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Medical Policy
|Selective Internal Radiation Therapy (SIRT) of Primary or Metastatic Liver Tumors
|Policy #:
|Current Effective Date:
|Last Review Date:
At the time of diagnosis, most liver tumors, whether primary or from metastases, are unresectable and chemotherapy is generally only palliative. Consequently, various alternative therapies have been investigated for potential palliation or even cure of unresectable liver tumors. Some examples of such treatments include cryosurgery, radiofrequency ablation, and chemoembolization. One of these therapies, Selective Internal Radiation Therapy (SIRT), also known as radioembolization, targets the delivery of small beads or microspheres containing yttrium-90 to the tumor since liver tissue is radiation-sensitive. This document addresses the use of SIRT.
Note: For other potential treatments for liver tumors, please see the following documents:
|Position Statement
Medically Necessary:
Selective internal radiation therapy (SIRT) is considered medically necessary as palliative treatment for individuals with:
Hepatocellular Carcinoma or Bridge to Liver Transplantation
SIRT is considered medically necessary as a primary treatment for surgically unresectable primary hepatocellular carcinoma (HCC) or, as a bridge to liver transplantation, when all of the following criteria are met for either indication:
Hepatocellular Carcinoma in Individuals Who May Become Eligible for Liver Transplantation
SIRT is considered medically necessary for the treatment of individuals with hepatocellular carcinoma who:
Investigational and Not Medically Necessary:
Selective internal radiation therapy (SIRT) is considered investigational and not medically necessary when the above criteria are not met.
SIRT for Primary Hepatocellular Carcinoma, Metastatic Colorectal Carcinoma and Neuroendocrine Tumors
There is extensive published literature regarding technical issues and clinical outcomes of SIRT and other locally ablative treatments for liver tumors. (Georgiades, 2001; Lau, 2003; Liu, 2003; Ramsey, 2001). These reviews summarize the generally favorable preliminary evidence on effects of SIRT; yet also note the lack of long-term follow-up data to document the duration of responses or survival after SIRT.
A meta-analysis by Vente and colleagues evaluated the available literature addressing SIRT for unresectable liver metastases (2009). The authors included all forms of SIRT, including SIR-Spheres and TheraSpheres®. This study included 30 articles that included 1,217 subjects. For individuals with colorectal cancer (CRC) metastases, a total of 19 eligible studies, which included 792 subjects, were included in the analysis. Of these, 195 had received SIRT as a first-line treatment and 486 received SIRT as salvage therapy. There was a significant difference in response when used for first-line therapy vs. salvage, with the response rates reported as 91% and 79% respectively (p=0.07). The median survival, regardless of the microsphere type, chemotherapy protocol, disease stage or salvage vs. first-line, varied between 6.7 to 17 months. Median survival from time of diagnosis ranged from 10.8 to 29.4 months. For individuals with hepatocellular carcinoma (HCC), the authors included 14 studies in their analysis. These studies included 425 subjects who underwent SIRT therapy. Of these studies, only 12 reported on tumor response, leaving 318 subjects. The authors noted that treatment with resin microspheres (e.g., SIR-Spheres) was associated with a significantly higher response rate when compared to glass microspheres (e.g., TheraSpheres®) (89% vs. 78%, p=0.02). Median survival was reported in only seven studies. Median survival from time of SIRT treatment varied between 7.1 to 21 months. Median survival from time of diagnosis or recurrence was reported to be between 9.4 to 24 months.
Two reports were published from a single randomized trial of individuals with unresectable metastases from colorectal cancer treated with hepatic artery infusion (HAI) of 5-fluorodeoxyuridine (5-FUDR) alone (n=34) or HAI of 5-FUDR with SIRT (n=36). The first paper by Moroz and colleagues (2001) reported on changes in normal liver and spleen volume following HAI+SIRT, but did not provide data on long-term treatment outcomes. The second paper, which is the main report of this study, reports that the study was initially designed to enroll 95 subjects (Gray; 2001). The study detected a 30% increase in median survival for those in the experimental arm compared with controls, with 90% power and 95% confidence. However, the investigators closed the study after entering 74 subjects (n=70 eligible for randomization). Reasons cited for the early closure included: 1) increasing individual and physician reluctance to participate; 2) decision by the FDA to accept intermediate endpoints to support applications for premarket application approval; and 3) lack of funding to complete the study. The smaller study population was adequate to detect increases in response rate (from 20% to 55%) and median time to disease progression (by 32% from 4.5 months) with 80% power and 95% confidence, but lacked sufficient statistical power to detect changes in survival.
To monitor responses to therapy, investigators serially measured serum levels of carcinoembryonic antigen (CEA) and estimated tumor cross-sectional area and volume from repeated computerized tomographic scans read by blinded physicians. They reported increased overall responses (complete plus partial) measured by area (44% versus 18%, p=0.01; HAI+SIRT vs. HAI, respectively) and volume (50% versus 24%, p=0.03), or by serum CEA levels (72% versus 47%, p=0.004). They also reported increased time to disease progression detected by increased area (9.7 versus 15.9 months, p=0.001) or volume (7.6 versus 12.0 months, p=0.04). However, there were no significant differences between treatment arms in actuarial survival rates (p=0.18 by log rank test) or in 11 quality of life measures. Treatment-related complications (grades 3-4) included 23 events in each arm (primarily changes in liver function tests). Nevertheless, investigators concluded that a "single injection of SIR-Spheres® plus HAI is substantially more effective" than the same HAI regimen delivered alone.
Despite the investigators' assertions, these results are inadequate to support their conclusions for the following reasons: 1) Accrual was halted early, leaving the study underpowered. 2) Although the study involved oversight by an institutional review board, the report suggests early closure was at the sole discretion of the principal investigator without independent review or prospectively designed data monitoring procedures and stopping rules. 3) While in this study, response rate and time to progression after SIRT+HAI appeared superior to the same outcomes after HAI alone, results for the SIRT+HAI group are within the range reported by other randomized trials of HAI in comparable subjects (Kemeny, 2002; Meta-Analysis Group, 1996). 4) Results of this study may reflect use of a shorter-than-standard duration of HAI therapy, and are confounded by administration of non-protocol chemotherapy before and after SIRT. 5) The reported increases in response rates and time to progression improved neither duration of survival nor quality of life.
Several additional studies were identified that used SIR-Spheres with HAI and reported outcome data in some form. One small randomized controlled trial was reported by Van Hazel and colleagues (2006). This study included 21 subjects with untreated advanced colorectal metastases within the liver. Longer time to progressive disease was reported in the group treated with SIRT combined with HAI when compared to the group treated with HAI-alone (18.6 months vs. 3.6 months). Median survival time was also significantly better in the combination treatment group, 29.4 months vs. 12.8 months in the HAI-alone group. The authors reported no difference in quality of life measurements between groups at three months. The authors note that only limited conclusions can be drawn from the results due to the small number of study subjects. The other studies were uncontrolled clinical series (Gray, 2000; Stubbs, 2001) or included retrospective control groups treated with HAI alone (Stubbs, 2001). All 3 studies treated individuals with liver metastases of colorectal cancer, but included variable percentages of individuals with clear contraindications to SIRT (16%–50% of subjects had documented extrahepatic disease) and all 3 failed to clearly document other important selection criteria (liver reserve, prior treatment). Median survival after SIRT in these uncontrolled series ranged from 9 to 13.5 months and 1-year survival ranged from 67%–82%. None adequately reported palliative outcomes or effects on disease symptoms.
A retrospective case series study was published by Kennedy and colleagues in 2008. This study included 148 subjects with hepatic metastases from neuroendocrine tumors including pancreas, lung, colon, ovary, kidney and small intestine. The mean follow-up period was 42 months at the time of publication. The authors report that there were no acute or delayed toxicity-related adverse events in 67% of the subjects. Fatigue was reported by 6.5% and nausea and pain reported by 3.2% and 2.7% respectively. Response to treatment, judged by imaging response, was reported to be 90%, with stable disease in 22.7%, partial response in 60.5%, complete response in 2.7%, and progressive disease in 4.9%. The authors indicate there were some participants lost to follow-up, but no details are provided. The report concludes by noting that compared to data from other studies, SIRT for the treatment of neuroendocrine tumors demonstrates a similar safety profile, improvement in debulking of tumor and survival is similar to other local treatment methods, and that controlled prospective studies are warranted to further investigate these potential benefits.
A large case series study was reported by Salem and colleagues (2002), and described treating approximately 300 subjects with liver carcinomas with SIRT under a humanitarian device exemption at 8 unnamed institutions. The report provided no additional details on baseline characteristics of the subjects and did not specify inclusion or exclusion criteria for treatment. Investigators only reported outcomes for a cohort of 54 HCC subjects with Okuda stage I and II (median survival: 23 and 11 months, respectively; overall survival at 1 year: 68% and 37%, respectively). Other early studies were uncontrolled clinical series of 22 subjects with unresectable HCC (Dancey, 2000) or 37 subjects with unresectable colorectal liver metastases (Herba, 2002) and reported no, or only limited, survival data (e.g., 54-week median survival in Dancey and colleagues [2000]). None adequately reported palliative outcomes or effects of SIRT on disease symptoms.
In 2004, Steel and colleagues reported on a non randomized parallel cohort study of health related quality of life in 28 subjects with primary HCC treated with SIRT (TheraSpheres) compared to HAI alone. The authors concluded that further research "that includes a larger sample size and longer follow-up is necessary to make definitive conclusions regarding the efficacy and effect on health related quality of life."
In 2009, Mulcahy and others reported on a case series study involving 72 subjects with hepatic tumors from metastatic CRC (mCRC). The tumor response rate was reported to be 40.3%. Median time to hepatic progression was 15.4 months and median duration of response was 15 months. The PET response rate was 77%. Overall survival from time of first treatment with SIRT was 14.5 months. The authors noted that survival was significantly impacted by tumor volume, with individuals with less than or equal to 25% tumor replacement volume having a mean survival rate of 18.7 months vs. 5.2 months for those with greater than or equal to 25% tumor replacement volume. Additionally, the presence of extrahepatic disease had a significant impact on survival. Subjects with extrahepatic disease had an overall survival of 7.9 months vs. 21 months for those without.
Salem and colleagues published the findings of a large prospective case series study in 2009. This study included 291 participants with HCC. Using World Health Organization (WHO) and European Association for the Study of the Liver (EASL) guidelines, response rates were reported to be 42% and 57% respectively. Survival times differed significantly between individuals with Child-Pugh A and Child-Pugh B classifications, with the former surviving a mean of 17.2 months and the latter 7.7 months. Furthermore, individuals with Child-Pugh B class disease with portal vein thrombosis survived a mean of 5.6 months. Similar findings regarding the impact of portal vein thrombosis on SIRT outcomes were reported by Woodall (2009).
A retrospective case series study involving 51 subjects with progressive chemotherapy-refractory mCRC treated with SIRT was published in 2011 by Nace and colleagues. CEA response was available in 41 subjects (80.4%), 17 (41%) showed a response to therapy. Thirty-one subjects (60.8%) had imaging available for review, and none demonstrated a complete response. Partial response was noted in 4 subjects (13%), stable disease in 20 (64%), and progressive disease in 7 (23%). Thirty-eight subjects (74.5%) died during the 3 year follow-up period. Overall survival was 10.2 months. Notably, subjects who had previously received cetuximab therapy had a significantly decreased median survival (5.1 months, p=0.001). The significant loss to follow-up, lack of a control group and other methodological flaws impair the generalizability of this study.
