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Throughout a golf career that encapsulates a stint as a collegiate player at Weber State University and a Class A membership with the PGA of America, Jared Shears has had ample opportunity to identify what works and what doesn't on the golf course. While many approaches have been tried—from rote drills to hypnosis to becoming one with the golf ball by going on a couple's retreat with it—Jared believes that improvement can realistically be narrowed down to five keys. He's come to this conclusion only after spending hour upon hour studiously watching film of hundreds of the game's greats. His analysis? These elite players keep their head steady and weight forward, maintain a flat left wrist, control the clubface, and guide the club's sweetspot on a diagonal swing path. Jared believes that, with practice, each of these key skills can be achieved by golfers of any skill or experience level.
Anytime Fitness, which boasts 1,689 clubs in North America, makes it easier for average folks to etch out time for exercise by doing one simple thing: staying open 24 hours a day for 365 days a year. As fitness seekers challenge themselves on cardio and Hammer Strength machines and hoist Iron Grip free weights in clean, well-stocked facilities, security monitoring ensures they're safe and producing enough sweat to meet official government standards. Members can also ramp up their exercise regimens with the help of Anytime Fitness's staff of personal trainers, who demonstrate moves and sling motivating tips. After workouts, guests can shower in the private restrooms or hop into one of the tanning booths available 24 hours a day.
Just past the glowing sand bars of the Lower Wisconsin River Valley, 80 acres of fertile hillsides present the ideal spot for winemakers at Weggy Winery to produce their award-winning vintages. With 30 different labels, the wines range from a sweet apple-and-black-currant dessert wine to a dry, clean white traminette to a smooth, red sabrevois. The Oak Ridge red, made from Wisconsin foch grapes, recently took home a gold medal from a California wine competition and a handwritten letter from a Sheboygan-area grandma who's convinced that bottle messages are the most efficient way to send mail.
Visitors can sample the estate-grown wine in the winery's tasting room, a sun-drenched space overlooking the vineyard. During the summer, groups can tour the acreage in the back of a tractor-pulled tram during a one-hour guided excursion which highlights the property's 16 acres, out of 24 total acres, of cherry, asian pear, and apple orchards, the property's 11,000 grape vines, and the spot where aliens once stopped for a brief but memorable picnic.


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Although these science standards are too new for politicians to have weighed in on them, the general movement toward common standards has bipartisan support. In a contentious election year, the idea that our kids deserve a world-class science education should be one issue we can all agree on.
Comment on this article at ScientificAmerican.com/aug2012
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Developer EventsWindows Azure Developer Stories
General ResourcesWindows PhoneWindows Azure
These postings are provided "AS IS" with no warranties, and confers no rights. You assume all risk for your use.
Resident Bloggers
Jonathan Rozenblit
Paul Laberge
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Marc Gagné
Every roadside stop on the 401 westbound east of Kingston is closed for renovations, so we've just been driving straight through without stopping. We're just 30 kilometres east of Kingston, where we'd planned to fill up, but the dashboard display says we're 11 kilometres away from an empty tank at the current rate of consumption.
Shall we chance it?
[This article also appears in Global Nerdy.]
How many hills do you have, how easy does the car push, and how tired are you? :)
You can do it! Or it will at least make one great video.
We ended up finding a gas station, with the display saying that we had 7 km worth of gas remaining.


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Simple, Soothing Nursery
This mom-to-be created a serene space with cool colors and functional furniture.
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Set the stage for the holidays with a dozen pretty, festive wreaths you can make yourself. - 25 Ways to Deck Out Your Mantel
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Thin Tendrils Necklace
Style: 25803537
Finely etched on a vintage locket, lines and vines surround a filigreed oval with the initials "JR" inside. Round spring closure. 18.5"L; 1.75"L, 1"W pendant. Gold fill, silver metal. Handmade.
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Great resort but the hotel was lacking in many areas--except it's position. Staff were surly, perhaps end of season itis? The extras - air-con, fridge and safe were a shock--should have been included in price. The restaurant attached to hotel (at end of road) was very good and the staff there were really friendly, serving great food. Hardly a "kalemera"... More
- Also Known As:
- Afrodite Hotel Roda
- Afrodite Hotel Roda, Corfu


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text:
Item specifics
- Products Status:
- Stock,Used
- Chipset Manufacturer:
- Application:
- Laptop
- With CPU:
- No
- Ports:
- VGA,USB 2.0,Ethernet,Wifi
- Hard Drive Interface:
- Memory Type:
- 667/800
- Model Number:
- Brand Name:
- For HP
Product Description
We are one of the leading laptop component suppliers in China, specialized in the export of refurbished laptop motherboards, especially be good at HP laptop motherboard, and in a position to supply laptop LCD, laptop keyboard, battery, and adapter. We have our own professional engineer team and repair service for you. With the high quality, good appearance and reasonable price, our customers are from all over the world: North America, South America, Europe, Australia, Africa, Asia.
Motherboard test function:
1. Check the appearance, such as turps, dust, tin soldering or other dirty mark on board.
2. Check whether lack of electronic insulation gummed paper.
3. Check whether lacks of fittings, rust, rot, heat elimination chassis.
4. Check internal and external connector of LCD display , Two memory, DVD driver, Network connection, Voice, Mouse, Keyboard, Dial, USB, SD connector, PC, 3.3V COMS battery, Battery whether charge and discharge, Full running 3D, Restart system at least two times.
Promised by Seller
1. 30 days warranty
2. Returning policy:
1) Full warranty against any defective product
2) Refund is for the product price only
3) Handling, postage and shipping charges are not refundable.
4) Defective product must be returned within 30 days of original arrival date.
5) Refund or replacement will be arrange after receipt of the returned item
6) Buyer must return item at his/her own cost
3. Testing procedure:
1)check the appearance, such as turps, dust, tin soldering or other dirty mark on board.
2)check whether lack of electronic insulation gummed paper.
3) check whether lack of fittings, rust, rot, heat elimination chassis.
4) check internal and external connector of LCD display , Two memory, DVD driver, Network connection, Voice, Mouse,Keyboard, Dial, USB, SD connector, PC, 3.3V COMS battery, Battery whether charge and discharge,Full running 3D, Restart system at least two times.
5) our testing link: please contact me for the link, since it isn`t allowed to be presented here.
4. International Buyers Please Note:
Import duties, taxes and charges are not included in the item price or shipping charges. These charges are the buyer's responsibility.
Please check with your countrys customs office to determine what these additional costs will be prior to bidding/buying.
5. Others:
All motherboard are fully tested ok before shipment and make sure it works in good condition..
Our motherboards does not include CPU,just a board
6:The goods are very refined,pls confirm you have the technology to install it by yourself,otherwise do that by a professional engineer.
What anything esle we can offer:
Keyboards, CPU, HDD, LCD screens,LCD Cable, Battery, Chipset, Adaptor,etc for different kinds of brand
We do our best to serve our each customer the best that we can.
We will refund you for items returned within 7 days of you receiving them, for any reason. A full refund will be given if items are returned in their original condition.
Merchandise which is damaged or missing components is not refundable.
Buyers are responsible for return shipping with proper packaging.
On receiving items, we will refund you immediately.
Warranty &Maintenance:
We provide 1 month replacement
***** Buyers are only responsible for the return shipping fees for warranty items.(In most cases, buyer will only have to return the problem components rather than the entire package.).
Before returning items, please make sure you get our (the seller's) return address, and write "gift" on the delivery detail sheet. Please use regular postal service and send us the tracking number. As soon as we receive the items, we will repair or exchange them ASAP.
Packaging Details
- Unit Type:
- piece
- Package Weight:
- 1.000kg (2.20lb.)
- Package Size:
- 20cm x 20cm x 15cm (7.87in x 7.87in x 5.91in)
Packaging Details
- Unit Type:
- piece
- Package Weight:
- 1.000kg (2.20lb.)
- Package Size:
- 20cm x 20cm x 15cm (7.87in x 7.87in x 5.91in)
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Haven't played this one, but from the bad taste in my mouth from Star Trek Online, I doubt i would like this new one.
