their normal-
tissue and organ-at-risk sparing. The 2 IMRT plans
result in clinically relevant liver sparing, as expressed by
the D30 liver and D50 liver (the minimum dose that
30% and 50%, respectively, of normal liver tissue is
exposed to). On the basis of computed mean liver doses,
both IMRT plans would have allowed delivery of the
desired target dose of 60 Gy, whereas conventional and
3D radiotherapy delivery techniques would have re-
quired a dose reduction to decrease the probability for
development of radiation-induced liver disease to accept-
able levels.
Image-Guided Radiation Therapy
IGRT can be understood from 2 perspectives.
Imaging that forms the basis of radiation treatment
planning should serve the purpose of guiding target
discrimination from normal tissues. The term IGRT
refers, however, to a distinctly different aspect of ensur-
ing that the defined target volume is in fact exposed in
its entirety to the prescribed radiation dose on a daily
basis. Thus, IGRT aids in establishing reproducible and
accurate patient and target setup for treatment delivery.
Image confirmation of patient and target volume setup
on the linear accelerator treatment couch has become an
integral component of quality-assurance measures in ra-
diation oncology. So-called port films are acquired at
least weekly to compare patient bony anatomy with CT
simulation-derived digitally reconstructed radiographs.
However, most often, the actual target volume cannot be
directly seen on such port films.
The concept of image guidance expands on these
measures by assessing the position of a target organ or
target volume relative to a room x, y, and z coordinate
system. Thus, target or organ motion relative to the
patient bony anatomy is registered, and accordingly,
Figure 2. Schematic display of 5-field static-field IMRT and sequential tomotherapeutic IMRT. The upper figures (A) depict the 5 gantry angles,
with each dot in the respective radiation fields, which are projected onto the patient's surface and represent a pencil beam that has been
individually modulated in its intensity. The lower figures (B) represent sequential tomotherapeutic IMRT with a display of 9 of 32 actually delivered
arcing segments. Again, each dot in the center figure represents an individually modulated pencil beam. This treatment was delivered over 4
consecutive couch indices (slices) of 340° rotation. The resulting dose distributions (blue, 100% of the dose equals 60 Gy; red, 90%; yellow,
70%; and green, 50% isodose lines) indicate that an "infinite" number of fields (arcing segments) over an almost-full rotation results in slightly
superior dose conformality to the target volume. For both IMRT inverse-planning calculations, dose constraints (see Figure 4) for the right kidney
and the spinal cord were respected. Note the resulting highly complex dose matrices for each static IMRT field or arcing segment (dose intensity
is rendered in shades of red).
S210 FUSS ET ALGASTROENTEROLOGY Vol. 127, No. 5
Page 6
corrective measures (table translations along the 3 prin-
cipal room axes) are applied. IGRT stands for a class of
technical solutions, all of which aim to optimize target
setup or treatment delivery.
The most commonly used form of IGRT refers to the
use of port films or electronic portal imaging devices to
assess the position of radio-opaque fiducial markers im-
planted into the target organ or otherwise indicative of
the location of the target volume. Software allows com-
parison of the position of those fiducial markers with
their location on treatment simulation–derived digitally
reconstructed radiographs. Although translations along
the principal room axes can be derived, rotational setup
errors may compromise the resulting corrected setup.
Three-dimensional imaging modalities today use mostly
CT imaging in the sense of pretreatment delivery-control
CT scans. These image data are consecutively compared
with the original simulation CT data, and correctional
shifts of the patient are derived (Figure 5). Because those
control CT scans are typically conducted by using the CT
simulator unit, the necessary patient transfer from the
simulation suite into the radiation treatment vault needs
to ensure that patient displacements are effectively min-
More recent developments, such as in-room CT units
(which are linked by rail systems with the treatment-
delivery unit) or so-called cone-beam on-board CT units
(physically mounted on the linear accelerator gantry), can
help overcome technical challenges. Although they are
commercially distributed, such units are costly and not
yet commonly available in the clinical environment.
Volumetric image guidance also allows for reconstruc-
tion of the radiation dose distribution or dose recalcula-
tion (Figure 5).
Ultrasound-based image guidance combines the ad-
vantages of volumetric imaging, lower cost, and wide
clinical acceptance and has become a de facto standard in
daily targeting for prostate cancer.23–26The established
role of ultrasound imaging in diagnostic imaging of
upper abdominal organs has led to the exploration of the
capabilities of ultrasound guidance for radiotherapy in
upper abdominal tumors, including liver malignancies.23
CT simulation-derived organ outlines are superim-
posed onto real-time acquired ultrasound images, and, by
virtually shifting these organ outlines, a match between
planned and actual organ position is accomplished. We
have found that outlines of the liver, intrahepatic vessels,
ectatic bile ducts, and implanted fiducial markers are
consistently and reproducibly visualized on transabdom-
inal ultrasound via the BAT ultrasound image-guidance
system (Nomos Corp.; Figure 6). All of the previously
described image-guidance techniques have been proven
to optimize target setup. This benefit can translate into
narrower safety margins that need to be added to a
clinical target volume, effectively reducing the probabil-
ity of normal tissue toxicity. Because only the safety
margin component of the variability of patient and target
setup is addressed by these systems, safety margins for
intrafraction organ motion need to be maintained.
Added efforts to account for respiratory organ motion
(so-called gating) can further reduce safety margins and
enable even safer treatment delivery.27
Stereotactic Body Radiation
SBRT is a recent conceptual development that
defines prescription and delivery of large single radiation
doses or a limited number of radiation fractions (hypo-
fractionated radiation therapy) to small target volumes
within extracranial major visceral organs such as lung
and liver.9,28–30From a technical standpoint, SBRT, also
referred to as extracranial radiosurgery or extracranial
radioablation, represents a further refinement of 3D-
CRT, including IMRT with stereotactic target localiza-
Figure 3. Dose prescription and specification of dose-delivery param-
eters for inverse sequential tomotherapeutic IMRT treatment planning
(the corresponding resulting plan is displayed in Figure 2B). Displayed
are actual dose requirements for the target volume and dose con-
straints for organs at risk. Treatments were delivered with a 2-cm
pencil beam mode (17 ? 10-mm pencil beam dimension) over a 340°
gantry rotation (start 350° to end 10°). Beam delivery was enabled
from gantry position 345° to 25° in individual arcing segments of 10°.
November Supplement 2004 INTENSITY–MODULATED AND IMAGE–GUIDED RT FOR HCCS211
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tion, similar to techniques developed and established in
intracranial radiosurgery.
Besides the requirement for optimized patient re-
positioning and immobilization (Figure 7), localized
treatment of small HCC emphasizes the need for
image guidance. Advanced imaging techniques need
to be used to individually characterize and optimally
minimize residual target setup errors. The ablative
character of these treatments, which render all tissues
in the high-dose region nonfunctional, mandates the
reduction of safety margins extending into normal
liver tissue. Figure 8 displays patient treatment setup
and radiation dose distribution for a small segment 8
HCC recurrence after resection treated in August
2002 by intensity-modulated SBRT in 3 fractions of
12 Gy (total dose of 36 Gy) delivered at 48-hour
intervals. A case with HCC adrenal gland metastases
was treated with a similar technique at the University
of Texas at San Antonio. Image guidance for SBRT
delivery used CT control imaging and ultrasound-
based image guidance. Local control was documented
in both cases at the most recent imaging follow-up (5
and 14 months of follow-up).
Clinical Experience With Intensity-
Modulated Radiation Therapy
As of today, peer-reviewed clinical data supportive
of the superiority of treating HCC with IMRT are lacking.
The only report referring to IMRT treatment of HCC
researched potential improvements on delivered 3D-CRT
by replanning with inverse-planning IMRT software.31Out
of a series of 68 patients treated by the Taiwanese investi-
gators with 3D-CRT, 12 developed radiation-induced liver
disease and were subjected to this comparison. IMRT was
documented to be capable of preserving target volume dose
coverage while improving or at least maintaining nonhe-
patic organ sparing. With respect to liver sparing, findings
suggested that 10 of 12 IMRT plans would result in higher
mean liver doses than the actually delivered 3D-CRT plan.