Sangro and colleagues (2011) reported the results of a large case series study of 325 subjects with HCC who were not considered candidates for other therapeutic approaches and who were treated with SIR-spheres. The median overall survival was 12.8 months, which varied significantly by disease stage (Barcelona Clinic Liver Cancer staging system [BCLC] A, 24.4 months; BCLC B, 16.9 months; BCLC C, 10.0 months). Survival also varied significantly by ECOG status, hepatic function (Child-Pugh class, ascites, and baseline total bilirubin), tumor burden (number of nodules, alpha-fetoprotein), and presence of extrahepatic disease. The most significant independent prognostic factors for survival in a multivariate analysis were ECOG status, tumor burden (nodules >5), international normalized ratio >1.2, and extrahepatic disease. Common adverse events included fatigue, nausea/vomiting, and abdominal pain. Grade 3 or higher increases in bilirubin were reported in 5.8% of subjects. All-cause mortality was 0.6% and 6.8% at 30 and 90 days, respectively. The authors concluded that their analysis provided robust evidence of the survival achieved with radioembolization, including those with advanced disease and few treatment options. However, the fact that some study centers used retrospectively collected data (n=216) and others prospective data (n=109) introduces potential for bias into this study. Additionally, both the selection criteria and treatment protocols varied between treatment centers and study subjects received SIRT as a first-line therapy or for those who had received prior surgical and non surgical treatments but had progressive disease. Such variations introduce significant methodological issues which have not been controlled for in the statistical analysis.
A retrospective, nonrandomized controlled study evaluating the use of SIRT as a salvage treatment for individuals with hepatic metastases was described by Bester and colleagues in 2012. The study involved 390 subjects, 339 who were treated with SIRT and 51 who either declined SIRT or were ineligible due to variant hepatic arterial anatomy or extensive hepatopulmonary shunting and who were subsequently used as controls. Of the SIRT treated subjects, 224 had metastatic colorectal cancer (mCRC), and the remainder had an assortment of other cancers, including neuroendocrine (n=40), breast, (n=16), unknown primary (n=10), pancreatic (n=8), gastric, (n=8), and others (e.g., melanoma; n=33). No significant differences were noted between the treatment and control groups at baseline, including the presence of extrahepatic disease and hepatic tumor burden. At the time of final follow-up, 59% (201/390) of the SIRT subjects had died, while 76% (39/51) of the control group had died. Overall survival was reported to be 12 months for the SIRT group and 6.3 months for the control group (p<0.001). In a subgroup analysis, overall survival was reported as 11.9 months for the mCRC group (p<0.001, vs. control) and 12.7 months in the non mCRC SIRT group (p<0.024, vs. control). SIRT treatment was a significant predictor of overall survival (p<0.002), with a 43% reduction in the hazard of death vs. control subjects. An important finding is that the site of primary tumor was not a significant predictor of outcomes. No SIRT-related deaths were reported within the three month follow-up period. However, several significant complications were noted, including Grade 1 abdominal pain in the immediate postoperative period as well as within 1 month of treatment. The authors comment that this study was limited due to lack of randomization, and its retrospective nature. It should also be noted that the selection of controls was subject to significant selection bias. The findings should be confirmed by a prospective randomized study.
Salem (2012) reported the results of a retrospective comparative study of 245 subjects with HCC treated with chemoembolization (n=122) or SIRT with TheraSpheres (n=123). Seventy five subjects (30%) did not complete the study (n=44 for SIRT, n=31 for chemoembolization) due to transplantation (n=73) or resection (n=2). The authors reported a median time to partial response as measured by World Health Organization (WHO) criteria was shorter with SIRT than chemoembolization (6.6 vs. 10.3 months, p=0.05). Using the European Association for Study of the Liver (EASL) necrosis criteria, the response rates were similar (chemoembolization: 69%; SIRT: 72%, p=0.75), with faster time to EASL response with SIRT (1.2 vs. 2.2 months, p=0.016). Of the remaining 170 subjects, 96 progressed (n=42 for SIRT, n=54 for chemoembolization). For median time to progression (TTP), SIRT outperformed chemoembolization (13.3 months vs. 8.4 months, p=0.046). One hundred thirteen subjects died (n= 59 for chemoembolization, n=54 for SIRT) during the median follow-up time (32.6 months for chemoembolization and 22.7 months for SIRT). In both univariate and multivariate analyses, treatment group was not found to be a significant prognostic factor in survival, but female gender (hazard ratio [HR]=1.69), ECOG status =0 (HR=0.57), Child-Pugh class A (HR=0.58) and UNOS T1/T2 (HR=0.33) were. There are many methodological issues with this study, including its retrospective nature, lack of randomization and blinding. The 12-month difference in median follow-up time may have also introduced bias into the results.
In 2013, Benson and colleagues described the results of a case series study of 151 subjects with a variety of liver metastases (colorectal, n=61; neuroendocrine, n=43; and other tumor types, n=47) that were refractory to other therapies subsequently treated with TheraSpheres. Disease control rates were 59%, 93% and 63% for colorectal, neuroendocrine and other primaries, respectively. Median progression free survival (PFS) was 2.9 and 2.8 months for colorectal and other primaries, respectively. PFS was not achieved in the neuroendocrine group. The median reported survival from SIRT was 8.8 months for colorectal and 10.4 months for other primaries. The authors stated that the median survival for subjects with neuroendocrine tumors has not been reached. Grade 3/4 adverse events included pain (12.8%), elevated alkaline phospatase (8.1%), hyperbilirubinemia (5.3%), lymphopaenia (4.1%), ascites (3.4%) and vomiting (3.4%). The authors concluded that individuals with liver metastases can be safely treated with SIRT. As a case series, conclusions may be subject to bias and further data is warranted.
Several articles described the use of SIRT with non-commercial forms of 90Y microspheres in 301 subjects (n=294 with HCC). These were generally uncontrolled clinical series of heterogeneous subject populations reporting response rates that ranged from 27% to 72% and 1-year survival rates of 32% to 88% (Lau, 1998; Lau, 1994; Lau, 2001; Leung, 1995; Tian, 1996). None adequately reported palliative outcomes or effects of SIRT on disease symptoms. One study (Cao, 1999) did report a significant difference in median survival after SIRT in 17 subjects (19.5 months) compared to HAI treatment of 53 subjects (6.5 months). However, the study did not provide data on baseline characteristics of the HAI-treated subjects or describe the HAI treatment regimen. In summary, the variability in populations, variable or indeterminate nature of microsphere systems administered, lack of long-term outcome data, and uncontrolled nature of the studies limit the applicability of these data.
In 2005, Lim and colleagues reported on a study of 32 subjects to prospectively evaluate the efficacy and safety of Selective Internal Radiation (SIR) spheres in individuals with inoperable liver metastases from colorectal cancer who have failed 5FU based chemotherapy. Thirty subjects were treated between January 2002 and March 2004. As of July 2004 the median follow-up is 18.3 months. Median participant age was 61.7 years (range 36-77 years). The authors concluded that: "In patients with metastatic colorectal cancer that have previously received treatment with 5-FU based chemotherapy, treatment with SIR-spheres has demonstrated encouraging activity. Further studies are required to better define the subsets of patients most likely to respond."
Liver-Related Symptoms Due to Tumor Bulk
Most studies addressing the use of SIRT for hepatic tumors are uncontrolled and have relatively short-term follow-up. However, there is sufficient data to demonstrate that there is a significant palliative benefit derived from SIRT for hepatic tumors from a wide variety of primary cancers. The published data to date supports the ability of SIRT to provide short-term symptom control for individuals suffering from hepatic tumors by decreasing tumor bulk and reducing neuroendocrine and endocrine effects of hepatic metastases. Furthermore, SIRT has become widely accepted as a treatment of specific liver-related symptoms due to tumor bulk (e.g., pain) from any primary or metastatic hepatic tumor.
Other SIRT Applications
Cianni and colleagues reported the use of an unspecified 90Y microsphere product on 110 subjects with liver metastases from a wide variety of primary cancers, including: colorectal, breast, gastric, pancreatic, pulmonary, esophageal, pharyngeal, cholangiocarcinoma and melanoma (2010). The authors reported complete or partial response in 45 subjects, stable disease in 42 subjects and progressive disease in 23 subjects. While the results in this study are promising for cancers beyond the previously discussed and well studied indications (HCC, colorectal, etc.), the data presented for others such as esophageal, breast, etc. are hampered by small sample sizes. Further studies with larger sample sizes are needed. The authors themselves state that "Further phase III clinical trials should clearly determine the real and effective impact of radioembolization with Y-90 on survival rates, experimenting with the combination of SIRT, chemotherapy and modern biological agents as a first-line treatment." A study by Sato and colleagues included 147 subjects with chemo-refractory metastatic hepatic tumors from a variety of primary tumors including colon, breast, neuroendocrine, cholangiocarcinoma and others (2008). Clinical toxicities reported include fatigue (56%), pain (26%) and nausea (23%). Imaging response was 42.8% (2.1% complete, 40.7% partial) and biological tumor response 87%. One year survival was 47%, 2 year survival was 30.9% and overall median survival was 300 days. Median survival according to primary tumor site was: 457 days for colorectal cancer, 776 days for neuroendocrine tumors, and 207 days for non-colorectal and non-neuroendocrine tumors. The authors note that the majority of subjects in this study were treated prior to the availability of growth factor inhibitors, which makes the impact of such treatment in conjunction with SIRT impossible to assess. They also note the heterogeneous population and open label study methodology makes the findings difficult to generalize to other populations.
Metastastatic Breast Cancer
At this time, the evidence addressing the use of SIRT to treat hepatic metastases from breast cancer is limited. Several of the studies previously mentioned included subjects with breast cancer as part of their study population, including Bester (n=16/390), Cianni (n=32/110), and Sato (n=2/147). However, these studies did not provide breast cancer-specific outcomes data.
Two small studies have investigated the impact of SIRT on this population. Bangash and colleagues reported a prospective case series study of 27 subjects who underwent salvage SIRT treatment for hepatic breast cancer metastases (2007). At 90-days after treatment, complete or partial tumor response on CT was noted in 9 subjects (39.1%). Stable disease was reported in 12 subjects (52.1%), and progressive disease was noted in 2 subjects (8.8%). Positive tumor response on PET was noted in 17 (63%) subjects. Median survival for subjects ECOG 0 vs. ECOG 1, 2, or 3 was 6.8 months (n=15) and 2.6 months (n=12), respectively (p=0.24). Survival by tumor burden <25% vs. >25% was 9.4 months (n=21) and 2.0 months (n=6), respectively (p<0.0001).
Another small prospective case series study involving 23 subjects with hepatic breast cancer metastases was reported by Jakobs and others (2008). At a median follow-up of 4.2 months complete response was seen in none of the subjects, but partial response was reported in 61%, of subjects. Stable disease and progressive disease were reported in 35% and 4% of subjects, respectively. The authors reported that the median overall survival was 11.7 months with median survival of responders being 23.6 months and non-responders 5.7 months. Comparing subjects with and without extrahepatic disease, median survival was 9.6 and 16 months, respectively (p=0.077). Median survival time for subjects with response was 23.6 months vs. those without response at 5.7 months (p=0.005). Treatment-related hepatic toxicity was noted in one subject.
Small size significantly limits the utility of these findings. Further study of the use of SIRT for hepatic metastases from breast cancer is warranted.
Bridge to Transplantation
SIRT has also been proposed as a treatment for subjects who have exhausted other treatment options, but continue to be viable candidates for orthotopic liver transplantation. This use has been the subject of a limited number of studies.
A case series study by Kulik and colleagues details the use of TheraSpheres in 150 subjects with unresectable HCC (2006). Of the 34 initially staged as UNOS T3, 19 (56%) were downgraded to stage T2 following treatment with yttrium-90 (90Y). Eight were successfully downgraded and received orthotopic liver transplants following treatment. The authors report survival to be 84%, 54% and 27% at 1, 2 and 3 years respectively.
