text:
Topic Contents
- General Information About Adult Primary Liver Cancer
- Cellular Classification of Adult Primary Liver Cancer
- Stage Information for Adult Primary Liver Cancer
- Localized Resectable Adult Primary Liver Cancer
- Localized and Locally Advanced Unresectable Adult Primary Liver Cancer
- Advanced Adult Primary Liver Cancer
- Recurrent Adult Primary Liver Cancer
- Changes to This Summary (02 / 23 / 2012)
- About This PDQ Summary
- Get More Information From NCI
Adult Primary Liver Cancer Treatment (PDQ®): Treatment - Health Professional Information [NCI]
This information is produced and provided by the National Cancer Institute (NCI). The information in this topic may have changed since it was written. For the most current information, contact the National Cancer Institute via the Internet web site at http://cancer.gov or call 1-800-4-CANCER.
Adult Primary Liver Cancer Treatment
General Information About Adult Primary Liver Cancer
Note: Some citations in the text of this section are followed by a level of evidence. The PDQ editorial boards use a formal ranking system to help the reader judge the strength of evidence linked to the reported results of a therapeutic strategy. (Refer to the PDQ summary on Levels of Evidence for more information.)
Incidence and Mortality
Estimated new cases and deaths from liver and intrahepatic bile duct cancer in the United States in 2012:[1]
- New cases: 28,720.
- Deaths: 20,550.
Hepatocellular carcinoma is a tumor that is relatively uncommon in the United States, although its incidence is rising, principally in relation to the spread of hepatitis C infection.[2] It is the most common cancer in some parts of the world, with more than 1 million new cases diagnosed each year. Hepatocellular carcinoma is potentially curable by surgical resection, but surgery is the treatment of choice for only the small fraction of patients with localized disease.[3] Prognosis depends on the degree of local tumor replacement and the extent of liver function impairment. Therapy other than surgical resection is best administered as part of a clinical trial. Such trials evaluate the efficacy of systemic or infusional chemotherapy, hepatic artery ligation or embolization, percutaneous ethanol injection, radiofrequency ablation, cryotherapy, and radiolabeled antibodies, often in conjunction with surgical resection and/or radiation therapy. In some studies of these approaches, long remissions have been reported.[3] A few patients may be candidates for liver transplantation, but the limited availability of livers for transplantation restricts the use of this approach.[4] Hepatocellular carcinoma can coexist with bile duct cancer (cholangiocarcinoma).[5]
Risk factors
Hepatocellular carcinoma is associated with cirrhosis in 50% to 80% of patients; 5% of cirrhotic patients eventually develop hepatocellular cancer, which is often multifocal.
Hepatitis B infection [3,6] and hepatitis C infection [7] appear to be the most significant causes of hepatocellular carcinoma worldwide, particularly in patients with continuing antigenemia and in those who have chronic active hepatitis. A series found that male patients older than 50 years who have both hepatitis B and hepatitis C infection may be at particularly high risk for hepatocellular cancer.[8][Level of evidence: 3iiiDiv] There is evidence that patients with both hepatitis B and hepatitis C infection who consume more than 80 grams of alcohol per day have an increased risk of developing cancer (odds ratio [OR] = 7.3) when compared to patients who abstain from alcohol.[9] Additionally, having a first-degree relative with hepatitis B plus hepatocellular carcinoma is associated with an increased risk (OR = 2.41) for family members who are hepatitis B carriers.[10]
Aflatoxin has also been implicated as a factor in the etiology of primary liver cancer in parts of the world where this mycotoxin occurs in high levels in ingested food.[6,11] Workers who were exposed to vinyl chloride before controls on vinyl chloride dust were instituted developed sarcomas in the liver, most commonly angiosarcomas. Other sarcomas of smooth muscular and vascular origin are also found.
In the United States, obesity has emerged as a very important risk factor for hepatocellular carcinoma and is the main contributor of nonalcoholic steatohepatitis, which may be related to an increase in the rate of hepatocellular carcinoma.[12]
The primary symptoms of hepatocellular carcinoma are those of a hepatic mass. Among patients with underlying cirrhotic disease, a progressive increase in alpha-fetoprotein (AFP) and/or in alkaline phosphatase or a rapid deterioration of hepatic function may be the only clue to the presence of the neoplasm. Infrequently, patients with this disease have polycythemia, hypoglycemia, hypercalcemia, or dysfibrinogenemia. (For more information on Hypercalcemia, refer to the PDQ summary of the same name.)
Prognostic factors
The biologic marker AFP is useful for the diagnosis of this neoplasm. By a radioimmunoassay technique, 50% to 70% of patients in the United States who have hepatocellular carcinoma have elevated levels of AFP. However, patients with other malignancies (germ cell carcinoma and, rarely, pancreatic and gastric carcinoma) also demonstrate elevated serum levels of this protein. AFP levels have been shown in studies such as RTOG-8301 to be prognostically important, with the median survival of AFP-negative patients significantly longer than that of AFP-positive patients.[13,14] Other prognostic variables include performance status, liver functions,[15] and the presence or absence of cirrhosis and its severity in relation to the Child-Pugh classification.[16]
Patients scheduled for possible resection require preoperative assessment with angiography in conjunction with helical computed tomographic (CT) scan or magnetic resonance imaging (MRI) with magnetic resonance angiography; these scans have obviated the need for angiography in most patients. Information on the arterial anatomy is helpful for the operating surgeon and may eliminate some patients from consideration for resection. The presence of tumor thrombi in the hepatic veins, the inferior vena cava, or the portal vein can significantly alter treatment approaches. Dynamic CT and MRI scans can document the relationship of the tumor to the hepatic and portal veins (and, on occasion, involvement of these structures), delineating tumors for which the chances for surgical cure are remote.[17] Laparoscopic evaluation may detect metastatic disease, bilobar disease, or inadequate liver remnant, and therefore obviate the need for open surgical exploration.[18]
Related Summaries
Other PDQ summaries containing information related to adult primary liver cancer include the following:
- Childhood Liver Cancer
- Liver (Hepatocellular) Cancer Screening
Cellular Classification of Adult Primary Liver Cancer
Malignant tumors of the liver are primarily adenocarcinomas, with two major cell types: hepatocellular and cholangiocarcinoma.
Histologic classification is as follows:
- Hepatocellular carcinoma (liver cell carcinoma).
- Hepatocellular carcinoma (fibrolamellar variant). The fibrolamellar variant is important because an increased proportion of these patients may be cured if the tumor can be resected. It is more frequent in young women. It also generally exhibits a slower clinical course than the more common hepatocellular carcinoma.
- Cholangiocarcinoma (intrahepatic bile duct carcinoma).
- Mixed hepatocellular cholangiocarcinoma.
- Undifferentiated.
Hepatoblastoma rarely occurs in adults.
Stage Information for Adult Primary Liver Cancer
Note: The American Joint Committee on Cancer has recently published a new edition of the AJCC Cancer Staging Manual, which includes revisions to the staging for this disease. The PDQ Adult Treatment Editorial Board, which is responsible for maintaining this summary, is currently reviewing the new staging to determine the changes that need to be made in the summary. In addition to updating this Stage Information section, additional changes may need to be made to other parts of this summary to ensure that it is up-to-date. The changes will be made as soon as possible.
TNM Definitions
Primary tumor (T)
- TX: Primary tumor cannot be assessed
- T0: No evidence of primary tumor
- T1: Solitary tumor without vascular invasion
- T2: Solitary tumor with vascular invasion or multiple tumors none more than 5 cm
- T3: Multiple tumors more than 5 cm or tumor involving a major branch of the portal or hepatic vein(s)
- T4: Tumor(s) with direct invasion of adjacent organs other than the gallbladder or with perforation of the visceral peritoneum
Regional lymph nodes (N)
- NX: Regional lymph nodes cannot be assessed
- N0: No regional lymph node metastasis
- N1: Regional lymph node metastasis
The regional lymph nodes are the hilar (i.e., those in the hepatoduodenal ligament, hepatic, and periportal nodes). Regional lymph nodes also include those along the inferior vena cava, hepatic artery, and portal vein. Any lymph node involvement beyond these nodes is considered distant metastasis and should be coded as M1. Involvement of the inferior phrenic lymph nodes should also be considered M1.
Distant metastasis (M)
- MX: Distant metastasis cannot be assessed
- M0: No distant metastasis
- M1: Distant metastasis
Metastases occur most frequently in bones and lungs. Tumors may extend through the capsule to adjacent organs (adrenal glands, diaphragm, and colon) or may rupture, causing acute hemorrhage and peritoneal carcinomatosis.
The T classification is based on the results of multivariate analyses of factors affecting prognosis after resection of liver carcinomas. The classification considers the presence or absence of vascular invasion (as assessed radiographically or pathologically), the number of tumor nodules (single vs. multiple), and the size of the largest tumor (≤ 5 cm vs. > 5 cm). For pathologic classification, vascular invasion includes gross as well as microscopic involvement of vessels. Major vascular invasion (T3) is defined as invasion of the branches of the main portal vein (right or left portal vein; this does not include sectoral or segmental branches) or as invasion of one or more of the 3 hepatic veins (right, middle, or left). Multiple tumors include satellitosis, multifocal tumors, and intrahepatic metastases. Invasion of adjacent organs other than the gallbladder or with perforation of the visceral peritoneum is considered T4.
AJCC Stage Groupings
Stage I
Stage II
Stage IIIA
Stage IIIB
Stage IIIC
- Any T, N1, M0
Stage IV
- Any T, any N, M1
For purposes of treatment, patients with liver cancer are grouped into 1 of 3 groups: localized resectable, localized unresectable, or advanced disease. These groups are described with the following AJCC stage groupings:
Localized Resectable Adult Primary Liver Cancer
(Selected T1 and T2; N0; M0)
Localized resectable liver cancer is confined to a solitary mass in a portion of the liver, or a limited number of tumors confined to one lobe, that allows the possibility of complete surgical removal of the tumor with a margin of normal liver. Liver function tests are usually normal or minimally abnormal, and there should be no evidence of cirrhosis beyond Child class A or chronic hepatitis. Only a small percentage of liver cancer patients will prove to have such localized resectable disease. Preoperative assessment that includes 3-phase helical computed tomography and/or magnetic resonance scanning should be directed toward determining the presence of extension of tumor across interlobar planes, involvement of the hepatic hilus, or encroachment on the vena cava. A resected specimen should ideally contain a 1 cm margin of normal liver. Patients with cirrhosis and resectable tumors are also eligible for liver transplantation;[1] if eligible, sometimes other measures are instituted until liver transplantation becomes available.
Localized and Locally Advanced Unresectable Adult Primary Liver Cancer
(Selected T1, T2, T3, and T4; N0; M0)
