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Winter Wanderer
12 countries \ 25 days \ from US$3515 per person
The Winter Wanderer is like a leisurely stroll through Europe's top destinations. Some of the highlights of the tour include: driving along the French Riviera, exploring the Eternal City of Rome (it's never too cold for Gelato!) and sampling traditional Spanish tapas in Barcelona not to mention retracing the history of WW2 and the Cold War in Berlin and Prague. Winter in Europe is not only magi...
Places I'd Like to Visit
- Austria
- Czech Republic
- England
- France
- Germany
- Holy See (Vatican City State)
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- Netherlands
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Carry this color and show your support for breast cancer research. Learn more about the Vera Bradley Foundation for Breast Cancer.
This style can be Personalized!
Learn more about Personalization
Perfect for a family outing or a day at the beach, this supersized tote was designed with plenty of room for towels, extra clothes and even toys. It's crafted in durable water-resistant polyester, with a water-resistant lining in a complementary color, making it a perfect pick for the pool or beach.
15 ¼" W x 14" H x 9 ¾" D with 12" strap drop
Machine wash cold, only non-chlorine bleach when needed; line dry; cool iron if needed

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Pialba, Queensland, 4655 more
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September 28, 2007
A current and comprehensive list of CCR's press releases, press statements, and case updates dating back to 2003.
This list can be ordered by date or name, and filtered by the issues to which the releases relate.
The search function may be more efficient when looking for specific releases.
Last modified
October 22, 2007


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- Oct 22:
- Family carries on after Caleb Moore's snowmobile death
- Mar 12:
- ESPN drops X Games snowmobile, motocross best trick events
- Feb 6:
- Caleb Moore's family to hold moment of silence for X Games snowmobiler
- Feb 1:
- Caleb Moore family donates organs after his death from X Games crash
- ESPN to review X Games' snowmobile contests after Caleb Moore's death
- Jan 31:
- Caleb Moore's death, first ever for X Games, prompts questions about safety
- Caleb Moore dies one week after snowmobile crash at Winter X Games
- Caleb Moore, Winter X Games snowmobiler, remains hospitalized
- Jan 30:
- Caleb Moore crash and rising injuries lead to X Games safety questions
- Jan 28:
- Caleb Moore in desperate condition after X Games snowmobile crash
- Jan 27:
- Caleb Moore facing "brain complication" after X Games snowmobile crash
- Jan 25:
- Caleb Moore, X Games snowmobiler, recovering after heart surgery
- Texas brothers Caleb and Colten Moore ready for Winter X Games snowmobile showdown
- Jan 27:
- Shaun White dominates in X Games superpipe for sixth consecutive gold
- Henrik Harlaut all smiles after big weekend at X Games in Aspen
- Caleb Moore facing "brain complication" after X Games snowmobile crash
- Nick Goepper of Indiana wins X Games ski slopestyle in Aspen
- Female slopestyle skiers/riders debate the need for their own courses
- Jan 26:
- Colorado rider Arielle Gold wins bronze as X Games alternate
- Vail Ski club coach Elena Chase has trained 20 X Games skiers
- Jan 25:
- Texas brothers Caleb and Colten Moore ready for Winter X Games snowmobile showdown
- Tucker Hibbert vying for 6th Winter X Games gold in snowcross
- Shaun White is super in pipe at Winter X Games, advances in slopestyle too
- Aspen fighting to remain host for Winter X spectacle after 2014 as three other ski areas vie for games
- Jan 24:
- Shaun White slides into X Games slopestyle and superpipe finals
- Aspen snowboarding star Gretchen Bleiler is back as sight to see at X Games
ASPEN — Caleb Moore, the Texas freestyle snowmobiler whose crash in Thursday night's finals sent him via helicopter to St. Mary's Hos- pital in Grand Junction, remained in intensive care late Friday after emergency heart surgery.
The 25-year-old, who came up short on a backflip and was pummeled by his tumbling sled on the landing, was able to walk away.
Moore was being checked by Aspen doctors for a concussion that knocked him out when they found bleeding around his heart.
He was airlifted to Grand Junction, where surgeons operated to address a heart contusion, said Moore's team spokeswoman, Chelsea Lawson. She said doctors were "optimistic" about Moore's recovery.
Minutes after the crash, Moore's brother Colten, 23, suffered a separated pelvis during a wreck on the same jump. Colten was treated and released from the Aspen hospital and was back home in Krum, Texas, late Friday recovering, Lawson said.
"The support for both Colten and Caleb has been unbelievable," their father, Wade Moore, said Friday night. "Colten is resting and recovering. And Caleb's recovery may take a little longer, but both are doing good."
Silver lining fits Alito fine. Evergreen boarder Dylan Alito won silver Friday in the "street" competition, improving on his last-place finish last year as a Winter X Games rookie. "I'm kind of the underdog in it. It's just cool to be on the X Games podium," the 22-year-old said. "A lot of my friends came out to see me today." On a small course with rails, stairs and a giant wall, six riders had 18 minutes to put in as many runs as they could, and their best two scores were combined to determine the winner.
Photos: X Games at Aspen, Jan. 25
Wallisch fails to qualify. The surprise of the day Thursday: Defending ski slopestyle champion Tom Wallisch failed to advance to Sunday's finals when he put his hands down on a switch-double 1080 on his final qualifying run. The Park City, Utah, skier had a nasty fall on his first run and needed an 81.66-point score on his second run to get the eighth and final qualifying spot. He had the final run of the eliminations, but after much deliberation the judges gave him an 80.66. "It definitely was not my best performance," said Wallisch, who injured a knee Jan. 11 at the Copper Grand Prix. "My knee was bothering me a bit."
Colorado connections. Cherry Creek High School graduate Bobby Brown had the best showing of the three area athletes in Thursday's slopestyle qualifier, ranking fourth going into Sunday's finals.
University of Colorado student Matt Walker, from Basalt, was knocked from the finals when Telluride's Gus Kenworthy had a 78-point second run. Walker was sitting in eighth place at 77 until Kenworthy took his final run. But Kenworthy was knocked from the finals when James Woods of England put down a 92.66-point second run, which was the best of the day.
Kenworthy also competed in ski superpipe but didn't advance out of Thursday's qualifying round. He is scheduled to compete Saturday night in the big air event.


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Middle Eastern Bean Salad with Parsley and Lemon (Balela)
Makes 4 generous servings, recipe adapted from Middle Eastern Bean Salad at MeleCotte who adapted it from the Balela Recipe at Relish.)
1 can (15 oz.) black beans, rinsed well and drained
1 can (15 oz.) garbanzo beans, rinsed well and drained
1 cup chopped green onion (or less)
1 1/2 cup chopped fresh tomato (about 6 small tomatoes)
1 cup finely chopped fresh parsley
Dressing Ingredients:
3 T fresh-squeezed lemon juice
1/2 tsp. garlic puree (or use finely minced fresh garlic)
4 T extra-virgin olive oil
1/2 tsp. salt
fresh ground black pepper to taste
Despite the fact that tomatoes shouldn't be refrigerated, this was actually very tasty even after being in the fridge for a few days. If you know you won't eat it all right away, you could mix together everything but tomatoes and add them each time you eat some.
South Beach Suggestions:
More Great Salads with Beans and Parsley:
(Recipes from other blogs may not always be South Beach Diet friendly; check ingredients.)
Barley and White Bean Salad with Parsley, Lemon, and Capers from Kalyn's Kitchen
Chickpea and Tuna Salad with Tomatoes, Olives, Basil, and Parsley from Kalyn's Kitchen
Carrot, Parsley, and Garbanzo Salad with Cumin from Kalyn's Kitchen
Tuna and Cannellini Bean Salad from Closet Cooking
Mixed Bean Salad with Walnut Dressing from Cook (almost) Anything At Least Once
(Want even more bean salad recipes? I find these recipes from other blogs using Food Blog Search.)