In 2009 Lewandowski and colleagues published the results of a non-randomized controlled study that compared transcatheter arterial chemoembolization (TACE; n=43) to SIRT with Theraspheres (n=43) as a method of downstaging subjects with T3 HCC as a bridge to transplantation. The authors reported that successful downstaging to T2 was observed in 31% (11/35) of TACE subjects and 58% (25/42) of SIRT subjects (p=0.023). This trend was noted in all lesion sizes. The median time to UNOS downstaging was not reached in the TACE group, but was reported as 3.1 months in the SIRT group (p=0.027). There was no significant difference in the number of subjects downstaged to resection, but 8 TACE and 18 SIRT subjects were downstaged to RFA treatment. The median WHO time to progressive disease was 19.6 months in the TACE group vs. 48.6 months in the SIRT group (p=0.008). One year progression rates according to EASL criteria were 4% in the TACE group and 8% in the SIRT group (p=0.01). Using the UNOS criteria, time to progression was 18.2 months for the TACE group and 33.3 months in the SIRT group. For TACE, overall survival without censoring to radical therapies (e.g., transplantation/resection) at 1, 2 and 3 years were 75%, 42% and 19% , respectively, and 81%, 69% and 59% for SIRT (p=0.008). When censored to radical therapies, overall survival at 1, 2 and 3 years were 73%, 28% and 19% for the TACE group and 77%, 59% and 45% for the SIRT group (p=0.18). Two out of 11 of the TACE subjects have recurred following transplantation with a 1-year recurrence free survival of 73%. Two out of the 9 SIRT subjects have recurred following transplantation with a 1-year recurrence free survival of 89%. This difference was not found to be statistically significant.
At this time, the data addressing the use of SIRT as a bridge to transplantation method is limited but promising. There is building consensus among experts in favor of the use of SIRT as reasonable and effective as a bridge to transplantation. This is partially based upon the evidence from the Kulik and Lewandowski studies described above, but also on the available data from studies of SIRT for other conditions that demonstrate significant tissue destruction and shrinking of liver lesions resulting in improved health outcomes.
As the incidence of HCC continues to rise and availability of donor organs remains low, the waiting time for potentially curative therapy with orthotopic liver transplantation (OLT) increases. Heckman (2008) noted the incidence of disease progression while listed for transplant was 10-23%. Various technologies have been explored to maintain transplant eligibility by controlling disease progression, of which transcatheter arterial chemoembolization (TACE) and RFA were the most frequently studied. A "bridge" to liver transplant involves ablative techniques to minimize and control disease progression to allow individuals with limited HCC to remain eligible on the OLT waitlist. The goal of bridging is to prevent drop-off from the waiting list and to improve post-transplant survival (DuBay, 2011).
The current Organ Procurement and Transplantation Network (OPTN) and United Network for Organ Sharing (UNOS) allocation policy (2014) provides incentives to use loco-regional therapies to downsize tumors to T2 status and to prevent progression while on the transplant wait list. In addition, the OPTN/UNOS policy appears to implicitly recognize the role of loco-regional therapy in the pre-transplant setting. These indications are in part related to the current OPTN/UNOS liver allocation scoring system referred to as the Model for End-Stage Liver Disease (MELD), for adults ages 12 and older, and the Pediatric End-stage Liver Disease (PELD) scoring system for candidates younger than 12 years of age. The MELD score is a continuous disease severity scale incorporating serum bilirubin, prothrombin time (i.e., international normalized ratio-INR), and serum creatinine into an equation, producing a number ranging from 6 (less ill) to 40 (gravely ill). The MELD score estimates how urgently the individual needs a liver transplant within the next three months. PELD is similar to MELD but uses additional factors to recognize the specific growth and development needs of children. PELD scores may also range higher or lower than the range of MELD scores. The PELD scoring system includes measures of serum bilirubin, INR, albumin, growth failure, and whether the child is less than one year old. Candidates that meet the staging and imaging criteria specified in the OPTN/UNOS Allocation of Livers and Liver-Intestines Policy: Candidates with Hepatocellular Carcinoma (HCC) sections 9.3.G.iv-v may receive extra priority on the "Waiting List." A candidate with an HCC tumor that is stage T2 may be registered at a MELD/PELD score equivalent to a 15% risk of candidate death within 3 months if additional criteria are also met. OPTN/UNOS defines Stage T2 lesions as:
The largest dimension of each tumor is used to report the size of HCC lesions. Nodules less than 1 cm are indeterminate and cannot be considered for additional priority. Past loco-regional treatment for HCC (OPTN Class 5 [T2] lesion or biopsy proven prior to ablation) are eligible for automatic priority.
The NCCN guideline in Oncology for hepatocellular carcinoma (2014) states:
Bridge therapy is used to decrease tumor progression and the dropout rate from the liver transplant list. It is considered for patients who meet the transplant criteria. Unresectable/inoperable lesions >5cm should be considered for treatment using arterially directed or systemic therapy.
Hepatic (liver) tumors can arise either as primary liver cancer or by metastasis to the liver from other tissues or organs. Local therapy for hepatic metastasis is indicated only when there is no extrahepatic disease, which rarely occurs for individuals with primary cancers other than CRC or certain neuroendocrine malignancies. At present, surgical resection with tumor-free margins and liver transplantation are the only potentially curative treatments. For liver metastases from CRC, randomized trials have reported that post-surgical adjuvant chemotherapy (administered systemically or via the hepatic artery) decreases recurrence rates and increases time to recurrence. Important prognostic factors for survival include site and extent of primary tumor, hepatic tumor burden, and performance status.
Unfortunately, most hepatic tumors are unresectable at diagnosis, due either to their anatomic location, size, number of lesions, concurrent nonmalignant liver disease, or insufficient hepatic reserve. Palliative chemotherapy by combined systemic and hepatic artery infusion (HAI) may increase disease-free intervals for individuals with unresectable hepatic metastases from CRC. However, durable responses to chemotherapy are less likely for those with unresectable primary hepatocellular cancer (HCC).
Various non-surgical ablative techniques have been investigated that seek to cure or palliate unresectable hepatic tumors by improving loco-regional control. These techniques rely on extreme temperature changes, particle and wave physics (microwave or laser ablation), or pharmacologic/biochemical interventions. Another of these, selective internal radiation therapy (SIRT), relies on targeted delivery of small beads (microspheres) impregnated with radioactive yttrium-90 (90Y). The rationale for SIRT is based on the following: 1) the liver parenchyma is sensitive to radiation; 2) the hepatic circulation is uniquely organized, whereby tumors greater than 0.5 cm rely on the hepatic artery for blood supply while normal liver is primarily perfused via the portal vein; and 3) 90Y is a pure beta emitter with a relatively limited effective range and short half-life that helps focus the radiation and minimize its spread. Candidates for SIRT are initially examined by liver angiography and technetium (99mTm) lung scan to rule out aberrant hepatic vasculature or significant lung shunting that would permit diffusion of injected microspheres.
Currently, two commercial forms of 90Y microspheres are available: TheraSpheres® (MDS Nordion, Ottowa, Canada) which are glass beads bound to 90Y, and SIR-Sphere® (Sirtex Medical Limited; Lake Forest, IL) where 90Y is bound to resin beads. Non-commercial forms are used mostly outside the United States. While the commercial products use the same radioisotope (90Y) and have the same target dose (100 Gy), they differ in microsphere size profile, base material (i.e., glass versus resin, respectively) and size of commercially available doses. These physical characteristics of the active and inactive ingredients affect the flow of microspheres during injection, their retention at the tumor site, spread outside the therapeutic target region, and dosimetry calculations. Note also that the U.S. Food and Drug Administration (FDA) granted premarket approval of SIR-Sphere®, for use in combination with 5-floxuridine (5-FUDR) chemotherapy by HAI, to treat unresectable hepatic metastases from colorectal cancer. In contrast, TheraSpheres® is approved by humanitarian device exemption (HDE) for use as monotherapy to treat unresectable HCC. For these reasons, results obtained with one product do not necessarily apply to other commercial (or non-commercial) products.
Metastatic tumor: A cancerous tumor that has spread beyond the boundaries of the primary organ to other organs and/or lymph nodes.
Palliative care: Medical treatments that are intended to alleviate pain and suffering.
The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
When services may be Medically Necessary when criteria are met:
|Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction
|Radiopharmaceutical therapy, by intra-arterial particulate administration [when specified as transcatheter tumor destruction procedure using yttrium-90 microspheres]
|Transcatheter occlusion or embolization for tumor destruction, percutaneous, any method, using yttrium-90 microspheres
|ICD-9 Diagnosis
|[For dates of service prior to 10/01/2015]
|For the diagnosis codes listed below for primary liver tumors:
|Malignant neoplasm of liver, primary
|Malignant neoplasm of intrahepatic bile ducts
|Malignant neoplasm of liver, not specified as primary or secondary
|Carcinoma in situ of liver and biliary system
|Awaiting organ transplant status
|For the following diagnosis code ranges for palliation of liver metastases:
|Malignant neoplasms
|Malignant carcinoid tumors
|Secondary neuroendocrine tumors
|Abnormality of secretion of glucagon, gastrin (Zollinger-Ellison syndrome), other disorders of pancreatic internal secretion
|Carcinoid syndrome
|ICD-10 Procedure
|[For dates of service on or after 10/01/2015]
|Introduction of radioactive substance into peripheral artery, percutaneous approach [when specified as SIRT using yttrium-90 microspheres]
|ICD-10 Diagnosis
|[For dates of service on or after 10/01/2015]
|For the diagnosis codes listed below for treatment of primary liver tumors:
|Malignant neoplasm of liver and intrahepatic bile ducts
|Carcinoma in situ of liver, gallbladder and bile ducts
|Awaiting organ transplant status
|For the following diagnosis code ranges for palliation of liver metastases:
|Malignant neoplasms
|Drug-induced, other and unspecified hypoglycemia
|Increased secretion of gastrin (Zollinger-Ellison syndrome)
|Carcinoid syndrome
When services are Investigational and Not Medically Necessary:
For the procedure and diagnosis codes listed above when criteria are not met or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
Colorectal Cancer
Hepatic Metastases
Hepatocellular Carcinoma
Liver Tumors
Metastatic Liver Tumors
Selective Internal Radiation Therapy
Selective Internal Radiation Treatment
yttrium-90 Microspheres
The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.
|Document History
Medical Policy & Technology Assessment Committee (MPTAC) review.
Hematology/Oncology Subcommittee review. Clarified bridge to transplant criteria.
Medical Policy & Technology Assessment Committee (MPTAC) review.
Hematology/Oncology Subcommittee review. Clarified medically necessary criteria regarding bridge to transplantation tumor size and number. Updated Rationale and Reference sections.
Updated Coding section with 01/01/2014 CPT changes; removed 37204 deleted 12/31/2013, and 75894.
MPTAC review.
Hematology/Oncology Subcommittee review. Updated title by removing specific product names. Revised medically necessary position statement to include treatment of liver-related symptoms due to any primary or metastatic tumors. Added medically necessary position statements for SIRT as a bridge to transplantation for individuals with HCC when criteria are met, or for those who may meet transplant criteria with SIRT as a result of decreased tumor size. Updated Rationale, Coding and Reference sections.
MPTAC review.
Hematology/Oncology Subcommittee review. Wording clarification made to medically necessary criterion for neuroendocrine tumors. Updated Websites.
MPTAC review.
Hematology/Oncology Subcommittee review. No change to position statement.
MPTAC review.
Hematology/Oncology Subcommittee review. Updated Coding and Reference sections.
MPTAC review.
Hematology/Oncology Subcommittee review. Updated position statement to consider SIRT medically necessary for the treatment of hepatocellular carcinoma, primary or metastatic hepatic carcinoid tumors, hepatic metastases of colorectal cancer or islet cell tumors. Updated Rationale, Coding and Reference sections
MPTAC review.
Hematology/Oncology Subcommittee review. No change to position statement. Updated Rationale and Reference sections
MPTAC review. No change to position statement.
Hematology/Oncology Subcommittee review. The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." Updated references.
MPTAC review.
Hematology/Oncology Subcommittee review. No change to position statement. Updated Rationale and Reference sections.
|MPTAC review. References updated, 2005 small study added to the rationale section. No change to position statement.
|MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.
|Pre-Merger Organizations
|Last Review
|Anthem, Inc.
|Selective Internal Radiation Therapy (SIRT, i.e. SIR-Spheres and TheraSpheres) Brachytherapy
|WellPoint Health Networks, Inc.
|Selective Internal Radiation Therapy of Primary or Metastatic Liver Tumors