Localized and locally advanced unresectable liver cancer appears to be confined to the liver, but surgical resection of the entire tumor is not appropriate because of location within the liver or concomitant medical conditions (such as cirrhosis). These patients may be considered for liver transplantation.[2,3,4] For other patients, percutaneous or intraoperative radiofrequency ablation (RFA) or other forms of ablation of small (<3 cm) appropriately located tumors, or transarterial chemoembolization (TACE) may be options.[5]
Advanced Adult Primary Liver Cancer
(Any T, N1 or M1)
Advanced liver cancer is present in both lobes of the liver or has metastasized to distant sites. Median survival is usually 2 to 4 months. The most common metastatic sites of hepatocellular cancer are the lungs and bone. Multifocal disease in the liver is common, particularly when cirrhosis or chronic hepatitis is present. Chemoembolization has been beneficial in selected patients who have no extrahepatic metastases.[6]
Localized Resectable Adult Primary Liver Cancer
Note: Some citations in the text of this section are followed by a level of evidence. The PDQ editorial boards use a formal ranking system to help the reader judge the strength of evidence linked to the reported results of a therapeutic strategy. (Refer to the PDQ summary on Levels of Evidence for more information.)
For patients with selected T1 or T2; N0; M0 disease.
Standard treatment options:
- Surgery: Resection of localized hepatocellular cancer varies from segmental resection to trisegmental (80% of liver) resection. In series of carefully selected patients, partial hepatectomy has resulted in a 5-year survival of 30% to 40%, with median survivals approaching 3 years.[1] In a retrospective study of patients with intrahepatic cholangiocarcinoma, hepatic resection demonstrated a 5-year survival of 23% and a tumor-free survival of 11%.[2][Level of evidence: 3iiiDii] Hepatic carcinoma is frequently multifocal and may involve multiple sites throughout the liver at the time of exploration, even when a dominant mass is found on preoperative assessment. Preoperative assessment should also include a search for extrahepatic metastases, since this condition will also preclude the planned hepatic resection. Intraoperative ultrasound assessment of the liver often finds satellite or second lesions.[3] Resection that involves more than a nonanatomic wedge of liver is poorly tolerated and leads to a high mortality rate in patients with severe cirrhosis. Severe cirrhosis may be a contraindication to major hepatic resection but may not contraindicate hepatic transplantation.[4,5,6,7] Hepatic transplantation for hemangioendothelioma, fibrolamellar hepatocellular carcinoma, and small (<5 cm) hepatocellular carcinoma in patients with or without cirrhosis has been associated with 5-year survivals of 20% to 30%.[8][Level of evidence: 3iiiA];[9]
Treatment options under clinical evaluation:
Chemotherapy or biologic therapy: Because of the high proportion of patients who experience relapse following surgery for localized hepatic cancer, adjuvant approaches have been employed using chemoembolization, regional arterial infusion of the liver or systemic therapy with chemotherapeutic agents. One randomized trial of 43 patients suggested improved survival with adjuvant injection of a single dose (1,850 MBq) of I-131 lipiodol via the hepatic artery. Median disease-free survival in the treatment group was 57 months compared to 13.6 months in the group that did not receive treatment beyond resection (P = .037).[10][Level of evidence: 1iiA,1iiB] Lipiodol was nontoxic, but required thyroid suppression before and after surgery. Enrollment in this trial was prematurely terminated because of early differences in survival between the treatment and control arms. Therefore, the results must be considered preliminary and will require confirmation.
Adoptive immunotherapy with interleukin-2 and anti-CD3 activated autologous lymphocytes was found to have lengthened recurrence-free survival, but not overall survival, in one study.[11][Level of evidence: 1iiDiv] Localized recurrences in the liver may occasionally be successfully treated by re-resection.[12,13]
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with localized resectable adult primary liver cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
Localized and Locally Advanced Unresectable Adult Primary Liver Cancer
Note: Some citations in the text of this section are followed by a level of evidence. The PDQ editorial boards use a formal ranking system to help the reader judge the strength of evidence linked to the reported results of a therapeutic strategy. (Refer to the PDQ summary on Levels of Evidence for more information.)
For selected patients with T1, T2, T3, or T4; N0; M0 disease.
Patients whose tumors are localized but unresectable due to location in the liver, concomitant medical considerations (such as cirrhosis), or even limited bilateral tumors, may be candidates for chemoembolization, cryosurgery, percutaneous ethanol injection, or radiofrequency ablation for cancers smaller than 5 cm. Survivals equivalent to resection have been reported.[1] One randomized trial in cirrhosis patients with small hepatocellular carcinomas demonstrated improved local recurrence-free survival in patients who underwent radiofrequency ablation as compared to percutaneous ethanol injections as their only form of treatment,[2][Level of evidence: 1iiDiii] but overall survival was not changed.[2][Level of evidence: 1iiA]
Clinical trials that use systemic chemotherapy, regional chemotherapy, and/or labeled or radiolabeled antibodies have demonstrated remission of unresectable hepatoma. Other approaches include embolization of the hepatic artery with gelatin foam powder or muscle fragments and chemotherapy, usually doxorubicin. These approaches often produce central tumor necrosis, reduction in tumor size, and relief of pain, but the benefits are usually transient. Any interference with arterial blood supply (including infusion chemotherapy) may be associated with significant morbidity and is contraindicated in the presence of portal hypertension, portal vein thrombosis, or clinical jaundice. A randomized study of chemoembolization versus conservative treatment found no survival advantage for chemoembolization.[3] This study was terminated early and was underpowered to detect any but large survival differences.
Standard treatment options:
|Radiofrequency ablation, chemoembolization, cryosurgery, or percutaneous ethanol injection: These techniques may be used in patients with small (<5 cm), localized, unresectable tumors.[1,4,5,6,7,8]
|Liver transplantation: For selected patients with localized unresectable hepatoma, particularly patients with fibrolamellar hepatomas, liver transplantation may offer a potentially curative treatment option.[9]
|Chemotherapy (regional infusion of the liver): Chemotherapeutic agents may be infused with a subcutaneous portal or implantable pump via a catheter placed in the hepatic artery. Older studies that use standard agents have demonstrated responses in 15% to 30% of such cases, but newer agents and techniques (i.e., biodegradable microspheres) have been evaluated in pilot trials,[10,11,12] as has regional chemotherapy with external-beam radiation therapy.[13] Many patients are not candidates for these approaches, which often require surgical intervention.
Systemic chemotherapy and/or targeted therapy: Prior to the SHARP trial (NCT00105443), durable remissions had rarely been reported, and randomized series had shown no significant survival benefits when compared with no treatment. In the SHARP trial, 602 patients with advanced hepatocellular carcinoma (slightly less than 50% of the patients in each group had carcinomas that were confined to the liver but were unresectable and had extrahepatic spread) who had not received prior systemic treatment were assigned to receive either sorafenib 400 mg twice daily or placebo.[14] All but 20 patients had Childs-Pugh A liver disease score; 13% were women. After 321 deaths, the median survival was significantly longer in the sorafenib group (10.7 months vs. 7.9 months on placebo; hazard ratio [HR] favoring sorafenib = 0.69; 95% confidence interval [CI], 0.55–0.87; P < .001).[14][Level of evidence: 1iA] While median time to symptoms was not significantly different, the percent achieving radiologic responses was higher in the sorafenib group.
A subsequent similar trial conducted with 271 patients from 23 centers in China, South Korea, and Taiwan with a 2:1 randomization on sorafenib achieved a median overall survival rate of 6.5 months on sorafenib versus 4.2 months on placebo (HR = 0.68; 95% CI, 0.50–0.93; P = .014).[15] Adverse events attributed to sorafenib in both of these trials included hand-foot skin reactions and diarrhea.
These studies establish a role for sorafenib in locally advanced as well as advanced hepatocellular cancers extending beyond the liver, which are not amenable to regional modalities. Studies are ongoing to evaluate the role of sorafenib after transarterial chemoembolization (TACE), with chemotherapy, or in the presence of more advanced liver disease.
|Surgery, chemotherapy, and radiation therapy: These modalities may be combined in clinical trials for patients with a dominant hepatic mass and multifocal involvement with small amounts of tumor; surgical resection, radiofrequency ablation, or cryosurgery of the mass may be followed by hepatic infusion of the remaining liver with chemotherapeutic agents alone or in combination with hyperthermia, radiation, or radiation with radiosensitizers.[1] Chemotherapy plus radiation has also been used to shrink tumors prior to resection.[16] However, the whole liver is not tolerant of large doses of radiation therapy.
|Radiosensitizers and external-beam radiation therapy without chemotherapy: The relative radiosensitivity of normal liver tissue compared with tumor tissue must always be considered when radiation therapy is contemplated.[17]
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with localized unresectable adult primary liver cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
Advanced Adult Primary Liver Cancer
For patients with any T, N1, M1 disease.
There is no standard therapy for patients with advanced metastatic liver cancer. Such patients should be considered candidates for clinical trials exploring the usefulness of new biologicals or antitumor drugs (phase I and II studies) or combinations of existing drugs, radiosensitizers, and radiation therapy. Palliation may sometimes be achieved in such studies.
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with advanced adult primary liver cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
Recurrent Adult Primary Liver Cancer
Note: Some citations in the text of this section are followed by a level of evidence. The PDQ editorial boards use a formal ranking system to help the reader judge the strength of evidence linked to the reported results of a therapeutic strategy. (Refer to the PDQ summary on Levels of Evidence for more information.)
The prognosis for any treated primary liver cancer patient with progressing, recurring, or relapsing disease is poor. The question and selection of further treatment depends on many factors, including prior treatment, site of recurrence, presence of cirrhosis, and hepatic function as well as individual patient considerations. Re-resection should be considered when feasible, but most patients experience recurrence, typically in the liver.[1] When re-resection is not possible, treatment options for patients with recurrent hepatocellular cancer may include the use of transarterial oily chemoembolization (TOCE), percutaneous ethanol injection therapy (PEIT), chemotherapy, or liver transplantation.[2] At a single institution in Hong Kong, 244 consecutive patients treated with curative resection were followed for intrahepatic recurrence. Of the 244 patients followed, 139 patients did not develop intrahepatic recurrence and had 1-, 3-, and 5-year survival rates of 87%, 79%, and 74%, respectively. Of the 105 patients who developed subsequent intrahepatic recurrences, 11 patients were treated with re-resection and had 1-, 3-, and 5-year survival rates of 81%, 70%, and 69%, respectively; 71 patients were treated with TOCE and had 1-, 3-, and 5-year survival rates of 72%, 38%, and 20%, respectively; 6 patients were treated with PEIT and had 1-, 3-, 5-year survival rates of 67%, 22%, and 0%, respectively; the remaining 17 patients had either systemic chemotherapy or conservative treatment, and had no survivors at 3 years.[2][Level of evidence: 3iiA] Clinical trials are appropriate and should be considered whenever possible.