Figure 4. Display of dose–vol-
ume histograms for the result-
ing plans presented in Figures 1
and 2. The clinical target volume
is rendered in bright red, and
the planning target volume is
represented in lighter red. All
plans were normalized so that
95% of the planning target vol-
ume was covered by the 60 Gy
prescribed dose. In addition to
mean liver doses (liver is ren-
dered in yellow), the D30 liver
and the D50 liver (the minimum
dose that 30% and 50% of liver
are exposed to, respectively)
are displayed. Mean liver doses
would have been critically high
in conventional radiotherapy and
3D-CRT planning. Five-field static-
field IMRT planning resulted in
treatment plans that could have
been safely delivered.
S212FUSS ET AL GASTROENTEROLOGY Vol. 127, No. 5
Page 8
However, 9 of 12 IMRT plans were computed to reduce
normal tissue complication probabilities. In this compari-
son, 3D-CRT field angles were individually optimized by
using coplanar and noncoplanar beam entry angles and up
to 8 individual fields, whereas IMRT plans were created by
using a standard coplanar 5-field configuration. Also, dose
constraints typically used for non-IMRT techniques (espe-
cially the stipulation of a relatively low maximum dose of
105%) were entered as the basis for inverse planning dose
optimization. Hence, the potential of IMRT to improve on
3D-CRT plans warrants further investigation.
In clinical use at the University of Texas Health
Science Center at San Antonio, target dose requirements
and organ-at-risk constraints are optimized to allow the
inverse-planning IMRT system to derive treatment plans
that we consider to come closer to individually optimal
treatment plans. In our series of 10 patients with HCC
treated by conventionally fractionated IMRT and an
additional 2 patients treated by intensity-modulated
SBRT between November 2000 and April 2004, clinical
target volumes averaged 456 cm3(range, 61.7–947 cm3
and 7–24 cm3for SBRT treatments), and planning target
volumes averaged 972 cm3(range, 221–1857 cm3and
36–76 cm3for SBRT). The D30 liver and D50 liver were
always kept ?25 and 35 Gy, respectively (mean D30
liver, 16.1 Gy; mean D50 liver, 26.1 Gy). Mean liver
doses averaged 29.8 Gy (range, 25.3–35.7 Gy), an ex-
pected increase over the D50 liver because the planned
target volume safety margins include normal liver tissue
at risk for complications and are exposed to the relatively
high prescription dose of 54 to 76 Gy (median, 62 Gy).
In this small series of patients with limited follow-up, no
case of radiation-induced liver disease was observed.
With respect to the published lack of occurrence of
radiation injury at mean liver doses ?31 Gy,2it is
notable that only 4 of 12 patients in this series exceeded
this limit by excess doses of 0.3 Gy to, maximally, 4.7
Gy. Thus, we consider these preliminary data as encour-
aging and supportive of future exploration of the tech-
Figure 5. In-room CT unit linked by a rail system with the treatment couch (Siemens Medical Solutions, Concord, CA; upper figure) and on-board
cone-beam CT unit mounted to the gantry of a linear accelerator (Elekta Inc., Norcross, GA; lower figure). Either unit would allow for image-guided
targeting with the patient in treatment position. The right upper figures show an original simulation CT with computed dose distribution and
corresponding control CT before delivery of 1 of 3 radiation fractions for stereotactic body radiation therapy (SBRT) of a small HCC. The computed
dose distribution has been superimposed onto the control CT scan to assess target volume coverage for the respective radiation fraction.
Because the control CT was acquired without intravenous contrast, organ (liver) outline and bony structures may provide better guidance than
the actual tumor volume. Note the minor variability in patient and target setup, as enabled by advanced patient immobilization techniques (see
also Figure 7).
November Supplement 2004INTENSITY–MODULATED AND IMAGE–GUIDED RT FOR HCC S213
Page 9
Clinical Experience With Image-
Guided Radiation Therapy
IGRT of liver tumors has been explored for sev-
eral years. As discussed, optimization of patient and
target setup and recognition of intrafraction organ mo-
tion need to be separated, although 1 imaging device
may help to recognize and correct for either component.
The University of Texas Health Science Center at San
Antonio experience in adapting an ultrasound-based ra-
diation targeting system has been presented.23According
to this experience, ultrasound targeting can significantly
improve on target setup and may allow reducing planned
target volume margins. Similar setup improvements can
be expected from positional assessment of implanted
fiducial markers or the use of 3-dimensional CT or
cone-beam imaging.32
Prospective clinical data comparing outcomes in terms
of tumor control and normal tissue toxicity are unavail-
able, and, given the widely acknowledged improvement
in target setup and normal tissue sparing, the conduct of
such studies cannot be expected. The implementation of
IGRT for HCC will, however, result in attempts at
radiation dose escalation, which in turn will be analyzed
by clinical feasibility and safety. Ultimately, integration
of image guidance into new, more aggressive radiation
treatment concepts may allow us to overcome the appar-
ent radiation resistance of HCC.18
Clinical Experience With
Stereotactic Body Radiation
SBRT for small HCC and metastatic liver disease
was initiated at the Karolinska Hospital, Stockholm,
Sweden, in the early 1990s.33Local tumor control was
documented in 6 of 8 patients with HCC after SBRT in
1 to 3 fractions and doses ranging from 15 to 45 Gy.9
The median survival was 8 months, and 2 patients were
alive at 13 and 39 months of follow-up. Four patients
died of progressive liver symptoms potentially associated
with radiation therapy (ascites, progressive cirrhosis, and
bleeding), and 1 patient each died from systemic disease
progression and stroke. The concept of SBRT has since
been adopted by numerous academic centers, and most
liver lesions treated are liver metastases. The toxicity
profiles and outcomes of such treatments have been very
encouraging.28,29,34Investigators from the University of
Colorado, the University of Iowa, and the University of
Texas Health Science Center at San Antonio have also
Figure 6. Display of the BAT ul-
targeting device (Nomos Corp.).
The upper figures show outlines
of CT-derived organ structures
superimposed onto real-time ac-
quired ultrasound images. Dis-
played are the outline of the
liver and the target volume con-
sisting of the HCC with inferior
vena cava thrombus. The lower
left figure is a 3-dimensional
rendering of
structures (liver in yellow, target
volume in red, right kidney in
green, and spinal cord in blue).
Note the color changes when
they are superimposed onto ul-
trasound anatomy (target in
blue; liver in yellow).
the CT-derived
S214FUSS ET AL GASTROENTEROLOGY Vol. 127, No. 5
Page 10
reported on preliminary clinical experience with SBRT
in small numbers of patients with HCC.28,35An ongoing
phase I/II multicenter trial aims to establish the maxi-
mum-tolerated radiation dose and the 6-month in-field
tumor response rates for HCC, as well as associated
disease-specific and overall survival (principal investiga-
tor, H. Cardenes, Indiana University).
HCC is the most common solid tumor in certain
parts of the world and has an increasing incidence in the
United States. Efforts are needed to address the related
mortality of the primary disease, as well as treatment-
related morbidity. Although traditionally, the use of
ionizing radiation has been a limited treatment option
for HCC and other liver tumors because of concerns
about radiation-induced liver disease, recent observations
suggest that some of the old perspectives regarding the
role of radiotherapy to the liver need to be revisited. In
this vein, there is a precedent for revisiting old dogma in
the treatment of HCC. Orthotopic liver transplantation
has not been traditionally used as a viable treatment
option for patients with macroscopic HCC. However,
over the past few years, up to 25% of liver transplanta-
tions have been performed in patients with known HCC.
Moreover, it may be feasible to design studies of com-
bined-modality treatment that incorporate IMRT or
SBRT under image guidance for known macroscopic
disease as a bridge to transplantation for patients on the
recipient waiting list. Such prospective studies will re-
quire careful consideration of rational primary and sec-
ondary end points that not only include traditional re-
sponse and toxicity data, but also are prepared to evaluate
cost utility and cost benefit, as well as focused quality-
of-life parameters.