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May 5, 2016
It's been 5 years since an Eastern Carolina family reported their son, father, and husband missing. Craig Swain is from Tyrrell County but was last seen in Washington County. Deputies say they can track where Swain was, up until a certain point, the night he went missing five years ago.
Craig Swain is now 43-years-old. He went missing at age 38. Investigators have retraced his steps with canine teams, dive teams, and from the air. They have been able to figure out he was visiting an uncle off Jones White Road in Washington County. From there they tracked him to a store, then a party at another home on Jones White Road. From there, another party goer reported Swain hit a car and left. Investigators say the person who's car Swain allegedly hit followed him, stopping him twice along the road. 911 was called, and a deputy started following the truck Swain reportedly had been driving. A chase started at 70 miles an hour around curvy backroads- ending with a crash into a mailbox on Reek Road. Whoever was driving that truck fled on foot. Investigators say there are plenty of loose ends: They can not verify if Swain was the one still driving the truck during the chase. But five years later, no word from the man who is called a devoted family man by his relatives.
"No closure at all, and if anybody knows anything I wish they would say something because I feel like the community has let me down. I'm a momma. That was my son. I love my baby," said the missing man's mother Ida Jackson-Swain
Investigators say they have pursued people of interest, but there are no arrests or charges at this point. The last place deputies can positively say Swain was seen was at the party.
We know the family and local churches have pooled together a reward for someone with information that leads to finding Swain.
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She is a global icon, the ultimate diva, the Brooklyn girl made good, the ugly duckling who blossomed into a modern-day Nefertiti, the Oscar-winning actress and bona fide movie mogul, and arguably the greatest female singer who has ever lived. Equally adored and despised, she is one of the world's most recognized celebrities those slightly crossed eyes, that nose . . . the voice. Yet even to the multitudes who idolize her, Streisand has remained aloof, unknowable, tantalizingly beyond reach . . . until now.
Drawing from in-depth interviews with eyewitnesses to her remarkable life and career, number-one New York Times bestselling author Christopher Andersen paints a fascinating, startling portrait of Barbra Joan Streisand the artist, the woman, a true American original.
"...hits all the high notes."
-USA Today
"...a scandalicious new bio packed with fresh dirt on the world's most reclusive diva."
-New York Post
"The book reads like buttah!"
-Al Roker, The Today Show
"[Andersen] has a knack for ferreting out memorable anecdotes of the 'no wire hangers' variety."
-New York Times Book Review, Inside the List
"Readers who can't get enough of Streisand will lap [this up]..."


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May 4, 2016
RALEIGH, N.C. (AP) -- North Carolina's video sweepstakes halls could be closed soon after the state's highest court refused a request from industry officials to delay those closings while they appeal to the U.S. Supreme Court.
The state Supreme Court on Wednesday denied the request from the sweepstakes game industry to delay last week's decision that sweepstakes halls are gambling operations. The refusal could shut down hundreds of businesses across North Carolina.
Industry officials say they don't expect the order to be enforced for 20 days, when it becomes final. In the meantime, its attorneys say they'll continue their fight through the courts with further appeals.
The industry had sought a few weeks to see if the U.S. Supreme Court would consider its claim of free-speech protections.
Previous Story
Companies that produce the software behind video sweepstakes games want to delay closing down North Carolina's sweepstakes halls as they seek help from the U.S. Supreme Court.
The companies lost last week when the state Supreme Court upheld a state law declaring the sweepstakes halls as gambling operations. The industry has asked the state Supreme Court to delay enforcement of the law that could shut down hundreds of businesses across North Carolina.
The industry says it needs a few weeks to see if the U.S. Supreme Court will consider its claim of free-speech protections. The high court ruled last year that video games are protected just like books and films.
North Carolina's sheriffs are gearing up to start enforcing the law outlawing video sweepstakes operations next month.
(Copyright 2012 by The Associated Press. All Rights Reserved.)
Copyright 2016 by The Associated Press. All Rights Reserved.
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Shutdown orders issued as Congress misses deadline
Speaker of the House John Boehner, R-Ohio, returns to his office after a procedural vote on the House floor, at the Capitol in Washington, Monday, Sept. 30, 2013. The Republican-controlled House and the Democrat-controlled Senate are at an impasse as Congress continues to struggle over how to prevent a possible shutdown of the federal government when it runs out of money. President Barack Obama ramped up pressure on Republicans Monday to avoid a post-midnight government shutdown, saying that failure to pass a short-term spending measure to keep agencies operating would "throw a wrench into the gears" of a recovering economy. (AP Photo/J. Scott Applewhite)