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with recurrent adult primary liver cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
Changes to This Summary (02 / 23 / 2012)
The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.
General Information About Adult Primary Liver Cancer
Updated statistics with estimated new cases and deaths for 2012 (cited American Cancer Society as reference 1).
This summary is written and maintained by the PDQ Adult Treatment Editorial Board, which is editorially independent of NCI. The summary reflects an independent review of the literature and does not represent a policy statement of NCI or NIH. More information about summary policies and the role of the PDQ Editorial Boards in maintaining the PDQ summaries can be found on the About This PDQ Summary and PDQ NCI's Comprehensive Cancer Database pages.
About This PDQ Summary
Purpose of This Summary
This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the treatment of adult primary liver cancer. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.
Reviewers and Updates
This summary is reviewed regularly and updated as necessary by the PDQ Adult Treatment Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).
Board members review recently published articles each month to determine whether an article should:
- be discussed at a meeting,
- be cited with text, or
- replace or update an existing article that is already cited.
Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.
The lead reviewers for Adult Primary Liver Cancer Treatment are:
- Russell S. Berman, MD (New York University School of Medicine)
- Giuseppe Giaccone, MD, PhD (National Cancer Institute)
- Franco M. Muggia, MD (New York University Medical Center)
Any comments or questions about the summary content should be submitted to Cancer.gov through the Web site's Contact Form. Do not contact the individual Board Members with questions or comments about the summaries. Board members will not respond to individual inquiries.
Levels of Evidence
Some of the reference citations in this summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Adult Treatment Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations.
Permission to Use This Summary
PDQ is a registered trademark. Although the content of PDQ documents can be used freely as text, it cannot be identified as an NCI PDQ cancer information summary unless it is presented in its entirety and is regularly updated. However, an author would be permitted to write a sentence such as "NCI's PDQ cancer information summary about breast cancer prevention states the risks succinctly: [include excerpt from the summary]."
The preferred citation for this PDQ summary is:
National Cancer Institute: PDQ® Adult Primary Liver Cancer Treatment. Bethesda, MD: National Cancer Institute. Date last modified <MM/DD/YYYY>. Available at: http://cancer.gov/cancertopics/pdq/treatment/adult-primary-liver/HealthProfessional. Accessed <MM/DD/YYYY>.
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Based on the strength of the available evidence, treatment options may be described as either "standard" or "under clinical evaluation." These classifications should not be used as a basis for insurance reimbursement determinations. More information on insurance coverage is available on Cancer.gov on the Coping with Cancer: Financial, Insurance, and Legal Information page.
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Last Revised: 2012-02-23
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It looks like when you signed up online on 8/5/2014, that you accidentally joined our greater Portland chapter instead of our Salem/Corvallis chapter that your zip code falls under. I have transferred your subscription to that chapter, so you will now have access to the correct area.
I hope this information helps! Please let me know if I can assist further. You can respond to this thread or submit a new Answers post. You can also reach us at 1-866-783-2980. We're open weekdays from 8:00 am - 9:00 pm and Saturdays 8:00 am - 5:00 pm ET.
Thanks again!
Prosthetic And Orthotic reviews in Portland
is good at making a particular type of brace for scoliosis, and he has a national reputation for this. He is gentle and nice with children. He is not ...MoreRead more of this review so good with follow-up and with communication in general regarding booking future appointments and monitoring long-term progress.
recently left Orthotic Solutions to start a new company, and as he put it, his business has had "growing pains." We had one appointment with him at his new company, and when we arrived they seemed surprised to see us. His front office did a terrible job at resolving an insurance related issue. His new business does not participate with any insurance providers. This makes it very very expensive to do business there. Based on advice of his pervious billing department, we switched insurance so his services would be in-network. Once we realized that his services would be out-of-network, we tried to figure out what the brace would actually cost us, and it was a black box. His office wanted to charge us our (high) deductible and call it even, but we couldn't figure out his much of that would actually be credited to our in-network deductible. They communicated conflicting information to us for about 4 weeks before we determined that we can no longer use his services. For example, they said they would pursue an authorization for in-network coverage, then they said they weren't really able to do that. They said they were applying for insurance participation, then weeks later said that wasn't part of "their new business model." Ultimately, we had to switch to a new orthotist because the financial arrangements were unclear and because I was not willing to book services then see what they cost after the fact after submitting a claim. Their advice to me was to use Care Credit (a medical credit card) to pay for services or to file an appeal with my insurance company after the fact. Neither of these is a reasonable solution. Patients need to know up front what their financial responsibility is, and his office would not provide that to me.
Bottom line is that although he is a good brace maker and a nice person, his office has difficulty communicating clearly and working to resolve insurance issues.
The process was amazing. did the impressions of my feet and had my new orthotics to me about a week ...MoreRead more of this review later. After a month of breaking them in, my feet feel much better.
I still fight with some heel pains, but when I remember to wear my anterior night splint -- that helps my feet from hurting after a long day of walking.
has done an excellent job of following up, asking questions about how my gate has improved and to ask what if any issues I've experienced.
She truly took the time to figure out what options were best for my feet."
BE WARNED about their Billing Department and what they say is covered and NOT covered by insurance. When I first spoke to the group I was not certain I would have the orthotics done because I could not afford it if it was not covered. Then a month after my appointment I received ...MoreRead more of this review a call from the office to tell me that my insurance would cover it 100%.
A bill arrived yesterday for $420. UNBELIEVABLE.
I give the doctor 4 stars.
I give the billing/appointment department -1 stars
In today's high unemployment and insurance coding problems we all have to be very careful in what we tell patients on the phone.
The fact is you can NOT tell someone on the phone that something is 100% covered by insurance and then send a bill for an outrageous amount. UNACCEPTABLE Medical Billing Practices.
We are all very pleased with this provided. The ladies in the office are very sweet and bend over backwards to help in any way they can. You will be very pleased and will continue to use them also.
Prosthetics in Portland
Arch Fitters
Best Orthotics
Broadbent, Dr. Bryan K.
Bullock, Dr. Gina M
Cascade Foot And Ankle Specialists LLC
Chung, Dr. David S.
Dr. Brian Bowen- Eastside Foot and Ankle
Dr. Troy Simmons
EmPOWERed Changes Hypnosis
Evergreen Prosthetics & Orthotics, LLC
Foot Solutions of Tigard
Garth's Foot Form
Goldstein, Dr. Jay C.
Good Feet
Hanger Inc
Hastings, Dr. Mark T.
Lake Oswego
Helper, Don
Insights to Health Clinic
Mah, Dr. Kenneth K.S.
Oregon Foot Clinic
Oregon Podiatry Clinic
Palmer, Dr. Thomas R.
Pollack, Dr. Kris
Lake Oswego
Providence Medical Group Sunset
Sampson, Dr. Robert A.
The Oregon Clinic - Administration Office
The Oregon Clinic PC
The Portland Clinic - Tigard Office
The Vancouver Clinic-Salmon Creek
The WalkEZstore.com
Tsai, Dr. Richard Z.
Yamhill County Foot Health Center
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WASHINGTON (AP) -- President Barack Obama is marking the Fourth of July by thanking service members and their families, who he said "represent what is best in America."
The president, accompanied by first lady Michelle Obama, hosted a barbecue and concert Wednesday for the families on the White House South Lawn.
Obama saluted "this generation of heroes" for their service and sacrifice to defend American freedoms, specifically thanking them for bringing Osama bin Laden to justice and working to get out of Afghanistan.
He said the nation "will always be there for you, just as you've been there for us." He said it was his promise, and America's promise.
Afterward, the Obamas shook hands and posed for pictures with eager visitors. The U.S. Marine Band and country singer Brad Paisley performed.
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The Garmin Approach S3 GPS Watch is a device golfers can use from the tee box to the green. It expands upon the distance-to-the-green information (front, middle, and back) found in the popular S1 and adds additional features to navigate the entire hole and speed up play.
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How do I upload a layout and show the world my work? Well, we'll walk you through how to do it in this video!
Printable View
How do I upload a layout and show the world my work? Well, we'll walk you through how to do it in this video!
Just bumping this as a friendly reminder to everyone, and for valuable information for all the newbies!!! :) Hope this helps!!!
Thanks for bumping it Stephanie. As a newbie, it is helpful.
I have never known before how to upload, thank you
I was wondering how to do that, thank you for posting this. When I finally get some layouts done I will have to post them. Thanks again from another newbie! :o)
I have a few I would like to upload. They are from scrapkits that I didnt buy from here. Am I allowed to upload them even if I didnt buy the kits from this website. I have bought some kits from here I just havent scrapped with them yet.
Here you'll find inspiration and ideas from our member creations using our products primarily! When posting a layout that includes elements from other products, we respectfully request that you not add links to other sites in your credits.
Hope this helps you
Thank you Ladies for such quick replies.
I was able to upload my first LO..looks ok but i heard i have to make it "web ready". I followed a tutorial on another site but it didn't work..it was for a higher version of PSE.
I use PSE 3 , when i was done my LO i merged all file & saved it as a jpg (i also saved my PSD files). My specification for my jpeg is 8.95 MB 3600 pixel x3600 , 300 resolution-I am not sure what i am doing here -I am hoping to find a tutorial for getting layouts ready for post (with step by step as i am very new)! Any direction would be very much appreciated.
thank you


