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This Australian documentary, that has won praise from professionals in the field, highlights how real estate distorts the rest of the economy.
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a way to have everybody pulling on the same end of the rope. Last summer's expansive forest fires shed light on growing class resentment in the West. Old log-gers and ranchers rankled at the new urgency to stamp out the blazes that threatened the recent Aspenesque settlers. The newcomers expected working class firemen to make protecting their expensive homes top priority. (Chr Sci Mntr, Spt 7) The tinder for this envy? Rich people moving in bid up the price of land, making it hard to afford by people on the margin. The fault really lies with our system of privatizing land value. If this rising value were collected by land dues and shared by rent dividends – the essence of geonomic policy – who'd complain? The more people move in, the higher the land value, and the fatter the dividend paid to residents. Then people on the margin might go out of their way to invite rich outsiders in.
a study of a phenomenon David Ricardo noted going on two centuries ago. When wine grapes rise to $10,000 a ton from the very best land (last year, cabernet sauvignon commanded an average of $4,021 a ton in the Napa Valley), then vineyard prices soar from $18,000 an acre in the 1980′s to $100,000 an acre five years ago and now for a top pedigree up to $300,000 an acre (The New York Times, April 9, via Wyn Achenbaum). Pricey land does not make wine pricey; spendy wine makes land spendy. While vintners make their wine tasty, nature and society in general – not any lone owner – make land desireable. Steve Kerch of CBS's MarketWatch (April 5) notes that much of what a home sells for on the open market is a reflection of intangible factors such as what school district the house sits in. The price the builder has to pay for the land also tends to be driven by the same intangibles. Because the value of land comes from society, and because one's use excludes the rest of society, each user owes all others compensation, and is owed compensation by everyone else. Sharing land's value, instead of taxing one's efforts, is the policy of geonomics.
the policy that the earth's natural patterns suggests. Use the eco-system's self-regulating feedback loops as a model. What then needs changing? Basically, the flow of money spent to own or use Earth (both sites and resources) must visit each of us. Our agent, government, exists to collect this natural rent via fees and to disburse the collected revenue via dividends. Doing this, we could forgo taxes on homes and earnings and subsidies of either the needy or the greedy. For more, see our web site, our pamphlet of the title above, or any of our other lit pieces; ask for our literature list.
an economic policy based on the earth's natural patterns. Eco-systems self-regulate by using feedback loops to keep balance. Can economies do likewise? Why don't they now produce efficiently and distribute fairly? The answers lie in the money we spend on the earth we use. To attain people/planet harmony, that financial flow from sites and resources must visit each of us. Our agent, government, must collect this natural rent via fees and disburse the collected revenue via dividends. And, it must forgo taxes on homes and earnings, and quit subsidies of either the needy or the greedy. As our steward, government must also collect Ecology Security Deposits, require Restoration Insurance, and auction off the occasional Emissions Permit. And that's about it – were nature our model.
an answer to a rarely asked question. If price is a reward for production, why do we pay for land, never produced by any of us? What is land price a reward for? Good behavior? How much money do we spend on the nature we use? Who gets it? What do they do with it? (If you answer all these correctly, you're not a genius but a geoist.) The worth of Earth is enough that were we to collect and share it, we could abolish taxes on the goods we do produce. For example, San Francisco's Redefining Progress has calculated that Cali-fornia could abolish all state and local taxes were it to collect the values of resources and of using na-ture as a dump. By exorcising the profit motive from depletion and pollution, rent collection could replace bossy regulation. Economies could self-regulate, as the rest of the eco-system does. See how big problems yield to big answers when we ask the right questions?
one of many words I coined over 20 years ago: geoism, geonomics, geonomy, geocracy, etc – neologisms that later others came up with, too. CNBC once had a Geonomics Show, and Middlebury College has a Geonomics Institute. If "economy" is literally "management of the household", then geonomy is "management of the planet". The kind of management I had in mind is not what CNBC was thinking – top-down. My geonomics is not hands-on, interfering, but hands-off, organic. It'd strive to align policy with natural processes, similar to what holistic healing does in medicine, what organic farming does in agriculture. Geonomics attends to two key components: One, the crucial stuff to track is fat – or profit, especially profits without production, such as rent, or all the money we spend on the nature we use. Society's surplus is the sine qua non for growth, needed to counter death – not merely more, but sustainable development, more from less. Two, the basic process to respect is the feedback loop. These let nature maintain balance automatically and could do the same for markets, if we let them. Letting them would turn our economies, now our masters, into a geonomy, our servant, providing us with prosperity, eco-librium (to coin a term) and leisure, time off – a hostile environment for economan but a cradle for a loving and creative humanity.
as unfamiliar as geo-economics. The latter is a course some universities offer that combines geography and economics. A UN newsletter, Go Between (57, Apr/May '96; thanks, Pat Aller), cited an Asian conference on geopolitics and "geoeconomics". The abbreviated term 'geonomics" is the name of an institute on Middlebury College campus and of a show on CNBC. Both entities use the neologism to mean "global economics", in particular world trade. We use geonomics entirely differently, to refer to the money people spend on the nature they use, how letting this flow collect in a few pockets creates class and poverty and assaults upon the environment, and how, on the other hand, sharing this rental flow creates equality, prosperity, and a people/planet harmony. This flow of natural rent, several trillions dollars in the US each year, shapes society and belongs to society.
of interest to Dave Lakhani, President Bold Approach (Mar 8) and Matt Ozga (Jan 29): "I write for the Washington Square News, the student run newspaper out of New York University. Geonomics seems like it has great significance, especially in this area. When was geonomics developed, and by whom?" About 1982 I began. Two years later, Chilean Dr Manfred Max-Neef offered the term geonomics for Earth-friendly economics. In the mid-80s, a millionaire founded a Geonomics Institute on Middlebury College campus in Vermont re global trade. In the 1990s, CNBC cablecast a show, Geonomics, on world trade as it benefits world traders. My version of geonomics draws heavily from the American Henry George who wrote Progress & Poverty (1879) and won the mayoralty of New York but was denied his victory by Tammany Hall (1886). He in turn got lots from Brits David Ricardo, Adam Smith, and the French physiocrats of the 1700s. My version differs by focusing not on taxation but on the flow of rents for sites, resources, sinks, and government-granted privileges. Forgoing these trillions, we instead tax and subsidize, making waste cheap and sustainability expensive. To quit distorting price, replace taxes with "land dues" and replace subsidies with a Citizens Dividend. Matt: "This idea of sharing rents sounds, if not explicitly socialist, at least at odds with some capitalist values (only the strong survive & prosper, etc). Is it fair to say that geonomics has some basis in socialist theory?" A closer descriptor would be Christian. Beyond ethics into praxis, Alaska shares oil rent with residents, and they're more libertarian than socialist. While individuals provide labor and capital, no one provides land while society generates its value. Rent is not private property but public property. Sharing Rent is predistribution, sharing it before an elite or state has a chance to get and misspend it, like a public REIT (Real Estate Investment Trust) paying dividends to its stakeholders – a perfectly capitalist model. What we should leave untaxed are our sales, salaries, and structures, things we do produce.