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Topic Contents
- General Information About Intraocular (Uveal) Melanoma Treatment
- Cellular Classification of Intraocular (Uveal) Melanoma
- Classification and Stage Information for Intraocular (Uveal) Melanoma
- Treatment Option Overview
- Iris Melanoma
- Ciliary Body Melanoma
- Small Choroidal Melanoma
- Medium and Large Choroidal Melanoma
- Extraocular Extension and Metastatic Intraocular Melanoma
- Recurrent Intraocular Melanoma
- Changes to This Summary (11 / 09 / 2012)
- About This PDQ Summary
- Get More Information From NCI
Intraocular (Uveal) Melanoma 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.
Intraocular (Eye) Melanoma Treatment
General Information About Intraocular (Uveal) Melanoma Treatment
Incidence and Mortality
Melanoma of the uveal tract (iris, ciliary body, and choroid), though rare, is the most common primary intraocular malignancy in adults. The mean age-adjusted incidence of uveal melanoma in the United States is approximately 4.3 new cases per million population, with no clear variation by latitude. Males have a higher incidence than females (4.9 vs. 3.7 per million).[1] The age-adjusted incidence of this cancer has remained stable since at least the early 1970s.[1,2] U.S. incidence rates are low compared with the rates of other reporting countries, which vary from about 5.3 to 10.9 cases per million. Some of the variation may be the result of differences in inclusion criteria and methods of calculation.[1]
Uveal melanoma is diagnosed mostly at older ages, with a progressively rising, age-specific, incidence rate that peaks near the age of 70 years.[3]
Host susceptibility factors associated with the development of this cancer include:[2,3,4]
- Caucasian race.
- Light eye color.
- Fair skin.
- The ability to tan.
In view of these susceptibility factors, numerous observational studies have attempted to explore the relationship between sunlight exposure and risk of uveal melanoma. To date, these studies have found only weak associations or yielded contradictory results.[3] Similarly, there is no consistent evidence that occupational exposure to UV light or other agents is a risk factor for uveal melanoma.[3,5]
Anatomic Location
Uveal melanomas can arise in the anterior (iris) or the posterior (ciliary body or choroid) uveal tract. Iris melanomas have the best prognosis, whereas melanomas of the ciliary body have the least favorable prognosis.[6] Most uveal tract melanomas originate in the choroid. The ciliary body is less commonly a site of origin, and the iris is the least common. The comparatively low incidence of iris melanomas has been attributed to the characteristic features of these tumors, i.e., they tend to be small, slow growing, and relatively dormant in comparison with their posterior counterparts. Iris melanomas rarely metastasize.[7] Melanomas of the posterior uveal tract generally have a more malignant, histologic appearance; are detected later; and metastasize more frequently than iris melanomas. The typical choroidal melanoma is a brown, elevated, dome-shaped subretinal mass. The degree of pigmentation ranges from dark brown to totally amelanotic.
Most uveal melanomas are initially completely asymptomatic. As the tumor enlarges, it may cause distortion of the pupil (iris melanoma), blurred vision (ciliary body melanoma), or markedly decreased visual acuity caused by secondary retinal detachment (choroidal melanoma). Serous detachment of the retina may occur. If extensive detachment occurs, secondary angle-closure glaucoma occasionally develops. Clinically, several lesions simulate uveal melanoma, including metastatic carcinoma, posterior scleritis, and benign tumors, such as nevi and hemangiomas.[8]
Anatomy of the eye.
Careful examination by an experienced clinician remains the most important test to establish the presence of intraocular melanoma. It is not possible to distinguish a small uveal melanoma from a nevus. Small uveal lesions are often observed for growth to make a diagnosis of melanoma. Clinical findings that may help to identify melanoma include:[6]
- Tumor thickness of more than 2 mm.
- Subretinal fluid.
- Visual symptoms.
- Orange pigment on the tumor surface.
- A tumor margin touching the optic disc.
Ancillary diagnostic testing, including fluorescein angiography and ultrasonography, can be extremely valuable in establishing and/or confirming the diagnosis.[9] In a large, retrospective, single-center series of 2,514 consecutive patients with choroidal nevi, the progression rates to melanoma at 5, 10, and 15 years were 8.6%, 12.8%, and 17.3%, respectively.[10]
Prognostic Factors
A number of factors influence prognosis. The most important factors include the following:
- Cell type. (Refer to the Cellular Classification of Intraocular [Uveal] Melanoma section of this summary for more information).
- Tumor size.
- Location of the anterior margin of the tumor.
- Degree of ciliary body involvement.
- Extraocular extension.
Several additional microscopic features can affect the prognosis of intraocular melanoma, including:
- Mitotic activity.
- Lymphocytic infiltration.
- Fibrovascular loops (possibly).
Cell type is the most commonly used predictor of outcome following enucleation, with spindle-A cell melanomas carrying the best prognosis and epithelioid cell melanomas carrying the least favorable prognosis.[1,4,9] Nevertheless, most tumors have an admixture of cell types, and there is no clear consensus regarding the proportion of epithelioid cells that constitutes designation of a tumor as mixed or epithelioid.[6]
Extraocular extension, recurrence, and metastasis are associated with an extremely poor prognosis, and long-term survival cannot be expected.[11] The 5-year mortality rate associated with metastasis from ciliary body or choroidal melanoma is approximately 30%, compared with a rate of 2% to 3% for iris melanomas.[12]
Cellular Classification of Intraocular (Uveal) Melanoma
Primary intraocular melanomas originate from melanocytes in the uveal tract.[1] Four distinct cellular types are recognized in intraocular melanoma (revised Callender classification):[2]
|Spindle-A cells (spindle-shaped cells with slender nuclei and lacking visible nucleoli).
|Spindle-B cells (spindle-shaped cells with larger nuclei and distinct nucleoli).
|Epithelioid cells (larger polygonal cells with one or more prominent nucleoli).
|Intermediate cells (similar to but smaller than epithelioid cells).
Most primary intraocular melanomas contain variable proportions of epithelioid, spindle-A, and spindle-B cells (mixed-cell melanomas). Pure epithelioid-cell primary melanomas are infrequent (approximately 3% of cases).[1] In the Collaborative Ocular Melanoma Study, mixed-cell type melanomas predominated (86% of cases).[3]
Classification and Stage Information for Intraocular (Uveal) Melanoma
Tumor Size
Uveal melanoma most often assumes a nodular or dome-shaped configuration, but occasionally tumors can be flat or diffuse and involve extensive areas of the uvea with little elevation.
Tumor size classifications according to boundary lines used in a Collaborative Ocular Melanoma Study (COMS) are as follows:[1]
|Small: Range from 1.0 mm to 3.0 mm in apical height and largest basal diameter of 5.0 to 16.0 mm.[1]
|Medium: Range from 3.1 to 8.0 mm in apical height and a basal diameter of not more than 16.0 mm.[2]
|Large: Greater than 8.0 mm in apical height or a basal diameter more than 16.0 mm, when the apical height is at least 2.0 mm.
Although most ocular melanomas have a raised configuration, about 5% grow in a diffuse pattern that also may have prognostic significance. The tumors have a horizontal, flat-growth pattern, with the thickness measuring approximately 20% or less than the greatest basal dimension. This uncommon variant of uveal melanoma seems to have a poorer prognosis, particularly when the diameter is large, and the margins are poorly defined.[3]
In clinical practice, the tumor base may be estimated in average optic disc diameters (1 dd = 1.5 mm). The average elevation may be estimated in diopters (3 diopters = 1 mm). Other techniques, such as ultrasonography, should be used to provide more accurate measurements.
An important function of ophthalmic ultrasonography is the detection of extrascleral extension.[4,5] Extrascleral extension measuring 2 mm or more in thickness can be demonstrated provided it is located behind the equator where the intraocular tumor, sclera, and adjacent orbital fat are readily imaged.[6] Orbital extraocular extension of choroidal melanoma may be found in eyes with medium and large tumors, but it is very rare in eyes with small melanomas.
Metastatic Disease
Systemic metastases are evident in only 1% to 4% of patients at the time of diagnosis of the primary ocular melanoma.[7] Because the uveal tract is a vascular structure without lymphatic channels, tumor spread occurs principally by local extension and by dissemination through the blood stream. Lymphatic spread is rare but may occur after local extension into the conjunctiva and its lymphatics.[8] Given the rarity of nodal metastases, sentinel node biopsies of nonclinically involved nodes are not done as part of the staging procedure.[7]
Systemic metastases are generally hematogenous in origin, and the first site identified is usually the liver.[9] Lung, bone, and subcutaneous sites are also common.[9] In the COMS trials, the liver was the only site of detectable metastasis in 46% of patients with metastases reported during follow-up or at the time of death; 43% had metastases diagnosed in the liver and other sites.[9] In patients with a history of ocular melanoma who present with hepatic metastases of unknown origin, metastatic melanoma should be considered in the differential diagnosis.
It is particularly unusual for choroidal melanomas of any size to invade the optic nerve or its meninges.[10] Metastasis of choroidal melanoma to the contralateral choroid is also rare.[9,11]
Definitions of TNM
An American Joint Committee on Cancer staging system has been developed for melanoma of the uveal tract.[7]
Table 1. Primary Tumor (T)a,b
|All Uveal Melanomas
|a Reprinted with permission from AJCC: Malignant melanoma of the uvea. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 547-59.
|b These definitions apply to both clinical and pathologic staging.[12] Note: In clinical practice, the largest tumor basal diameter may be estimated in optic disc diameters (dd, average: 1 dd = 1.5 mm). Tumor thickness may be estimated in diopters (average: 2.5 diopters = 1 mm). However, techniques such as ultrasonography and fundus photography are used to provide more accurate measurements. Ciliary body involvement can be evaluated by the slit-lamp, ophthalmoscopy, gonioscopy, and transillumination. However, high-frequency ultrasonography (ultrasound biomicroscopy) is used for more accurate assessment. Extension through the sclera is evaluated visually before and during surgery, and with ultrasonography, computed tomography, or magnetic resonance imaging.Note: When histopathologic measurements are recorded after fixation, tumor diameter and thickness may be underestimated because of tissue shrinkage.
|c Iris melanomas originate from, and are predominantly located in, this region of the uvea. If less than half of the tumor volume is located within the iris, the tumor may have originated in the ciliary body and consideration should be given to classifying it accordingly.
|d Primary ciliary body and choroidal melanomas are classified according to four tumor-size categories.
|Primary tumor cannot be assessed.
|No evidence of primary tumor.
|Tumor limited to the iris.
|Tumor limited to the iris not more than 3 clock hours in size.
|Tumor limited to the iris more than 3 clock hours in size.
|Tumor limited to the iris with secondary glaucoma.
|Tumor confluent with or extending into the ciliary body, choroid, or both.
|Tumor confluent with or extending into the ciliary body, choroid, or both, with secondary glaucoma.
|Tumor confluent with or extending into the ciliary body, choroid, or both, with scleral extension.
|Tumor confluent with or extending into the ciliary body, choroid, or both, with scleral extension and secondary glaucoma.
|Tumor with extrascleral extension.
|Tumor with extrascleral extension ≤5 mm in diameter.
|Tumor with extrascleral extension >5 mm in diameter.
|Ciliary Body and Choroidd
|Tumor size category 1.
|Tumor size category 1 without ciliary body involvement and extraocular extension.
|Tumor size category 1 with ciliary body involvement.
|Tumor size category 1 without ciliary body involvement but with extraocular extension ≤5 mm in diameter.
|Tumor size category 1 with ciliary body involvement and extraocular extension ≤5 mm in diameter.
|Tumor size category 2.
|Tumor size category 2 without ciliary body involvement and extraocular extension.
|Tumor size category 2 with ciliary body involvement.
|Tumor size category 2 without ciliary body involvement but with extraocular extension ≤5 mm in diameter.
|Tumor size category 2 with ciliary body involvement and extraocular extension ≤5 mm in diameter.
|Tumor size category 3.
|Tumor size category 3 without ciliary body involvement and extraocular extension.
|Tumor size category 3 with ciliary body involvement.
|Tumor size category 3 without ciliary body involvement but with extraocular extension ≤5 mm in diameter.
|Tumor size category 3 with ciliary body involvement and extraocular extension ≤5 mm in diameter.
|Tumor size category 4.
|Tumor size category 4 without ciliary body involvement and extraocular extension.
|Tumor size category 4 with ciliary body involvement.
|Tumor size category 4 without ciliary body involvement but with extraocular extension ≤5 mm in diameter.
|Tumor size category 4 with ciliary body involvement and extraocular extension ≤5 mm in diameter.
|Any tumor size category with extraocular extension >5 mm in diameter.
Table 2. Regional Lymph Nodes (N)a
|a Reprinted with permission from AJCC: Malignant melanoma of the uvea. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 547-59.
|Regional lymph nodes cannot be assessed.
|No regional lymph node metastasis.
|Regional lymph node metastasis.
Table 3. Distant Metastasis (M)a
|a Reprinted with permission from AJCC: Malignant melanoma of the uvea. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 547-59.
|No distant metastasis.
|Distant metastasis.
|Largest diameter of the largest metastasis ≤3 cm.
|Largest diameter of the largest metastasis 3.1–8.0 cm.
|Largest diameter of the largest metastasis ≥8 cm.
Table 4. Anatomic Stage/Prognostic Groupsa
|a Reprinted with permission from AJCC: Malignant melanoma of the uvea. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 547-59.
|Any T
|Any T
|Any N
There are a variety of other factors that are not part of the AJCC staging system but that may help in refining estimates of prognosis.[7]
Prognostic features
There are a number of key prognostic features that are important to collect in malignant melanoma of the uvea, even though they are not included in staging algorithms. These include the following:[7]
Molecular features
|Chromosomal alterations.
|Gene-expression profile: class 1 or class 2.
Clinical and histopathologic features
Treatment Option Overview
Role of Observation
Iris melanomas have relatively good outcomes with a 5-year survival rate of more than 95%. They are predominantly of the spindle-cell type and are usually smaller in size than posterior melanomas because of earlier detection. Conservative management is generally advocated whenever possible, but surgical intervention may be justified with unequivocal tumor growth or with extensive disease at initial examination.
The management of small choroidal melanomas is controversial, and it is not clear whether treatment of small tumors prevents metastasis.[1] The natural history of small choroidal melanoma is poorly understood. Small, pigmented, choroidal lesions cannot always be differentiated reliably on examination. Growth is a presumed indicator of malignant potential.[2] The likelihood of progression from the time of diagnosis to the time when tumor growth warrants treatment has not been well characterized. Some ophthalmologists advocate observation. This has been justified on several grounds, including the difficulty with establishing a correct diagnosis, the lack of any documented efficacy for globe-conserving treatments, and concerns for severe treatment-related morbidity. Others have advocated earlier therapeutic intervention.[1,3,4]
Although patients diagnosed with small choroidal tumors were not eligible for participation in the Collaborative Ocular Melanoma Study (COMS), these patients were offered participation in a prospective follow-up study to evaluate the natural history of small lesions. Two-year and 5-year tumor growth estimates of 21% and 31%, respectively, were reported.[5] Clinical risk factors associated with tumor growth included:[3,5]
- Increased tumor thickness.
- Presence of subretinal fluid.
- Orange pigmentation.
- Absence of drusen.
- Absence of retinal pigment.
- Margin at the optic disc.
- Epithelial changes surrounding the tumor.
Role of Surgery
The selection of treatment depends on the following:
- Site of origin (choroid, ciliary body, or iris).
- Size and location of the lesion.
- Age of the patient.
- Occurrence of extraocular invasion, recurrence, or metastasis.
In the past, enucleation (eye removal) was the standard treatment for primary choroidal melanoma, and it is still used for large tumors. However, enucleation has been largely replaced by radiation therapy (i.e., brachytherapy with radioactive plaques; or external-beam, charged-particle radiation therapy) to spare the affected eye.[6,7]
Pre-enucleation external beam radiation therapy (EBRT)
In the case of large, choroidal tumors judged to require enucleation, the role of pre-enucleation EBRT was tested in a randomized trial and had no impact on overall survival (OS).[8,9][Level of evidence: 1iiA] In a COMS trial, 1,003 patients with large choroidal melanomas (≥2 mm in height and ≥16 mm in diameter, or ≥10 mm in height irrespective of diameter, or ≥8 mm in height and border <2 mm from the optic disc) with no known metastases were randomly assigned to receive enucleation alone or after preoperative external photon-beam radiation from cobalt 60 or accelerators (20 Gy in five daily fractions) to the orbit and globe.[8,9] Through 10 years of follow-up, the median survival in both arms was approximately 7 years, and the 10-year all-cause mortality was 61% in both arms (relative risk for death of 1.00; 95% CI, 0.85–1.18). Metastasis-free survival was also virtually identical in both arms.
Transscleral local resection
Eye-sparing transscleral local resection plays a very limited role in the management of uveal melanoma. It is used in patients with large choroidal and ciliary body tumors who are not candidates for radiation therapy but are highly motivated to retain their eye.[10,11,12] The procedure is technically demanding and is generally performed only in centers with specialized expertise in this surgery. There is a substantial risk of retinal detachment, intraocular bleeding, and complications associated with the anesthesia-induced hypotension used to decrease the risk of bleeding. Adjuvant brachytherapy or neoadjuvant proton-beam therapy is often administered. Experience is limited to retrospective, single-center, case series.[10,11,12][Level of evidence: 3iiiDiv]
Surgical resection of metastases
Surgical resection of metastases from ocular melanoma has been reported in case series of highly selected patients with occasional favorable outcomes.[13,14] However, the favorable outcomes may be the result of strong patient-selection factors, and the role of resection in this setting is unclear.[13,14][Level of evidence: 3iiiDiv]
Role of Radiation Therapy
Episcleral brachytherapy using plaques containing small radioactive "seeds" is the most common form of radiation used in the management of intraocular melanoma. Iodine-125 (125 I), cobalt-60 (60 Co), palladium-103 (103 Pd), iridium-192 (192 Ir) and ruthenium-106 (106 Ru) are examples of radioactive isotopes used in the brachytherapy plaques. Isotopes with relatively low photon and electron emissions (125 I, 103 Pd, and 106 Ru) are more easily shielded to reduce the exposure to adjacent normal tissues, and 125 I is probably the most commonly used radioisotope.[15] Although plaque radiation therapy allows preservation of the eye, visual acuity is frequently lost over time.
In a case series of 1,106 patients who were treated with plaque radiation therapy for uveal melanoma and who had an initial acuity of at least 20/100, 68% developed poor acuity (i.e., 20/200 or worse) within 10 years.[16]
Factors associated with worse acuity outcomes included the following:[16]
- Age older than 60 years.
- Diminished baseline acuity.
- Diabetes.
- Increased tumor size and thickness.
- Location near the fovea or optic disc.
- isotope (106 Ru, 60 Co, or 192 Ir vs. 125 I).