text:
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Got a crispy FOB SBD or Podcast?
anybody know where i can find a recording of this show, been looking all over and cant seem to find it
I checked with live cheese, apparently they had trouble recording this show and never released the tapes...I recall a few mikes in the crowd that night, but I have not seen a recording around yet.
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subset: commoncrawl


text:
This is not the next Subaru Impreza. It is a concept that 'hints' at a future design direction.
The Impreza design concept was yesterday unveiled at the Los Angeles Motor Show, and previews the company's new design strategy, blending such high-minded ideas as 'dynamic flow' and 'confident stance'. We say 'mmm, tasty'.
See pics of the Subaru Impreza design concept
Underneath that rather dandy new four-door-coupe stance sits a 2.0-litre boxer engine - down from the 2.5-litre of old - mated to a 'Lineartronic Continuously Variable Transmission' (CVT) and permanent all-wheel-drive, representing Scooby's next generation powertrain. Good news, because it means the company's brief dalliance with 2WD is at an end.
Certainly a massive improvement over the current Impreza styling, and one we can only hope makes it to production. Subaru - make it happen...


text: No recent wiki edits to this page. A great warrior Seraph of God's Warhost, Micah was a powerful angel - one of his most powerful alongside Avengelyne. He had long held God in contempt for his love of humanity, believing after Armageddon that the angels would no longer be needed and their light extinguished. He even fooled Avengelyne into asking God why he loved the humans so much, getting her cast out of Heaven. Late in the twentieth century, God disappeared from Heaven. Micah took this opportunity to rebel, gathering many of the Warhost to his cause and taking control of the lost souls in Purgatory. He also managed to imprison the evil Dragon. Humanity was destroyed but for the few remaining guarded in Jerusalem. After one hundred years of battle, the final battle between Micah and his forces and the angels led by Avengelyne was set to take place on the prophesied place - Megiddo. With Magog acting as Death, his forces met on the plains of Israel. After Magog defeat and a surprise attack by Passover, Micah retreated back in time. He planned to kill Adam and Eve and end humanity from the start. Avengelyne and Passover followed him to the Garden of Eden. Right after Adam and Eve comitted the original sin, Micah made his move. Avengelyne stood in between the humans and saved them from their deaths, sacrificing herself instead. It was then God spoke, never having left in the first place. He told Micah this was the answer to his question he made Avengelyne pose so long ago. As a reward for her selflessness, Avengelyne was reformed and Micah was destroyed by God's will.