I'm not sure any trek game can live up to my trek expectations. I'll just stick to the shows lol.
@Ace-of-Shuffle said:
Now people claim the Wii U is weak, however you do not understand how the Wii U works and a combination of the Wii U IR E344 sensors along with the Stream storage on the Wii U gamepad can create graphics that rival todays modern PC's.
First you must realize that the Wii U and the Wii U gamepad are gaming devices:
Now what happens is that as a game is being loaded from the disc, the Wii U takes the graphical and computing data and executes math. Which allows for advanced calculations along with object and event placement. This can take a toll on the CPU as the GPU in the Wii is handed the more basic tasks.
HOWEVER, the Wii U gamepad in many games is used to STREAM DATA to the screen using IR E344 sensors. It also has built in Gyro storage so that the Wii U can detect the gamepads position in some games.
NOW the thing that the PC(yet), the Xbox One, and the Playstation 4 can not do, is use this to the advantage! The Wii U gamepad sends some extra data to the Wii U gamepad, and then the Gamepad cycles it back to the Wii U. Basically holding extra data for Math and Graphics and sending it back so the GPU and CPU in the Wii U does not do all the work but can still release the same impressive graphics we seen so far. The Wii U gamepad sends that held data on the side refreshed at every second so that the games are double in detail and the A.I. is twice as smart. Sort of like a Dual GPU. but it's a virtual GPU formed from the memory transfered between the Wii U and the gamepad.
So the Wii U really has twice the ram and double the graphic compacity. Let us compare:
This is Pikmin 3 running at 1080p, using the same engine that Project X uses. Notice the next gen detail, but also notice the blur in the far background and foreground. A problem that the X!, PC and PS4 have as well.
But take a look at Project X, same engine, same resolution, same 60fps, but the blur is gone and the draw distance is high. This is only using the Virtual GPU at half potential!!!
This is not possible on next generation consoles. So the Wii U is still in the phase, but soon all the games will be untilizing this ability like Project X. Super MArio 3D World already uses it for color correction and Background graphical math, so you can see that there will be no competition in terms of power.
The Wii U games will be a thing to behold, and I ca't wait for the new games that show us what the next generation is. More than just a partial upgrade like many here accept!
Your dumbass title was enough to get me to not bother reading anything you said.
@True_Gamer_ said:@miiiiv said:@True_Gamer_ said:@miiiiv said:@True_Gamer_ said:
Xbox360 didnt have a GPU comparable to a PC GPU of $130.
I've never said that the 360 had a gpu comparable to a $130 pc gpu. The 360 was actually pretty cutting edge on it's release date, having a gpu with unified shaders before gpu's with such technology were available to pc's
But PS4 has a gpu that on launch is comparable to the R7 260x at $129 http://www.newegg.com/Product/Product.aspx?Item=N82E16814150688
Now look at the 360 in 2005....In order for history to repeat itself console makes should have put stronger parts in their machines....but they went nintendo on consolites rears....I dont even want to go into what the poor Xbone is.
From a performance standpoint:
ps3 >> $600 pc from 2006
$1500 pc (2006) >> ps3
ps4 > $400 pc (from today, ofc.)
$1500 pc (today) >>> ps4
In that sense, I think history kind of repeats itself. But you are right, for history to repeat itself more accurately, the ps4 would have to be more powerful.
You dont say anything about the 360. Which was like
360>>>>$1000 PC from 2005
The PS4 is PoS compared to the monster that the 360 was in 2005.
In today's terms the PS4 would have to have an R9 290 which of course would lead to at LEAST $850 manufacturing costs....
Name a better GPU at about 100 watts.
Xbox 360's Xenos has about 90 watts TDP while Radeon X1900 XT has 100 watts.
PCPartPicker part list: http://pcpartpicker.com/p/2gbCy
Price breakdown by merchant: http://pcpartpicker.com/p/2gbCy/by_merchant/
CPU: AMD Athlon II X4 740 3.2GHz Quad-Core Processor ($74.99 @ Newegg)
Motherboard: Gigabyte GA-F2A55M-HD2 Micro ATX FM2 Motherboard ($42.99 @ Newegg)
Memory: G.Skill Ares Series 8GB (2 x 4GB) DDR3-1600 Memory ($65.45 @ Newegg)
Storage: Seagate Barracuda 500GB 3.5" 7200RPM Internal Hard Drive ($49.99 @ Newegg)
Video Card: PowerColor Radeon R9 290 4GB Video Card ($405.91 @ Newegg)
Case: Sentey CS1-1398 PLUS ATX Mid Tower Case ($11.25 @ Newegg)
Power Supply: EVGA SuperNOVA NEX750B BRONZE 750W 80+ Bronze Certified Semi-Modular ATX Power Supply ($49.99 @ Newegg)
Optical Drive: Lite-On iHOS104-08 Blu-Ray/DVD/CD Drive ($52.37 @ Amazon)
Total: $752.94
(Prices include shipping, taxes, and discounts when available.)
(Generated by PCPartPicker 2013-12-06 19:42 EST-0500)
First time I ve heard of anyone having this problem...With your HD making noise it could be your Xbox
I have both consoles. If I were to buy 1 just for launch games the XB1 is the way to go. But there are plenty of games. AC4 will last you quite a while(im playing that on PC). Marvel heroes is cool, NFS, COD, etc. I only have resogun and marvel heroes on my ps4 and Im enjoying chasing high scores on resogun.
Sang-froid has an interesting setting.
@XxR3m1xInHDn3D said:@Stringerboy said:@WadeFan said:
Ryse. All I was hearing was how it was going to be GOTY. TLOU wasn't to me because all GS did was rate it low for shock value.
Strange, I don't recall one person saying that.
No one did but cows need to make it up because of how badly TLoU flopped
Yep, it was definitely TLoU, followed by KZ:SF.
Fun times. -
@airshocker said:@charizard1605 said:@airshocker said:@charizard1605 said:@airshocker said:@charizard1605 said:@airshocker said:@charizard1605 said:
World premiere is a meaningless catch phrase. Apparently you're the idiot that thinks it guarantees you some form of creativity from a console-maker that has shown it lacks exactly that.
Where in fuck did you get the idea that this is an HD remake is what I would like to know.
I am not even going to touch the rest of your flame bait post.
Because they've been crapping out HD remakes and Nintendo, again, lacks creativity?
They've been crapping out HD remakes? Really?
Okay, make a list of their HD remakes. I'll wait.
That's right, you Nintendo fanboys are really good at waiting.
Lol, this is just sad now.
You're pulling shit out of your ass to troll, and not even doing a good job of that.
I'd rethink my strategy for the next round
You know what's REALLY sad? The fact that you have a Wii U and are seriously trying to regain any sense of dignity. It's long gone, bro.
Actually, I'm doing quite well in BF4. No need to rethink anything. You wouldn't know anything about that though because...lol Wii U.
No need to respond to this. I'm done with you now.
He doesn't have a Wii U, he's a fakeboy. :P
Hey man :D


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Learn a new language. Perform random acts of kindness. Inspire someone. Make something new every day.
With the holidays almost over, time to reflect on the changes we want to make to improve our lives in 2013.
Make sure you achieve your goals and keep your promises in the new year. We've recreated the popular MSK New Year's Resolutions templates for 2013 to help you stay on track of your targets. Just a simple registration on myMoleskine is needed to download the free templates.
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The New Year's Resolutions MSK templates could help you with at least one of your goals: Getting Organized.
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On Twitter with the hashtag #moleskine2013
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Download the New Year's Resolutions MSK templates from myMoleskine here.


text:
Animal Diaries Archive
2005 - january february march april may june july august september october november december
Animal Enrichment
6 May 2005
We as reptile keepers get up to so much on a day to day basis; often we don't even have time to scratch ourselves! There is however one thing we do work into our busy schedule each day, and that is animal enrichment. Animal enrichment is more or less increasing an animals quality of life. To give you a good example of this, I have included a photo of Basil. Basil is a 12 foot Burmese Python weighing up to 60 kg. I've taken her out of her enclosure and placed her out on the grass to give her a chance to stretch her 'legs' and get the best part of an hours sunbake. This also gives her the opportunity to do some exploring, triggering behaviours observed out in the wild. As you can see I have this extremely complex operation all under control.