125 I brachytherapy yields equivalent overall and melanoma metastasis-specific survival rates to enucleation for medium-sized melanomas.[17][Level of evidence: 1iiA] The randomized COMS Medium Tumor Trial compared 125 I episcleral-plaque brachytherapy (85 Gy at 0.42–1.06 Gy/hr) to enucleation in 1,317 patients with medium-sized choroidal tumors (tumor height 2.5 mm–10.0 mm and tumor diameter ≤16.0 mm that were not contiguous with the optic disc).[17] Eighty-five percent of the patients treated with 125 I brachytherapy retained their eye for 5 years or more, and 37% of them had visual acuity better than 20/200 in the irradiated eye 5 years after treatment.[17] No statistically significant differences in mortality were observed between the two study arms after 12 years of follow-up, whether considering death from all causes or death with histopathologically confirmed melanoma metastasis.[18] Five- and 10-year all-cause mortality rates were 19% and 35% in both study arms; cumulative all-cause mortality at 12 years was 43% in the 125 I arm versus 41% in the enucleation arm (RR, 1.04; 95% CI, 0.86–1.24). Five-year metastasis-specific mortality rates were 13% in both arms; at 10 years, the rates were 21% and 22% (RR for metastasis-specific mortality, 1.07; 95% CI, 0.81–1.41 through 12 years).
In a companion study within the COMS, 209 patients were prospectively assessed for quality of life during the first 5 years of follow-up.[19] Both study groups reported increasing difficulty with vision-oriented daily activities and ocular pain as time elapsed. Most measures of visual function were similar between the two groups, but there were statistically significant differences favoring the brachytherapy group in comfort with driving for the first year after therapy and in reported peripheral vision for the first two years after therapy. These differences disappeared by year 5 of follow-up.[19][Level of evidence: 1iiC]
Charged-particle EBRT (using protons, carbon ions, or helium ions) is the other major form of radiation therapy used in the management of ocular melanomas.[20,21,22,23] This form of radiation therapy requires sophisticated equipment available only at selected centers, and charged-particle EBRT involves patient cooperation during treatment (e.g., voluntarily fixating the eye on a particular point so the tumor is positioned properly in the radiation beam). A lower risk of early and late local radiation failures has been reported after charged-particle EBRT than after brachytherapy, possibly resulting from differences in dose distribution of the two techniques.[20][Levels of evidence: 1iiDiv and 3iiiDiv]
In a single-center, single-surgeon study 184 patients with uveal melanomas smaller than 15 mm in diameter and smaller than 10 mm in thickness were randomly assigned to receive 125 I brachytherapy versus helium ion radiation (to an estimated dose of 70 Gy equivalents in five fractions over 7 to 11 days in each arm).[24] The local tumor regrowth rate by 4 years was 13.3% in the brachytherapy arm versus 0% in the helium ion arm (P < .001). However, the rates of metastasis, death from metastasis, and overall mortality was very similar in both arms.[24][Level of evidence: 1iiDiv]
Because of its dose distribution, charged-particle irradiation can be used to treat larger tumors and tumors closer to the fovea or optic disc than plaque brachytherapy. A large, single-center, single-surgeon series of 2,069 patients treated with proton-beam therapy had an actuarial local control rate of 95% (95% CI, 93%–96%) at 15 years. The cumulative rate of enucleation was 16% (95% CI, 13%–20%), most frequently as a result of neovascular glaucoma, blind uncomfortable eyes, or local recurrence (46%, 31%, and 23% of enucleations). As with plaque radiation, risk factors for deterioration in visual acuity after charged-particle radiation were tumor size, location near the fovea or optic disc, baseline acuity, and underlying diabetes.[21]
Similarly, another large, single-center, single-surgeon, consecutive series of 886 patients treated with proton-beam irradiation reported a local control rate of 92.1% (95% CI, 89.8%–94.6%) and ocular conservation rate of 87.3% (95% CI, 83.9%–90.9%) at 10 years.[22]][Level of evidence: 3iiDiv] The actuarial OS at 10 years was 64.1% (95% CI, 59.5%–69.0%).
In a single-center, phase I/II study of 57 evaluable patients treated with carbon ion-beam irradiation and followed for a median of 26 months, only one patient had a local tumor recurrence, but 26 patients had enucleation caused by the development of neovascular glaucoma or severe eye pain from increased intraocular pressure.[23]
In an attempt to lower the complication rate and improve functional outcome, a decreased dose of 50 cobalt Gy equivalents (CGE) has been compared to 70 CGE proton beam (each delivered in 5 fractions, usually within a 7-day period). Patients (n = 188) with tumors smaller than 15 mm in diameter and smaller than 5 mm in height that were located near the optic disc or macula were randomly assigned to the two doses in a double-masked study design. At 5 years, there were no statistically significant differences in local tumor control, rate of metastasis, visual acuity, or complication rates. However, the visual fields were better in the 50 CGE group.[25][Level of evidence: 1iDiv]
As noted above in the section on the Role of Surgery in the Treatment Option Overview section of this summary, the role of pre-enucleation external photon-beam radiation therapy has been tested in a randomized trial and has shown no impact on OS for large choroidal tumors treated with enucleation.[8,9]
External-beam–photon-beam (gamma-ray) radiation therapy with gamma-knife stereotactic radiation surgery as a single-fraction [26] or fractionated stereotactic radiation [27,28] is being investigated as an alternative to brachytherapy or charged-beam radiation for posterior uveal melanomas, particularly for tumors too large or too close to the optic disc or macula to treat with brachytherapy. Because the dose rate of radiation delivery is slower than is the case with charged particles, specialized techniques are used to immobilize the eye [26] or to avoid delivery of the photons while the eye is moving or closed.[28] Experience is more limited with external-beam–photon therapy than for either brachytherapy or charged-particle EBRT, and there are no controlled comparisons to either of the other techniques. Early results from single-center series suggest similar levels of local tumor control and eye retention rates, but patient-selection factors may play a role.[28][Level of evidence: 3iiiDiv]
Role of Transpupillary Thermotherapy
Transpupillary thermotherapy (TTT) directs an infrared laser, usually at a wavelength of 810 nm, through a dilated pupil in one or more sessions to induce heat necrosis of uveal melanomas. This method carries the theoretical advantage of high-precision destruction of tumor tissue under direct visualization. However, TTT has important limitations that confine its use to very restricted circumstances.[1,29] The limited ability of TTT to penetrate thick tumors with sufficient energy restricts its use to small melanomas, or tumors of a size that some ophthalmologists recommend for follow-up without any initial therapy. (Refer to the Role of Observation section in the Treatment Option Overview section of this summary for more information.) When used as the primary therapy, there are relatively high rates of local recurrence and retinal vascular damage. Recurrence rates are particularly high when the tumor abuts the optic nerve and overhangs the optic disc.[1][Level of evidence: 3iiiDiv]
In a single-center study, 95 patients with small choroidal melanomas (diameter <10 mm and thickness <3.5 mm) were randomly assigned to TTT versus 125 I brachytherapy (100 Gy).[30] The tumor regression rates in the TTT and 125 I arms were 92% and 98%, respectively (P = .4). With a mean follow-up time of 56.2 months, there were four recurrences in the TTT arm and one in the 125 I arm. However, the study is too small to provide clear information on efficacy differences.
TTT is also under evaluation as an adjunct to primary therapy with proton-beam radiation. In the setting of large uveal melanomas, proton-beam therapy is associated with exudative, inflammatory, and glaucomatous complications that may require enucleation. In a single-center trial, 151 patients with uveal melanomas at least 7 mm thick or at least 15 mm in diameter were randomly assigned to receive proton-beam radiation (60 CGEs over four daily fractions) with or without TTT (810 nm wavelength at 1, 6, and 12 months after therapy) and followed for a median of 38 months.[31] There were no differences between the two groups in maculopathy, papillopathy, or glaucoma. The enucleation rate was lower in the TTT group (about 2% vs. 18% at 5 years, P = .02). However, the study was not masked, and replication would be important.
There are uncertainties regarding the optimal management of intraocular melanoma at all stages. Physicians should discuss with eligible patients opportunities for entry into ongoing clinical trials. Information about ongoing clinical trials is available from the NCI Web site.
Iris Melanoma
Melanocytic stromal proliferations and nevi of the iris are the most common tumors of the iris, but melanoma is rare.[1,2] Clinical differentiation between an iris nevus and a melanoma might sometimes be difficult and at times may be impossible. Melanomas of the iris are usually small discrete lesions, though they may occasionally be diffuse, infiltrative, or multiple, and they may result in heterochromia, chronic uveitis, or spontaneous hemorrhage into the anterior chamber of the eye (hyphema). Iris melanomas that involve more than 66% of the angle circumference are associated with secondary glaucoma.[3]
Routine evaluation of iris melanomas includes gonioscopy, transillumination of the globe, and indirect ophthalmoscopy with 360° of scleral depression. Photographic documentation is essential to document progression in size or growth of the tumor.[4] Anterior segment fluorescein angiography may be helpful to demonstrate the vascularity of the lesion but is not diagnostic. High-resolution ultrasound biomicroscopy can be used to measure small lesions (basal dimensions and thickness) and to assess tumor involvement of the anterior ciliary body, angle, and overlying sclera.[5] The main disadvantage with this technology is its limited penetration of large lesions. In these cases, conventional ultrasonography is more accurate.
In general, iris melanomas have relatively good outcomes. Only about 3% of these melanomas develop metastases within 5 years.[1] Iris melanomas are predominantly of the spindle-cell type and are usually smaller in size than posterior melanomas. Clinical features, including prominent tumor vascularity, rapid growth, and heterogeneous pigmentation, are associated with an epithelioid cell component.[6] Involvement of the iridocorneal angles is frequently associated with ciliary body invasion.[6]
Given their rarity and good prognosis, trials with sufficient power are practical. Therefore, treatment experience is based principally on case series and case reports. Conservative management is generally advocated whenever possible, but surgical intervention may be justified with unequivocal tumor growth and with extensive disease at initial examination.
Standard treatment options:
|Observation with careful follow-up: In asymptomatic patients with stable lesions; follow-up includes serial photography.[3]
|Local resection: When progressive and pronounced growth is documented.[2]
|Enucleation: If the tumor is not amenable to local resection (diffuse involvement of the iris, involvement of more than 50% of the iris and anterior chamber angle, intractable glaucoma, and extraocular extension).[7]
|Plaque radiation therapy: Offered as an alternative for large, diffuse, surgically nonresectable lesions of the iris.[8]
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with iris melanoma. 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.
Ciliary Body Melanoma
Melanoma involving the ciliary body is a rare tumor that carries a poor prognosis. In some cases, diagnosis may be difficult because of similarity to other eye diseases. The differential diagnosis of ciliary body melanoma should be considered in cases of unilateral pigmentary glaucoma and chronic uveitis.[1]
Ultrasound biomicroscopy can be used to evaluate tumor shape, thickness, margins, reflectivity, and local invasion.[2,3] Patients with tumors greater than 7 mm in thickness are at increased risk for metastatic disease and melanoma-related death compared with patients with thinner tumors.[4]
Standard treatment options:
There are several options for management of ciliary body melanoma. All of them are reported from case series.[Level of evidence: 3iiiDiv] The choice of therapy, however, depends on many factors.
|Plaque radiation therapy: Local control rates are high, but treatment is associated with a high incidence of secondary cataract.[4,5]
|External-beam, charged-particle radiation therapy: This approach is offered at specialized referral centers. It requires careful patient cooperation, with voluntary fixation of gaze.[6,7,8]
|Local tumor resection: This option is mainly suitable for selected ciliary body or anterior choroidal tumors with smaller basal dimension and greater thickness.[9,10]
|Enucleation: This option is generally reserved for large melanomas when there is no hope of regaining useful vision. It is also indicated in the presence of intractable secondary glaucoma and extraocular extension.[5,8]
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with ciliary body and choroid melanoma, small size. 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.
Small Choroidal Melanoma
A wide range of 5-year mortality rates have been reported among patients treated for small choroidal melanomas, with an average rate of about 16%.[1,2] Several studies indicate that the two most important clinical factors predictive of mortality are larger tumor size (at the time of treatment) and documentation of tumor growth.[3]
The management of small choroidal melanomas is controversial. The likelihood of progression from the time of diagnosis to growth warranting treatment has not been well characterized. Many ophthalmologists advocate initial observation. This initial management strategy is justified on several grounds, including the difficulty in establishing a correct diagnosis, the lack of any documented efficacy for globe-conserving treatments, and concerns for severe treatment-related morbidity. Others have advocated earlier therapeutic intervention.[4,5,6]
Standard treatment options:
|Observation: This strategy is important for patients with an uncertain diagnosis or in whom tumor growth has not been documented. It is also used for asymptomatic patients with stable lesions (particularly elderly or debilitated patients), and patients with a tumor in their only useful eye.[2]
|Plaque radiation therapy: This treatment is used for small- or medium-sized uveal melanomas, amelanotic tumors, or tumors that touch the optic disc for greater than 3 clock-hours of optic disk circumference.[7,8]
|External-beam, charged-particle radiation therapy: This approach is offered at specialized referral centers. It requires careful patient cooperation, with voluntary fixation of gaze.[7,8,9,10]
|Gamma-knife radiation surgery: This treatment may be a feasible option for small-sized to medium-sized melanomas.[11,12,13]
|Transpupillary thermotherapy: As noted above, this approach has very limited use, but it can be used as a primary treatment or as an adjunctive method to plaque radiation therapy.[5,6,14,15,16,17,18] (Refer to the Role of Transpupillary Thermotherapy section in the Treatment Option Overview section of this summary for more information.)
|Local tumor resection: This strategy is used mainly for selected ciliary body or anterior choroidal tumors with smaller basal dimensions and greater thickness.[19]
|Enucleation: This approach is used when severe intraocular pressure elevation is a factor. It may also be considered with small- and medium-sized melanomas that are invading the tissues of the optic nerve.[20]
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with ciliary body and choroid melanoma, small size. 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.
Medium and Large Choroidal Melanoma
Eye-sparing radiation therapy, either by plaque brachytherapy or external beam, is the preferred option for most patients with medium-sized choroidal melanoma. Enucleation remains the standard therapy for large, choroidal melanomas and melanomas that cause severe glaucoma or invade the optic nerve.
Standard treatment options:
Tumor growth pattern is a factor in the therapeutic decision. If there is a diffuse melanoma or if there is extraocular extension, enucleation should be considered, but radiation therapy can be employed for less extensive disease.
Medium-sized choroidal melanomas
|Plaque radiation therapy.[1,2,3,4]
|External-beam, charged-particle radiation therapy: This approach is offered at specialized referral centers. It requires careful patient cooperation, with voluntary fixation of gaze.[5,6,7]
|Local eye-wall resection.[8,9]
|Combined therapy, with ablative laser coagulation or transpupillary thermotherapy to supplement plaque treatment.[10,11]
|Enucleation. This approach is considered primarily for diffuse melanomas or for cases in which there is extraocular extension; radiation complications or tumor recurrence may sometimes make enucleation necessary.[10]
Large choroidal melanomas
|Enucleation when the tumor is judged to be too large for eye-sparing approaches.
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with ciliary body and choroid melanoma, medium/large size. 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.
Extraocular Extension and Metastatic Intraocular Melanoma
Extrascleral extension confers a poor prognosis. For patients with gross tumor involvement of the orbit, treatment requires orbital exenteration. However, there is no evidence that such radical surgery will prolong life. Most patients with localized or encapsulated extraocular extension are not exenterated. This subject is controversial.[1,2,3,4,5]
No effective method of systemic treatment has been identified for patients with metastatic ocular melanoma. Available clinical trials should be considered as an option for these patients.
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with extraocular extension melanoma and metastatic intraocular melanoma. 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 Intraocular Melanoma
The prognosis for any patient with recurring or relapsing disease is poor, regardless of cell type or stage. The question and selection of further treatment depends on many factors, including the extent of the lesion, age and health of the patient, prior treatment, and site of recurrence, as well as individual patient considerations. Surgical resection of metastases diagnosed subsequent to initial management of ocular melanoma in single-center, case series of highly selected patients has been reported. The extent to which the occasional favorable outcomes are the result of strong selection factors is not clear, so this approach cannot be considered standard.[1]
Clinical trials are appropriate, and eligible patients should be advised to consider participation in them 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 intraocular melanoma. 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.
|Hsueh EC, Essner R, Foshag LJ, et al.: Prolonged survival after complete resection of metastases from intraocular melanoma. Cancer 100 (1): 122-9, 2004.
Changes to This Summary (11 / 09 / 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.
This summary was comprehensively reviewed and extensively revised.
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 intraocular melanoma. 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 Intraocular (Uveal) Melanoma Treatment are:
- 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.
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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® Intraocular (Uveal) Melanoma Treatment. Bethesda, MD: National Cancer Institute. Date last modified <MM/DD/YYYY>. Available at: http://www.cancer.gov/cancertopics/pdq/treatment/intraocularmelanoma/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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Episode Plot
The gang arrives on a small island and decides to take a break. Charizard and Scyther have an argument. Later Ash thinks about how different Cissy and Danny were as Gym Leaders. As they were sleeping, Team Rocket steps in and tries to steal their Pokémon. Can Charizard and Scyther set aside their differences and help their friends?
- The "Who's that Pokémon" of this episode is Porygon, making this Porygon's only appearance in the US Pokémon anime.
- When James's Victreebel uses Sleep Powder, Meowth says that it's strong. James says it is strong as well but you see his nose has grown out as if he is lying, but he wasn't lying, as it did knock out Misty and Tracey.
|This article is an anime stub.
Please help the Pokémon Wiki by expanding it.
| This article has an incomplete plot or synopsis.
Reason: N/A
Please help the Pokémon Wiki by expanding it.