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Disappointed with how they are handling Iris in the anime
by, 23rd July 2012 at 09:33 AM (1431 Views)
I think I am now finally starting to see what Hellion and Shinneth have been ranting about since BW started.
When Iris first debuted, I initially liked her simply on the basis that she wasn't a third female coordinator. As much as I liked the contests, I didn't want to sit through endless female coordinators doing the same thing over and over again. I also liked the BW trio's chemistry much more than the DP trio.
However after that wore off, Iris had to stand on her own as her own character and see what she brought to the table instead of comparing her to others. And I have to say...I'm disappointed. For most of BW1 she felt ignored and was kept to the sidelines, but then when she does do things she's glorified in an almost perfect manner.
Iris is shown to have almost no flaws. There is no real reason for her to be traveling with Ash, (and I thought Dawn's reason to travel with Ash was poor originally, but at least she quickly became a friend so that disappeared), and her character is shown to be way too perfect. The writers never glorified Misty like this, actually allowing her to have real flaws and have her be just an average battle to boot.
Iris is given powerful Pokemon for almost no reason. When May got her Blaziken in AG's finale everyone felt she earned it. When Dawn got Mamoswine it was at least shown to have a number of character growth moments. When Misty got Gyarados it was after she left the show and calmed one down. Giving Iris the most powerful Pokemon anyone on the main group ever had and then using it to tear through a tournament is just wrong.
Its really sad. Iris had the potential to be a really great and unique character but the writers have executed her poorly. With the news that the 6th gen may come in 2013...Iris is also probably going to be the shortest-lived female protagonist on the show. I am not sure if that's the reason they're speeding up her "champion" like God status, but oh well.
Its amazing how the writers can take a character you could have liked but then mishandled them into being something totally different. I am not sure what could redeem Iris between now and BW's end, but I at least hope Drayden and possibly Ash both beat her in a full fledged battle near the end of BW.
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text:
The Muse Is in
An Owner's Manual to Your Creativity
By Jill Badonsky
(Running Press Book Publishers, Paperback, 9780762444670, 226pp.)
Publication Date: January 2013
List Price: $18.00*
* Individual store prices may vary.
Shop Local
Enter your zip code below to find indies closest to you.
How to power up one's genius and troubleshoot problems along the way, with tips for proper care and maintenance.
About the AuthorJill Badonsky, M.Ed., is a creativity coach, workshop leader, artist, and marketing consultant who is the founder and director of The Muse Is In, an organization devoted to coaching, teaching, facilitating, and marketing workshops and retreats for awakening creativity. She wrote and starred in a one-woman show, "I Can't Handle Reality, But It's the Only Place to Get a Good Cup of Coffee," and writes a monthly column on creativity for "Blessings," a San Diego newspaper.


text:
Stock Vector Illustration:
green planet earth showing a green globe with drop shadow
- Image ID: 48823039
- Copyright: Nicemonkey
High quality images curated from over 150 countries.
Over 50 million photos, vectors, illustrations, and more.
Simple and flat pricing by image or by month.
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text:
The rules are simple
1. If you are buying you will send payment first. When trading, the CAG with the lower feedback ships first, if we have almost the same amount of feedback we can ship at the same time.
2. I always reply to PMs, please do the same.
3. To avoid any issues or surprises, ask any questions you have before we finalize the transaction.
Xbox One
Batman Arkham Knight (sealed)
Assassins Creed Black Flag + Unity code
Xbox One controller (sealed)
Playstation 4
Resident Evil: Revelations 2
I am mainly interested in a 1 year PS Plus sub, Paypal, or Amazon/Gamestop/Target gift cards. I will also look into Xbox One exclusive games.


text:
List Price: $39.95Publisher: University of Iowa PressBinding: PaperbackPages: 37356016Size: 6.00" wide x 9.00" long Weight: 0.748Language: English
InRacial Things, Racial Forms, Joseph Jonghyun Jeon focuses on a coterie of underexamined contemporary Asian American poets—Theresa Hak Kyung Cha, Myung Mi Kim, Mei-mei Berssenbrugge, and John Yau—who reject many of the characteristics of traditional minority writing, in particular the language of identity politics, which tends to challenge political marginalization without contesting more fundamental assumptions about the construction of racial form. In the poets' various treatments ofthings(that is, objects of art), one witnesses a confluence of heretofore discrete factors: the avant-garde interest in objecthood and the racial question of objectification. By refashioning avant-garde investigations ofthingsinto questions about how American discourse visualizes raceinandonthe body, these poets implicitly critique dominant modes of racial visibility, seeking alternatives to the unreflective stances that identity politics often unwittingly reproduces. At the heart of Jeon's project is the assumption thatracial form is continually recalibrated to elide ideological ambiguities and ambivalences in contemporary culture. Thus, rather than focusing exclusively on the subject—on interiority and individual experience—Racial Things, Racial Formsalso uses the calculated strangeness of the avant-garde art object as an occasion to emphasize the physical and visual oddness of racial constructs, as a series of everchanging, contemporary phenomena that are in conversation with, but not entirely determined by, their historical legacy. In this critical study, Jeon argues that by invoking theforeignnessof an avant-garde art object as a way to understand racial otherness, these writers model the possibility of a post-identity, racial politics that challenges how race is fundamentally visualized. In addition to appealing to those interested in Asian American studies and race in American literature,Racial Things, Racial Formsaddresses readers interested in contemporary poetry, art, and visual culture, paying particular attention to the intersections between literary and visual art.
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text:
1995 Chevrolet Corvette Q&A
1995 Chevrolet Corvette Question: Car Loosing Anti-freeze
Last week when I drove my Vette (which has 35K original miles) the Warning Light - Add Coolant came on. I had put close to 1 gallon of coolant in it about a week ago. It does not appear to be loosing fluid but I then put close to another gallon of coolant in it this weekend. What I should I tell a repair shop to look at? I THOUGHT I had had the radiator flushed about 6 mos. ago, but perhaps they did not complete the work. I also notice some rust deposits on the dipstick for the coolant. What should I do? - Houston Vette
Answer 1
First thing to do is have a shop pressure test the cooling system to determine where the coolant is going and you can find a shop near your here www.repairpal.com/directory But it sounds to me that you might have a blown headgasket and they can also test the coolant for exhaust gases present as Napa makes a test kit about $48. You can check repair prices here www.repairpal.com/estimator Let us know what they find. - hemicuda
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text:
-- Matches taped Tuesday night in Evansville, Indiana for this week's episode of WWE Superstars were:
* Jey Uso and Jimmy Uso vs. Camacho and Hunico
* Sin Cara vs. Antonio Cesaro (with Aksana)
* Kane vs. Heath Slater
* Epico and Primo (with Rosa Mendes) vs. Darren Young and Titus O'Neil (with A.W.)
Brodus Clay beat Drew McIntyre in approximately two minutes in a pre-show dark match. McIntyre worked Clay's injured knee, but Clay prevailed and won with the running splash.


text:
Buttermilk Soup
23 Sep 2009
The buttermilk soup is a creamy soup made with egg, cream and buttermlk. Flavored with lemon and almonds to taste, the buttermilk soup is an excellent starter to begin with. It is a little heavy and can be enjoyed as a snack to once in a while!
|2 Large, separated
|Lemon juice/Vanilla extract
|1 Tablespoon
|1⁄4 Cup (4 tbs)
|4 Cup (64 tbs)
|Heavy cream
|1⁄2 Cup (8 tbs)
Beat egg yolks, and lemon rind and juice with sugar until light and frothy.
Beat buttermilk; stir into egg-yolk mixture.
Beat egg whites stiff; add pinch of salt.
Whip cream.
Carefully fold egg whites into cream.
Add to egg-yolk mixture.
Do not blend too thoroughly; leave rather lumpy in texture.
Ladle into soup cups; chill thoroughly.
Garnish with lemon rind
Recipe Summary
Ingredient:Milk Product
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Buttermilk Soup Recipe