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Da Vinci takes the name of their company very seriously. Their paints are exciting, intense, and rated among the best in the world for quality.
The paints are permanent, with the highest tinting strength and pigment concentration available. However, they are especially soft, with a creamy consistency for smooth, easy dispersion with water.
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Color Chart Note — Use this color chart as an approximation of the real color. If exact color matching is necessary, use actual samples of the materials.
see also ...
Da Vinci is a trademark of the Da Vinci Paints Company.


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By Charles Hallman
Staff writer
Over the course of three decades, the late Sid Ordower brought the greats and some-to-be greats in gospel music each week on local Chicago television. The likes of Albertina Walker, Mahalia Jackson, Mavis Staples — along with her sisters and their father, James Cleveland, and Otis Clay routinely appeared on Jubilee Showcase, a half-hour long show that ran from 1963-1984. Beginning November 30 and throughout the month of December, PBS will air a 50th anniversary commemorative television special on Jubilee Showcase, said his son Steve Ordower in a recent MSR phone interview. "He was an owner-operator [of his shows], which was pretty rare back in those days," he explains. "Unfortunately, the first 13 episodes were erased, and he was livid. Continue Reading →


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Residents of Orchard Grass Hills encountered an ax-wielding intoxicated man just before sunrise Saturday morning.
Oldham County Police arrested David G. Mikel, 21, of Crestwood, at 6:55 a.m. Saturday on charges of wanton endangerment and assault.
Police found Mikel in the front yard of his home, 7441 W. Orchard Grass Blvd., yelling obscenities and swinging an ax as people ran from him.
Neighbors told police Mikel, who was highly intoxicated, became enraged after someone allegedly knocked on his front door.
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May 2, 2016
North Carolina's attorney general is calling on lawmakers and the governor to reconsider recommendations he made more than six years ago that he believes will make schools safer.
Attorney General Roy Cooper said Wednesday that he has written new Gov. Pat McCrory to revisit the recommendations made in a school safety study in 2006.
They include more school resource officers; a statewide school tip line to report threats anonymously and more training for educators on recognizing potential safety threats.
Cooper said in a news release that schools have put many of the recommendations in place, including routine lockdown drills.
Cooper started the program with the Center for the Prevention of School Violence, which the attorney general says should be re-established.
Copyright 2016 by The Associated Press. All Rights Reserved.
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Ryō Tasaka
Revision as of 01:38, February 13, 2013 by Kunoichi101 (Talk | contribs)
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Ryō Tasaka (田坂亮, Tasaka Ryō), born on July 9, 1977, is a Japanese mangaka and assistant to Masashi Kishimoto. He also worked with Kengo Kurando on the series Monsters.
- Monsters (2008, Weekly Shōnen Jump)