an answer for Jonathan of the Green Party (Nov 7): "What does 'share our surplus' mean?" Our surplus is the values that society generates synergistically. It's the money we spend on the nature we use: on land sites, natural resources, EM spectrum, ecosystem services (assimilating pollutants). It's also the money we pay to holders of government-granted privileges like corporate charters. We could share it by paying for the nature we use and privileges we hold to the public treasury then getting back a fair share of the recovered revenue. Used to be, owners did owe rent ("own" and "owe" used to be one word). And presently, some lucky residents do get back periodic dividends: Alaska's oil dividend and Aspen Colorado's housing assistance. Doing that, instead of subsidizing bads while taxing goods, is the essence of geonomics. Jonathan: "Is local currency what you mean?" Editor: It's not. Community currency is a good reform, but every good reform pushes up site values. That makes land an even more tempting object of speculation. Now, any good will eventually do bad by widening the income gap – until you share land values.
shaped by reality. In the 1980′s, the Swedish government doubled its stock transfer tax. Tax receipts, however, rose only 15%, since traders simply fled to London exchanges. Fearing a further exodus, the Swedish government quickly rescinded the tax altogether. (The New York Times, April 20) That willingness to tax anything leads us astray. Pushing us astray is that unwillingness to pay what we owe: rent for land, our common heritage. Assuming land value is up for grabs, we speculate. We cap the property tax on both land and buildings and the rate at which assessments can go up; while real market values rise quicker, assessments can never catch up. Our stewards, the Bureau of Land Management, routinely sell and lease sites below market value, often to insiders, says the Government Accounting Office. Once we grasp that rent is ours to share, we'll collect it all, rather than let it enrich a few, and quit taxing earnings, which do belong to the individual earner. That shift is geonomic policy.
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Original Article
Standardized uptake value by positron emission tomography/computed tomography as a prognostic variable in metastatic breast cancer†
Article first published online: 19 APR 2012
DOI: 10.1002/cncr.27579
Copyright © 2012 American Cancer Society
Volume 118, Issue 22, pages 5454–5462, 15 November 2012
Additional Information
How to Cite
Morris, P. G., Ulaner, G. A., Eaton, A., Fazio, M., Jhaveri, K., Patil, S., Evangelista, L., Park, J. Y., Serna-Tamayo, C., Howard, J., Larson, S., Hudis, C. A., McArthur, H. L. and Jochelson, M. S. (2012), Standardized uptake value by positron emission tomography/computed tomography as a prognostic variable in metastatic breast cancer. Cancer, 118: 5454–5462. doi: 10.1002/cncr.27579
- †
Presented in part at the 47th Annual Meeting of the American Society of Clinical Oncology; June 3-7, 2011; Chicago, IL and at the 2011 American Society of Clinical Oncology Breast Cancer Symposium; September 8-10, 2011; San Francisco, CA.
Publication History
- Issue published online: 30 OCT 2012
- Article first published online: 19 APR 2012
- Manuscript Accepted: 1 MAR 2012
- Manuscript Revised: 16 FEB 2012
- Manuscript Received: 13 DEC 2011
- Abstract
- Article
- References
- Cited By
- metastatic breast cancer;
- positron emission tomography/computed tomography;
- maximum standardized uptake value;
- prognosis;
- overall survival
In this retrospective, single-institution study, the authors examine the maximum standardized uptake value (SUVmax) on positron emission tomography/computed tomography (PET/CT) images as a prognostic variable in patients with newly diagnosed metastatic breast cancer (MBC).
Patients with ≥1 metastatic lesion on PET/CT images that were obtained within 60 days of their MBC diagnosis between January 1, 2001 and December 31, 2008 were included. Patients were excluded if they had received chemotherapy ≤30 days before the PET/CT images were obtained. Electronic medical reports were reviewed to determine the SUVmax and overall survival. Because of intraindividual variation in the SUV by body site, separate analyses were conducted by metastatic site. Relationships between site-specific PET/CT variable tertiles and overall survival were assessed using Cox regression; hazard ratios for the highest tertile versus the lowest tertile were reported.
In total, 253 patients were identified, and their median age was 57 years (range, 27-90 years). Of these, 152 patients (60%) died, and the median follow-up was 40 months. On univariate analysis, SUVmax tertile was strongly associated with overall survival in patients who had bone metastases (N = 141; hazard ratio, 3.13; 95% confidence interval, 1.79-5.48; P < .001). This effect was maintained on multivariate analysis (HR = 3.19; 95% confidence interval, 1.64-6.20, P = .002) after correcting for known prognostic variables. A greater risk of death was associated with SUVmax tertile in patients who had metastases to the liver (N = 46; hazard ratio, 2.07; 95% confidence interval, 0.90-4.76), lymph nodes (N = 149; hazard ratio, 1.1; 95% confidence interval, 0.69-1.88), and lung (N = 62; hazard ratio, 2.2; 95% confidence interval, 0.97-4.95), although these results were not significant (P = .18, P = .31, and P = .095, respectively).
The current results indicate that PET/CT has value as a prognostic tool in patients with newly diagnosed MBC to bone. Cancer 2012. © 2012 American Cancer Society.
Metastatic breast cancer (MBC) represents a significant public health problem, because approximately 33% of the 1 million women who are diagnosed annually worldwide with early stage disease eventually will experience relapse, and a smaller number of patients present de novo with this disease.1 After diagnosing MBC, clinicians and patients can use prognostic information to guide the selection of appropriate therapies to improve quality of life and maximize survival. Currently available prognostic tools focus on several clinicopathologic features, such as age and time from diagnosis of primary breast cancer, as well as tumor-related factors, like expression levels of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2). Although useful, this approach is limited because of the extensive heterogeneity in breast cancer biology and variable responses to treatments like endocrine therapy, chemotherapy, and novel targeted agents.2 Therefore, a more refined prognostic system is desirable, because this could guide the selection of more effective therapies and allow greater individualization of treatment.