The future implementation of modern radiation plan-
ning and delivery techniques into the multidisciplinary
armamentarium for HCC is complemented by the wide
clinical availability of IMRT. Image guidance is also
widely accepted by radiation oncologists, as documented
by the fact that, as of early 2004, more than 400 ultra-
Figure 8. Resulting delivered-dose distribution for stereotactic body
radiation therapy (SBRT) of a small HCC. Depicted in an axial, coronal,
and sagittal view are the target volume in red, with planning target
volume safety margins of 5 mm transversally and 10 mm craniocau-
dally, as well as the 100% (36 Gy in blue), 90% (red), 70% (orange),
and 50% (yellow) isodose lines.
Figure 7. Stereotactic body immobilization system (BodyFIX; Medical
Intelligence, Schwabmuenchen, Germany). The upper figure depicts
the negative "vacuum cast" molded individually for each patient and
providing for the required patient setup accuracy. The lower figure
represents a typical patient setup for SBRT treatment on the linear
accelerator table.
November Supplement 2004 INTENSITY–MODULATED AND IMAGE–GUIDED RT FOR HCCS215
Page 11
sound targeting systems were installed and in clinical use
in the United States. Also, cone-beam on-board imaging
systems are becoming available by all major linear accel-
erator manufacturers, albeit at significant cost.
Given the lack of presently available clinical data in
the use of the presented technology, we may speculate on
the future role of radiation therapy in the treatment of
HCC. In the primary, curative treatment of small, local-
ized HCC, SBRT adds a noninvasive alternative or com-
plement to minimally invasive and operative therapies.
This concept may also become a viable treatment to
bridge time to transplantation in qualifying patients.
New consideration for the role and capacity of radiation
therapy should be given in the treatment of HCC too
large for resection and transplantation. Modern radiation
techniques and concepts have capabilities that offer much
more than palliation in the symptomatic near-end situ-
ation and should be considered earlier in the disease
course than is currently common.
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SY, Jian JJ, Lin YM, Cheng TI, Horng CF, Huang AT. Radiation-
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10. Tokuuye K, Sumi M, Kagami Y, Murayama S, Kawashima M,
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11. Seong J, Park HC, Han KH, Chon CY. Clinical results and prog-
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12. Guo WJ, Yu EX. Evaluation of combined therapy with chemoem-
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13. Cheng SH, Lin YM, Chuang VP, Yang PS, Cheng JC, Huang AT,
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Hepatol 1999;14:1025–1033.
14. Stillwagon GB, Order SE, Guse C, Leibel SA, Asbell SO, Klein JL,
Leichner PK. Prognostic factors in unresectable hepatocellular
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Radiat Oncol Biol Phys 1991;20:65–71.
15. Robertson JM, Lawrence TS, Dworzanin LM, Andrews JC, Walker
S, Kessler ML, DuRoss DJ, Ensminger WD. Treatment of primary
hepatobiliary cancers with conformal radiation therapy and re-
gional chemotherapy. J Clin Oncol 1993;11:1286–1293.
16. Park HC, Seong J, Han KH, Chon CY, Moon YM, Suh CO. Dose-
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carcinoma. Int J Radiat Oncol Biol Phys 2002;54:150–155.
17. Dawson LA, McGinn CJ, Normolle D, Ten Haken RK, Walker S,
Ensminger W, Lawrence TS. Escalated focal liver radiation and
concurrent hepatic artery fluorodeoxyuridine for unresectable in-
trahepatic malignancies. J Clin Oncol 2000;18:2210–2218.
18. Aoki K, Okazaki N, Okada S, et al. Radiotherapy for hepatocellular
carcinoma: clinicopathological study of seven autopsy cases.
Hepatogastroenterology 1994;41:427–431.
19. Ling CC, Humm J, Larson S, Nose H, Yoshimori M, Akine Y,
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mality. Int J Radiat Oncol Biol Phys 2000;47:551–560.
20. Lohr F, Dobler B, Mai S, Hermann B, Tiefenbacher U, Wieland P,
Steil V, Wenz F. Optimization of dose distributions for adjuvant
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Onkol 2003;179:557–563.
21. Bai YR, Wu GH, Guo WJ, Wu XD, Yao Y, Chen Y, Zhou RH, Lu DQ.
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World J Gastroenterol 2003;9:2561–2564.
22. Crane CH, Antolak JA, Rosen II, Forster KM, Evans DB, Janjan NA,
Charnsangavej C, Pisters PW, Lenzi R, Papagikos MA, Wolff RA.
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23. Fuss M, Salter BJ, Cavanaugh SX, Fuss C, Sadeghi A, Fuller CD,
Ameduri A, Hevezi JM, Herman TS, Thomas CR. Daily ultrasound-
based image-guided targeting for radiotherapy of upper abdominal
malignancies. Int J Radiat Oncol Biol Phys 2004;59:1245–1256.
24. Lattanzi J, McNeeley S, Pinover W, Horwitz E, Das I, Schultheiss
TE, Hanks GE. A comparison of daily CT localization to a daily
ultrasound-based system in prostate cancer. Int J Radiat Oncol
Biol Phys 1999;43:719–725.
25. Little DJ, Dong L, Levy LB, Chandra A, Kuban DA. Use of portal
images and BAT ultrasonography to measure setup error and
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gins. Int J Radiat Oncol Biol Phys 2003;56:1218–1224.
26. Fuss M, Cavanaugh SX, Fuss C, Cheek DA, Salter BJ. Daily
stereotactic ultrasound prostate targeting: inter-user variability.
Technol Cancer Res Treat 2003;2:161–170.
27. Wagman R, Yorke E, Ford E, Giraud P, Mageras G, Minsky B,
Rosenzweig K. Respiratory gating for liver tumors: use in dose
escalation. Int J Radiat Oncol Biol Phys 2003;55:659–668.
28. Fuss M, Thomas CR Jr. Stereotactic body radiation therapy: an
ablative treatment option for primary and secondary liver tumors.
Ann Surg Oncol 2004;11:130–138.
29. Herfarth KK, Debus J, Lohr F, Bahner ML, Rhein B, Fritz D, Hoss
A, Schlegal W, Wannenmacher MF. Stereotactic single-dose ra-
S216FUSS ET ALGASTROENTEROLOGY Vol. 127, No. 5
Page 12
diation therapy of liver tumors: results of a phase I/II trial. J Clin
Oncol 2001;19:164–170.
30. Hof H, Herfarth KK, Munter M, Hoess A, Motsch J, Wannen-
macher M, Debus JJ. Stereotactic single-dose radiotherapy of
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Phys 2003;56:335–341.
31. Cheng JC, Wu JK, Huang CM, Liu HS, Huang DY, Tsai SY,
Cheng SH, Jian JJ, Huang AT. Dosimetric analysis and com-
parison of three-dimensional conformal radiotherapy and in-
tensity-modulated radiation therapy for patients with hepato-
cellular carcinoma and radiation-induced liver disease. Int J
Radiat Oncol Biol Phys 2003;56:229–234.
32. Mackie TR, Kapatoes J, Ruchala K, Lu W, Wu C, Olivera G, Forrest
L, Tome W, Welsh J, Jeraj R, Harari P, Reckwerdt P, Paliwal B,
Ritter M, Keller H, Fowler J, Mehta M. Image guidance for precise
conformal radiotherapy. Int J Radiat Oncol Biol Phys 2003;56:
33. Lax I. Target dose versus extratarget dose in stereotactic radio-
surgery. Acta Oncol 1993;32:453–457.
34. Wulf J, Hadinger U, Oppitz U, Thiele W, Ness-Dourdoumas R,
Flentje M. Stereotactic radiotherapy of targets in the lung and
liver. Strahlenther Onkol 2001;177:645–655.
35. Schefter T, Gaspar LE, Kavanagh B, Ceronsky N, Feiner A, Stuhr
K. Hypofractionated extracranial stereotactic radiotherapy for
liver tumors. Int J Radiat Oncol Biol Phys 2003;57(2 Suppl):
Address requests for reprints to: Martin Fuss, MD, Department of
Radiation Oncology, UTHSC at San Antonio, 7703 Floyd Curl Drive,
San Antonio, Texas 78229. e-mail: email@example.com; fax: (210)
We are grateful to Gerald D. Dodd III, MD, for mentorship; Marie
D. Klisch, MD, for data collection; Irma Diaz, CMD, and Jose A.
Madrigal, CMD, for IMRT dosimetry treatment-planning assistance;
and Cristina Fuss, MD, for providing expertise in implementation of
ultrasound-based IGRT of the upper abdomen.