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Volunteers are more valuable to your nonprofit than ever before—literally and figuratively. The Independent Sector has updated their estimated dollar value of volunteer time to an average of $20.25 per hour for 2008 ($19.29 for Michigan).
Keep track of volunteer hours and multiply them by $19.29 to learn the value of volunteer labor to your organization. Include the value as part of in-kind contributions in your budget. And, consider what it would cost your NP in real dollars should you need to purchase the services and expertise your volunteers currently provide.
Posted by Bobbe Luce at 04/09/2009 09:16:07 AM |


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Community Information Database
You are browsing the Subject Heading Theater Performances which contains 10 record(s)
- All About Theatre
All About Theatre has been offering theatrical training and quality productions to the greater Santa Cruz County community for over ten years now. We focus our energy and creativity on training our st... [Full Record] [Add to Personal List]
- Jewel Theatre Company
Founded in 2005, JTC operates under a contract with Actors' Equity Association (the union for professional actors and stage managers in the U.S.) and is dedicated to creating extraordinary produc... [Full Record] [Add to Personal List]
- Mountain Community Theater
Mountain Community Theater is Santa Cruz Countys longest continuously running community theater company. MCT is a member-run non-profit organization that derives its support primarily from performanc... [Full Record] [Add to Personal List]
- Santa Cruz County Actors Theatre
Actors' Theatre is a production company producing the 8 Tens Festival which is greatly loved not only by the public, but also by the theatre community as well, for being an outlet to nurture and ... [Full Record] [Add to Personal List]
- Santa Cruz Performing Arts
Santa Cruz Performing Arts is a small local nonprofit organization that offers user, theater, and dance programs, as well as sound design, light and sound equipment rentals, and production support. ... [Full Record] [Add to Personal List]
- Santa Cruz Shakespeare
Monday-Friday, 9am to 5pm (office hours) Tuesday-Sunday, matinee and evening performances (July & August) Santa Cruz Shakespeare is a professional repertory theatre company, performing three ... [Full Record] [Add to Personal List]
- Scotts Valley Performing Arts
Community Theatre Company Scotts Valley Performing Arts is a non-profit corporation providing Scotts Valley and the Santa Cruz County community with opportunities to participate in the performing art... [Full Record] [Add to Personal List]
- Theatre In The Mountains
Theatre in the Mountains is dedicated to providing theatrical opportunities for children and adults throughout the year. The performances are held in the Loma Prieta Community Foundation/CT English Mi... [Full Record] [Add to Personal List]
- WEST Performing Arts
Arts education classes in theatre, dance, music and literature. Art events and productions. Art workshops for families.... [Full Record]
- Young Actors' Theatre Camp
The Young Actors Theatre Camp hosts several overnight camps and weekend workshops throughout the year. Our Overnight Camps are in the Santa Cruz Mountains while our weekend workshops are held in SF... [Full Record] [Add to Personal List]