text:
Rebecca Eddy de Broekert is responsible for communicating the mission of The Heritage Foundation, as well as its effectiveness in promoting conservative values, to Heritage members living in the Southern region of the United States. Before joining Heritage in 2006, de Broekert worked at the Leadership Institute, where she had served as a Major Gifts Development Officer with responsibility for donor relations in a six-state region. Before that, she worked as Director of Donor Relations for Enterprise Development International, and as Assistant Director of Development for the National Fatherhood Initiative and Judicial Watch.
Before entering the nonprofit sector, de Broekert gained four years of successful sales experience as a Senior Account Executive at WAVA, Salem Communications' flagship station in the Washington, D.C., area. While there, she received the Outstanding Sales Achievement Award for sales billing in 2001 and 2002.De Broekert spent two and a half years in Johannesburg, South Africa, focusing on religious studies at Rhema Bible Training Centre. She is currently completing her coursework for a bachelor's in nonprofit management and also serves on the board of The Freedom Center in Leesburg, Va. She currently lives with her husband, Jacques, in Leesburg.
De Broekert is responsible for members in the following states: Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Virginia.
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Our mission is to formulate and promote conservative public policies based on the principles of free enterprise, limited government, individual freedom, traditional American values, and a strong national defense. Read More
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text:
South Carolina ETV
Lifeline Home | Overview | Education | Transparency in Gov | Public Safety | Quality of Life | Citizens & Communities
ETV Learn
ETV at a Glance
Explore these ETV links and resources:
South Carolina Aquarium
The South Carolina Aquarium's mission is to inspire conservation of the natural world by exhibiting and caring for animals, by excelling in education and research, and by providing an exceptional visitor experience. The South Carolina Aquarium welcomes guests of all ages, introducing them to the amazing animals that call South Carolina home, as well as exotic animals from the island of Madagascar.
The South Carolina Aquarium is home to the Sea Turtle Rescue Program, the only one in the state of South Carolina. ETV's Palmetto Scene recently featured the Sea Turtle Rescue Program and its efforts to rehabilitate and protect threatened and endangered sea turtles.
To ensure that sea turtles have a future in our oceans, the South Carolina Aquarium Sea Turtle Rescue Program aids sick and injured sea turtles with the ultimate goal of returning them to the wild. The program is able to do so through a partnership with the South Carolina Department of Natural Resources. To date, the program has rehabilitated and released more than 130 sea turtles.
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text:
Beraca is an innovative brazilian company with an internation approach that has been investing in the development of sustainable technologies for more than 55 years.
Through its Health and Personal Care division, Beraca is a leading provider of natural and organic certified active ingredients from the Amazon Rainforest and other brazilian biomes.
Focusing on developing sustainable products with high perfomance and proven efficacy. Beraca's portfolio includes vegetable and essential oils, butters and clays, among other ingredients for different applications in the cosmetic, pharmaceutical and fragrance industries.


text:
John McCain - Why I Can Ask These Questions - Today's Christian Videos
Embed saddlebackforum 18670 views 2010-10-01T23:14:05 Saddleback Pastor Rick Warren recently had the opportunity to sit down with Presidential candidates John McCain and Barack Obama, to ask them some questions that might not usually be asked. For the whole interview, go to www.GodTube.com/SaddlebackForum!
More Today's Christian Videos
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text:
Football Releases Depth Chart Following Spring Practice
Green Wave set to return 23 lettermen which started games in 2014, including four of five offensive linemen
Football Nears End Of Spring Drills With Saturday Session
Green Wave to conclude practice on Sunday from 8-10 a.m. at Yulman Stadium
Football Continues Spring Drills With Indoor Session
Green Wave move to New Orleans Saints Facility with focus on special teams and option before scrimmaging
Football Continues Spring Drills With Wednesday Practice
Green Wave fine tune all three phases of the game with an eye on Saturday's scrimmage
Game Notes
Tulane vs. Southestern Louisiana - Yulman Stadium - Sept. 13, 2014
Tulane hosted Southeastern Louisiana in the first night game on campus since 1974 - Yulman Stadium - Sept. 13, 2014
2013: Did not play as a true freshman and redshirted the season.
High School: Four-year letterman at Norland High for coach Daryle Heidelburg...rated a two-star recruit by Rivals.com, Scout.com and 247Sports.com...received a 70 rating while ranking as the No. 208 safety in the country and the No. 401 recruit in the state by 247Sports.com...helped lead the Vikings to a combined 41-11 overall record, a 10-2 showing in District 16-5A play, four trips to the state playoffs, a state championship as a junior and a runner-up showing as a sophomore...as a senior, earned honorable-mention all-state and third-team all-county honors after posting four interceptions...as a junior, had 39 tackles, eight pass break-ups and two interceptions...recorded six tackles as a freshman...also lettered three years in track and field...off the field, was a member of the Heritage Panel, Teen Court, Sigma Beta and Mu Alpha Theta while earning Superior Achievement in Biology and Academic Excellent Computer for College Careers.
Personal: Born William Alexander Townsend, Jr., on Aug. 23, 1994, in Hialeah, Fla...son of Nadine Cayemitte...has one brother, James, and two sisters: Camisa and Christien...majoring in public health.


text:
|Amount Per Serving
|% Daily Value
|Organic Gotu Kola Leaf (Centella asiatica)
|400 mg
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Organic India Brahmi-Gotu Kola -- 90 Vegetarian Capsules
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|Amount Per Serving
|% Daily Value
|Organic Gotu Kola Leaf (Centella asiatica)
|400 mg
Good thinking...
Gotu kola (Also known as Brahmi), the brain food of herbs, has long been prized by students and yogis for its memory-enhancing properties. Native to Sri Lanka and South Africa, the gotu kola extract and herb has been used for centuries to relieve mental fatigue, and as a tonic for overall brain and nervous system support. Rich in vitamins A, B, E, K and magnesium, researchers have found that it also contains several glycosides that exhibit healing properties.
Taking Brahmi-Gotu Kola capsules increases circulation and oxygen flow to the brain which increases energy without taxing the adrenal system. Our Brahmi-Gotu Kola Formula is made with a select combination of organic cultivated and ethically wildcrafted herbs and roots, formulated to help support memory, enhance physical, mental, and emotional clarity, and promote longevity.
Adaptogenic herb - helps reduce the negative effects of daily stress.
Part used: Gotu Kola- leaf, Ashwagandha- root, Gingko rhizome, Bacopa extract.
Blend actions: Combines renowned herbs for mental clarity gingko, gotu kola & bacopa. A balanced formula that helps to stimulate, detoxify, build and support the nervous system. Tulsi is added as a carrier herb to assist in assimilation. Ginger is added to counter the cooling effects of gotu cola.
Qualities: Air, cooling formula, warming, building, bitter, sweet.
Systems: Nervous, circulatory, and digestive.
Ayurveda: Decreases Pitta and Kapha, Increases Vata when used in excess.
All in one!
Our Brahmi-Gotu Kola herbal formula parallels the actions of: gingko bilboa and ginseng.
Vitacost price: $5.75


text:
News and events
Winners of first UCL physics hackathon announced
PhD students from UCL Physics & Astronomy took part in the department's first 'hackathon' last week. In this competition, students representing the department's five research groups competed to complete projects in just two days.
Published: Jun 22, 2015 3:12:04 PM
Titan's atmosphere even more Earth-like than previously thought
Scientists at
UCL have observed how a widespread polar wind is driving gas from the
atmosphere of Saturn's moon Titan.
Published: Jun 18, 2015 3:02:47 PM
ESA shortlists three space missions with major UCL contributions
The European Space Agency has announced the shortlisted proposals for its next mid-sized science mission.
Published: Jun 17, 2015 10:50:34 AM
Seeing elements transform at the atomic scale for the first time
Atoms of one chemical element morphing into another have been observed for the first time.
Published: Jun 15, 2015 4:05:28 PM
New calculations to improve carbon dioxide monitoring from space
How light of different colours is absorbed by carbon dioxide (CO2) can now be accurately predicted using new calculations developed by a UCL-led team of scientists. This will help climate scientists studying Earth's greenhouse gas emissions to better interpret data collected from satellites and ground stations measuring CO2.
Published: Jun 15, 2015 9:58:05 AM
Dr Codina Cotar accepts department's Athena SWAN award at Greenwich ceremony
In April we reported that the department had been announced as one the latest recipients of an Athena SWAN award.
Published: Jun 25, 2015 2:28:57 PM
Jackson Lewis Scholarship 2015
Congratulations goes to Andre Shamsabadi (MSci Chemistry) for winning this years Jackson Lewis Scholarship. The scholarship was founded in 1966 under the will of Mr H. L. Jackson which recognises outstanding academic performance in one year of study.
Published: Jun 25, 2015 2:14:24 PM
Deans List 2015
Congratulations to five chemistry graduands who have received a commendation for this year's Dean's List.
Published: Jun 25, 2015 2:10:33 PM
Dr Serge Guillas awarded ESRC-DFID-NERC funding for tsunami project
The Economic and Social Research Council (ESRC), the Department for International Development (DFID) and the Natural Environment Research Council (NERC) have approved funding for a project led by Dr Serge Guillas on the topic of Big Data for Resilience: realising the benefits for developing countries.
Published: Jun 23, 2015 10:25:50 AM
Urban Alchemy
Urban Alchemy explores the material stories and processes of urban change through imaginative salvage and chemical print experiments. Roofing zinc becomes etching plate from which portraits of those removing this zinc from the rooftops of London's ever changing skyline emerge. Slate and bricks become ink and plywood hoardings are transformed through woodcut.
Published: Jun 18, 2015 1:39:27 PM


text:
'Compromise' budget clears Legislature, awaits Governor's approval
Late this afternoon, a "compromise" budget gained approval from the full Arizona Legislature. The budget contains a reduction to the Arizona university system of $198 million in FY2012—amounting to a $30 million cut to Northern Arizona University.
The bill now goes to Gov. Jan Brewer for her consideration.
NAU prepared its FY12 budget based on Gov. Brewer's original recommendation in January for a $170 million reduction to the university system, which would have meant a $25.8 million cut to NAU.
"Northern Arizona University understands the difficult position the Legislature is in, and we believe investing in education is a path to solving our economic challenges," said NAU President John Haeger. "This additional cut of more than $4 million is significant. We have a long list of items to review before we determine how to deal with this additional reduction."
Arizona State University's budget will be reduced by $90 million while the University of Arizona will be cut by $78 million.
The Legislature also passed changes to employee benefits that would create a waiting period of 90 days for new employees before they become eligible for health insurance coverage. It also would change the employee/employer contribution rate to the Arizona State Retirement System from 50/50 to 53 percent for employees and 47 percent for employers. New employees will not be eligible to join ASRS for the first six months of employment.
Additional details on changes to benefits and how it will affect NAU employees is expected to be released in the coming weeks.
"We anticipate that changes to employee benefits and retirement will affect NAU's ability to recruit and retain qualified employees as well as impact already difficult compensation issues," Haeger said.
The president has scheduled a campuswide forum for 3:30 p.m. Wednesday, May 4, at the High Country Conference Center to discuss the next steps with regard to the university's budget.
Send any budget questions to email@example.com, or visit the university's Budget website for information and updates.
Inside NAU is published by the NAU Office of Public Affairs for faculty, staff and friends of Northern Arizona University. We welcome story ideas related to NAU's mission, its employees and its students. Submit story ideas using our online form.
Publisher: John D. Haeger, President; Public Affairs: Tom Bauer, Julie Bergman, Cindy Brown, Tracie Hansen; Office Manager: Isa Rueda