November Supplement 2004 INTENSITY–MODULATED AND IMAGE–GUIDED RT FOR HCCS217


text:
He is preceded in death by his parents, Lonnie and Bertle Griffin; and his brother, Lonnie F. Griffin.
Steve is survived by his loving wife, friend, and Soul Mate of 57 years, Shelby "Jean" Griffin of the home; son, Steve Griffin Jr. and wife Lisa of Richlands; daughters, Teresa Tefft and husband Ray of Richlands and Lisa Avery and husband Wayne of Kinston; sisters, Mary Bateman of Richlands, Kathleen White of Jacksonville, Rachel Moore of Portsmouth, Va., Elizabeth Croom of Richlands, and Joy Thomas of Comfort; and grandchildren, Stephen Griffin III, Amber Joan Fisher, Sarah Jean Bedard, Mary Ashley Griffin, and Joey Walter Bedard.
A memorial service celebrating Steve's life will be held at 5 p.m. Saturday, March 8 at Johnson Funeral Home of Richlands with Pastor Steve Evans officiating. A gathering of friends and family will follow the memorial service also at the funeral home. Burial will be private at the family's request, at a later date.
In lieu of flowers, donations may be made to the
Arrangements by Johnson Funeral Home of Richlands.

subset: commoncrawl


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- 800.878.7323
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Revolutionary Wealthby Alvin Toffler
"Reading this book is a lot like watching the preview of a new action movie: one rapid-fire, fragmentary scene after another, loud, flashy, logically unconnected to the one that came before or the one that comes after. It is very exciting, but when it is over you have no clear idea what the movie is actually about." Robert M. Solow, The New Republic (read the entire New Republic review)
Synopses & Reviews
Publisher Comments:
Starting with the publication of their seminal bestseller, Future Shock, Alvin and Heidi Toffler have given millions of readers new ways to think about personal life in today's high-speed world with its constantly changing, seemingly random impacts on our businesses, governments, families and daily lives. Now, writing with the same rare grasp and clarity that made their earlier books classics, the Tofflers turn their attention to the revolution in wealth now sweeping the planet. And once again, they provide a penetrating, coherent way to make sense of the seemingly senseless.
Revolutionary Wealth is about how tomorrow's wealth will be created, and who will get it and how. But twenty-first-century wealth, according to the Tofflers, is not just about money, and cannot be understood in terms of industrial-age economics. Thus they write here about everything from education and child rearing to Hollywood and China, from everyday truth and misconceptions to what they call our "third job" — the unnoticed work we do without pay for some of the biggest corporations in our country.
They show the hidden connections between extreme sports, chocolate chip cookies, Linux software and the "surplus complexity" in our lives as society wobbles back and forth between depressing decadence and a hopeful post-decadence.
In their earlier work, the Tofflers coined the word "prosumer" for people who consume what they themselves produce. In Revolutionary Wealth they expand the concept to reveal how many of our activities — whether parenting or volunteering, blogging, painting our house, improving our diet, organizing a neighborhood council or even "mashing" music — pump "free lunch" from the "hidden" non-money economy into the money economy that economists track. Prosuming, they forecast, is about to explode and compel radical changes in the way we measure, make and manipulate wealth.
Blazing with fresh ideas, Revolutionary Wealth provides readers with powerful new tools for thinking about — and preparing for — their future.
"This latest futurist forecast by the Tofflers, the husband-and-wife authors of Future Shock, anxiously surveys hundreds of technological, economic and social developments, including globalization, the rise of China, the decay of Europe, the decline of nuclear families, kids today, satellites, genetic engineering, alternative energy sources, frequent-flyer miles, the Internet and the rise of a new economic group, 'prosumers' (those who create goods and services 'for [their] own use or satisfaction, rather than for sale or exchange'). Above all, the authors note the ever-accelerating speed and transience of all things such that nanoseconds are now too slow and will be replaced by even zippier 'zeptoseconds.' The Tofflers try, none too incisively, to order the chaos by invoking the 'deep fundamentals' of time, space and the cutting-edge 'knowledge economy' that is fast outdistancing obsolete industrial-era government institutions. The Tofflers' mantra of 'revolutionary wealth' implies that there's money to be made from the maelstrom, but their specific prognostications — the 'explosion' of a nonmonetary 'prosumer' economy of family care, hobbies and volunteerism; embedded 'pinky chips' combining ID and credit cards; the comeback of barter — seem underwhelming or unlikely. 200,000 first printing" Publishers Weekly (Copyright Reed Business Information, Inc.)
"If we were living through a great economic revolution, would we know it? It's easy to get carried away, after all. Herman Kahn and Anthony Wiener of the Hudson Institute predicted in 1967 — in a carefully researched publication — that by 2000 we would have undersea colonies, personal flying platforms and cities lit by artificial moons. Futurology has its perils, but it holds no terrors... Washington Post Book Review (read the entire Washington Post review) for Alvin and Heidi Toffler, perhaps the world's most famous prognosticators. Their latest book, 'Revolutionary Wealth,' foretells the next great economic revolution. In fact, since the preferred Toffler style — in such blockbusters as 'Alvin's Future Shock' and 'The Third Wave' — is to highlight recent events as a taste of things to come, we are led to believe that the revolution is here already. But what is this economic revolution that they herald? That is not quite clear. It will be big and fast, certainly, and government institutions are likely to be left behind. Moreover, the Tofflers think we are going to get dramatically richer. There has to be some truth in this, at least from an economic perspective. As the Berkeley economist J. Bradford DeLong has noted, global income per person grew nearly tenfold during the 20th century. In the 19th century, it merely trebled — which was more than enough to astonish Karl Marx. No other century comes close. So economic growth itself is a relatively recent story. Those statistics seem a fair reflection of the speed with which the world has been changing for the last 200 years, even if they tell only part of the story of economic and social change. We live in revolutionary times, but so did our parents, and their parents — indeed, the last 10 generations. It isn't quite clear, then, whether the revolution the Tofflers have in mind is business as usual or an even more astounding process of economic change. One presumes the latter, although, beyond the occasional nugget, 'Revolutionary Wealth' eschews a historical perspective. The Tofflers do well when throwing ideas at the wall and seeing what sticks: a dieters' credit card that won't work at Taco Bell, urine analysis every time you use your own bathroom or a hepatitis vaccine administered through genetically engineered bananas. Some of the forecasts are provocative — notably the rise of a Chinese leader, a Mao II, who sweeps away the communists with a strange, savage Christian fundamentalism. Many will scoff, but this unlikely event is the sort of imaginative thinking that a decent futurologist needs to produce. Still, the Tofflers do not spend enough time making the case for Mao II. Nor do we get much elaboration of the observation that the end of the age of oil will disrupt political and religious structures in the Middle East. A good point, but can we hear more? Moreover, too much of the book is wasted on the familiar. We are told that people today watch a lot of hospital dramas and have access to medical information on the Internet, and so they arrive at their doctors' offices armed with preconceptions about their treatment. Instead of extrapolation or further investigation of what this means, the Tofflers offer bluster: 'Here, changes in relationships to the deep fundamentals of time and knowledge have radically altered medical reality.' It is a shame that the Tofflers did not dip further into the growing literature on earlier economic revolutions. Robert J. Gordon of Northwestern University has skeptically contrasted the Internet to five truly revolutionary technologies: electricity, the internal-combustion engine, bulk chemical processing, information technologies such as the telephone and the telegraph, and (funny but true) indoor plumbing. These astonishing clusters of innovation set a high benchmark for anyone claiming that change is about to accelerate today. History also tells us that new technologies often outpace social and organizational change but have little effect until society catches up. Paul A. David, an economic historian at Stanford, has shown how much had to bend or break before electrification became economically significant: a huge shock to the labor market as borders were closed in 1914, and in the 30 years following Edison's illumination of the streets of New York, a reorganization of American factories encompassing everything from the architecture to the employment contracts. It would have been fascinating to see the Tofflers discuss these remarkable stories and draw lessons for today's communications technologies. Unfortunately, the Tofflers have little time for history and less still for economists, whom they dismiss as 'inerrantist' and overfond of jargon. But 'Revolutionary Wealth' contains more jargon than a dozen economics papers, including such gems as 'obsoledge,' 'complexorama' and 'producivity.' This is not mere quibbling. Good futurology is the art of telling a good story. The story must be new, and it must be persuasive; the scenarios need to be plausible as well as provocative. 'Revolutionary Wealth' is breathlessly enthusiastic, but that is not the same thing. This will be a useful scrapbook for the apparently limitless army of professional soothsayers, but most readers will prefer a simpler, stronger tale. Or so I predict. Tim Harford, a Financial Times columnist, is the author of 'The Undercover Economist.'" Reviewed by Tim Harford, Washington Post Book World (Copyright 2006 Washington Post Book World Service/Washington Post Writers Group)
(hide most of this review)
"Brilliant, incisive, and seminal, this book will be talked about for years to come. Highly recommended." Library Journal
"Toffler's pessimism has certainly tempered in the years since Future Shock; this time the authors take a historical perspective and wax philosophical on this little slice in time we call the twenty-first century." Booklist
"[The Tofflers] argue convincingly that we are on the verge of a post-scarcity world that will slash poverty and 'unlock countless opportunities and new life trajectories,' at least if we avoid the rapidly escalating risks to such progress." Nick Gillespie, The New York Times Book Review
Bursting with practical ideas about when, where, and how America and the world are changing, "Revolutionary Wealth" provides a clear, coherent framework that gives readers powerful tools for thinking about--and preparing for--what the Tofflers call the most massive, most creative, fastest expansion of the money economy in human history.