Positron emission tomography/computed tomography (PET/CT) is a widely used diagnostic tool that combines anatomic imaging with functional imaging using [18F]-2-fluoro-2-deoxy-D-glucose (FDG), a biomarker of cellular metabolism. This yields quantitative information about tumor activity by assigning a standardized uptake value (SUV) as a measurement of the relative uptake of FDG in a given lesion. The improved diagnostic performance of PET/CT imaging over conventional imaging (such as ultrasound, bone scan, and CT alone) has been investigated in a variety of settings, including for the staging of high-risk patients with early breast cancer3, 4 and in the detection of bone metastases in patients with MBC.5
Although studies have examined PET/CT imaging as a predictor of treatment response in the primary tumor,6, 7 significantly less is known about how PET/CT imaging can be used as a prognostic tool by quantifying radiotracer accumulation in metastases. Limitations in published series include small numbers, lack of histologic correlates, and the intraindividual variation in SUV by body site, which occurs because of a variety of technical reasons, including motion artifact. Therefore, in the current retrospective, single-institution study, we examined baseline FDG avidity on PET/CT images assessed by the maximum SUV (SUVmax), by body site, as a predictor of overall survival (OS) in patients with MBC.
After we obtained approval from the Institutional Review Board, institutional databases from January 1, 2001 to December 31, 2008 and patients were included if, by report, they had evidence of ≥1 FDG-avid lesion on a PET/CT image that was obtained within 60 days of their MBC diagnosis (Fig. 1). Lesions at any of the following common MBC sites were eligible for inclusion; bone, liver, lymph node (LN), and lung. According to standard staging criteria, patients with axillary LN metastases were included only if they had additional sites of MBC. The date of MBC diagnosis was defined as the date a patient underwent biopsy of a metastatic site (when available) or the date of first radiologic imaging consistent with metastases as assessed by the treating physician. Because of possible confounding effects on image acquisition, patients who had received chemotherapy within 30 days before PET/CT imaging were excluded (Fig. 1). Patients were permitted to be actively receiving endocrine therapy (for early stage or newly diagnosed MBC). Electronic medical records were reviewed to determine known prognostic variables, including age, histology, grade, tumor phenotype (ER, PR, and HER2 expression), first-line treatment administered, and time from early stage disease to MBC as well as OS, which was calculated from the date of MBC diagnosis to the date of either death or last follow-up.
According to institutional standards PET/CT images from the middle skull to the upper thighs were obtained 60 minutes after administration of 12 to 15 millicuries FDG on 1 of 4 hybrid PET/CT systems; and, using standard formulae, the SUVmax by site (bone, liver, LN and lung) was calculated. For patients who had multiple metastases by site, the single lesion with the highest SUVmax was used for calculations. In a secondary analysis, all PET/CT scans were reviewed by a single investigator who had 7 years of experience in the interpretation of PET/CT (G.A.U.), blinded to survival data, and the SUVmax was recalculated. This demonstrated a close correlation between the SUVmax by report and by secondary review, as measured by the Spearman rank correlation. Therefore, in an attempt to recreate real-world practice, subsequent analyses were based on the SUVmax by original report. At this point, lesions that were deemed unmeasurable by G.A.U. were excluded from analysis, resulting in the exclusion of 21 patients (Fig. 1). OS was estimated for the entire cohort using the Kaplan-Meier method. Cox models were used to correlate OS with standard prognostic variables, irrespective of anatomic site.
All PET/CT images were analyzed by anatomic site, and patients with a lesion at that site were classified based on tertiles of SUVmax. Tertiles (as opposed to quartiles, quintiles, etc) were chosen to balance the flexibility gained by adding more groups with the need to keep group sizes sufficiently large for subgroup analyses. Some patients who had lesions at multiple sites contributed to several analyses. Relations between SUVmax tertiles and OS were assessed using Cox regression. Hazard ratios (HRs) for the highest versus the lowest tertile are reported in the text, and HRs for the middle versus the lowest tertile also are reported in the figures and tables. When a PET/CT variable was identified as significant (P < .1) on site-specific, univariate analysis, multivariate models were built to adjust for that variable. All statistical analyses were performed using the statistical software packages SAS (version 9.2; SAS Institute Inc., Cary, NC) and R (version 2.11.1; R Foundation for Statistical Computing, Vienna, Austria). P values < .05 were considered significant.
On initial review, we identified 285 patients who underwent PET/CT imaging within 60 days of their MBC diagnosis; and, after a review by the dedicated nuclear radiologist (G.A.U.), 32 patients were excluded (Fig. 1). Therefore, the final analysis included 253 patients (median age, 57 years; range, 27-90 years) who underwent PET/CT imaging a median of 9 days before MBC diagnosis (range, from 58 days before to 59 days after MBC diagnosis). The median time from diagnosis of early stage disease to MBC diagnosis was 2.2 years (range, 0-24.9 years). Other baseline characteristics are provided in Table 1.
|Baseline Characteristic
|No. of Patients
|Tumor phenotype
|ER/PR positive AND HER2 negative
|HER2 positive
|Triple negativea
|Unknown (missing HER2 status)
|Indications for PET/CT
|Other abnormal radiology
|Locally advanced breast cancer
|Abnormal tumor markers
|Other abnormal laboratory testc
|Indication not determined
|Stage at initial breast cancer diagnosis
|Treatment for early breast cancerf
|Neoadjuvant/adjuvant chemotherapy
|Adjuvant endocrine therapy
|Adjuvant radiation
|First therapy for MBCg
|Endocrine therapy
|Targeted with or without endocrine therapy
Most patients (n = 202; 80%) had a history of early stage breast cancer and subsequently developed metastatic disease. In the remaining 51 patients (20%), MBC was diagnosed within 60 days of primary breast tumor diagnosis. Almost all patients (n = 214; 85%) had invasive ductal carcinoma and ER/PR-positive, HER2-negative was the largest subgroup (n = 142; 56%). Most patients (n = 116; 46%) received endocrine therapy as their first-line treatment. Seventy-four patients (29%) received chemotherapy, and 49 patients (19%) received targeted therapy, possibly combined with chemotherapy or endocrine therapy (Table 1).