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This is one the most famous Cuban cocktails, the mojito, whose great flavor is given by mint leaves, lime and cane sugar.
Added: 40 days ago by
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Cookies and Cream Cocktail Recipe
Cookies and cream cocktail is a strictly adults only treat, perfect for parties. Oreo cookies are combined with cream ice cubes and some beautiful liqueurs to make a rich velvety cocktail.
Added: 91 days ago by
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Found at many a dinner party in the 60s and 70s, this dish makes a quick and easy starter, which is packed full of taste.
Added: 166 days ago by
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Cocktail Sausage Meatballs in Sauce Recipe
This is great for an appetizer or party, also for potluck dinners. The meatballs should be served warm, and you may want to double or triple the recipe and keep the meatballs on low in a slow cooker while they are being served.
Added: 279 days ago by
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Summer cocktail is a simple party drink which is perfect for any summer party. Vodka, wine, sparkling apple juice and cranberry juice are combined with ice to create a fruity, sweet but slightly tart cocktail that everyone will love. For an non-alcholic version, simply replace the vodka and wine with Mineral Water and more cranberry Juice.
Added: 290 days ago by
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November/December 2013
It took 19 years and the involvement of four presidents, two governors, seven senators, four congressmen, the Nevada Centennial Committee, and countless Nevada residents working with four different postmaster generals to issue three commemorative centennial stamps recognizing the accomplishments of the Battle Born State.
July/August 2013
In 1953, Judge Clark J. Guild, founder of the Nevada State Museum, along with James W. Calhoun, recognized that the state's wide-open spaces prevented many Nevada schoolchildren from visiting the museum in Carson City. The men sought a way to take the rich and countless stories of Nevada's cultural and natural heritage to the children and the people of the Silver State.
May/June 2013
Tonopah photographer Jim Galli has earned quite the reputation for connecting the past to the present via his black-and-white images. But these aren't digital pictures converted with modern computer software—these are the real deal, taken with a circa 1910 Kodak Cirkut panoramic camera.
March/April 2013
In Goodsprings, the action is at the Pioneer Saloon, the last saloon standing—and continuously operating—from the burg's glory days of the early 1900s. "At its peak in 1916 Goodsprings had 800 residents. Stores, restaurants, churches, a theater, and nine saloons lined Main Street. The Hotel Fayle, advertised as the 'finest in the West,' opened with great fanfare."
January/February 2013
Goodman, who had employed Mark Twain and Dan DeQuille, said regretfully, "Isn't it so singular that Mark Twain should live and Dan DeQuille fade out? If anyone had asked me in 1863 which was to be an immortal name, I should unhesitatingly have said Dan DeQuille."
November/December 2012
While cow thieves were an ever-present problem and called forth such extreme measures as group lynchings and the employment of professional man-hunters, a much more primal challenge faced the stock-growers of the late 19th-century West: extreme weather.
September/October 2012
Nevada's Lost City is both scientific and romantic. Buried beneath the sands of the Mojave Desert was information that archaeologists used to define the western-most settlement of the Ancestral Puebloans. The Lost City is archaeological proof that they lived and thrived in Southern Nevada.
July/August 2012
Just prior to 5 p.m. on Thursday, July 18, 1912, Ed Kalenbauch and Ellsworth Bennett watched a cluster of ominous thunderheads hover over Granite Peak from the door of Kalenbauch's office at Seven Troughs Coalition Mining Company. They just so happened to comment on the storm's potency when they saw a wall of water 10 feet high surge down Seven Troughs Canyon.
May/June 2012
In 2011, Nevada's government officials decided to shut down the prison, citing reports that claimed NSP was more expensive to operate than other facilities and that the prison needed structural upgrades that were too costly to justify. Now, the prison is emptied of its charges—what happens to NSP, only the future knows.
March/April 2012
Born in 1859, George Washington Gale Ferris Jr. came across the plains with his family in 1864 from Galesburg, Illinois and settled near Genoa. Ferris was drawn to the Carson River, and, on hot afternoons, he would climb on his pony and clop down to the water. Local lore maintains that it was the handiwork of William Cradlebaugh that drew Ferris to the riverside.
January/February 2012
If you were living in Tonopah in 1908, 1980, 1996, or August 2011, you likely share this in common—you took part in a grand-opening celebration of the Mizpah Hotel. But how can a hotel open four different times?
November/December 2011
The cure was divorce and the scene a familiar one in Reno during the 1930s. In March 1931, the Nevada Legislature shocked the nation when it not only legalized gambling in the state, but reduced the residency requirement for divorce from three months to six weeks.
September/October 2011
In the year 1900 a recalcitrant burro—affectionately dubbed the desert canary because of his braying propensities—which had strayed away from a prospector's campsite during the night, was the indirect cause of another flash of gold excitement in the Tonopah area, which followed the decline of the Comstock by almost 20 years.
July/August 2011
Nevada may never have produced a more brilliant or complex woman than Sarah Winnemucca. Part saint, part sinner, part missionary, part camp follower, she was the epitome of the good-bad heroine.
July/August 2011
Wovoka's life spanned years of freedom and oppression for the Native American tribes of Nevada and the Western United States. He urged his people to live in peace in their new circumstances, but never abandoned his hope for a return to the old ways.
May/June 2011
Dwindling down from a peak of more than a million sheep in 1910, Nevada's sheep empires have vanished, and only a handful of outfits remain to tend less than 200,000 sheep on private land and the diminishing public domain.
March/April 2011
Kennecott Copper Corporation and Consolidated Coppermines Company, two famous names in Nevada's mining register, have been identified with the Ely district for decades, mining ore from deep pits and producing blister copper in enormous volume.
January/February 2011
High up in the mountains, 35 miles southwest of Las Vegas, is found one of the places most significant to Nevada's early history. This is the old Potosi Mine, the first lode mine ever worked in the state.
November/December 2010
From the discovery of the Comstock Lode through the Great Depression, gambling in Nevada was a tug-of-war issue between individual liberties and Victorian values.
September/October 2010
In 1896, my great-great-great uncle, Oliver Goldsmith, published Overland in Forty-Nine, his recollections of traveling the California Trail, and gave hardbound copies to his family and friends. It is a remarkable account and tells of the hardships endured by equally remarkable people.


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An autopsy is scheduled today on the body of Nashville restaurateur Jay Luther, who died after being stuck in a cafe refrigerator overnight, despite pressing a burglar alarm that called police to the scene. Luther, who was co-owner of the Germantown East Cafe, likely died after "being overcome by carbon dioxide given off by the dry ice," police
said in a statement.
Read more: http://feeds.abcnews.com/click.phdo?i=031c963f2345e6f12403e77b65883038
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Call it the Summer of Spielberg!
CBS has ordered Steven Spielberg's Extant for Summer 2014, the network announced Wednesday.
The futuristic thriller follows...read more
Poppy Montgomery will never forget when Unforgettable was un-canceled."I got the call and I was like, 'Where's Ashton Kutcher? This is Punk'd!'" she tells TVGuide.com. "I was like, 'This is not real, c'mon, people!' It was really fast. I really thought it was a practical joke. I trust that the networks and studio know what they're doing and what they need and want. If it's not meant to be, it's not meant to be, and I really thought it wasn't last year. So many shows get canceled. It's so rare to bring a show back."Get the scoop on Unforgettable and more of your favorite returning summer showsThe CBS drama — which stars Montgomery as Carrie Wells, a detective who can remember literally everything except the night her sister Rachel was murdered — will return for its second season Sunday (9/8c, CBS), 14 months after the network initially canceled it despite a worldwide following and numbers that would make any competitor green with envy. The show ...read more
Sometimes even network executives admit they've made mistakes. After canceling Unforgettable last year, CBS is bringing back the cop drama this summer. AMC changed its mind about dropping The Killing and, most recently, Lifetime decided to revive Drop Dead Diva.read more
Frankie & Johnny Are Married movie trailer - starring Hector Elizondo, Kathy Baker, Mandy Patinkin, Alan Rosenberg, Michael Pressman, Lisa Chess. Directed by Michael Pressman. Theatrical Release Date: 5/28/2004 Genre: Drama Rating: R
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In a hilariously misguided attempt to save his rocky marriage, Director Michael Pressman casts his wife opposite hot-shot actor Alan Rosenberg in a new play. But when Rosenberg can't differentiate between stage and real-life love scenes, it's up to Pressman to fix his marriage and keep the show on the road. Frankie and Johnny are married is a smart, witty romantic comedy about risking it all to save everything.