About the Author
Alvin and Heidi Toffler's other books include The Third Wave, Powershift, The Culture Consumers, War and Anti-War, and Creating a New Civilization. The authors are founders of Toffler Associates, advisers to companies and governments worldwide on advances in economics, technology and social change. In France, where the Tofflers' work has won the prestigious Prix du Meilleur Livre Étranger, Alvin Toffler has been named an Offcier de L'Ordre des Arts et Lettres. Heidi Toffler holds multiple honorary doctorates in law and letters and has been awarded the medal of the President of the Italian Republic for her contributions to social thought. Their monthly column appears in major newspapers around the world.
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Dr. Keith T. Rott, MD
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- (706) 295-5331
Dr. Keith T. Rott graduated from the Emory University School of Medicine in 1998. He works in Rome, GA and 1 other location and specializes in Rheumatology. Dr. Rott is affiliated with Cartersville Medical Center, Floyd Medical Center and Redmond Regional Medical Center. He speaks English and Spanish.
Gender: Male
Languages Spoken: English, Spanish
Medical School: Emory University School of Medicine; Graduated 1998
*This physician has multiple office locations. See Office Information for details.


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Elizabeth Schoonmaker
Books by this Author
My Life in 8 Words
Author Revealed
Q. What is your motto or maxim?
A. Be spontaneous!
Q. What is your favorite occupation, when you're not writing?
A. Gardening
Q. If you could meet any historical character, who would it be and what would you say to him or her?
A. Thank you, Vincent VanGogh
Q. What 3 personal qualities are most important to you?
A. Honesty, natural and kindness
Q. What are your most overused words or phrases?
A. Hold on


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Wright Plus 2015 Concert
Wrap-up your Wright Plus experience at Unity Temple with a lively evening concert by Chicago's premier gypsy-jazz band, Swing Gitan. The group plays foot-tapping music on acoustic instruments in the style of 1930's guitarist Django Reinhardt. It's a blend of the jubilant swing of early jazz and the feisty passion of gypsy music, with a strong dose of guitar pyrotechnics and virtuosic improvisation.
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Tin Fish
Renowned for fresh seafood and oysters as well as aged steaks. A much respected wine list and bar deep in aged spirits.
CITY:Tinley Park
Kite Fly
All ages are welcome to come and create a kite and enjoy a day of fun! Concessions will be available to purchase for a picnic lunch with your friends and family!
CITY:Oak Forest
Time Travelled Collectible Toy Show
Ever wonder where you can find those old collectible toys that you can never find anymore? Join us for our Toy Show and choose from a huge selection of collectibles such as G.I. Joe, Hot Wheels, Action Figures, PEZ and more!
CITY:Oak Forest
Halloween Casket Races
The Annual Casket Race is back! The Casket Race features trophies for 1st, 2nd and 3rd place, plus the most frightfully funny and creepy designs. Cheer on your favorite team - or join the race!
CITY:Forest Park
25th Annual Berwyn Route 66 Car Show
The 25th Annual Berwyn Rt66 Car Show sponsored by Paisans Pizzeria & Bar will be held on Ogden Avenue in Berwyn. Berwyn has always been a great Route 66 town with a thriving, dynamic and fast-growing community at its hear. Stand on Historic Route 66 and see over 500 vintage and custom cars, trucks and motorcycles. This show has something for everyone! Demonstrations of Automobile Flamethrowing will thrill spectators!
BAM Fest
The Berwyn Park District presents BAM (Berwyn Arts & Music) Fest on Saturday, July 25th in Proksa Park. This Youth Arts & Music Festival will feature live music, youth art galleries, art creation stations, workshops and fun activities. This event will also feature a battle of the bands and teen lounge with live DJ's.
Paramount Theatrical Production: West Side Story
It's quite possibly one of the greatest love stories ever to be told in a musical. Set in the blue-collar neighborhood of New York's Upper West Side, racial tensions run high as residents try to grind out a daily living. A turf war is being fought as the Jets, a white gang, and the Sharks, a Puerto Rican gang, battle over boundaries. In the heart of the turmoil, former Jets member Tony meets Maria at a local dance. The chemistry is instantaneous, and for a few hours, there is no race, no hatred, no barriers, just two young people in love. But Maria is the sister of Sharks' leader Bernardo, and no one is going to make it easy for Tony and Maria to escape.
Family Camp Out
Enjoy a summer night camping under the stars. Scavenger hung, a late night campfire, hot dog and S'Mores roast is included. Must bring own tent, sleeping bag and camping equipment.
CITY:Oak Lawn
Time Travelled Collectible Toy Show
Have you ever wondered where you can find those old collectible toys that you can never find anymore? Join us for our Toy Show and choose from a huge selection of collectibles such as G.I. Joe, Hot Wheels, Action Figures, PEZ and more!
CITY:Oak Forest
Art dans la Rue
Embrace European culture at Downtown Oak Park's French street festival featuring art, food, wine, music, film, dance and more! The event will be held on August 4th from 12-9 p.m.
CITY:Oak Park
Summer Nights On Madison
Join us in Downtown Forest Park June through August! Special shopping events, drink & food specials, live music and much more-every Thursday night through August. Check the Summer Nights Facebook Page for details.
CITY:Forest Park
Dog Days of Summer
On July 30th this Thursday Night is for the dogs! Madison Street pays homage to the Animal Care League of Oak Park! Dogs and cats will be available for adoption. Contests for dog lovers of the area! Special savings and free treats too. 5% of sales will go to the Animal Care League of Oak Park.
CITY:Forest Park
Lagoon Fire on the Water
Bring your blanket and cards and relax. We will have fires going in the lagoon for everyone to come and see. We will also have balloon artists (free) and refreshments for purchase. A great night for the whole family!
CITY:Oak Forest
Smallville Superfest
This festival is to celebrate the spirit of everyone's favorite SuperHero and what he stands for. "Man of Steel" which was released in 2013, was filmed in Plano, IL and appears as "Smallville" in the film.
Illinois State Open
The Illinois State Open is a five-round miniature golf tournament sanctioned by the USPMGA and held at the championship-level Ball Fore Miniature Golf Course.
Old Times Family Picnic
Bring your friends and neighbors out for a day of old fashion fun! This day will offer food vendors, live music, kiddie rides, bean bag tournaments, kids games, a petting zoo, and much more! Don't miss out on the fun!
CITY:Oak Forest
Walk to Cure Arthritis
The Walk to Cure Arthritis is the Arthritis Foundation's nationwide signature event that unites communities across the country to put an end to arthritis. The event features a three mile and one mile course, with arthritis information and activities for the entire family. Pet owners are encouraged to bring their dogs.