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You can now invite anyone to meet at your favorite Starbucks.
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25 year old woman | Midlothian, TX, USA | Seeking men 24-32 within 40 miles
I'm kind of a shy girl, but once you get to know me I really burst out of my shell. I love to laugh and do fun, creative, and unique activites. I love to dance. I am an elementary school teacher, I love being a good influence on a child's life. I'm also a spunky, laid back sort of girl, but I do enjoy dressing up for a night on the town. I'm a HUGE baseball fan. I used to play competitive softball and would love a guy who could play catch with me and go to batting cages. Also, I like other sports, but I do need a guy to teach me football :) I'm looking for a guy that can make me laugh and put a smile on face. I'm looking for A BEST FRIEND...He can be a goof at times, but serious when he needs to be. I'm a hopeless romantic, so I need a guy that will open doors, bring me flowers, suffer through chick flicks, and in return I'll go see action packed movies and watch an abundance of ESPN LOL. I'm looking for a best friend, someone that I can go out with and be all fancy, or go out to just chill at Pluckers, eating some wings, and watching a great game.
Book club , Coffee and conversation , Cooking , Dining out , Hobbies and crafts , Movies/Videos , Museums and art , Music and concerts , Exploring new areas , Nightclubs/Dancing , Performing arts , Playing cards , Playing sports , Shopping/Antiques , Travel/Sightseeing , Watching sports , Wine tasting
Aerobics, Baseball, Bowling, Dancing, Football, Hockey, Other types of exercise, Swimming, Walking / Hiking
I exercise 3-4 times per week.
I have Cats, Dogs
I have a brown Shih Tuz named Bullitz...like bullets, but with a much cooler spelling.
Middle of the Road
My favorite places are the movies (Theaters, especially the drive-in)! I'm a huge movie buff, anything but gory and scary, and I tend to quote my favs. I also enjoy amusement parks...I love the thrill! I also spend a lot of time at BLD in Mansfield
Texas A&M University–Commerce, Commerce, TX
My taste in music is eclectic, from country to my rap, but mainly Top 40s, popular music. I am a bit of a reality TV junkie. I love Big Brother, Survivor, The Bachelor, etc... I do enjoy movies, my favorite being A League of Their Own.
I enjoy movies, I like them so much I'm a weird one and even like the previews. Baseball games are great. I just love to hang out at parks, coffee houses, anywhere really. I LOVE to play softball!! One of my fav restaurants is Pluckers.
I have read all of the Hunger Games and they were awesome. Now I'm reading the book, The Perks of Being a Wallflower (it's pretty good so far), because I have to read the book before I can see the movie :)
Z{{Cta}} {{#if HasMoreInfo}} ?{{CtaSecondary}} {{/if}}
|What she is looking for
|5'0" (152cms)
|5'4" (162cms) to 6'3" (190cms)
|Body type:
|Slender, About average, Athletic and toned, A few extra pounds
|No preference
|No preference
|I'll tell you later
|No Way
|Social Drinker
|No preference
|Education / Teacher / Professor
|No preference
|$35,001 to $50,000
|No preference
|Never Married
|Never Married
|Have kids:
|Wants kids:
|Definitely, Someday
|White / Caucasian
|White / Caucasian
|Christian / Other
|Christian / Catholic, Christian / Protestant, Spiritual but not religious, Christian / Other
|Bachelors degree
|Some college, Associates degree, Bachelors degree, Graduate degree, PhD / Post Doctoral
I am a certified teacher (pre-k through 8th grade, Special Ed and ESL). I currently teach kindergarten and have so much fun doing it :)