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Results 1 to 10 of 14
09-30-2008, 08:19 AM #1GDS Admirer
- Join Date
- Jul 2008
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- 261
How to create natural looking flowers
I often wonder how do you extract the flowers from the pictures to get them look so real and to get perfectly clean edges? I have a lot of pictures of flowers from my garden and would like to use them in my LO. I'm PSE 6.0 user and wondering if I could do that.
I am not sure how everyone else does it, but for the few leaves I have extracted, I use my Macro feature on the camera. That gets a good closeup and the rest of the background is somewhat blurry. That helps me out, since extracting is not my favorite thing to do.
I use the lasso tool too in conjunction with the magic wand to get a pretty close selection of what I want. Since I am not good with the eraser tool, I generally contract my selection by a few pixels to get rid of any little bits I missed.
I am sure other people have their favorite methods too. I use PhotoshopCS2
09-30-2008, 10:06 AM #3GDS Addict
- Join Date
- Aug 2007
- Location
- B.C., Canada
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- 4,888
What really helps is to have clean crisp edges on the part of the photo you want to extract. I use the lasso tool and eraser in combination with a mask sometimes. You can also try the Magic Extractor which is part of the Image tool menu. Try and crop as close to the part you want, and then try that. It sometimes does a great job if the areas are well defined.
I am using PSE 4 and think the tools are better in PSE 6. I'm waiting for PSE 7 to be released and then am upgrading to that.,
One trick that I've found really handy, is to apply the stroke to the object to check on stray pixels, too. Makes them easy to find to erase and make the object really clean....although you have to REMEMBER to do it. OH and REMEMBER to "unapply" it when you're done, before you save LOL!
Good luck!
09-30-2008, 12:20 PM #5GDS Admirer
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09-30-2008, 12:41 PM #6Supreme Team Alumni Member/Instructor
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- Apr 2007
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You've received some great advice so far. Here would be my tip, if you don't mind re-shooting your photos.
Pick the flower and then take a picture of it against a contrasting-colored background. So, if your flower is a beautiful, bright pink, take a picture of it against a white background or if it's a soft, light color, take a picture of it against a black background. Like Liz said, use the macro setting on your camera if you have one and try the best you can not to use the flash (that way you won't have strange lighting on the extracted flower and you can create your own light source once you get it extracted onto your layout).
That's my 2-centsMy blog - where everything is Absolute Poppycock
The Magic Extractor Tool in PSE6 does an amazing job. You have gotten some great tips here. Can't wait to see your photos.
wow!! I am sooooooooooooooooo glad that I came into this posting! You all are fabulous! I, too, was wondering the same thing and after reading all of the answers posted by you wonderfully talented ladies, I think I just might be able to do this!! I have PSE and I love it!!!
I do have one question.... If someone happens to see this: do most cameras have the macro option. I just looked at my camera and there are way too many settings, so I though someone here might be able to easily direct me to where it might be found....I suppose i could try and find my manual, or google the my camera type. I have had my camera for a year or less, and I have never heard of the macro setting.... i am just learning tons and tons of stuff her. You all rock!
I don't know if you've heard Candi, but GDS has just opened enrollment for their NEWEST class...a PHOTOGRAPHY class, and it's a super deal at an introductory price of $20! You can check it out HERE....I'm signed up and I can't WAIT...starts NOVEMBER 1st.
10-22-2008, 06:37 AM #10GDS Dabbler
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- Sep 2008
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For Victoria32, PS Elements 7 has been available for several weeks! Have fun!