CITY:Orland Park
Chicagoland Unconventional Bicycle Expo (CUBE)
The only place where you can test ride:unicycles, recumbents, trikes, cargo bikes, tandems and electric bikes all in the same place. Then walk the show and see a full line of the newest accessories, clothing, shoes, etc. Not to mention the touring companies, and bike clubs. You won't want to miss this show. It's the only one of it's kind in the America's.
CITY:Tinley Park
Winterfest in Downtown Oak Park
Collect sweet treats at this signature holiday cookie walk on December 5th (11 a.m.-3 p.m.). Take photos with Saint Nicholas and enjoy a variety of family friendly entertainment acts.
CITY:Oak Park
Taste: Just a Bite of Forest Park
On August 27, join all participating eateries for a weekend of locally made home grown food! Special tasting plates and drink specials will be featured at all restaurants.
CITY:Forest Park
StoryWalk Grand Opening
This nationally recognized program encourages literacy and promotes physical activity.
CITY:Oak Lawn
Summer Concert Series
Summer Concert Series kicks off on Sunday, May 31 on the Village Green. BAND TBD visit website www.oaklawn-il.gov for more information.
CITY:Oak Lawn
Green Halloween
Follow the Green Pumpkin Trail to collect healthy treats from local businesses and participate in kids' activities including pumpkin painting and costume swap. Join us October 17th from 11 a.m.-3 p.m.
CITY:Oak Park
Holiday Preview
Join us and see what fabulous offerings the boutiques and shops have for Holiday 2015! Bring a food donation for the Forest Park Food Pantry and receive a special savings!
CITY:Forest Park
Spring at the Farm
Dickson-Murst Farm is turned into an antique truck and tractor show with petting zoo, hayrides, crafts and music the ole' time way!
Montgomery Fest
Each summer, Montgomery Fest brings together neighbors and friends from throughout the area to enjoy a weekend of old-fashioned family fun. Held the second weekend in August along the banks of the Fox River, highlights of the Fest include musical performances, carnival rides, a wide range of food vendors, free pony rides and petting zoo, a fishing derby, a car show and a parade.
Paramount Theatrical Production: A Christmas Story
One of the most watched and beloved Holiday movies ever made comes to life in a full-blown musical production on the Paramount stage. It's the story of nine-year-old Ralphie Parker growing up in middle-America in the 1940s. With Christmas right around the corner, Ralphie has his bespectacled sights set on one thing – a Red Ryder BB Gun. But at every turn, the young daydreamer hears those five words that are the bane of his existence: "you'll shoot your eye out."
Western Open
The Western Open is a ten-round miniature golf tournament sanctioned by the USPMGA and held at the championship-level Ball Fore Miniature Golf Course.
Movies on the Green
Movies on the Green are held on our Village Green. The event is free. Bring a blanket or lawn chair! Enjoy a movie under the stars! Begins at Dusk.
CITY:Oak Lawn
Microbrew Review
Sample craft beer from Midwestern microbreweries at this zero-waste event presented by Seven Generations Ahead. Join us in Downtown Oak Park August 15th from 3-7 p.m.
CITY:Oak Park
Forest Park Sidewalk Sale
Big deals all along Madison Street! Bring friends and browse our stores and grab a bite to eat at one of our many restaurants!
CITY:Forest Park
El Día de los Niños
Traditional Latin American event recognizing the importance of children and endorsing their well-being. Live entertainment and activities.
Berwyn's Oktoberfest 2015
Save the dates for Friday, September 18th from 6-11 p.m. and Saturday, September 19th from Noon-11 p.m. and make the trip to Berwyn's Historic Depot District. The event boasts an international food court, carnival and amusement rides, family entertainment pavilion, and crafters and vendors. Enjoy live musical performances, a Beer Garden featuring special Oktoberfest seasonal selections!
Thursday Night Out
Participate in the popular dine-around program and enjoy world music at Thursday Night Out's outdoor concert series - wine and beer available to purchase. May 21-August 27 Thursdays 5-9 p.m.
CITY:Oak Park
Shop Outdoor Sale
Join us in Downtown Oak Park July 16th (10am-9pm), 17th (10am-8pm), and 18th (10am-5pm) for our shop outdoor sale. Browse tables and racks to find the best deals of the season.
CITY:Oak Park
Celebrate fall at this free two day music festival offering a premier line-up, seasonal food, microbrews, wine and Kids' Root Beer Garden. September 18th 4-10 p.m. & September 19th 12-10 p.m.
CITY:Oak Park
Home for the Holidays in Downtown Oak Park
Catch the old-fashioned holiday spirit with free horse-drawn sleigh rides and a visit from Santa!
CITY:Oak Park
Autumn Wine Walk
Experience an afternoon of wine-tastings at unique boutiques and specialty shops! Enjoy appetizers from local restaurants and great deals while shopping for the Holidays!
CITY:Forest Park
2015 Annual Holiday Walk
Live window displays, horse-drawn carriage rides and Santa and his reindeer are just part of the magic of The Annual Holiday Walk. Enjoy winter on Madison Street!
CITY:Forest Park
Oak Forest Park District Farmers Market
Join us every Saturday for fresh grown and hand crafted goods. We will also have weekly events in conjunction with the market. See you there!
CITY:Oak Forest
Alsip Street Fair
Featuring children's Musician "Laura Doherty and The Heartbeats". and the headlining "Brass from the Past". Also a petting zoo, pony rides, inflatables, kids crafts and gaming, face painting, balloons, bingo, cocktails, food, a raffle, vendors, and more!
Spooktacular Golfing
Come golfing at our mini golf course with this "spooktacular" set up! Ghosts and gruesome goblins inhabit this golf course for the day to create a unique and fun golfing experience!
CITY:Oak Forest
12th Annual Spring Housewalk
"Decades of Design in River Forest" is the theme of our 2015 spring house walk, which features five homes in River Forest, spanning 125 years of architectural design and community history. The 12th annual walking tour of the interiors of five private homes takes place from 1-5 p.m. on Sunday, May 3rd. This year's walk puts the spotlight on the wide variety of homes in the village, from the landmark Blocki House, built around the time the village was incorporated in 1880, to a contemporary home built in 2005 which features a glass atrium. Advanced tickets are $30, $25 for members and can be purchased on our website. Tickets also can be purchased for $35 on the day of the walk at Christ Episcopal Church.
CITY:River Forest
Earth Day / Arbor Day
Children's activities, crafts, petting zoo and pony rides. More than 80 exhibitors; energy solutions, natural products, eco-vehicles and animal presentations.
CITY:Homer Glen
Forest Park Wine Walk
Experience an afternoon of wine-tastings at unique boutiques and specialty shops! Enjoy appetizers from local restaurants and great deals while shopping the best on the street.
CITY:Forest Park
Forest Park Music Fest
Celebrate Summer at the all new Music Fest on Madison. Enjoy Chicago's best up-and-coming bands, artisans, local food vendors and merchant sidewalk sales.
CITY:Forest Park
Sugar Grove Corn Boil
Live entertainment, carnival, crafts, 5K run, fireworks and lots of corn! Fun for the whole family. Free parking and shuttles.
CITY:Sugar Grove
Gallery Night: Beach Calm
Come out for the opening of "Gallery Night" and enjoy free drinks, appetizers and good times. Enjoy relaxing beach scenes masterfully crafted with colored pencil by students of Andria Burchett from Beech Tree Studio in Geneva. If you can't make it for the opening event, the artwork will be on display through April 29th during regular business hours.
North Aurora Days
The Village of North Aurora is proud to continue the North Aurora Days tradition of providing a fun-filled weekend of activities and entertainment for the whole family in our great community. The sponsors, volunteers, and participants of North Aurora Days have been working hard to plan and provide a great celebration filled with fun for the entire family. This year's festival will begin on Friday, August 7th with various events during the day. The emergency vehicle parade kicks off the Friday night festivities leading the spectators to our main stage, where they will enjoy a variety of food, beverages, and musical entertainment. Saturday, August 8th will be filled with a 5/10k race, fishing derby, Touch-a-Truck and more all ending on Sunday, August 9th with the fun filled pet parade.
CITY:North Aurora
Viva Italia: Italian Night
O Sole Mio! Join us for a fabulous Thursday night of great food, music an store specials. We have a lot of Italy on Madison Street!