|Disease Site
|SUVmax: Median (Range)
|Bone, N = 141
|Low tertile
|4.7 (2.1-5.8)
|Middle tertile
|7.2 (5.9-9.2)
|1.36 [0.76-2.44]
|High tertile
|11.2 (9.3-29.6)
|3.13 [1.79-5.48]
|Liver, N = 46
|Low tertile
|5.4 (3.6-6.2)
|Middle tertile
|9.0 (6.3-11.1)
|1.86 [0.82-4.19]
|High tertile
|15.5 (11.2-51.2)
|2.07 [0.90-4.76]
|Lymph node, N = 149
|Low tertile
|4.2 (1.2-5.9)
|Middle tertile
|7.5 (6.0-9.5)
|1.44 [0.89-2.31]
|High tertile
|13.6 (9.6-34.0)
|1.13 [0.69-1.88]
|Lung, N = 62
|Low tertile
|2.3 (1.1-3.2)
|Middle tertile
|5.1 (3.3-7.4)
|1.08 [0.45-2.62]
|High tertile
|11.3 (7.5-24.0)
|2.20 [0.97-4.95]
Overall, 103 patients (41%) had evidence of visceral metastases (defined as lung or liver disease) on PET/CT images. According to anatomic site, the numbers of patients with metastases on PET/CT images were as follows; bone, 141 patients (56%); liver, 46 patients (18%); LN, 149 patients (59%); and lung, 62 patients (25%). In total, 228 patients (90%) had at least 1 biopsy result that confirmed the MBC diagnosis. Among the patients with FDG-avid lesions, according to anatomic site, the numbers with positive biopsies were as follows: bone, 71 of 141 patients (50%); liver, 30 of 46 patients (65%); LN, 44 of 149 patients (30%); and lung, 37 of 62 patients (60%). At median follow-up of 40 months, 152 patients (60%) had died, and the median OS was 40 months (95% confidence interval, 33-47 months).
Positron Emission Tomography/Computed Tomography Review
A review of all available PET/CT scans demonstrated a close correlation between the SUVmax by original report and by independent review (G.A.U.). The Spearman correlation for these analyses by site was as follows; bone, 0.90; liver, 0.90; LN, 0.88; and lung, 0.85. The definition of tertiles translated into broadly similar SUVmax values in bone, liver, and LN (approximately <6, 6-10, and >10). However, lower cutoffs were defined in the lung tertiles (<3.4, 3.4-7.4, and >7.4) (Table 2).
Standard Prognostic Variables
We first examined known prognostic variables for the whole cohort irrespective of disease site and demonstrated the inferior OS of patients with triple-negative disease (negative for ER, PR, and HER2; HR, 3.0) compared with ER/PR-positive and HER2-negative disease (P < .01). Similarly, patients who had visceral metastases (N = 103) had inferior survival (HR, 1.4; P = .03) compared with patients who did not. Conversely, A longer time from primary breast cancer to MBC diagnosis was associated with improved OS (P < .01; HR, 0.9 and 0.5 for 3-5 years and >5 years, respectively, vs <3 years). Patients who received targeted therapy (including with endocrine therapy or chemotherapy) or chemotherapy alone in the first-line setting had significantly decreased survival (P < .001; HR, 1.6 and 3.5, respectively) compared with patients who received endocrine therapy.
Maximum Standard Uptake Value As a Prognostic Variable
A strong correlation between the SUVmax in bone and OS was observed (P < .001) (Table 3). By using the tertile with the lowest SUVmax as the reference group (median, 4.7; range, 2.1-5.8), patients in the highest tertile of SUVmax (median, 11.2, range, 9.3-29.6) had the shortest survival (HR, 3.13) (Fig. 2A). The magnitude of this effect was greater than that for some of the other prognostic variables that were assessed in the bone cohort, such as the presence of visceral metastases (HR, 2.7; P < .001), but it was smaller than the effect of other variables, such as triple-negative histology (HR, 4.16; P < .001). Receipt of targeted therapy and chemotherapy in the first-line setting were associated with inferior OS (HR, 1.4 and 3.5, respectively; P < .001).
|Univariate Analysis, N = 141
|Multivariate Analysis, N = 120
|Median [Range] or No. of Patients/Total No. (%)
|HR [95% CI]a
|HR [95% CI]a
|Low tertile
|4.7 [2.1-5.8]
|Middle tertile
|7.2 [5.9-9.2]
|1.36 [0.76-2.44]
|2.17 [1.13-4.17]
|High tertile
|11.2 [9.3-29.6]
|3.13 [1.79-5.48]
|3.19 [1.64-6.20]
|Tumor phenotype
|ER/PR positive AND HER2 negative
|92/138 (67)
|HER2 positive
|26/138 (19)
|1.20 [0.68-2.13]
|0.64 [0.28-1.47]
|Triple negative
|20/138 (15)
|4.16 [2.32-7.48]
|2.82 [1.18-6.74]
|Grade 3b
|89/122 (73)
|1.62 [0.92-2.85]
|1.92 [1.04-3.56]
|Visceral metastases
|40 (28)
|2.70 [1.73-4.23]
|2.38 [1.26-4.50]
|Age, y
|57.0 [27.0-89.0]
|0.99 [0.97-1.01]
|117/140 (84)
|12/140 (9)
|1.05 [0.58-1.91]
|11/140 (8)
|0.60 [0.36-1.02]
|Time from primary breast cancer to MBC diagnosis: Categorical, y
|76 (54)
|21 (15)
|1.05 [0.58-1.91]
|44 (31)
|0.60 [0.36-1.02]
|First therapy for MBCc
|Endocrine therapy
|77 (56)
|Targeted with or without chemotherapy/endocrine therapy
|27 (20)
|1.44 [0.77-2.67]
|1.02 [0.42-2.43]
|33 (24)
|3.53 [2.13-5.86]
|1.95 [0.84-4.51]
It is noteworthy that grade (P = .09), age (P = .45), histologic subtype (P = .95), and time from primary breast cancer to MBC diagnosis (P = .14) had no significant effect on prognosis (Table 3). We also examined the impact of endocrine therapy at the time of PET/CT imaging and observed no effect on prognosis (P = .62; N = 50 patients on PET images; results not shown).
A greater risk of death was also observed among patients with higher SUVmax in other metastatic sites (liver, LN, and lung), but this achieved statistical significance only in bone (Table 2, Fig. 2B-D). Multivariate models were constructed by site, as described above. In multivariate analyses, the prognostic effect of SUVmax in bone was maintained (P = .002) after correcting for known prognostic variables (Table 3).