In a hilariously misguided attempt to save his rocky marriage, Director Michael Pressman casts his wife opposite hot-shot actor Alan Rosenberg in a new play. But when Rosenberg can?t differentiate between stage and real-life love scenes, it's up to Pressman to fix his marriage and keep the show on the road. Frankie and Johnny are married is a smart, witty romantic comedy about risking it all to save everything.
more Nina Tassler Movies videos
more Nina Tassler credits (1 total credits)
The Big Bang Theory has turned into a full-blown supernova. The sitcom, now in its sixth season, has been on a roll this year, posting ratings highs several weeks in a row. On Jan. 10, it crossed the threshold of 20 million viewers for the first time.
"We think it's pretty amazing," says executive producer Steve Molaro, who took over as showrunner this season from Bill Prady, co-creator of the series with Chuck Lorre. "It's an honor to have so many people watching the show." Molaro credits the sitcom's exposure in syndication — particularly on TBS, where Big Bang often tops the cable ratings charts — for boosting the CBS episodes. "Syndication has reached a lot of new people," he says. "I try not to get caught up in the numbers, but it's fun."
Fans of CBS' comedies How I Met Your Mother and Two and a Half Men can't rest easy quite yet, but could have good news soon.
"We will be happy to be reporting in a few days that things will be resolved," CBS chief Nina Tassler told reporters at the winter TV previews Saturday about the possibility of a Season 9 renewal for HIMYM. "We're confident and excited that things will work out. Almost everything is complete."
CBS is serious about tackling broadcast TV's summer problem, and to prove it, the network is hauling out two big names: Steven Spielberg and Stephen King.
The Steves are behind the upcoming 13-episode CBS summer series Under the Dome, based on King's best-selling thriller about a New England town that becomes sealed off from the rest of the world. read more
CBS is moving forward with Under the Dome, a drama based on Stephen King's 2009 novel, for the upcoming summer 2013 season. The network requested a straight-to-season order of 13 episodes of the science fiction series. read more
The next few weeks will be rough for the networks, as they parse what works — and what doesn't — among this year's crop of new shows. We asked the five broadcast network heads, plus a few key cable bosses, to give us their thoughts on what will big on the small screen.
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Pairings Bistro
Online Reservations
Had a great time at the restaurant for our date night. Food was excellent, wine was great, along with a fine selection of beers! Can't afford this every night, but well worth it for the quality and service!
I had the veal chop and cream of crab soup. Both were very good. For dessert I had the lemon basil ice cream over grilled pound cake and fresh berries. By itself the ice cream is very strong make sure you get a bite of everything.
Pairings is almost unique in Bel Air - a local establishment with more than pedestrian fare. We always enjoy our prix fixe four-course meal with the variety of wines. This last time, however, we did feel just a little rushed. Every course came hard on the heels of retrieving the dishes of the previous course, with little time to catch our breath! It did detract a bit from the overall experience, but it was still a very enjoyable meal and ambience.
What I don't like: service is slow( hate to have an empty glass and especially while I am eating), I feel like they could be more attentive. a row of tables way too close for comfort( you can hear the table next to conversation and they definantly can hear yours). What I like; I love the small plates, I love the wine choices and especially like the cheese board offerings. And the reason I am giving my opinion for the first time after visiting many times over the years is because I finally had a waiter who was PERFECT. He was very attentive I never had to wait to order or get a drink it is as if we were his only table in a full restaurant. I loved the service. GREAT JOB ERIC A. this was on the receipt so I hope I got the right person!!!
This truly is a wonderful restaurant. The food is first-class and delicious. The service is incredibly professional. They have really captured the balance between being of service to you when you need it but not overwhelming you and making you feel rushed. This is hands down one of the best restaurants in all of harford county (and I would even go as far as saying it competes with some of Baltimore's top restaurants). If you've never heard of it before, you'd be surprised by the location; but once you go, you realize how exquisite the experience is. Absolutely superb!
Tuesday evening early dinner at 4:45PM. Had a reservation and was seated immediately. Placed filled up by 6:00PM. Had the 4 course fixed price meal with wine pairings. All my food was outstanding with the exception being the salad which was ok. My wife had the Steak au Poivre with a Romaine Caesar salad. The steak was very peppery and a little underdone for her taste. She forgot to specify she preferred medium for her beef. Service was prompt, friendly and not oppressive. We enjoyed the meal and the restaurant. Would go there again.
Pairings is Harford County's best restaurant!! Love the wine flights addition!! Looking forward to mushroom risotto!!
I have been here twice and was very pleased both times. The service is great and the food is amazing. My husband and I both had the pre-fixe menu and it was well worth it. It was also happy hour so wine by the glass was half off. I chose the white sangria and it was a giant glass of heaven. Hands down the best cream of crab soup I have ever had. The steak was cooked to perfection and fantastic. The dessert was fresh and delicious. Not too sweet but just right. All the food was well balanced and thoughtfully prepared. We had a date night and left the kids with a sitter. Unless your children are very well behaved I wouldn't recommend bringing them. So happy to have an amazing restaurant in Har Co.
Pairings is a restaurant we have gone to several times. It always meets and exceeds expectations. Food and service are great. If you go, don't skimp...get the wine pairings and enjoy it.
This is a local restaurant for us, but we hadn't tried it yet. The soup, salad, appetizer,and entree were excellent--served timely and hot. Our server said the portions were smaller than some other restaurants, but we found them perfect. Nice to be able to eat three courses without feeling stuffed. There was room for the chocolate hazelnut cheesecake which we loved. There was no pressure to try lots of wines, and they offered 3 oz or 6 oz glasses. We will certainly visit Pairings again soon.
The pairings of wine to food (shows my level of importance listing wine first) is spectacular. Even when I switched wines on one of the dishes the server and I worked on a good idea that came out well. While I would not recommend this for a family, it's surely a great place for me and the Mrs. to celebrate our 15 yr anniversary.
Steak au poivre with truffle fries and a go-with carmenere from their Sunday Supper menu: absolutely delicious! My friends had chicken breast over sundried tomato risotto and pork tenderloin with grilled peach salsa over heirloom black & white rice. They loved both! It's wonderful to have a restaurant in the area with a great chef! I also liked that it was casual, not stuffy, and the prices were very, very reasonable. This was my first visit, but I'll be back often.
The soup, salad and desert was excellent but was disappointed in my main course. I had the chicken and sun dried tomato risotto. The chicken seemed to have no flavor - just plain chicken grilled. My friends loved their main course, one had steak and the other pork loin. Very expensive. Only recommend for very special occasions.
Good food, with the correct wine in the pairings menu makes for a great experience.
I was skeptical at best but it was my wife's birthday and this is where she wanted to go. I would go back in a heartbeat. Service was great, food was amazing. We did the wine pairing. I really liked all their choices except the dessert wine. I'm just not a dessert wine guy…
I am here at least once a month for a lavish dinner and they never let me down. My friend and I enjoyed dinner at Pairings on a Wednesday evening and we were able to take our time and spend more than 3 hours at the table relaxing and catching up and enjoying good food and wine. We started with the Incognito white blend to go with our tuna and frites, and then we switched to a Mollydooker red for our duck pizza (which was OUTSTANDING). We finished with the caramel creme brulee and the Guiness chocolate cake, both of which were incredible, and I had a glass of something sweet and bubbly (Emily recommended it and I don't remember what it was but it was perfect). The staff was friendly and helpful, and the food and drinks were top notch.
Normally you can count on a dinner that is just right. Not tonight, the salmon was over cooked and the glaze way too sweet.
Pairings is a gem located in Harford County serving the BEST lunch and dinner in town. If you're looking for a gourmet meal with outstanding service, this is the place for you!