CITY:Forest Park
Taste of Main Street
Join us for this annual tradition and enjoy an eclectic mix of small plates and sweets. Stick around for an after-party with entertainment. Tickets include food samples and after-party.
Paramount Theatrical Production: Oklahoma!
This is the show that set the standard for all future musicals by incorporating music, lyrics and dance into a well-crafted serious story. It's also the debut collaboration of one of the most prolific writing teams in American theater history – Rodgers and Hammerstein. Set in the turn of the century Oklahoma Territory, tensions are mounting between the local farmers and cowboys over the use of land. In the midst of it all is the rugged cowboy Curly who's fallen for the strong-headed farm girl, Laurey. Despite their fiery spirits and at times tumultuous relationship, the two are destined to start a new life together in the soon-to-be state called Oklahoma!
Hailstorm Brewing Company
Hailstorm Brewing is a regional craft brewery with a full tap room offering a variety of rotating and seasonal craft beers. (Food is available from nearby restaurant).
CITY:Tinley Park
Summer Solstice Festival
Craft Beer and Indie Music Festival along the Fox River. Stay tuned for detailed line-up.
Clean Sweep Garage Sale
One person's junk transforms into another's treasure at the annual Depot District Clean Sweep Garage Sale. Browse 5 stories of good finds and leave knowing that you've lived the spirit of the word "recycle." Future generations will thank you for this shopping trip. Free electronic recycling will be available via a "donation" to Seguin Services. Bounce Sports will be offering free use of their batting cages from 9 a.m. to 2 p.m. for those that attend the sale! The event will take place in Berwyn's Depot District in the Municipal Parking Facility between 8 a.m. and 3 p.m. on Saturday, June 7th.
Batavia Riverwalk
As the centerpiece of downtown Batavia, the Riverwalk extends along the Depot Pond and Fox River to a north point pavilion, where grand views of the Fox River are available.
Open Air Market - Mokena
Open-air market featuring traditional farmers market vendors and artisan crafters. Saturday 8:30AM-12:30PM.
Egg-Streme H2O Adventure - Lockport
Join the Lockport Township Park District for Egg-streme H20 Adventure for all ages on Fri., April 3 from 5pm-7pm at Challenge Fitness Pool, 2021 S. Lawrence Ave., Lockport. Hop and splash around our green pool, enjoy music, treats and games while gathering a basket of eggs. Fees are per child. Fee: $9/Resident-$11/Non-resident. Registration is required. To register or for more info., call 815-838-3621, ext. 0.
Music in the Plaza
Enjoy music under the stars. Food and beverages are available. Don't forget your lawn chairs and blankets. This date will also feature the artists who design the Benches on the Avenue.
CITY:Tinley Park
Party in the Park Celebration
A three day outdoor festival which includes live entertainment, food, children's games, activities, car show/cruise night and fireworks.
CITY:Orland Hills
Ribs on the River & Whitewater Festival
The smell of BBQ ribs will be wafting around the Bicentennial Riverfront Park as the United City of Yorkville hosts its 4th annual Ribs on the River backyard BBQ contest! Enjoy Whitewater events, food and entertainment throughout the day. For more information or to register to participate in the BBQ contest, contact the Yorkville Parks and Recreation Department.
Gluten Free and Allergen Friendly Expo 2015
The GFAF Expos are the largest and fastest growing special diet consumer events in the US. Started in 2007, the events are professionally managed and have expanded from one to seven cities throughout the United States. In addition to meeting the needs of the Celiac community, the Expo welcomes those with gluten sensitivities, auto-immune/inflammatory diseases and autism. What do you get with your Expo Ticket? Entry into the vendor fair with over 100 brands Valuable coupons at the vendor booths Samples from the vendors Discounted products available for purchase Informative classes related to the gluten free and allergen-friendly lifestyle Free reusable bag to carry your goodies Meet your favorite vendors, authors and blogger
Music in the Plaza
Enjoy music under the stars. Food/beverages are available. Don't forget your lawn chairs.
CITY:Tinley Park
Windmill City Festival
The Windmill City Festival has long been a staple of the community and has become a tradition for many families. Come participate in the festivities that every family member is sure to enjoy. Hours: Thurs. at 6 p.m., Fri. at 12 p.m., Sat. at 8 a.m., and Sun. at 11 a.m.
Cinco de Mayo Restaurant & Bar Crawl
Join us in the global celebration of Mexican culture! The Cinco de Mayo Fiesta is a food and bar crawl that will feature live entertainment, food and libations and fun for the 21+ crowd. Registration begins at 5:30 p.m. at event headquarters at La Quinta de Los Reyes Restaurant. Participation in the crawl is $15 pre-sale and for BDC members. Registration at the door will be $20 for non-BDC members. Wrist bands include admission to the crawl, free trolley between venues, one drink ticket, $3 beer at participating venues, drink specials, commemorative 12 oz mug to the first 150 registrants and catered buffet and entertainment beginning at 7:30 p.m. at La Quinta de los Reyes. The crawl will tour Berwyn's Cermak Road and takes place rain or shine! This event is brought to you by the Cermak Road Special Events Commission of the Berwyn Development Corporation.
Music in the Street
Be part of the Depot District's tradition at the 5th Annual Music in the Street event on July 18th. The festival will feature live local bands, food and vendors. Admission is free, open to all-ages, and dog-friendly.
Dinner Detective Murder Mystery Show
The Dinner Detective is the largest, award-winning, interactive comedic murder mystery dinner show in the Chicagoland area. We are now running public and private shows in 34 cities across the country every week. The shows are set in the present day. Unlike other murder mystery dinner shows, here you will find no cheesy costumes, no recited campy dialogue and no hokey song and dance. Our performers are dressed just like everyone else, leaving all of the guests to suspect who is a part of the show and who is not. In many instances, guests are seated with the performers and don't even realize it until they die...the performers, that is! Our Detectives proceed to interrogate everyone and find clues as more people die. At the end of the night, prizes are awarded to the Top Sleuth who solves the crime. Each ticket includes a reception with tray passed appetizers, mixed green salad, choice of entree (beef, chicken or pasta), dessert, award winning interactive Murder Mystery show, prizes and so much more. **Every Saturday night through 12/26/2015.
Discover Tinley Community Awareness Expo
Visit Discover Tinley to learn more about what the Village of Tinley Park has to offer. This free event features entertainment, food samples and giveaways at many of the booths. 10AM-3PM
CITY:Tinley Park
Concert In The Park
This will be the 32nd annual Concert In The Park. Join the Palos Park community as we enjoy a concert band perform crowd favorites. A dance floor is provided. 5-9:30PM.
CITY:Palos Park
Tinley Park Brew & Fest
The Brew & Vine Festival is the Tinley Park Chamber of Commerce's signature event that draws 4000+ attendees from the Southwest Suburbs, Chicagoland, and from across the Midwest. Sample brews, wine and food from more than 65 vendors. Enjoy live entertainment and a great night out.
CITY:Tinley Park
The Diary of Anne Frank
The Diary of Anne Frank is a look into the mind and life of a normal teenage girl who was put through extraordinary circumstances. Anne and her family are forced into hiding while the Nazis take over Europe. Through this retelling, we see what life was like for Anne while being hidden from the world for two years. As WWII marches on, Anne grows and matures, questioning why she is being persecuted. It's a compelling story that shouldn't be missed.Recommended for grades 5-12.
CITY:Arlington Heights
The McCartney Years
There are many Beatles tributes, but only one note-for-note recreation of a Paul McCartney "Wings Over America" concert from 1973…and this is it! The McCartney Years is the premiere Paul McCartney concert experience.
34th Annual American Music Festival
Americana and roots music fans will find a full menu of talent at FitzGerald's 34th Annual American Music Festival brought to you by FitzGerald's. The summer 3-day event features more than 50 artists from Chicago and around the country. FitzGerald's American Music Festival takes place rain or shine on three stages -- club, tent and SideBar. Hours are 4:30 p.m. to 1 a.m. on July 2, 4:30 p.m. to 2 a.m. on July 3 and 4; 1 p.m.-3 a.m.
Benches on the Avenue
This award-winning public art program features benches that showcase the unique and colorful designs of professional and amateur artists. The theme for 2015 is "Heroes and Villains".