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We are a California Community College Program serving CalWORKs students and their families by providing educational and career opportunities combined with an array of high quality support services that enable students to complete their educational goals, find meaningful employment, and successfully transition into the work force. Through collaboration and advocacy with our College and community partners, we prepare a segment of California's work force by promoting the economic self sufficiency of CalWORKs student through the attainment of a higher education.
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Israeli Social Entrepreneurs Are Transforming Their Hometowns"We chose to work with younger students, because at the age of 10 or 11 the children have not yet formed limiting beliefs about their abilities and potential, and are not as restricted by their By Amishai Gottlieb 0
11 Ways You Can Support Israel Right NowThere are many things you can do to support Israel. #4 will inspire you. By Amishai Gottlieb 0
Summer Success for Onward Israel, A Growing Internship Program in Israel"This summer, I have gotten to do what I love most in a fascinating and beautiful country, while learning and growing in ways I never could have expected." By Amishai Gottlieb 0
Emergency Hotline for ImmigrantsIn response to Israel's ongoing security situation, The Jewish Agency is offering an emergency hotline for immigrants (olim) to help cope with the stresses and emotional difficulties related to By 0
In the Shade of Terror, Olim Choose Be'ersheva"The choice of young Jews from around the world to build their future in Israel, in preference over other countries, is a real victory of Zionism." - Jewish Agency Chairman Natan Sharansky By Amishai Gottlieb 0
Beyond Birthright: New Government Support for Medium-Length Programs in IsraelExpanded support will help fill the gap between short-term programs like Taglit-Birthright Israel and long-term programs. By 0
The Jewish Agency Responds to TerrorAn Emotional Meeting with a Terror Victim's Elderly Mother and Israel's President, Reuven Rivlin By 0
5 Things You Can Do to Help Israel NowMany of us want to help Israel during this difficult time. But what can we do to help the situation? What if we live far away? Here's our list of five things you can do to help now. By 0
Meeting with Victims of TerrorThe Jewish Agency met with several victims of terror and their families in the past week to give them support and hear their stories. By 0


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- Mar 13:
- Saudi convict al-Turki sues federal, state officials for defamation
- Aug 12:
- Federal appeals court clears way for lawsuit by Saudi inmate al-Turki
- Jan 3:
- Appeal likely in Saudi man's Colorado sex offense
- Jan 2:
- Judge denies Homaidan al-Turki's request to return to Saudi Arabia
- Oct 31:
- Clements' slaying sparked prison move of Saudi inmate
- Colo official: Saudi inmate investigated in death
- Oct 24:
- Saudi Arabia seeks native convicted of sex assault
Homaidan al-Turki's application to serve the remainder of his sentence in Saudi Arabia cleared reviews by prison officials and is awaiting final approval by Colorado Department of Corrections Director Tom Clements, department spokeswoman Katherine Sanguinetti said Friday. The foreign national offender transfer application would then undergo a federal review, and if approved, al-Turki would be sent to Saudi Arabia.
Al-Turki was convicted in 2006 of unlawful sexual contact by use of force, theft and extortion—all felonies—as well as misdemeanor counts of false imprisonment and conspiracy to commit false imprisonment. He was sentenced to 28 years to life in prison. The U.S. attorney's office dropped similar federal charges.
A judge in 2011 reduced al-Turki's minimum sentence by 20 years, based on a Colorado Supreme Court ruling that now makes al-Turki eligible for parole. Sex offenders in Colorado, however, typically must participate in rehabilitation programs while incarcerated before being considered for release.
18th Judicial District Attorney George Brauchler, who took office last month, opposes the transfer, saying there are no assurances that al-Turki will serve the remainder of his sentence once he's out of the United States.
"It is completely unacceptable that a sex offender of any nationality be released before completing his sentence," Brauchler said in a statement. "Mr. Al-Turki has never accepted responsibility for his crimes nor undergone any rehabilitation as a sex offender. I am hopeful that the Department of Corrections will put the interests of justice and the protection of women above the interests of the Saudi government."
Prosecutors said the Indonesian housekeeper, who was in her early 20s, has since returned to her home country.
Federal prosecutors had no immediate comment.
Al-Turki says he's innocent and a victim of anti-Muslim sentiment. He testified at trial that FBI agents persuaded his housekeeper to accuse him of imprisoning and sexually assaulting her in his basement after they failed to build a case that he was a terrorist.
His 2006 conviction angered Saudi officials and prompted the U.S. State Department to send Colorado Attorney General John Suthers to Saudi Arabia to meet with King Abdullah, Crown Prince Sultan and al-Turki's family.
Al-Turki brought his wife, five children and the housekeeper to Colorado in 1995 and was a student at the University of Colorado. He was a well-known member of Denver's Muslim community.
According to court documents, al-Turki first came under investigation when authorities examined whether his operation of a business violated terms of his student visa. Al-Turki owned Al-Basheer Publications & Translations, which distributed Islamic works in English.
Al-Turki's company holds the copyright to "The Lives of the Prophets," a CD set of Islamic sermons that tell stories about Muslim prophets recorded by the U.S.-born radical cleric Anwar al-Awlaki, who was killed along with his 16-year-old son in a drone strike in Yemen in 2011. Al-Awlaki attended Colorado State University in Fort Collins and lived in Denver in the late 1990s.
Federal law enforcement authorities in Denver have declined to say whether it was al-Turki's relationship with al-Awlaki that brought al-Turki under scrutiny.