Great place for a wine and tasting dinner. Reasonably priced. The price-fix dinners with included parings always leave you satisfied. It is nice to get a different wine for each course picked especially for that course. Much nicer than 1 bottle for the night, and you don't have to "guess" what might match with the food. If you are not near this restaurant, it is worth taking a drive.
I will definitely be back to this restaurant. The food was amazing, along with the wine pairings for every course. The woman who greeted us when we arrived was very apologetic that we had to wait for our table and even offered us a glass of wine while we waited. My only complaint was that our server was not as attentive as he could have been. I found myself waiting for my wine pairings for a few courses and was hard to track him down when we were ready to pay our bill. We weren't in a rush, so it wasn't a problem this time!
The food, wine, and service were all great! I would definitely recommend Pairings Bistro to my friends and family.
I've been to Pairings a lot and this was my first time dining outside. The patio was great to enjoy the warm weather and a chilled glass of wine. I sat out there for six hours, sharing wine and food with my friend. Emily was very patient with the slow pace of our meal. She made great wine recommendations for us. We ate a couple cheeses (manchego and the Red Dragon -- awesome!), fried oysters, duck flatbread, and then dessert (creme brulee and Guiness cake - both amazing). I love this place.
With the limited choices in Harford County for a unique dining experience, Pairings Bistro more than lives up to expectations. You can expect the traditional- tasty menu items with seasonal plates added every few months. The wines by the glass are very good and you can always count on them be served at the right temperature. This includes the reds and as surprising as this sounds is something lacking at most restaurants these days. Great job Jon, Kathy and Adrian and Co at Pairings!
My friend and I enjoyed the four course wine pairing menu and were blown away by the exceptional quality of the food with each course. The portions were perfect and the wine glasses were kept full with some delicious choices. We even left with a case of mixed wines based on our evening's sampling. The waitstaff was very informative and offered outstanding customer service. Certainly a venue that I plan to do again and will recommend to friends!
Pairings Bistro is located in a nondescript business park near the Festival of Bel Air, and if their yellow catering van is not on the parking lot, you may just drive on past without notice. Which would be a shame, as Pairings Bistro stands out in the chain restaurant wasteland known as Bel Air. Not to say that a burger or acoustically-challenged shrimp are not appreciated, but sometimes you just want to see a chef present dishes a little off the beaten path. Such as boar ribs, or spicy quail. Perhaps an elegant salad with fresh dressing, or a delicate cream of crab soup served with a sidecar of sherry. All this, with an extensive yet reasonably priced wine list, within a stone's throw of Harford Mall, so-to-speak. A real gem!
So thankful a restaurant like this made it to our county. Adds a little excitement to the usual.
The service was outstanding as was the cream of crab soup! We enjoyed everything except the closeness of the surrounding tables. We rated the food as very good because the steak was prepared with too much pepper and the side that was served with the duck did not meet our expectation.
I treated my finance for his birthday - EVERYTHING was wonderful!
My favorite restaurant in Harford County. Never disappointed!
My husband and I both did a prix fixed menu...all the choices counded delectable. Highly recommend the having the wine pairings with your meal. You cannot go wrong with anything on the menu!
I would go back in a heartbeat. The food was excellent and the presentation very good.
Top spot in Harford County with great wine choices, gourmet dining and seasonal menus. If you are a foodie then don't miss this small gem with a bistro type atmosphere. Finally, a top spot that is not a chain!!
This establishment did not disappoint! The food was amazing , beer and wine list expansive and service great. We can't wait Togo back and try more items on the menu!
we have been to Pairings many times, but this was our first visit for brunch. Food was good, service was just a little slow.
My wife and I had our anniversary dinner here, and we left all smiles. Great food and service. They didn't have any NY Strips left at our dining time (830) but they offered a delicious alternative. Wife got the duck. Great value to get the 4 course meal deal they have.
For what ever reason the fish specials never measure up to the normally outstanding quality of the food served at Pairings. Such was the case Saturday night.
Great selection of unique cheeses and wines, and of course their regular entrees and a la carte items were terrrific.
This restaurant surpasses any restaurant in the area. Definitely not suitable for children. From the outstanding food and menu choices to the great service and the ambiance it is nice to have a elegant place to dine without driving a distance. It is the most creative menu I have seen in the area.
The abilities to eat a small but delicious meal makes this one of our favorites. Last week my husband and I shared a salad and dessert and each had an entre and it was under $80 for an exceptional meal including two beer and a glass of wine.The price is not the reason we go back often.The food is excellent..They have wine pairings ,hence the name,with all items on the menu. The wines are all terrific.They sell their wines also.
One member of the party got the flat bread, tasty and the crust was over cooked.
I love this place. It was so nice that I could purchase a 6-pack of beer for a friend, enjoy an amazing dinner, and also buy a bottle of wine for my friend (the wine we drank while eating our meal). The sliders and duck confit flatbread were amazing, and the pumpkin cheesecake dessert was fantastic (one of the things I love about Pairings: They don't skimp on desserts). The half-price glasses of wine during happy hour, which now goes until 7pm, were great.
We very much appreciated the great service , the amazing food and the wine pairing. It was an exceptional restaurant experience that we will talk about to all our friends and family . We enjoyed the four course with wine pairings. I was very happy with each pairing. The pumpkin cheese cake was the most delicious food I have ever tasted. I can't wait to go back
The food was excellent, as usual. In this review, I want to complement the restaurant on offering three exceptional red blends. I had a "flight" (trio of 3 small glasses), and the Crypto blend blew me away.
We have been to Pairings only twice but each time we have been thoroughly pleased with every aspect of our experience. The ambiance is excellent and it was very quiet on our visit. We love the wine pairing with each food course and they are very good at spacing the courses out so you don't get stuffed. In fact our dinner experience lasted two hours and we didn't mind. The portions are perfect and the food delicious! Highly recommend the cream of crab soup and the butterscotch creme brulee. Our server was professional and friendly and had a great knowledge of wine. It was a nice way to celebrate our 12th anniversary! I call this Bel Air's best-kept secret. I hope you give it a try!
My soup was cold , salad was sitting in a puddle of water, entre was good , dessert fantastic! Eggnog tres leche was so delicious !
I was looking forward to Pairings for a month, since I made my reservation. Upon our arrival (a few minutes before our reservation) we were told that it would be a few minutes as our table wasn't quite ready, but they were just paying their check! as we waited, 3 parties arrived and were seated before us (parties of 4). 30 minutes later I inquired as to why, they couldn't "re-arrange" a 4-top for us, since we. Had been waiting for quite some time and were again told, there were a few tables just finishing and it would be "any minute" now. We were seated shortly after that and offered a glass of wine on the house for our wait. The food was ok. Steak was over done, salad a bit charred, and almost missed out in my Guinness cake!
I love Pairings, and will be back many more times in the future. The food is always amazing, and the service has always been impeccable. I highly recommend doing the pairing menu -- the 4 course is plenty of food. They certainly do know what they are doing, and match each dish very carefully with a wine combination. Also, they have always been very accommodating for someone who has Celiac's and cannot eat gluten. I've never had a bad experience here, so Pairings Bistro is a must!
Excellent food, excellent service. This is our favorite restaurant and it is always a wonderful dining experience. Mike and Sue Parker
I am a Realtor and Pairings Bistro is my #1 pick for a client/business lunch. The location, food, service is superior. I always order the same thing....cream of crab soup and the flash grilled Romaine Caesar salad. Highly recommend!
Our waitress was very attentive to our needs. The food and wine was very good. We would recommend Pairings to everyone.


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Bathroom Modification for Wheelchair
How to remodel your small bathroom for wheelchair access The diagram below shows a simple solution to remodel a small, typical, 5′ x 8′ bathroom. Notice the major difference is widening the bathroom doorway. Bathroom doors are usually the smallest … Continue reading
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Wheelchair Ramps for your temporary needs
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When I booked the hotel on hotels.com, the hotel description promis a kids friendly hotel, with kids club. We arrived at find out the kids club was closed. And the last day we stayed there the pool was closed. When we complained to the reception we didn't get any response just a sorry we can't help you. The hotel is... More
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- Iberostar Royal Playa De Palma Hotel Playa De Palma
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SOURCE: Grand Rounds Presentation, UTMB, Dept. of Otolaryngology
DATE: 9 February 2000
RESIDENT PHYSICIAN: Robert H. Stroud, M.D.