To the best of our knowledge, this retrospective study represents the first large series to correlate FDG avidity on PET/CT images and OS in patients with newly diagnosed MBC, and it has several key findings. First, the SUVmax in bone was strongly correlated with OS, and this effect was maintained in multivariate analyses after correction for tumor phenotype, grade, and the presence of visceral metastases—the prognostic variables that had P values < .1 on univariate analysis. Second, a greater risk of death was also observed among patients who had a higher SUVmax in other metastatic sites (liver, LN, and lung), but the difference did not reach statistical significance. Third, an independent review of PET/CT images demonstrated that the SUVmax was highly reproducible by the reader and could be applied outside of a specialist center. Taken together, these findings suggest a possible role for PET/CT imaging as an additional prognostic tool for patients with newly diagnosed MBC.
Because cancers typically demonstrate greater than physiologic metabolic activity with high glucose uptake, higher FDG uptake on a PET/CT image may be indicative of a more aggressive phenotype. In a variety of malignancies, a higher SUVmax at diagnosis has been associated with inferior survival.8-18 In breast cancer, there are significant challenges to the use of PET/CT imaging as a prognostic tool, including extensive tumor heterogeneity, variable uptake of FDG, and differential response to subsequent treatment. Higher SUV correlates with a variety of adverse prognostic variables, including tumor grade, HER2 expression, ER negativity, and greater numbers of circulating tumor cells.17, 19-22 The use of PET/CT imaging in a prognostic model is compounded further by differential site-specific metastases for biologic subgroups of breast cancer. For example, strong expression of ER and PR, like what occurs in lobular carcinoma, is associated with a relative increased risk of bone metastases and lower SUV values on PET/CT images.22 Therefore, in an attempt to take into account variable tumor biology as well as intraindividual variation in FDG uptake, we examined SUVmax at individual anatomic sites and corrected for known prognostic variables that were identified as significant on univariate analysis.
In our study, patients who had bone metastases (N = 141) and the highest SUVmax tertile (9.3-29.6) had inferior survival compared with patients in the lowest tertile (2.1-5.8; HR, 3.13; P < .001). This effect was maintained in multivariate analyses (HR, 3.19; P = .002) after correcting for known prognostic variables. Similar findings were observed in patients who had metastases in liver (N = 46; HR, 2.07), LN (N = 149; HR,1.1), and lung (N = 62; HR, 2.2), although these results did not reach statistical significance (P = .18, P = .31, and P = .095, respectively).
The current study has several strengths. First, this was a large series that included a broad representation of various subgroups of breast cancer, including 54 patients (21%) with HER2-positive disease and 50 patients (20%) with triple-negative breast cancer. Second, 90% of patients had at least 1 biopsy confirming the diagnosis of MBC (the gold standard), which contrasts to some other series in which the diagnostic performance of PET/CT imaging was compared with other imaging modalities and the results were confounded by the variable performance of the comparator. Third, we correlated FDG uptake (SUVmax) with OS, which is a clean endpoint, as this considers both variable tumor biology and treatment administered. Because the median OS of patients with MBC is 2 to 3 years,2 our results are relatively mature (median follow-up, 40 months). Finally, SUVmax values, which were rereviewed by a single investigator, were highly correlated with the values abstracted from the electronic medical record. We opted to use SUVmax by report in this study, because this reflects real-world practice, in which clinical decisions are made based on PET/CT reports, and selected cases are reviewed on an individual basis.
There are limitations to the current study, which was retrospective, did not assess tumor:background ratios, and included a heterogeneous population both in terms of variable follow-up imaging (timing and modality) and treatment regimens administered. Because not all patients at our institution with possible MBC underwent PET/CT imaging or had FDG-avid disease, selection bias may have played a role. Although 90% of patients underwent a biopsy of at least 1 site, we cannot be absolutely sure that all of the FDG-avid lesions observed on PET/CT images truly represented MBC. For example, although 44 patients in the LN analysis had biopsy-proven MBC in LN, this does not preclude the possibility that many false-positive, high SUVmax values (eg, reactive LNs) were included incorrectly in the correlation between SUVmax and OS. Furthermore, we examined PET/CT imaging from only 1 time-point and, thus, are unable to comment on the predictive effect of PET/CT imaging (with regard to treatment effect). Finally, because this was a retrospective study, the cost-effectiveness of PET/CT imaging could not be assessed.
Several studies have investigated the possible correlation between changes in SUVmax and response (or lack thereof).6, 7, 23-26 In both the preoperative and metastatic settings, a decline in the SUVmax has been associated with tumor response to endocrine therapy and chemotherapy and may be useful to identify a group of patients who are resistant to therapy.6, 7, 23, 27 Furthermore, it has been suggested that PET/CT imaging may be a superior predictor of progression-free survival in patients with bone metastases compared with other novel approaches, such as enumerating circulating tumor cells.26 In fact, emerging data indicate that PET/CT imaging is superior to conventional imaging, such as radionuclide bone scans, for detecting bone metastases from breast cancer.5, 28-30 However, caution is advised, because most data are from retrospective studies, variations in FDG response have been reported by body site, and the choice of therapy and sequence themselves may have an impact on changes in the SUVmax.27, 31
Significant challenges remain in defining the optimum use of PET/CT imaging in MBC. Some investigators have attempted to define specific cutoffs for SUV to define subgroups that may have inferior survival or may benefit most from selected therapies.19 However, given the variation in SUV and differential impact on survival by site, this may not be reproducible; and, if cutoffs are appropriate, then site-specific cutoffs may be advised. In this regard, the SUVmax may be a suboptimal PET/CT parameter in isolation, because it does not factor the size or the number of metastatic lesions into the analysis. Alternative PET/CT prognostic variables may include mean SUV, metabolically active volume, functional lesion volume, or total lesion glycolysis, all of which can be calculated using modern software.32 The composite measurement, total lesion glycolysis, is an attractive PET/CT parameter, because it attempts to overcome some of these limitations by incorporating metabolic volume into the assessment of FDG avidity.33 Therefore, currently, we are investigating total lesion glycolysis as a prognostic variable in patients with newly diagnosed MBC. An alternative approach is the use of novel radiotracers for subgroups of breast cancer, such as patients with HER2-positive disease, designed to offer greater specificity; however, to date, no dominant tracer has demonstrated superiority to FDG.34-37 Ultimately, prospective studies will be needed to individualize parameters and tracers for PET/CT imaging. Nonetheless, we hope that PET/CT imaging has a future role in novel drug development, in individualizing therapeutic approaches by selecting appropriate initial therapies for patients, and as an early signal to change therapy in patients who are not benefiting from a treatment.