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Guy Walker Morriss
Position: C
Height: 6-4 Weight: 255 lbs.
Born: May 13, 1951 in Colorado City, TX
High School: Sam Houston
College: TCU (school history)
Drafted by the Philadelphia Eagles in the 2nd round (28th overall) of the 1973 NFL Draft.
Weighted Career AV (100-95-...): 61 (892nd overall since 1950)
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Output includes all games from 1920 to 2015.


text:
29 U.S. Code § 724 - Non-Federal share for establishment of program or construction
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For the purpose of determining the amount of payments to States for carrying out part B of this subchapter (or to an Indian tribe under part C of this subchapter), the non-Federal share, subject to such limitations and conditions as may be prescribed in regulations by the Commissioner, shall include contributions of funds made by any private agency, organization, or individual to a State or local agency to assist in meeting the costs of establishment of a community rehabilitation program or construction, under special circumstances, of a facility for such a program, which would be regarded as State or local funds except for the condition, imposed by the contributor, limiting use of such funds to establishment of such a program or construction of such a facility.
Source(Pub. L. 93–112, title I, § 104, as added Pub. L. 105–220, title IV, § 404,Aug. 7, 1998, 112 Stat. 1151.)
Prior Provisions
A prior section 724,Pub. L. 93–112, title I, § 104,Sept. 26, 1973, 87 Stat. 370; Pub. L. 95–602, title I, § 122(b)(1),Nov. 6, 1978, 92 Stat. 2987; Pub. L. 99–506, title II, § 205,Oct. 21, 1986, 100 Stat. 1817; Pub. L. 102–569, title I, § 125,Oct. 29, 1992, 106 Stat. 4381, related to non-Federal share for construction, prior to the general amendment of this subchapter by Pub. L. 105–220.
LII has no control over and does not endorse any external Internet site that contains links to or references LII.


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Sportline 480 Tough Timer
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The Sportline® Tough Timer 480's GripSkin outer shell creates a slip-proof, shock-resistant and water-tight timing device that's perfect for any sporting event! Features include: an oversized LCD, digital tally counter, two-place fast-finish memory, time and date, and more!
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May 2, 2016
CHAPEL HILL, N.C. (AP) -- P.J. Hairston scored a career-high 20 points to help No. 23 North Carolina beat McNeese State 97-63 on Saturday.
Reggie Bullock added 17 points for the Tar Heels (9-3), who made 13 of 28 3-point attempts and never trailed. James Michael McAdoo scored 12 points, Leslie McDonald added 11 points, and Brice Johnson had 10 points for North Carolina.
The Tar Heels blew open the game early with a 22-4 run to take a 27-8 lead midway through the first half.
McDonald led the charge, scoring all of his points in the first half. He made his first two shots, both of which were 3-pointers, during the decisive run.
Jeremie Mitchell scored 13 points to lead the Cowboys (6-4), whose five-game winning streak ended.
Craig McFerrin added 10 points for McNeese State, which dropped to 0-4 against teams from the Atlantic Coast Conference.
Copyright 2016 by The Associated Press. All Rights Reserved.
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Please Rate This Review - Half Life 2
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Please Rate This Review - Half Life 2
Half-Life 2: A Blast From The Past
: Everything, especially using the Gravity gun to decapitate zombies
: An overclichéd plot.
: Who is the Gman????
Half-Life 2 is a game that came out 7 years ago. 7 years ago, you might think; everything about it must be old/ancient/sucky! I mean, 7 years ago. Iphones were a thing of science-fiction, Steam had barely taken its first steps, and Youtube hadnt even been born yet! Shock! Which is why I was a bit hesitant when I purchased Half-Life 2.
But I bought it, and played it. And here is my conclusion: Half-Life 2 is to games what Lionel Messi is to football.
It deserves to be in a class all by itself.
It isnt just that its a great game, it is the very definition of what a great game should be. An astounding gameplay experience, a well-crafted plot, intense firefights, a perfect dystopian world, puzzling challenges, complex boss fights and an unparalleled sense of realism make it one of the best games I have ever played.
In this first-person shooter, you are Gordon Freeman (incidentally voted best videogame hero of all time yes, even above Mario), who awakes in a dystopian earth taken over by Aliens. You then join the resistance, and proceed to overthrow the Alien oppresion and free people from their evil rule. On the way you must fight Combine soldiers (soldiers bearing striking resemblances to Storm Troopers), zombies, and other creatures such as giant insects who stand in your path to freedom.
At first sight, this game would score typical on your ranking of video games; a soldier with unique abilities and seemingly-endless health, going on an all solo mission to save the world. But if something has characterized Valve, it is its love for innovation, reinvention of old formulas, and perfection; and here, it is no exception. Unique, engrossing, diverse, exceptional are but a few of the words you could use to describe this game. It is simply brilliant.
The most eye-catching aspect of the game is its gameplay. It is as varied and innovative as it is intense; one minute youre mowing down soldiers with a machine gun attached to your airboat, next youre sniping off Zombies with your crossbow, and finally you have to escape the jaws of man-eating insects in a rudimentary car. Puzzles are also a major component of this game; unique, physics-based puzzles, guaranteed to vex you. Because they ARE complicated (for example, finding and using floating barrels to lift a plank, which will in turn allow your car to pass over a ramp), unlike the garbage ones you find in other games whose difficulty extend to finding an oh-so-secret button. This game flows seamlessly from puzzle to action, level to level, each one with a certain gaming style, creating an experience youll love.
Another noticeable thing is its realism. You dont play as Gordon Freeman. This game is so immersive, it makes you feel as though you ARE Gordon Freeman, in a real-life situation. A lack of cutscenes, a great physics aspect, having to be aware of sounds which can mean the difference between life and death, realistic enemies and allies The AI is flawless. Despite the fact that its quite dated, it impressed me. Enemies will not rush at you wildly; theyll plan, think, ambush. You throw a grenade, they will run out of the room and call for reinforcements. Shoot them, theyll duck, wait for you to reload, and then shoot. Snipe at them from a distance, theyll lob a grenade in your general direction and wait for results. Each battle is different, each soldier, zombie, turret and insect a threat. The intensity of it all will keep you on your toes, keeping your body pumped full of adrenaline throughout the whole game.
Valve has also reinvented the weapons no surprise there. Oh sure, you have your typical guns (shotguns, smgs, grenades), but trust them to come up with something completely different to change the game around. Weapons firing energy balls of death, pheromones to command an army of giant insects, waterized motor boat with a rechargeable machine gun, and what is uniquely the best thing of the whole game, the Gravity Gun. This gun gives full rein to your imagination, allowing you to pick up anything you deem deadly and hurl it at 100 mph at your foes. Propane tanks, saws, enemy grenades, and (why not) paint-cans can all be used to dispatch your enemies. Not only that, but there are levels in which you can use this gun to lift your very own enemies in the air and use them as shields, or toss them at foes. Utter brilliance.
A dystopian/1984-based city, a reservoir, a godforsaken village, are all but a few of the places I visited throughout Half Life 2. The setting is incredible on two parts; firstly, the dystopian feel this game has is just incredible, one of the best dystopias I have ever seen actually. And also, (like the gameplay) the setting and tone of the levels change almost instantaneously; one minute youre trying to hold off 3 helicopters at the same time in a dark, sandy beach, with bullets flying around you and tons of action. Next youre in Nova Prospekt (an underground prison), your heart pounding in your ears, trying to creep softly so as to not wake up gigantic monsters. Half-Life 2 will have you running from place to place, enjoying a wide selection of maps and areas, each with a distinct setting; gothic and dark, action packed, plain scary, plain fun.
The story is beautiful, engrossing and extremely well developed, featuring a wide range of characters (including the double-crosser and the hot love interest), and keeping you hooked until the very end. The only flaw is how extremely clichéd it is. You are a soldier, a legendary hero, who arises from the past to bring hope for a resistance thats all but in shambles. A soldier who must battle evil, face overwhelming odds, destroy every soldier, zombie and man-eating insect that gets in his path in order to save humanity from extinction. A great plot. One that is repeated in Star Wars, Lord of the Rings, Eragon, Braveheart, King Arthur and countless other films and books. This game features many original concepts, but an original plot isnt one of them. A pity really. Also, whilst featuring many connections to the previous game (as all sequels should), you are a bit lost if youre a new player. Questions are left unanswered, even for experienced Half-Life players; namely, how the aliens have invaded, why everyone regards you as a hero, and who the hell is that floating suited business-man that keeps talking to you.
Overall? One of the best games I have ever played, and a definite recommendation. Everything about it is amazing; the way it flows, the gameplay, the AI, the weapons Everything. It will be pointless to try to describe it in words. Youll just have to experience it for yourself.
9.99 / 10
: This game was bought for PC via steam retail. About 35 hours were commited to gameplay. Game was completed twice.
: Game was rated 16+ by ESBR. Rightly so - blood and death is constant throughout the game.
Deaf & Hard of Hearing
: Game features an excellent subtitles, which do not only encompass dialogue, but also ambient sounds, meaning you won't miss out at all.
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Here are a few things that will affect traffic in around downtown ATX!
1.) Zilker Park Relays (tonight/Friday 8/31)-
2.) UT Game tomorrow/Saturday 9/1) kickoff at 7pm, but tailgating will be way early and streets shut down
Other news, The Longhorn network hooked up with AT&T U-Verse.. all Longhorn can be seen on channel 1609. The Longhorns are also on YouTube! Hook 'em!
3.) TriRock Triathlon- Labor Day/Monday 9/3- at Auditorium Shores
Have a Happy & Safe Labor Day/weekend! YOU ROCK!