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DETROIT - Nothing beats watching one of the latest flicks in a movie theater, all while snacking on popcorn and candy from the concession stands.
If you're looking for the ultimate movie-watching experience, Metro Detroiters have chosen their favorite movie theaters in the Detroit area.
VOTE 4 THE BEST: 2012 winners of best movie theaters
Emagine Theatres
Recommended over 900 times and placing first in this year's contest is Emagine Theatres, with multiple locations throughout Metro Detroit.
Emagine Theatres says its theaters play all of the latest films, play concerts and other alternative types of entertainment. They also offer rooms designated for children's birthday parties, corporate events and more.
"Excellent theatre that is very clean, the seats are extremely comfortable, and the food and beverages which includes a nicely stocked bar that adds another pleasurable dimension to your fantastic movie experience," said Andre, who voted in this year's contest.
Click here to find directions to all Emagine Theatres locations.
Farmington Civic Theater
Located in Downtown Farmington and voted second best Detroit movie theater is Farmington Civic Theater.
Designed by C. Howard Crane, who also designed Detroit's Fox Theatre, Farmington Civic Theater says its 1940s-era theater features clean, friendly staff and the best popcorn around.
"The Civic has been the best since my mom was a little girl," said Sheryll.
To learn more and find directions to Farmington Civic Theater, click here.
Bel Air 10 Digital Theater
Located on East 8 Mile Road in Detroit, Bel Air 10 Theater also makes the list of best Detroit movie theaters.
Formerly the Phoenix Theatre, Bel Air 10 Theater says it is now a family destination for the Detroit area. The movie theater adds that its professional staff, expanded concession menu and all digital projection and sound system will make your visit and safe and enjoyable one.
"I love the fact that Detroit has a newly remodeled Digital theater," said Joe. "The staff at Bel Air is wonderful."
Click here to learn how to get to Bel Air 10 in Detroit.
MJR Digital Cinemas
With locations throughout Metro Detroit, the MJR Digital Cinema in Sterling Heights was also recommended as one of the best in Metro Detroit.
MJR Theatres says all of its movie theaters and films are presented in Digital HD and their ticket prices are one of the cheapest.
"The best prices and cleanest theaters in Metro Detroit," said Kim. "Plus, what other theater has such a fun theme song? CLAP! CLAP! CLAP!"
To find the location nearest you, click here.
Click to view the complete list of recommended best movie theaters in Detroit.
Copyright 2012 by ClickOnDetroit.com. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.