In conclusion, in this large, retrospective study of patients who had chemotherapy-naive, newly diagnosed MBC, an increased SUVmax in bone was correlated with inferior survival. Similar effects were noted at other metastatic sites but did not reach statistical significance. These findings suggest that PET/CT imaging is a potential prognostic tool for patients who have newly diagnosed MBC.
No specific funding was disclosed.
The authors made no disclosures.
- 1Stewart BW, Kleihues P, eds. World Cancer Report. Lyon, France: IARC Press; 2003.
- 2Therapeutic options for metastatic breast cancer. Expert Opin Pharmacother. 2009; 10: 967-981., , .
- 3Preoperative staging of large primary breast cancer with [18F]fluorodeoxyglucose positron emission tomography/computed tomography compared with conventional imaging procedures. J Clin Oncol. 2008; 26: 4746-4751., , , et al.
- 4Effect of F-FDG PET/CT imaging in patients with clinical stage II and III breast cancer. Int J Radiat Oncol Biol Phys. 2008; 71: 695-704., , , et al.
- 5Integrated positron emission tomography/computed tomography may render bone scintigraphy unnecessary to investigate suspected metastatic breast cancer. J Clin Oncol. 2010; 28: 3154-3159., , , et al.
- 6Early metabolic response to neoadjuvant letrozole, measured by FDG PET/CT, is correlated with a decrease in the Ki67 labeling index in patients with hormone receptor-positive primary breast cancer: a pilot study. Breast Cancer. 2011; 18: 299-308., , , et al.
- 7Early F-2-fluoro-2-deoxy-d-glucose positron emission tomography may identify a subset of patients with estrogen receptor-positive breast cancer who will not respond optimally to preoperative chemotherapy. Cancer. 2010; 116: 805-813., , , et al.
- 8Prognostic significance of SUV on PET/CT in patients with esophageal cancer: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol. 2009; 21: 1008-1015., , , , .
- 9Standardized uptake value is of prognostic value for outcome in head and neck squamous cell carcinoma. Acta Otolaryngol. 2010; 130: 756-762., , .
- 10Prediction of survival and cancer recurrence using F-18 FDG PET/CT in patients with surgically resected early stage (stage I and II) non-small cell lung cancer. Neoplasma. 2011; 58: 245-250., , , , , .
- 11High maximum standard uptake value (SUVmax) on PET scan is associated with shorter survival in patients with diffuse large B cell lymphoma. Int J Hematol. 2011; 93: 502-508., , , et al.
- 12The maximum uptake of F-deoxyglucose on positron emission tomography scan correlates with survival, hypoxia inducible factor-1alpha and GLUT-1 in non-small cell lung cancer. Eur J Cancer. 2007; 43: 1392-1398., , , et al.
- 13Primary tumor standardized uptake value measured on fluorodeoxyglucose positron emission tomography is of prognostic value for survival in non-small cell lung cancer: update of a systematic review and meta-analysis by the European Lung Cancer Working Party for the International Association for the Study of Lung Cancer Staging Project. J Thorac Oncol. 2010; 5: 612-619., , , et al.
- 14Preoperative 18[F]-fluorodeoxyglucose positron emission tomography standardized uptake values predict survival after esophageal adenocarcinoma resection. Ann Thorac Surg. 2006; 81: 1076-1081., , , et al.
- 15The measurement of SUVmax of the primary tumor is predictive of prognosis for patients with endometrial cancer. Gynecol Oncol. 2011; 123: 82-87., , , .
- 16Prognostic significance of baseline positron emission tomography and importance of clinical complete response in patients with esophageal or gastroesophageal junction cancer treated with definitive chemoradiotherapy. Cancer. 2011; 117: 4823-4833., , , et al.
- 17Circulating tumor cells and [18F]fluorodeoxyglucose positron emission tomography/computed tomography for outcome prediction in metastatic breast cancer. J Clin Oncol. 2009; 27: 3303-3311., , , et al.
- 18Fluorine-18 fluorodeoxyglucose positron emission tomographic maximal standardized uptake value predicts survival independent of clinical but not pathologic TNM staging of resected non-small cell lung cancer. J Thorac Cardiovasc Surg. 2007; 133: 1419-1427., , , , .
- 19Clinicopathological and prognostic relevance of uptake level using 18F-fluorodeoxyglucose positron emission tomography/computed tomography fusion imaging (18F-FDG PET/CT) in primary breast cancer. Jpn J Clin Oncol. 2008; 38: 250-258., , , et al.
- 20Correlation of high 18F-FDG uptake to clinical, pathological and biological prognostic factors in breast cancer. Eur J Nucl Med Mol Imaging. 2011; 38: 426-435., , , et al.
- 21Degree of tumor FDG uptake correlates with proliferation index in triple negative breast cancer. Mol Imaging Biol. 2010; 12: 657-662., , , et al.
- 22Comparison of triple-negative and estrogen receptor-positive/progesterone receptor-positive/HER2-negative breast carcinoma using quantitative fluorine-18 fluorodeoxyglucose/positron emission tomography imaging parameters: a potentially useful method for disease characterization. Cancer. 2008; 112: 995-1000., , , et al.
- 23Positron emission tomography/computed tomography in the management of recurrent/metastatic breast cancer: a large retrospective study from the Royal Marsden Hospital. Ann Oncol. 2011; 22: 307-314., , , .
- 24Sequential positron emission tomography using [18F]fluorodeoxyglucose for monitoring response to chemotherapy in metastatic breast cancer. Clin Cancer Res. 2006; 12: 6437-6443., , , .
- 25Bone metastases in patients with metastatic breast cancer: morphologic and metabolic monitoring of response to systemic therapy with integrated PET/CT. Radiology. 2008; 247: 189-196., , , , , .
- 2618F-FDG PET/CT findings and circulating tumor cell counts in the monitoring of systemic therapies for bone metastases from breast cancer. J Nucl Med. 2010; 51: 1213-1218., , , et al.