CITY:Tinley Park
Blues On The Fox
A celebration of Aurora's rich Blues history with incredible music and top Blues artists! Full line up to be announced 10 am on April 2!
Puerto Rican Heritage Festival
It's a two-day festival celebrating the rich heritage of Puerto Rico. Put on by the Aurora Puerto Rican Cultural Council, the weekend features endless food vendors offering wonderful cuisine; domino competitions; traditional folk music; other Puerto Rican bands; a kids' play area; novelty vendors; Puerto Rican craftsmanship vendors and non-stop fun. And don't forget to take in the sights and sounds of the Puerto Rican Day Parade on Sunday.
Flat Stanley
Stanley Lambchop is just like everyone else. That's the problem. For Stanley, life is too normal. He wants to travel the world, do something amazing. Something no one's ever seen before. Careful what you wish for Stanley! One night the bulletin board on the wall above Stanley's bed comes loose and falls-right on top of Stanley. The next morning Stanley Lambchop wakes up flat. Not just a little flat…Really flat! In a whirlwind musical travelogue Stanley, the ultimate exchange student, explores the globe and learns that heroes come in all shapes and sizes. More info at www.holdenarts.org.
Geneva City-Wide Garage Sale
The Geneva Chamber of Commerce will be welcoming thousands of shoppers to Geneva by offering the convenience of a city-wide Geneva garage sale. it will be held April 24th and 25th, 2015 from 8 am – 4 pm both days.
April Food Day
April Food Day is an event to promote awareness of food pantries by bringing your local community together to participate in a local food drive.
CITY:Tinley Park
Dollinger Family Farm
October brings pumpkins, hayrides, corn maze, train rides, farm animals, and fun. Also come see our Civil war reenactment the third weekend in October. Warrior Dash Midwest in June. On site gift shop.
Riverside Arts Weekend
The Riverside Arts Weekend (RAW) features a juried arts fair, theater, music, architecture and other arts-related events. This is a vibrant cultural weekend that brings thousands of visitors and residents together to mingle and walk the streets of historic downtown Riverside. The weekend will be located inside Guthrie Park in Riverside, IL.
Kane County Flea Market
The best in the Midwest or anywhere. Up to 1,000 dealers display and sell antiques, collectibles and "fancy junque." A country breakfast is served on Sundays.
CITY:St. Charles
Depot District Mini-Golf Pub Crawl
Grab your putter and 3 friends and tour the Depot District's repertoire of taverns and restaurants at the 11th Annual Depot District Mini-Golf Pub Crawl! Each venue will display a handmade mini-golf green to challenge the event's spirited crowd! The event will tour Berwyn's Depot District and takes place rain or shine! A free heated trolley will be available. Sign-in from 11 am to Noon at Connie's Family Restaurant with Tee off at Noon from our participating venues. Join us at the "19th Hole" after-party with food, beginning at 6 pm at Perception Lounge. And don't forget about the prizes! Prizes will be awarded for team's with the lowest - and highest - scores, and the Twisted Putter Trophy will be awarded to the venue voted as having the best designed hole.
White Christmas The Musical
Celebrate the holiday season with Irving Berlin's White Christmas, the merry and bright stage production based on the classic silver screen romantic comedy. When two former Army buddies, who are now Broadway performers, follow a sister act booked at a charming Vermont Inn, they soon discover that it is owned by their former commander. With no snow and no customers, the General is nearly bankrupt. To save the lodge, the two acts team up and put on a festive show packed with Irving Berlin favorites like Blue Skies, Count Your Blessings, I Love a Piano, and, of course, White Christmas. White Christmas is joyful entertainment for the entire family and will have audiences dreaming of tree tops glistening and sleigh bells in the snow.
CITY:Oakbrook Terrace
First Midwest Bank Half Marathon & 10K
Be a part of the 7th annual First Midwest Bank Half Marathon and enjoy one of the Midwest's finest events of its kind. Proceeds will benefit American Cancer Society for Prostate Cancer and Research, The South West Special Recreation Association and Lake Katherine Nature Center & Botanic Gardens.
CITY:Palos Heights
Peter and the Star Catcher
An enchanting, swashbuckling prequel to Peter Pan, Peter And The Star Catcher is an epic romp through the Neverland you never knew. A company of twelve actors play more than a hundred unforgettable characters on a journey to solve the mystery of how Peter Pan become "The Boy Who Never Grew Up." This regional premiere of the hit Broadway play is the captivating coming-of-age tale of one of classic literature's most beloved and unforgettable characters.
CITY:Oakbrook Terrace
Soulfeed Smooth Jazz Festival
Soulfeed Smooth Jazz Festival™ is proud to present the 7th Annual Smooth Jazz Festival featuring Hiroshima, Walter Beasley AND Mambo Express with Emcee: Denise Jordan Walker.
Mid-American Canoe and Kayak Race
Famously fun times! This historic, amateur canoe/kayak race is for paddlers of all ages and abilities, featuring 11 canoe divisions, 8 kayak divisions and 1 open (non-competitive) division. From the ultra-competitive to young families and newbies just wanting to enjoy a memorable paddling experience – it's all here!
Bye Bye Birdie
To conclude its 2015-2016 season, Drury Lane Theatre presents the classic All-American musical Bye Bye Birdie. It's the late 1950's, and teenagers from across the United States are going crazy for the handsome rock star, Conrad Birdie. Meanwhile, his manager Albert is going into debt and is banking on Conrad's success. Disaster strikes when Conrad receives a draft notice to join the military. Albert stages a publicity stunt for Conrad to kiss one lucky fan on The Ed Sullivan Show before he leaves for the army. Fifteen-year-old Kim MacAfee from Sweet Apple, Ohio is selected. Conrad Birdie gets more than he bargained for when he arrives in the Midwestern town which is reeling with excitement for his visit.
CITY:Oakbrook Terrace
St. Charles Fine Art Show
The 18th Annual St. Charles Fine Art Show is an award winning, highly regarded show featuring the work of approximately 100 juried artists in various mediums. The show takes place on Memorial Day weekend.
CITY:St. Charles
Rani Arbo & Daisy Mayhem Concert
Musically, Rani Arbo & Daisy Mayhem are a melting pot of American folk melody and style, "a mini music festival of different styles filtered through the vibrant interaction of all four players." (Dirty Linen) Their shows sparkle with songs and stories that celebrate and tackle the human condition. Tickets starting at $26.
CITY:River Forest
9th Annual Red Carpet Corridor - Joliet Area Historical Museum
The 9th Annual Red Carpet Corridor including activities at the Joliet Area Historical Museum. It is all about family fun on the most famous road in America - Route 66. This year's event will be Saturday, May 2, from 8 AM to 5 PM, and Sunday, May 3, from 8 AM to 3 PM. Sponsored by the twelve communities which make up the 90-mile linear museum from Joliet to Towanda, the annual festival invites everyone to experience the good life in the slow lane. Each community will produce its own events. From full-blown festivals to antique and craft sales, art sales, car and motorcycle shows, live entertainments, and plenty of yard, garage, and sidewalk sales along the way, everyone is sure to discover something unique. Food, snacks and treats will be in abundance, and there are plenty of historic sites, outstanding free museums and unique mom & pop businesses to help create a nostalgic journey for all to enjoy. Visitors can simply enjoy the drive, stop and have their picture taken with Elvis, or do a little shopping in any of the great stores along the Mother Road.
Uncork Illinois Wine Festival
Wine aficionados will have a unique opportunity to sample over 150 wines from more than 15 local wineries and taste locally-produced artisan foods at Downtown Oak Park's Uncork Illinois.
CITY:Oak Park
Rainforest Cafe
A wild place to shop and eat! Dine among dolphins, monkeys, gorillas and the tropical fish of the rainforest. Rainforest Cafe serves American cuisine with adventurous flair, such as Jungle Steak and Shrimp, Tribal Salmon, and Mojo Bones slow roasted spareribs. Inquire about special group bookings and Birthday Bash celebrations.
Anne Hills & Michael Smith in Concert
Join us at West Suburban Temple Har Zion for a great Folk Concert, starring Anne Hills and Michael Peter Smith! Tickets are $25, doors open at 8:30 p.m. and the concert starts at 9 p.m.
CITY:River Forest