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Google Apps has been embraced by millions of schools and campuses, but is your classroom getting the most from it? Join educator Aaron Quigley as he shows K–12 teachers how to use Google Apps for Education to streamline communication, save time, and increase content mastery. Administrators can learn how to set up Apps for Education, verify your domain name, and add users, while teachers learn how to sort personal from school email, set up email signatures, add events to calendars, and create lesson plans with Google Drive. Administrators and teachers alike can learn how to set up custom Google sites for collaboration with parents and students, and extend Google Apps with apps like YouTube and Google Scholar.
Every user of your institution's Google Apps for Education account has the opportunity to create Google sites. Google Sites is a way to create a very quick template-based website. Inside of the educational institution, these are a great way to inspire collaboration, because a lot of different people could be working on a single site at the same time. In this chapter, we're going to use Google Sites to create a school based collaborative website. It's designed to help community members and staff members collaborate on the creation of a community garden. Lets go ahead and get started by creating the layout of our first site. To get to sites, all we have to do is to log into our Google Apps for Education account, and click on Sites in the upper navigation.
To create our first site, let's click on the Create button on the left hand side. As we create our first site, there's a couple things that we can do. We can either start with a blank template. Now, a blank template is not just a white page. We can add some color and themes to it, but it doesn't have any information or content. We can also choose to browse the gallery for more information. The websites in the gallery are often provided by other users And typically come with some content to them. Because we're adding all the content ourselves, we're going to go and keep it selected as a blank template. We're going to call this site Collaborative Community Garden Website.
Now by default, Google's going to take whatever title you put for this site and it's going to hyphen for spaces and it's going to make that be URL or the web address people need to type in when they go to this particular website. They would actually need to type in https.//sites.google.com/a/your domain.com/, and then whatever title you have. We also have the opportunity to change this URL. I'm going to go ahead and title this the OVS Garden Site for Orange Valley School Garden. The next step is to go ahead and select a theme. To do this, I'm going to select the Theme drop down menu.
Now this is an optional step. You do not need to apply a theme to your website. You can start with a completely blank theme and add your own images and graphics. As I scroll down the theme list I'm looking for something that would be appropriate for a school garden. Eventually I come to a theme that's actually titled Garden. I'm going to go and select that. And the final step is the More options. Here we have some opportunities to add some site categories and site descriptions. Now, site categories are really important if you plan to have a lot of different Google sites. This way you have the opportunity to organize and categorize those sites so you can quickly search for them and find the appropriate site.
I'm going to go ahead and call this one collaboration. I'm going to put a comma to add a new category and I'm going to say school wide. So, that way, in the future, if I have additional collaboration sites, I can also tag them as collaboration and if I have additional school wide sites I can tag them as school wide. So a user of Google Apps for Education could then log in to their Orange Valley School account, they could go to Google Sites and they could click on school wide and view all of the school wide websites. I can also add a site description. I'm going to say that this is the OVS community garden planning website. Now that I have site categories and the site description I've created a theme and I've given my site a title and I'm going to go ahead and click the Create button.
So there we go. At this point we've created the shell of our website. There'es not a lot of content to it. As of right now, all it has is some basic information such as a site title. The only pages that are available are a home page and a site map. And if I click on site map, I can see that it only shows me the home page. So the next step is going to be to add the basic content of this website before we start collaborating with our other collegues.
There are currently no FAQs about Google Apps for Educators.
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Hear Better-Pay Less
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text:
NARS 27 - Yachiyo
126 reviews
83% would repurchase
Package Quality: 4.2
Price: $$$$
Package Quality: 4.2
Price: $$$$
on 10/3/2012 6:02:00 PM
Age: 19-24
Skin: Combination, Fair, Not Sure
Hair: Brown, Other, Other
Eyes: Brown
Unique! I ordered it online based on the reviews. When it arrived my first thought was "What the hell did I spend all this money on?". I thought it looked cheap and the brush head was all flat.
So I washed it and while drying the full shape that I had seen online came out :)
This brush makes blush look like it's supposed to - like you are blushing. Other reviewers have explanied enough details so I don't have to add to that.
I rarely buy brushes and I don't like spending too much money. But this is not spending, it's investing :) I will keep it forever <3 love!
ONLY COMPLAINT: It's better for matte blushes than for glittery. I find that when using it to apply Nars Orgasm it picks up too much glitter and highlights pores. So I'm taking one lippie off.
on 9/2/2012 11:44:00 AM
Age: 25-29
Skin: Combination, Fair, Neutral
Hair: Brunette, Wavy, Fine
Eyes: Brown
This is not the softest brush I own, but little does it matter to me. It applies any colour beautifully and evenly and distributes the product very well on the cheek. I use it for blush and for a light, diffused contouring as well.
It looks beautiful and fragile, but works like a soldier. I have gotten rid of many MAC brushes that I owned, but I would never kick this one out.
Versatile and efficient, worth every penny I paid for it. This is not a spontaneous-current-lover review, I have been using this brush for more than 2.5 years now, I am very settled down and sure of my feelings ;)
on 8/22/2012 3:37:00 PM
Age: 30-35
Skin: Normal, Fair-Medium, Not Sure
Hair: Brunette, Other, Other
Eyes: Brown
I didn't want to like this. It's too expensive, and it looked a little flimsy. I was all kinds of skeptical. But then I went through this bizarre phase where suddenly I felt like I'd forgotten how to apply blush, and I just kept looking like a clown. So I researched, I poured over reviews, and yada yada yada, I bought the brush.
But you'd better believe I kept the receipt. Nordstrom will take anything back, and I was prepped to take this back the minute it wasn't as magical as everyone made it sound. Two weeks later, I threw the receipt away.
Basically, this brush is so good that you'd have to go out of your way to look bad after using it. It's basically foolproof. I've been using it with my holy grail NARS blush in Gaiety, and I look fresh and alert and just glowy. Someone mentioned that there's a technique to using it - involving drawing a triangle with the tip and then smoothing with the side, but honestly I've just been going at it in my usual clumsy fashion, attacking my cheeks any old how, and the results are still great. Totally smooth, no harsh edges, just lit-from-within goodness. Honestly, you can't ask for more from a blush brush.
on 8/3/2012 11:16:00 AM
Age: 44-55
Skin: Oily, Dark, Cool
Hair: Brown, Other, Fine
Eyes: Brown
The price I gave a three but I purchase my brush from ebay from a lady that sells them in Australia for a lot less than in the U.S. the brush has the number 27 on it so I am guess it is a real brush. I also trust the vendor as she makes her own knock off version for a cheaper price.
I absolutely love this brush I have purchased three because I lost one and I want to have the extra on hand. This brush does not prevent you from using to much blush but the trick is just to use the tip. If you do this then you will not pick up too much and them work the brush into a circular motion and it will make your blush look so natural. The best blush that I have used with this brush is the nars taj mahal (oh my goodness!) I always get compliments with this blush because it diffuses the color in a way that makes it look so natural. If you really want to try this go to eBay and look for the vendor in Australia, you will not be sorry.
on 7/24/2012 10:19:00 PM
Age: 18 & Under
Skin: Combination, Tan, Neutral
Hair: Black, Wavy, Coarse
Eyes: Black
This is the best Blush brush i've ever owned! Its soft, so lightweight, easy to use, dense, fluffy, and perfectly tapered and shaped in such a way nobody could go wrong with this brush. It's WAY expensive but I don't regret buying it....It works for so many things but I use it for blush. Even the reaaally pigmented blushes (Bright red, hot pink, orange) can be applied to look natural and gorgeous. I haven't looked back at any rounded/angled blush brushes since I bought this. Something about this is the unique shape makes it a little difficult to dry after washing but it's maintained its shape and fluffiness all the same! I can't go on enough about this brush, Its one of the most important of all my brushes!
on 6/19/2012 8:28:00 AM
Age: 19-24
Skin: Normal, Tan, Not Sure
Hair: Brown, Other, Other
Eyes: Brown
First off, this brush looks really classy. It's a really unique looking product and although I was hesitant to buy it mainly due to the price but also because it looked unsturdy and a bit awkward to use, I'm glad I did.
The tapered tip does an amazing job at contouring the hollows of your cheeks and diffuses bronzer/blush at the same time, so it cuts the time spent perfecting your make up in half.
Also when applying whilst holding the thin handle you can really control how much product you're applying, so it makes it easy to build your colour as per your liking and you end up with nice and natural but professional look.
There is honestly a million ways you could use this and in my opinion it's a fool proof brush. You can't look wrong after using it.
That being said, I paid $70 for it (hence 4 lippies instead of 5) which is an absurd amount of money to spend on a make up brush and because of this I will remember to stock up when I go to the States lol.
If you can justify spending this much on a brush, I'd say go ahead and buy it, you'll most probably love the results. If you'd rather die than spend this much on a brush, Japonesque does a similar brush (the white bamboo version), I'm not sure how it works, I haven't come across it in Australia yet. It looks the same as the Yachiyo but I've heard that it doesn't work the same. Might be worth giving a try though, as it is a cheaper alternative.
on 6/17/2012 10:54:00 PM
Age: 19-24
Skin: Combination, Fair-Medium, Cool
Hair: Blond, Curly, Medium
Eyes: Green
I love this brush. It allows you to have a lot of control over how you apply your brush with the versatile shape of the hair. It is also so small and lightweight! I love the way this makes my blush look and how I can use pigmented blushes that were collecting dust because they were too easy for me to overdo-- not anymore. Love it, so glad I finally bit the bullet with the price, worth it!
on 4/8/2012 11:57:00 AM
Age: 44-55
Skin: Normal, Fair-Medium, Neutral
Hair: Blond, Wavy, Fine
Eyes: Blue
Like a pushup bra for your face! A revolution in blush application though this is an antiquity because it is the same brush that geisha girls used. Result: a highly defined but soft look that lifts the face, sculpts the cheek as effectively as contouring. It is a flat brush pointed like an arrow.and it is used by using the edge to first draw a triange on the cheek (point toward the nose) and filling it in with the flat side - a stunning appearance that could not be achieved with any other brush. I will never use a regular blush brush again! If you have this brush and are not satified with it you need to learn how to use it from a Nars makeup artist or perhaps look for an application video on line. I want you to love it as much as I do.
on 4/2/2012 1:31:00 PM
Age: 19-24
Skin: Acne-prone, Medium, Cool
Hair: Brown, Wavy, Coarse
Eyes: Brown
I waited for this brush to go on sale since I couldn't justify a $50 price tag. This brush does do the job, but it doesn't work any better than a powder brush for applying a pigmented blush. I ended up losing this brush and I have to say to say that I don't miss this brush. When using pigmented blushes like Illamasqua, MUFE, or Tarte, I just use the Trish McEvoy 2B Sheer Blush Brush or the 56 Sephora Brush. I took off one lippie since the wiring does come off after a period of time. Another lippie since the shape of the britsles changes, unlike other brushes I own.
on 3/14/2012 9:34:00 AM
Age: 30-35
Skin: Combination, Fair-Medium, Warm
Hair: Brown, Curly, Coarse
Eyes: Hazel
I always thought this was an amazing brush (despite its copious and never ending shedding) as I had never been able to apply blusher without looking like an over made up clown. This brush really made a difference - it made subtle blusher application easy. I fell in love with it - that was until my toddler son broke the handle. I superglued it back together which lasted for a few months until breaking again. Since then, it has gradually unravelled and is now a shadow of its former self. No - my children shouldn't be playing with my makeup brushes but they do and this is the only one that broke. It's fragile and needs to be handled with care. I have since bought the Becca One Perfecting brush which is hands down the best brush I own. Blusher looks amazing - even the ones I couldn't wear before.
Popular Makeup Brushes


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text:
Knicks sign veteran Quentin Richardson for playoff run
Apr 16, 2013, 3:37 PM EDT
We expected the New York Knicks would fill the last empty roster spot they had for the playoffs — not to get any meaningful minutes, but to give the Knicks another practice body and maybe a situation player.
They went with veteran swingman Quentin Richardson. The team announced the signing Tuesday.
We last saw Richardson with the Magic last season, where he played limited minutes and averaged 4.5 points a game on 37.6 percent shooting. The one thing he did well was knock down threes, at a 34.7 percent clip.
Richardson spent four seasons with the Knicks before, 2005-06 to 2009. He was often a starter and back in 2007 averaged 13 points a game.
Why Richardson? Here's what coach Mike Woodson said, via ESPNNewYork.com.
"It gives us one more perimeter guy that can defend a little bit, that can make shots and space the floor like we play," Mike Woodson said Tuesday on ESPN New York 98.7 FM radio. "I just think it adds to what we're trying to do.
"We do have a lot of perimeter guys, but my thing has always been whoever plays, you've got to make the most out of your minutes. And if we get somebody in the game that's struggling a little bit, then maybe I can turn to Quentin … to get it done. That's the reason for bringing him to our ballclub."
Richardson certainly had some battles defending LeBron James, but let's not expect that again. Knicks fans, if you're seeing a lot of Richardson on the court in the playoffs, it will be a bad sign. You've got better players already on the roster.
- JHathwell - Apr 16, 2013 at 4:24 PM
Am I crazy or didn't there used to be a deadline for players to sign and still be playoff eligible?
- JHathwell - Apr 16, 2013 at 4:31 PM
Never mind. Players who haven't played in the NBA this season are eligible.
- miamatt - Apr 16, 2013 at 4:51 PM
It never hurts to have another veteran body on the bench, and Q does look to be a system fit for New York, as coach Woodson said.
- Mr. Wright 212 - Apr 16, 2013 at 5:39 PM
Can't knock the GM of the year for finding guys who can be specialists on defense (obviously for Pierce and LeBron) and knock down an occasional 3 ball. That's all that is expected of him. Pierce is slower than molasses, and no one can guard LeBron, but at least you have a few more fouls at your disposal. I honestly hope we both hold serve so that we can see a classic series between the Knicks and Heat. It will be fun.
- money2long - Apr 16, 2013 at 5:39 PM
actually PBT, if knicks fans are seeing a lot of Q-rich on the court in the playoffs, it could actually be a good thing in the sense that NY would already have the game in hand !!
- 4thquartermagic - Apr 16, 2013 at 7:22 PM
Ha. Look out Heat! The Knicks have Q coming off the bench!
- badintent - Apr 16, 2013 at 7:38 PM
- dysraw1 - Apr 16, 2013 at 8:47 PM
Q.is definitely a guy who has gotten under Lebrons skin, hope he has something left in the tank.
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Whenever I run a game it displays an error (program can't start because the *.dll file is missing from your computer , reinstalling the program may fix the problem) but after reinstalling again and again it display same error. As I have 1.7GB graphics card and DirectX version11, I can't understand what went wrong. Help me in this situation.
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Just put the missing dll name on google and you'll get link to download it. Usually it's old system files or framework files.