- 27The role of chemotherapeutic drugs in the evaluation of breast tumour response to chemotherapy using serial FDG-PET [serial online]. Breast Cancer Res. 2010; 12: R37., , , et al.
- 28Comparison of 18FDG-PET with 99mTc-HMDP scintigraphy for the detection of bone metastases in patients with breast cancer. Ann Nucl Med. 2005; 19: 573-579., , , et al.
- 29F-18 fluorodeoxyglucose positron-emission tomography in the diagnosis of tumor recurrence and metastases in the follow-up of patients with breast carcinoma: a comparison to conventional imaging. Invest Radiol. 2003; 38: 250-256., , , et al.
- 30Detection of bone metastases in breast cancer by 18FDG PET: differing metabolic activity in osteoblastic and osteolytic lesions. J Clin Oncol. 1998; 16: 3375-3379., , , , .
- 31Heterogeneity of metabolic response to systemic therapy in metastatic breast cancer patients. Clin Oncol (R Coll Radiol). 2010; 22: 818-827., , , et al.
- 32Feasibility and performance of novel software to quantify metabolically active volumes and 3D partial volume corrected SUV and metabolic volumetric products of spinal bone marrow metastases on 18F-FDG-PET/CT. Hell J Nucl Med. 2011; 14: 8-14., , , et al.
- 33
- 34Oncologic PET tracers beyond [F]FDG and the novel quantitative approaches in PET imaging. Q J Nucl Med Mol Imaging. 2008; 52: 50-65., , , , , .
- 35Imaging the pharmacodynamics of HER2 degradation in response to Hsp90 inhibitors. Nat Biotechnol. 2004; 22: 701-706., , , , , .
- 36Positron emission tomography (PET) with radiolabeled F(ab′)2-trastuzumab fragments in patients (pts) with HER2-positive metastatic breast cancer (MBC): initial feasibility results: Paper presented at: 2008 ASCO Breast Cancer Symposium; Washington, DC; September 5-7, 2008. Abstract 79., , , et al.
- 37Cu-64-trastuzumab imaging in patients (pts) with HER2-positive metastatic breast cancer (MBC) receiving trastuzumab (T) therapy: initial results. Paper presented at: 2009 ASCO Breast Cancer Symposium; San Francisco, CA; October 8-10, 2009. Abstract 83., , , et al.

subset: commoncrawl


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can we please get a torrent for If Loving You Is Wrong
What are you listening to right now? V3
Who's The Best Bad Guy?
Can we have a sensible conversation using only famous movie one-liners?
What TV show are you watching right now? V3
iZombie Discussion Thread
Technical maintenance (March, 17)
Kickass.to domain back
Merry Christmas!
A few things
How to mux Audio
Walking through The Devil's Canyon
Nowhere Nexus - Part II
Power of the Wolf [Hosted Poem for ChasingCoyote]
The things I haven't done
Elvis Presley
springer gtm
footy classified
the girl 2
alien ebooks
raw sex
van halen
dakota skye povd
walt simonson


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Hatalmas Farok, Óriás bráner
Nami Spa Day
Nami is in the SPA center. But this isn't casual SPA center. Here you can get erotic massage, tit fuck and many more. Sorry for Japanese version, all you can do is click around and try to get all scenes.Megtekintve: 78819
Mrs.Claus The Unfaithful Wife (Full Version)
During Christmas time Santa's sexy wife has no attention from her old and fat husband. This is what horny elf Rupert noticed and now he's thinking how to fuck Mrs.Claus while Santa don't see that.Megtekintve: 170839
Sex Stories: On Holidays - Part 2
We decided to split this game into two files for a faster loading and better performance .. hope this helps. This time our sexy couple Roberto and Kylie are traveling on holidays to sunny beach. On their way they meet beautiful and horny flight stewardess Neila, who wants to join them and make threesome, so she decides to seduce Roberto first.Megtekintve: 96092
Sex Stories: On Holidays - Part 1
We decided to split this game into two files for a faster loading and better performance .. hope this helps. This time our sexy couple Roberto and Kylie are traveling on holidays to sunny beach. On their way they meet beautiful and horny flight stewardess Neila, who wants to join them and make threesome, so she decides to seduce Roberto first.Megtekintve: 104984
Unohana's Horny Xmas: Full Version
Have you been a good girl? Asks Santa to large breasted girl Unohana. It's a Xmas game for all the lovers of Bleach series. Use different tools and techniques to strip her and fill pleasure bar. After that you'll be able to fuck her sweet ass.Megtekintve: 172639
Campus 2
This is continuing of previous game. You need a code from first game to play this part (try this 12531333). In this episode Alyssa prepares for her first college party. It's up to you to choose what she'll do. Make decisions and see what will happen with her and her pussy.Megtekintve: 128771
This is interesting adult game about college campus. The main heroine of this game is Alyssa, who just moved in to her dorm. She makes some friends in few moments and her sexual experience can begin. With whom will Alyssa loose her virginity? Type 'Butt' in game when you don't know what to do.Megtekintve: 118075
Meeting Rebecca
This game is about how young girls getting pregnant during porn movie session. The main hero wants to become a father :) That's why he do everything he can to cultivate his seed and plant it well inside Rebecca's sweet pussy.Megtekintve: 99830
Pool Maze
In few words this game is a Billiard in the labyrinth. Your task is to lead your ball through the labyrinth to the final level. Put your red ball to the red hole, to pass the level. But remember that you must hit any other ball. Aim and hit with your mouse.Megtekintve: 174427
Exposing sexy Alicia
Meet Alicia - she has some strange disease and your task is to make her feel better. Actually you have to fuck her because she has sex addiction. Ask your nurse to join you and make a nice threesome.Megtekintve: 244477
Fuck Town: Cleaning Services
You play as Calvin and you work for a cleaning company. Meet hot girl named Mallory who ordered your services to clean her apartment. Complete certain tasks and fuck this huge boobed slut.Megtekintve: 113137
Squeaky-Squirrel Anal Rodeo
Meet sexy squirrel girl Makoto Nanaya from Blazblue. Watch how she gets fucked by a strange penis in her tinny little asshole.Megtekintve: 99120
Purge and Sheeva
If you know Mortal Kombat you'll enjoy this small sex animation. Meet horny Sheeva and enjoy 4 different shemale animations.Megtekintve: 93377
Pirate Slave
In this free adult game you can fuck some brunette which was taken from enemy's ship as a hostage. Yes, you play as an angry drunk pirate. First you can play with her using some of available tools. Find all hotspots and pass to the sex scenes.Megtekintve: 159080
Yokubou No Ori
This girl is crazy about sex. She's ready to fuck with everyone: Police officer, her high-school teacher, guys from the store and even green sticky monsters. Use navigation buttons at the bottom right corner to switch scenes and enjoy entire game.Megtekintve: 167527
Elegant Assassin Lydia EP 2: Infiltration Incomplete