text: iPad with Retina Display <KMND 1510 AM Enter to win an iPad with Retina display! *This is a multi-market contest. Contest closes 8/30/13. Sign in to Participate Category: Contest Ends: Friday August 30 at 10:59PM CDT Share on Facebook Share on Twitter More Send to a friend! Print this page Pin it! Reddit This! Share on Tumblr!


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Five Reasons I Have NEW Hope For Film/
The last seven days have done a good job convincing me we can build this world a whole lot better and that we have the passion and know-how to keep an ambitious and diverse film culture from falling into ruin. I have been doing some meetings, going to events, meeting folks — the days are long, but the inspiration has been great. It does so much good to observe things done well and I gathered quite of few as of late.
The documentary world has knit together a series of alliances, models, forums, and structures that the fiction film world should really take note of. When the sun was setting today, and I was recognizing that it was such a inspiration-filled last few days, a dark shadow past over when I realized much of that uplift was from another form. That's not a bad thing really. It's nice to have role models. Indie filmmakers the world over should thank their documentary siblings for all they have given us.
What inspired me (and in no particular order)?Read More


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50 U.S. Code § 2405 - Deputy Administrator for Defense Nuclear Nonproliferation
prev | next
(a) In general
There is in the Administration a Deputy Administrator for Defense Nuclear Nonproliferation, who is appointed by the President, by and with the advice and consent of the Senate.
(b) Duties
Subject to the authority, direction, and control of the Administrator, the Deputy Administrator for Defense Nuclear Nonproliferation shall perform such duties and exercise such powers as the Administrator may prescribe, including the following:
(1) Preventing the spread of materials, technology, and expertise relating to weapons of mass destruction.
Source(Pub. L. 106–65, div. C, title XXXII, § 3215,Oct. 5, 1999, 113 Stat. 959.)
LII has no control over and does not endorse any external Internet site that contains links to or references LII.


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Customising the JA Purity template
From Joomla! Documentation
This article or section is in the process of an expansion or major restructuring. You are welcome to assist in its construction by editing it as well. If this article or section has not been edited in several days, please remove this template.
This article was last edited by Jwwicks (talk| contribs) 6 years ago. (Purge)
- 1 Introduction
- 2 Template Layout
- 3 Customisation - Basics
- 4 Customisation - Intermediate
- 5 Customisation - Advanced
- 6 Known Issues and Bugs
- 7 See also
JA Purity is a highly customizable template available by default in standard Joomla 1.5 installations. JA Purity was designed by JoomlArt.com and features the following:
- Screen width configuration (Fluid/Narrow/Widescreen/Fixed in pixel or percentage)
- Multiple colors schemes (Red, Green, Blue and Black )
- Well Structured, xHTML/CSS validated and SEO-optimized source
- Cross-browser support for Internet Explorer 6+, Firefox, Safari, Opera
If you have a support question about the JA Purity template check for a solution on the following forum.
Before You Start
Before you start hacking away at the template you may want to download the tutorial template. This will save you from worrying about any updates to the Joomla source that might overwrite your edits. Once you download the archive, rename it as my_japurity.zip and then log into the Administration area of your Joomla site and install the template. This tutorial is based on the latest template version as of Joomla version 1.5.11. You may want to use the modifications to index.php since they strip out some embedded text strings in the source and use the MACROS in the language initialization files.
Template Layout
Here's the directory structure for the template. Click to see a description of the directory contents (if available) <imagemap> Image:JA_Purity_directories.jpg default Ja purity directory structure desc bottom-left </imagemap>
Front Page
Click on the picture to see the descriptions (if available) <imagemap> Image:JA_Purity_Tutorial_Main.png|640px rect 19 9 220 67 Customise the Logo rect 253 9 1102 67 Customise the Header Background rect 1140 13 1197 34 Customise Accessibility rect 1113 40 1265 64 Customise Searching rect 0 76 279 657 Customise - Module Position Left rect 278 76 1002 657 Customise - Main Content Area rect 1002 76 1280 657 Customise - Module Position Right rect 0 657 1280 817 Customise - Spotlight Area rect 0 817 1280 1024 Customise - Module Position Footer rect 0 0 1280 73 Customise Header Area default Customising the JA Purity template desc bottom-left </imagemap>
User 1
User 2
User 3
User 4
User 5
Customisation - Basics
Administration Features
Enable Horizontal Navigation Menus
Customise Module Position and Content
Customise - Header Area
Customise - Module Position Left
Customise - Main Content Area
Customise - Module Position Right
Customise - Spotlight Area
Customise - Module Position Footer
Customise the Logo
Customise the Logo
Change the Position of Your Logo
Customise the Header
Customise the Header Background
Change the Size of the Header
Add or Change the Header Color Scheme
Customise the Favicon
Center the Horizontal Menus
Change the Color of the Horizontal Menus
Use a Gradient Image for the Background in the Horizontal Menus
Customisation - Intermediate
Customise Accessibility
Customise Searching
Customisation - Advanced
Known Issues and Bugs
- Left position fails to collapse when no module present.
- PROBLEM: When Joomla cache is enabled reference Joomla 1.5.10 and before) and clicking a menu item it doesn't change color. It is impossible to understand which is the active menu item. SOLUTION: for now the only solution is to disable the cache function in the mod_mainmenu: go to 'Tools>Module Manager' and select the 'Main Menu' module (type=mod_mainmenu). Under 'Parameters>Advanced Parameters' select 'Caching>No Caching'.