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You can go wild for the night when you're wearing this Zebralicious Zebra Sexy Women's Costume. This costume features a body suit, a hood, a belt, and a tail. The bodysuit to his costume will make you look just like this favorite zoo animal. The suit is covered in white and black stripes and has a white fluffed collar. The hood has the same faux fur accent and has the face of a zebra on it as well. It has a faux fur mane that will really finish the look. The included belt is black and looks like a corset piece, and is great for making sure that this costume fits as best as possible. Gallop your way to the party with a large smile on your face when you're wearing this fun and sexy costume.
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JE044: Air Time!
Revision as of 00:57, November 5, 2012 by Rainbow Shifter (Talk | contribs)
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With his battle against Whitney behind him, Ash focuses on the next gym in the Johto region. While eating he meets the producer of Poke talk Radio who wants Ash to be in the next show. After being told by Professor Oak that everyone in Pallet Town will be listening in on his interview, he becomes a nervous wreck, until he meets DJ Mary who tells him to think of the interview like a battle. During the next segment Ash and co. are asked to do a radio play. Will they be able to pull it off, with some unlikely help?
- With only 8 characters in it, this is the shortest dub title in the entire anime.
- Ash and his friends blast off in this episode, but it was only a fantasy that went along with the radio story.
- "Television couldn't kill radio but maybe Ash will."
Professor Oak about Ash's interview.
|This article is an anime stub.
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| This article has an incomplete plot or synopsis.
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State Sen. Rod Whittemore and Rep. Sharon Treat discussed the Health Insurance Reform Law which will be revisited in the legislature this session. Also Dr. Stephen Sears will give an update on the flu season.
State of Maine website information
The Maine Bureau of Insurance
Bureau of Insurance review of Anthem 2012 Individual Rate Filing Summary
Maine Center for Economic Policy Report on PL90
Maine Heritage Policy Center Report on Maine's Health Insurance Reform Law
Information about the 2012-2013 flu season
Maine Watch with Jennifer Rooks episode #2820


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|This article or section requires a cleanup in order to meet
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A key to one of the suites at the luxury hotel by a lake. For some odd reason, it often disappears.
Pokémon Diamond/Pearl/Platinum
- Found hidden at the resort at Route 213.
- A woman at Valor Lakefront lost this key and wanted it back. Return it to her.
Type of Item
- Key Items
|This article is a stub. Please help the Pokémon Wiki by expanding it.


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Credit: © Chris Weeks/WireImage
Lea Michele (Apr 14th, 2012)
Lea Michele styled her beach waves with wispy waves.
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Step 3: Flat-iron bangs and run through fingers for piecey look.
Step 4: Mist with hairspray to hold the hairstyle.


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in Our City
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Just a few images from around our city to highlight some of the things that we are most proud of. From the military to the beaches, from the farms to our centers of business, and as always, our people,
Department: Agriculture
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News, events and resources.
The countdown has begun! Summer Reading Games are right around the corner. Beginning on June 15th, you can sign up to win prizes, read lots, and enjoy fabulous programs at the library with a water theme. There's a game for all ages: Read to Me for preschoolers, Make a Splash for children entering 1st to 4th grade in the fall, plus Tween, Teen and Adult Summer Reading Games. Save the date for the end of summer party, a celebration on Sunday, August 29th with games, snacks and fun!


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WV gets beat by Maryland 37-0.
Maryland gets beat by FSU 63-0.
They beat a ranked OSU.
Forgot the WVU game in between. So who knows Like last year they at times seem very good and other times horrible.
Well...they're playing Baylor now, another chance to find out....
Looking breakin' bad.
Let Prohm's Posse Ride: Hallice, Brady, Stu, Lard, Naz, Deonte, Monte, Matt, Simeon, Jordan, and Babb.
Probably just as good as us.
Well, they're down by 45 to Baylor late in the 3rd Q. But, then again, Baylor looks REALLY good!(BTW -- I don't like Baylor's shiny metallic helmets -- I didn't like Tulsa's, either. I hope we don't go that route.)
Hard to tell playing Baylor, they've made everyone look bad so far.
WVU is bipolar.
OSU game was a complete and utter fluke. If they had Paul Rhoads as their coach and had pulled off those upsets on a consistent yearly basis it'd be one thing. But they are just PATHETIC defensively in all other competitions. I seriously thought they were playing with 8 men on defense tonight...they were just INVISIBLE.
Burning couches and houses tonight......
I watched play Maryland and that told me all I needed to know.
We have 4 remaining games that are winnable, and WVU is one of them. @K-State, TCU, KU and @WVU seem to be well withing the realm of possibility for us to beat. I think we'll split and finish 3-9 unless Rhoads can pull an upset special.
Originally Posted by acgclone
We have 4 remaining games that are winnable, and WVU is one of them. @K-State, TCU, KU and @WVU seem to be well withing the realm of possibility for us to beat. I think we'll split and finish 3-9 unless Rhoads can pull an upset special.
Might wanna change your avatar considering he committed to Oregon...
Originally Posted by hoiballin33
Has anyone really been far as decided to use even go want to do look more like? You've got to be kidding me. I've been further even more decided to use even go need to do look more as anyone can. Can you really be far even as decided half as much to use go wish for that?
Originally Posted by bos
They beat a ranked OSU.
Oklahoma State isn't actually a top 25 team.
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