PLEASE: don't hit the gallery button all the time, click it once and then wait for gallery to get loaded (it's a heavy file and it doesn't have a preloader). Play as sexy Lydia, and help her take out waves of Elite Soldiers. Quickly press the corresponding keyboard keys. But anyway you'll lose and Lydia's life will be in the hands of those soldiers. Enjoy everything what's happening there.Megtekintve: 164471
Tales of Steam
Do you like saunas? It's a nice relaxing during the bath. But what could make you feel even better? Of course, slutty sexy redhead which actually doesn't mind to get fucked in there by you. Quickly seduce her and stick your dick inside her mouth, pussy and ass.Megtekintve: 136589
Mokoto Blowjob
This is a short adult game where you can enjoy how nice looking Mokoto gives a good blowjob. Press the buttons on the right side and see how she licks, sucks, swallows and many more.Megtekintve: 67844
Sex Stories: On Holidays
The third part of famous Sex Stories series. This time our sexy couple Roberto and Kylie are travelling on holidays to sunny beach. On their way they meet beautiful and horny flight stewardess Neila, who wants to join them and make threesome, so she decides to seduce Roberto first.Megtekintve: 232131
Kakutou Imouto
Fight against blue haired big breasted Hentai bitch. Beat her and round after round you'll see some sex scenes with her. Use your mouse to click on her body when attack mode is available. At the end you'll be able to fill her with your cum.Megtekintve: 427524


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Alex Welsh
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I am a freelance Video Specialist with a focus in DSLR video production. I am proficient in Adobe's Creative Suite. I have experience with live events, weddings, sports broadcast, and commercial production.
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Apr 29, 2009 · What is a browser? was the question we asked over 50 passersby of different ages and backgrounds in the Times Square in New York. Watch the many responses ... - read more
Aug 01, 2012 · iTunes ! http://bit.do/Haddaway Haddaway performing What Is Love © Coconut Records http://www.coconut-music.com Official Website http://haddawaymusix.com ... - read more
Please vote if the answer you were given helped you or not, thats the best way to improve our algorithm. You can also submit an answer or search documents about what is youtube counting numbers 1 100.


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The Berkshires are widely known for tourism, but what about people flocking to the region for its food? Well those in the industry are working to make that a reality.
A vacant position at the head of Berkshire County's workforce and career center has been filled.
It's the peak of the summer vacation season, meaning thousands have flocked to the Berkshires. But where do year-round residents go to relax?
Massachusetts and regional tourism agencies are working on ways to attract more visitors from overseas.
The Berkshires are known as a tourist destination, but until recently North Adams hasn't fully tapped into the industry.
Events across the Berkshires this weekend are garnering some national attention.
Charles Birnbaum is the president and founder of The Cultural Landscape Foundation. Created in 1998, the organization aims to teach people how to identify and appreciate landscape and landscape architecture.


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Photo Galleries
< MyNorthwest
Jason Rantz attends pots and pans anti-Israel brigade in Seattle
The protesters marched for about 40 minutes through Capitol Hill streets, holding up traffic. There were some passers-by shouting support, others shouting them down. It was entirely peaceful, though I use that term only to indicate there was no violence; there rhetoric oozed with hatred against Israel.
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Photo by KIRO Radio/Jason Rantz
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Original article: Jason Rantz attends pots and pans anti-Israel brigade in Seattle
More Photo Galleries
Amanda Knox and her family celebrate acquittal
Italy's highest court overturned the murder conviction against Amanda Knox and her ex-boyfriend Friday over the 2007 slaying of Knox's roommate, bringing to a definitive end to the high-profile case.
Week in Photos
Photos from around the world this week.
Hundreds gather to commemorate one-year mark of Oso mudslide
A solemn crowd gathered to honor 43 people who lost their lives a year ago in the deadliest landslide in U.S. history.
Photos: Oso one year after deadly mudslide
Sunday is the one-year anniversary of the slide, and although most of the mangled cars and homes have been cleaned up, reminders of loss are everywhere.
Week in photos
Take a look at the best photos of the week from around the world.
Tuesday in photos
St. Patrick's Day, March 17, 2015.
Monday in photos
Monday, March 16, 2015.
Week in photos
Photos from around the world this week.
Friday in photos
The second of three Friday the 13ths in 2015; Friday, March 13, 2015.
Thursday in photos
Thursday, March 12, 2015.


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N.P.Trent Antiques
Elgin Art Deco watch with 15-jewel movement, a silver-painted face and a feather-engraved case, with a new black crocodile band. It was retailed by "Fahys." It has been cleaned and is in excellent running condition.
Owned by Stuart and Audrey Peckner, N.P. Trent Antiques has been a sought-after resource collectors for more than a quarter of a century. Located in Hudson. NY, the showroom specializes in period Englnd decorative accessories, devoting 2,500 square feet to a diverse selection of fine 17th-, 18th- , and 19th-century pieces. This amazing assortment of jewelry and accessories was specially curated from Mrs. Peckner's personal collection.


text: OverviewBack to top of page EO Products - Hand Cream Jasmine - 2 oz. Code#:60799 Manufacturer:EO Products Size/Form:2 oz. Packaged Ship Weight:0.25 A uniquely innovative blend of natural ingredients, our antioxidant-rich, restorative hand cream is designed to markedly improve the texture of active hands.Mango Seed Butter – deeply moisturizingAntioxidant Blend –protecting and nourishingBetaglucan (from Oats) – stimulating collagen to aid in skin repairOur Organic Herbal Blend – therapeutic & healing for dry hands


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Classifieds in our Illinois Dental News can be viewed by clicking here. Members must be logged in to view this information.
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Melbourne car park roof in Bourke Street.I just the different views you get from roof tops.
Canon 5D24-105L
Lightroom 3 processing
car park, 70s, roof, melbourne, andrew wilson, cars, buildings
Photography has made me view the world in slow motion. I now attempt to see what is there and not only what wants to be seen. One day I hope people will see me as a photographer.
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