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Comfortable Ladies Shoes
Pedestrian Shops can help you find the perfect balance of comfort and style with your new footwear. From summery sandals to warm winter boots, our selection will keep you and your feet happy and healthy! Stop by one of our Boulder, Colorado shops for a personal fitting, or have your new shoes shipped directly to you at no charge. Thanks for choosing Pedestrian Shops!
Rieker Celia 51 - Women's ShoesSophisticated Slip On
Regular Price: $104.95
Special Price: $79.95
Rieker 608B9 - Women's SandalsIntricate


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AQUA LEISURE SwimSchool Water Muscles
$4.99 $4.47 You Save $0.52 or 10%
Item # 11496885
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Product Details
Give the little ones the confidence to get in the water with AQUA LEISURE® SwimSchool® water muscles. These arm floats are made from heavy-gauge vinyl, and they have two chambers for extra flotation.
Get your new AQUA LEISURE® floats today from Sports Authority.
- Vinyl construction
- Twin, separate air chambers
- No-leak valves
- Non-slip inner surface for added safety
- For ages 3-6


text: Welcome to our new Website and thanks very much to George Irwin who put it together for us. Please let us know if you find any problems with the website, or if there's anything you think we could add! (There is still some information to go on, but hopefully this will be done very soon)


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AmberFollow Amber
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Trips I've Done
Best of USA (Start Los Angeles)
1 country \ 14 days \ from US$3739 per person
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Favorite Tours
Best of USA (Start Los Angeles)
1 country \ 14 days \ from US$3739 per person
The name says it all. With 4 hot USA cities wrapped into 1 tour, these are 2 weeks you don't want to miss out on! Start in the 'City of Angels' & hit the streets to see the Walk of Fame and the stars' homes in Hollywood Hills. Fly north to San Fran, famous for its cable cars & the Golden Gate Bridge, before partying with the high rollers in Vegas. Then after all the West Coast action, more exci...
Places I've Been (?)
- United States
Places I'd Like to Visit
- United States


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This concept introduces to the ASA and AAS Triangle Congruence shortcuts.
This video gives more detail about the mathematical principles presented in ASA and AAS Triangle Congruence.
This video shows how to work step-by-step through one or more of the examples in ASA and AAS Triangle Congruence.
Checks your understanding of ASA.
Checks your understanding of ASA proof method.
Checks your understanding of AAS Congruence.
A list of student-submitted discussion questions for ASA and AAS Triangle Congruence.
To activate prior knowledge, make personal connections, reflect on key concepts, encourage critical thinking, and assess student knowledge on the topic prior to reading using a Quickwrite.
To stress understanding of a concept by summarizing the main idea and applying that understanding to create visual aids and generate questions and comments using a Concept Matrix.
Come up with questions about a topic and learn new vocabulary words to determine answers using an Ask, Answer, Learn table.
Do a hands on activity to help conceptualize congruent triangles.
This study guide is an overview of triangle congruence: defining corresponding parts of congruent triangles, postulates and theorems for congruences (SSS, SAS, AAS, ASA), and postulates and theorems for congruences for special triangles.


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This Week our columnist GERALD KITABU discusses with STANSLAUS NYEMBEA, Programme Officer for Lawyers Environmental Action Team (LEAT) on foreign investments and land grabbing in Tanzania: EXCERPTS:
Question: What can you say is land grabbing?
Question: What can you say is land grabbing?
Answer: Land grabbing is the process whereby small holders are dispossessed of their land through interventions by outside actors. In recent years, the world has been witnessing massive exploitation of huge pieces of land in poor countries.
Due to political instability and the drastic rise in the prices of fossil fuels namely diesel, petroleum and kerosene, European countries, which are mostly in need of these fuels, have decided to find the alternatives of solving the problem.
They are acquiring huge chunks of land through controversial contracts that sometimes do not benefit locals. In most cases the signed contracts do not create equitable balance between the investors' interests and the locals' during land acquisition processes and procedures.
As I said earlier, foreign investment follows oil crisis in the past few years which continues to rise prompting oil security fears within the developed world. As energy prices across the globe remain volatile, many developed countries think that it is very important to explore new sources of oil and gas to help alleviate the stress on consumers and businesses.
Q: If that is the case, what is the connection between fuel crisis and land grabbing in Tanzania?
Q: If that is the case, what is the connection between fuel crisis and land grabbing in Tanzania?
A: As I said earlier, following recent fossil fuel crisis coupled with political instability in oil producing countries and elsewhere in the world, the developed world, particularly western Europe and America has drawn a road map to find alternative sources of energy from renewable energy.
Renewable energy such as bio-fuel requires among others, big land, fertile soil and water for growing crops such as paddy, Jatropha, sugar cane, maize, cassava, and palm oil. The only place where fertile land and water is plenty is Africa.
A research conducted by LEAT, shows that towards the end of 1990's, many European and American companies started acquiring huge chunk of land in different regions and districts in Tanzania such as Kigoma, Coast region, Arusha, New Katavi region and elsewhere to grow such crops to meet their demands back in Europe and America.
Tanzania qualified for this because it has the potential of producing about 4,010 and 1,726 million litres of ethanol and bio-diesel per year, according to the study.
Tracks of land are being given out to foreign investors. By 2008, around 20 foreign companies and other 5 were in joint ventures. Potential land for food production such as in Rufiji, Rukwa, Mbarali, Rufiji, Kisarawe, Wami was identified and/or allocated to bio-fuels companies. Since then, 4.5ml ha of land have been requested by bio-fuel investors out of which 641,179ha have already been allocated to investors, processes going on.
Q: what are the benefits of such investments?
Q: what are the benefits of such investments?
Answer: Research conducted by LEAT shows that there are both positive and negative impacts regarding the investments. However, negative impacts outweigh positive ones. So many times, the process of land acquisition bypasses the voice of local people.
In most cases, the positive impacts are short in nature. For example, there have been short term employments, short term income such as food vendors who happen to vend their food at factories and companies, government revenues increased, some infrastructures improved.
However, experience shows that the investors are not sustainable and the nature of their investments have very devastating effects on local production especially soil fertility, something which can trigger food insecurity and dependence. For example, apart from land grabbing, foreign investments in renewable energy has seen many villagers work long hours in the investor's farms which means they are left with very little time to concentrate on their own farms to produce enough food, something which, if not regulated, may cause food shortage in future.
There are a few opportunities accrued from the investments. For example, some companies promised to create thousands of jobs but ended up creating only 750 jobs and until now most of them have been retrenched citing shortage of water as the major problem. If that is the case, why didn't the investor assess these problems during the feasibility study? Furthermore, experience in many places shows that employment is not that much rosy due to terms of contracts which are normally controversial in nature.
Q: Any other negative effects?
Q: Any other negative effects?
A: LEAT discovered that in some places land grabbing is accompanied by environmental degradation such as deforestation. So, when this happens, it is the women who suffer most especially when it comes to shortage of water and other basic social services. In some places where women earn good income, family ties as well as marriages have broken down.
Loss of access to local resources is another problem whereby women are at risk of loosing their land because many vocal people and negotiators are men. Many people, after being employed in companies have a tendency of abandoning their farms hence food insecurity.
Other negative impacts include land degradation especially deforestation which leads to water scarcity. There have been a series of conflicts between locals and investors in some places over water utilization. Occupational Health services sometimes are not observed, investors prefer women for cheap labour than men because women are passive. So, generally speaking, the investments affect more women than men.
Most investors have the culture of dispossession and harvesting without investing. So to say, there is a danger of creating vagabonds and criminals in big cities due to the influx of people whose farms have been grabbed by investors to big towns and cities like Dar es Salaam.
Q: What do you think is the solution?
Q: What do you think is the solution?
A: LEAT has always emphasized on empowering local communities so they may be able to invest in various sectors. This should go along with changing of land laws and policies so that the locals can benefit from the investments.
Stern measures should be taken against defaulting investors, including revoking their investment certificates. Stern measures should also be taken against local officials who collude with defaulting investors.
There must be public pressure and demand for accountability. This would be possible if the public is well enlightened of their land rights. There is a need to investigate and assess foreign investments carefully before and during the investment process to establish whether the investments are worth and of benefit to Tanzanians.
There must be awareness creation among the villagers and the general public at large. However, rights based approach that supports small-holder producer's needs to be adopted.
There is a need to invest in small scale producers by empowering them because despite their small production unit, they are the ones who have been feeding the nation since independence.
Government should provide visible space for small producers by defining the practical and strategic relationship of large scale farmers and out-growers.
However, there is a need to put in place a policy on biofuel to inform all actors of the best practices in the sector. Guidelines may not be enough. Policy instruments are needed to help adjust the overall demand for non-food biomass at levels which can be supplied by sustainable production.
Since every village has Land committees, these committees should be sensitised and work closely with district authorities when it comes to investment issues.
Lastly but not least, many villages in Tanzania have no title deeds. Land grabbing is partly contributed by lack of such title deeds. Tanzania Investment Centre should actively monitor land investment by inspecting summaries right from the village level. Finally the investors should be given a trial period of between five to ten years during which failure to abide to the laws of the country, should lead to revoking of their licences. The lease term should be reduced from 99 to 33 years.
Lastly but not least, many villages in Tanzania have no title deeds. Land grabbing is partly contributed by lack of such title deeds. Tanzania Investment Centre should actively monitor land investment by inspecting summaries right from the village level. Finally the investors should be given a trial period of between five to ten years during which failure to abide to the laws of the country, should lead to revoking of their licences. The lease term should be reduced from 99 to 33 years.