FACULTY PHYSICIAN: Anna M. Pou, M.D.
SERIES EDITOR: Francis B. Quinn, Jr., M.D.
|Return to Grand Rounds Index|
Skin lesions are a frequent occurrence in the head and neck. Many times this will be the patients reason for seeking medical attention, while at other times it will be noticed during the course of a routine physical examination. It is important for the otolaryngologist to be able to distinguish between obviously benign lesions and those that are malignant or pre-cancerous. The greatest chance for cure with minimal cosmetic and functional deficits depends on early diagnosis and treatment. This discussion will focus on basal cell (BCCa) and squamous cell (SCCa) carcinomas of the head and neck including their epidemiology, presentation, diagnosis and treatment. Several benign lesions that are often confused with these cancers will also be discussed, as will lesions that are generally considered pre-malignant. For the purposes of this discussion, skin malignancy will refer only to BCCa and SCCa. Melanoma, Mohs' surgery and reconstruction of defects after the treatment of cutaneous malignancies are the subjects of separate Grand Rounds presentations and will therefore be omitted.
Epidemiology and Etiology
Skin malignancies are the most common cancers in humans with 600,000 to 800,000 new cases in the United States each year. Basal cell is the most common type, accounting for 90% of all cutaneous neoplasms in the head and neck and almost one quarter of all cancers diagnosed in the U.S. SCCa is the second most common histopathologic type with nearly 100,000 new cases in the U.S. each year. Although highly dependent on sex, geographic location and cell type, the lifetime probability of developing BCCa varies from 11 to 28% and 1.5 to 11% for SCCa. For both cell types, the incidence increases with age. Generally, those over 60 are at highest risk for developing SCCa, while BCCa is relatively common in patients over 40. The incidence is increasing in younger patients, perhaps due to changes in fashion, and tumors of either cell type may be seen in patients in their 20s. Men are 2 to 3 times more likely than women to develop a skin malignancy. In both sexes, 80% of skin cancers arise in the head and neck.
Numerous different factors seem to interact to cause skin cancer. The most important of these factors seems to be exposure to ultraviolet radiation (UV). It is estimated that 90% of non-melanoma skin cancers are due to UV exposure. Laboratory experiments indicate that UV light in the ultraviolet B (UVB) band (wavelength 280 to 320 nm) has the greatest potential for carcinogenesis. It is radiation in this frequency range that is responsible for the common sunburn. UVB has been shown to induce photochemical damage to DNA and its repair mechanisms, and has been shown to be immunosuppressive. Ultraviolet A (UVA, wavelength 320 to 400 nm) was initially believed to be non-carcinogenic. It is much more prevalent than UVB. Recent studies have indicated that UVA does have some carcinogenic potential in laboratory animals with exposure to high doses for long periods of time. In addition, UVA seems to augment UVB responses and thereby may act as a co-carcinogen. This has raised concerns over the safety of tanning beds that emit UVA light. Ultraviolet radiation C (UVC, wavelength 200 to 290 nm), is a potent carcinogen that is filtered by the ozone layer of the earths atmosphere. The depletion of the ozone layer as a result of the widespread use of chlorofluorocarbons has prompted concerns over the potential for a drastic increase in the incidence of skin malignancy. Mathematical models predict a 2 to 4% increase in the incidence of skin cancer for every 1% reduction of the ozone layer. This could result in an additional 30,000 cases per year in the United States.
Race and ethnic heritage have strong influence in the risk of developing a skin malignancy. Whites of Celtic ancestry (Irish, Scottish and Welsh) have the highest incidence, while blacks have the lowest incidence but the highest mortality. Skin malignancies in blacks seem to be less dependent on sun exposure as they tend to be more common in non-exposed skin and frequently occur at the sight of scarring, burns or previous trauma. This difference in the incidence of skin cancers among ethnic groups is attributed to the melanin content of skin and the ability to tan. A pale complexion with the inability to tan, the tendency to freckle and sunburn and red or blonde hair indicate a high risk for the development of skin cancer. Most studies indicate that the ability to tan is the single most important protective factor. Persons of Scandinavian descent who are fair-skinned but tan easily have relatively low rates of skin cancer, while persons of Irish descent who are unable to tan have a much higher incidence. Patients who have a history of skin malignancy have a 12 to 15-fold increased risk for the development of second skin cancer within 5 years of diagnosis of the first.
Other factors have been shown to increase the risk of developing a cutaneous malignancy. Ionizing radiation has been shown to be quite carcinogenic. The first radiation-induced cancer was a skin malignancy in an x-ray technician reported in 1902. The incidence of BCCa and SCCa has been shown to be higher than expected in survivors of the Japanese atomic bomb. In addition, many patients treated with radiation for benign skin conditions including ringworm, hirsutism and hemangioma have an increased incidence of skin cancers. Health-care workers with radiation exposure, uranium miners and airline pilots also have an excess of skin cancers. The greatest risk factor seems to be the accumulated dose of radiation. Fortunately, the use of radiation for the treatment of benign conditions has largely been abandoned, and precautions have been put in place to minimize occupational exposure.
Chronic exposure to chemicals including polycyclic aromatic hydrocarbons and arsenic has been shown to cause skin cancer. Arsenic exposure may be either occupational or medicinal. Fowlers solution was ingested for the treatment of syphilis, asthma and psoriasis. Workers in the refining of ores, pest control, farming, glass blowing and wine growing all experienced arsenic exposure as well. These cancers typically appear years after exposure, are often multiple, may occur on unexposed parts of the skin and are associated with hyperpigmentation and keratoses. Cigarette smoking has not definitively been shown to cause skin malignancies, but animal studies suggest an association.
Several medical conditions may predispose to skin cancers. These include xeroderma pigmentosum, an autosomal recessive disorder that results in the inability to repair DNA damage from exposure to UV radiation with a high incidence of BCCa, SCCa and melanoma. The nevoid basal cell carcinoma syndrome is an autosomal dominant disorder characterized by multiple BCCa, jaw cysts, rib abnormalities, palmar and plantar pits with calcification of the falx cerebri. Other genetic disorders that are at high risk for developing cutaneous malignancies include albinism (autosomal recessive), epidermodysplastic verrucoformis (autosomal recessive), epidermolysis bullosa dystrophica (autosomal recessive and dominant) and dyskeratosis congenital (sex-linked recessive). In addition, previous trauma such as burns or ulcers with the resultant scarring is associated with the development of skin malignancies (Marjolins ulcer). Immunosuppressed patients, such as those with lymphoma or leukemia, or post-transplant patients also demonstrate an increase in the incidence of cutaneous malignancy and cancers in these patients frequently behave more aggressively.
Normal Skin Histology
The skin is the largest organ of the body and is approximately one sixth of the total body weight. It has four major functions including protection, sensation, thermoregulation and metabolic activity. It varies over regions of the body in thickness, color and presence of appendages such as hairs, glands and nails. Despite these variations, all skin has the same basic structure and organization. The external layer consists of a keratinized squamous epithelium known as the epidermis. The epidermis may be broken down into five layers representing stages of maturation of epidermal cells. The innermost layer is the stratum basale or germinativum. This is the germinal layer of the epidermis. More superficial is the stratum spinosum. Adjacent to this layer is the stratum granulosum in which cells have granules that contribute to the process of keratinization. Above this lies the stratum lucidum, which may only be appreciated in especially thick skin. The most external layer is the stratum corneum which is made up of flattened, fused cell remnants composed mostly of the fibrous protein, keratin.
Deep to the epidermis is the dermis. This layer is composed of fibro-elastic connective tissue that is highly vascular and serves to nourish and support the epidermis. The hypodermis or subcutaneous layer lies deep to the dermis. This layer contains variable amounts of adipose tissue. Hair follicles, sweat glands, sebaceous glands and nails are termed epidermal appendages as they develop from downward growths of epidermis into the dermis and hypodermis.
Pre-Cancerous Lesions
Several benign lesions are important to recognize as they may precede the development of a skin cancer. The most common of these lesions are actinic keratoses (AK), sometimes called solar keratoses. AK is the most common pre-malignant lesion of the head and neck. They occur almost exclusively on sun-exposed areas of the face and neck and are most common in fair-skinned patients, the same population and sites known to be at high risk for the development of SCCa and BCCa. AK results solely from sunlight induced damage. The risk for progression to BCCa or SCCa is 5% to 20%. The lesions typically have an erythematosus base with an adherent scale. They rest superficially on the skin and demonstrate little infiltration. Frequently they develop from a rough scale that may be palpated prior to the lesion becoming clinically apparent. AK occasionally develops marked hyperkeratosis and may present as a cutaneous horn. As the risk for progression is significant, these lesions should be treated and not observed. Depending on the clinical situation, they may be treated with cryotherapy, shave excision, topical 5-fluorocil (5-FU) or trichloroacetic acid (TCA) peel. Full-face dermabrasion may also be useful for severe, diffuse disease.
Keratoacanthoma is often clinically and histopathologically confused with SCCa. Two general types have been described, solitary and multiple. In solitary keratoacanthoma, the lesions usually grow rapidly over several months. They are most common in elderly males. Several phases of development have been recognized: growth, plateau and involution. Typically the tumor appears in the growth phase as a firm, dome-shaped papule that progresses to nodule of 1 to 2.5 cm in greatest diameter over 6-8 weeks. The center often becomes ulcerated and filled with keratinous material. The lesion then enters the plateau phase. The tumor then spontaneously involutes within 6 months, healing with a slightly depressed scar. Ninety five percent of solitary keratoacanthomas occur on sun-exposed areas, and solitary lesions have never been reported on palms, soles or mucosal surfaces. There are reports of keratoacanthoma progressing to SCCa in immunosuppressed patients. It is unclear whether this represents true transformation, or simply initial misdiagnosis. The most common location is the nose, and aggressive lesions with invasion and destruction of the underlying structures have been reported.
Multiple keratoacanthoma has two forms. The first is the multiple, self-healing epithelioma of skin. These lesions usually begin in childhood or adolescence and can be located anywhere on the body including the palms, soles and head and neck. Usually no more than 12 are present at any one time and the course is similar to that of solitary keratoacanthoma with spontaneous involution. The second form is the eruptive keratoacanthoma. These usually do not occur until adulthood when hundreds of characteristic 2-3mm papules appear. The mucosa of the mouth and larynx may be involved.
The treatment of keratoacanthoma can be difficult, as most lesions will spontaneously involute. Surgical excision is the treatment of choice when the lesion cannot be observed. Intralesional 5-FU and methotrexate have induced involution with healing. Mohs surgery may be used to treat large lesions and those that are difficult to distinguish from SCCa.
Bowens disease is synonymous with carcinoma in situ of the skin and represents pre-invasive SCCa. The histologic appearance is full-thickness dysplasia of the epidermis without a breech of the basement membrane. Clinically the lesions are well-circumscribed, erythematous plaques with irregular borders. They tend to occur in sun-exposed areas. Lesions may occur in non-exposed skin in patients with a history of arsenic exposure.
Basal Cell Carcinoma
The typical presentation of BCCa is that of a raised, nodular lesion with a smooth, pearly border. There is often telangiectasia and prominent vascular on and adjacent to the lesion. The center may ulcerate and crust. Patients may describe pruritis as one of the earliest symptoms, and may describe the lesion early in its development as pimple-like.
Several different clinical types of BCCa have been described. The most common is the nodular or noduloulcerative. These lesions typically are raised, waxy or pink in color with a well-defined border. A capillary network is readily visible. The characteristic presentation and clear demarcation make this type relatively easy to treat. A variant of the nodular type is the cystic BCCa, which has tongues of tumor separated by spaces within the stroma. Some lesions may be confused with melanoma by the production of a brown pigmentation. These lesions differ from nodular BCCa only by the production of the pigment and behave similarly to nodular BCCa.
The superficial multicentric BCCa often presents with one or several erythematous, scaly patches. The lesions have irregular borders and increase in size by spreading peripherally. These lesions are more common on the extremities and trunk and less common in the head and neck. The indistinct borders make treatment more difficult.
Morpheaform BCCa is more clinically subtle and more aggressive in its growth pattern. It has also been known as sclerosing or fibrosing BCCa. The lesion typically is a flat macule with a yellow or whitish plaque. The margins may be quite indistinct and the lesion may resemble a scar. The lesion may go unnoticed for years, but may eventually ulcerate. Histologic evaluation may reveal subclinical, fingerlike extensions into the dermis. This subtle spread makes complete excision difficult.
Less common, but also of a more aggressive nature, is the keratotic BCCa. These tumors are also known as basosquamous or metatypical carcinoma. It was initially thought that this tumor represented a lesion intermediate between BCCa and SCCa. It now appears as though this lesion is a BCCa that keratinizes. The clinical behavior is more aggressive than other histologic types, but the potential for metastasis is limited.
The typical cell in BCCa resembles the cells of the stratum basale of the epidermis but lack intercellular bridges. There is scant cytoplasm and the nuclei are large, oval and elongated with relatively uniform size and configuration. The tumors contain a connective tissue stroma oriented parallel to the cell masses that causes a palisading and stromal retraction. This is known as "peritumoral lacunae." The mucinous component of the stroma often shrinks with the dehydration of fixation and may retract from the tumor islands. This is known as clefting and may aid in diagnosis.
There are four basic histologic types: solid, keratotic, cystic and adenoid. In the solid type, there is little cellular differentiation, and masses of tumor cells invade the dermis. The peripheral layer may exhibit palisading of the nuclei. Keratotic BCCa show differentiation toward hair structures. They typically have undifferentiated cells with parakeratotic cells and horn cysts. Cystic tumors display spaces within the tumor and are differentiated toward sebaceous glands. Glandular or tubular formation is the hallmark of adenoid tumors. The epithelial cells form strands that form lace-like patterns.
The stroma of the BCCa is essential for its development and growth. Transplantation of tumor cells without stroma is unsuccessful. This dependence on the stroma may account for the low rate of metastasis. Metastatic BCCa is rare with an incidence in the range of 0.0028% to 0.1%. When it occurs, the tumor most commonly spreads to the regional lymph nodes. Hematogenous spread to the lungs and bone may also occur, but is quite rare. Adenoid and keratotic BCCa have a higher propensity for metastasis, but any of the clinical or pathologic types may do so. Metastases typically occur from primaries in the head and neck that have been present for long periods of time.
While metastatic disease is rare, BCCa may invade locally with destruction of underlying and adjacent structures. The path of growth is along that of least resistance. Invasion of bone, cartilage and muscle is therefore a late occurrence as periosteum, perichondrium and fascia offer a barrier to tumor invasion. The tumor may spread along these structures for some distance however, and recurrence is common in lesions on structures such as the eyelid, nose and scalp where lateral growth occurs along these resistant planes just deep to the skin. In contrast, embryonic fusion planes offer little resistance to deep tumor invasion. The most susceptible areas include the inner canthus, philtrum, mid-lower chin, nasolabial groove, pre-auricular area and retro-auricular sulcus. These areas have a very high recurrence rate after what seems to be adequate therapy.
Tumor growth is also highly dependent upon blood supply. BCCa elaborate angiogenic substances that account for the telangiectatic vessels characteristic of their appearance. Large tumors frequently have a necrotic center as a result of growth beyond their vascular supply. Because of insufficient blood supply, BCCa usually does not invade the subcutis. Perineural spread is rare, but is more common with aggressive or recurrent tumors.
Squamous Cell Carcinoma
While not as common as BCCa, SCCa is a common neoplasm. Chronic sun exposure seems to be even more important for the development of SCCa than for BCCa. The closer one lives to the equator, the smaller the ratio of BCCa to SCCa. In Michigan, the ratio is 8:1, while in Texas, the ratio is 2:1. SCCa usually presents as an erythematous, ulcerated, crusting lesion. The base of the lesion may be quite granular and friable, bleeding with minimal trauma. A marked inflammatory response in the adjacent tissues often causes a surrounding area of induration. The lesion may change slowly over time. When covered with a crust, removal may reveal a rolled margin. Lesions may present as a small chronic ulcer, particularly in an old scar, or may be noted as superficial multifocal change in sun damaged skin. The latter lesions may be difficult to diagnose, requiring multiple biopsies before the diagnosis is made. On occasion, SCCa may be vegetative with a cystic feel. These exophytic lesions frequently do not invade deeply. As with BCCa, SCCa may be pigmented. They are often confused with keratoacanthoma, but the growth of SCCa is slower. Of course when suspicion is high, biopsy is warranted.
Some SCCas arise in an area of actinic change, while others arise de novo. Those arising in sun-exposed areas tend to behave less aggressively than those arising de novo. All SCCa tumors have the potential for invasion and metastasis, but those arising de novo do so more often than those arising in areas of actinic change. Clinically, the skin around the tumor can be examined for signs of solar change, while histologically, actinic change can be seen in the skin surrounding the lesion.
Squamous cell carcinoma has much higher rate of metastasis than BCCa. The rate of lymphatic spread is highly variable between investigators. Lesions arising in areas of actinic change have a likelihood of metastasis in the range of 3% to 5%. It has been estimated that at least 8% of lesions arising de novo develop regional metastasis. Lesions arising in areas of scar or chronic inflammation have a metastatic rate between 10% and 30%. The rate of metastasis rises as the tumor invades deeper, with lesions penetrating to Clarks levels IV and V having a 20% regional metastatic rate. Tumors with a higher histologic grade (i.e. poorly differentiated tumors with marked anaplasia) also demonstrate a greater risk of lymphatic spread. While SCCa arising in the skin is known to have metastatic potential, it is far less than SCCa arising on a mucosal surface. For this reason, SCCa of the lip is left for a separate discussion. SCCa may also spread via perineural invasion. The midface, lips and skin over the mandibular branch of the fifth cranial nerve seem to be especially at risk. Perineural invasion may lead to central nervous system involvement.
The histology of SCCa reveals masses of epidermal cells proliferating downward into the dermis. These masses may be well differentiated, easily recognized cells, or may be atypical or anaplastic. More differentiated tumors usually show evidence of keratin production such as keratin pearls. Broders classification uses a grading scale from 1 to 4, with grade 1 being well differentiated and grade 4 poorly differentiated. The diagnosis of poorly differentiated tumors may rely on immunohistochemical stains. Cytokeratin stains are usually positive in SCCa. Vimetin may be present in poorly differentiated tumors, while markers of keratinocyte differentiation such as involucrin and filagrin are present in well-differentiated tumors but less often in poorly differentiated lesions.
Several histopathologic types of SCCa have been described. These include generic, adenoid, bowenoid, verrucous and spindle-pleomorphic types. The generic type arises in an area of actinic change. The adenoid type demonstrates pseudoglandular arrangement with tubular or alveolar formations resulting from dyskeratosis and acantholysis. The lumina are filled with layers of epithelium and desquamated cells. These tumors have the classic nodular, ulcerative appearance, often arising in skin of the periauricular region. In the bowenoid type, invasive SCCa arises in an area with co-existent Bowens disease.
Verrucous SCCa is rarely seen in the skin of the head and neck but is more common in the mucosa of the oral cavity and larynx. It presents as a whitish, cauliflower-like lesion. Histologically, the tumor is well differentiated with marked hyperkeratosis, parakeratosis and acanthosis. Invasion is often with blunt, pseudopod-like growth.
The last histologic type is the spindle or pleomorphic type. This type is the least common. Histologically there is little evidence of differentiation. The cells are quite anaplastic and keratinization is usually lacking. The spindle-shaped cells are intermingled with collagen, arranged in whorls and may have pleomorphic giant cells.
The American Joint Committee on Cancer has designed a staging system based on the TNM classification for BCCa and SCCa of the skin similar to staging systems for cancers of other sites. Clinical staging is based upon physical examination and palpation of the lesion and regional lymph nodes. Pathological staging depends on complete resection of the entire site and confirmation of any lymph node involvement. The system excludes lesions of the eyelid, vulva and penis.
Primary Tumor (T)
Primary tumor cannot be assessed |
No evidence of primary tumor |
Tis |
Carcinoma in situ |
Tumor < 2cm or = 2 cm in greatest dimension |
Tumor > 2 cm in greatest dimension but not > 5 cm in greatest dimension |
Tumor > 5 cm in greatest dimension |
Tumor invades deep extradermal structures (e.g., cartilage, skeletal muscle, bone) |
Regional Lymph Nodes (N)
Regional lymph nodes cannot be assessed |
No regional lymph node metastasis |
Regional lymph node metastasis |
Distant Metastasis (M)
Presence of distant metastasis cannot be assesses |
No distant metastasis |
Distant metastasis |
Stage Grouping
Stage 0 |
Tis |
Stage I |
Stage II |
T2 or T3 |
Stage III |
Any T |
Stage IV |
Any T |
Any N |
There are multiple treatment options for the management of BCCa and SCCa; many of these are used primarily by the dermatologist. An example of such a method is electrodessication and curettage (ED&C). It is most useful in small, less than 2 cm, basal cell cancers. It may be used with SCCa, but the lesions should be carefully selected. The cure rates range from 92% to 98% in experienced hands. The rationale behind its application is that BCCa and SCCa have a soft feel that allows them to be differentiated from the surrounding normal tissue. Various sizes of curettes are used to remove the palpable tumor in its entirety. After normal-feeling tissue is reached on all margins of the excision, electrodessication of the resulting wound is performed. The process may be repeated several times. The wound is then allowed to heal by secondary intention.
The advantages of ED&C are that it is quick and relatively easy to perform as an in-office, outpatient procedure. It allows for the maximal sparing of normal tissue with high cure rates. The disadvantages include the care of an open wound that may heal with depressed or hypertrophic scarring. Delayed bleeding is also a concern. As stated previously, proper technique with carefully selected lesions can produce high cure rates. Contraindications for this treatment modality include deeply invasive lesions, morphea-like and sclerotic BCCa and recurrent tumors.
Cryotherapy is another method of treatment used primarily in BCCa. Again the treating physician should be experienced in the procedure for maximal efficacy. The most common cryogen is liquid nitrogen administered either by spray or the use of cryoprobes. Temperatures of -30°F to -50°F are considered to be lethal to cutaneous malignant tissue. The tumor and an area of surrounding tissue are frozen to assure adequate ablation. Temperature probes inserted at the margin of the lesion are sometimes used to insure that sufficiently low temperatures are attained. The tissue is allowed to thaw and the freeze-thaw cycle is repeated.
The indications, advantages and success of cryosurgery are similar to those of ED&C. The technique is quite advantageous for lesions overlying cartilage, as it is resistant to necrosis. The disadvantages include a prolonged healing time of 3 to 10 weeks during which time the wound may become markedly edematous. Hypopigmentation of the resultant scar may also occur. Its use is generally limited to well-circumscribed lesions. The technique is contraindicated in morphea-like or recurrent tumors, as there is no method for precise control of the margins.
Most head and neck surgeons have the majority of their experience with surgical excision of cutaneous malignancies. The treatment modality may be successfully applied to both BCCa and SCCa. The success rate is in the range of 93% to 95%. A key advantage is the ability to attain tissue for histological evaluation. Frozen section evaluation of the margins can help to insure complete excision while preserving maximal normal tissue. Defects may be reconstructed by primary closure for amenable wounds, skin grafting, healing by secondary intention and locoregional flap reconstruction. Cosmesis is generally excellent, particularly for defects that can be closed primarily. The disadvantages include the fact that it may be more time-consuming and expensive than alternative techniques. Many surgeons feel that these minor disadvantages are outweighed by the ability to confirm the diagnosis histologically and assure the adequacy of the margins. Morphea-like lesions or those with ill-defined borders are perhaps better treated with Mohs surgery as the margins of the tumor may be difficult to discern without microscopic examination, and multiple excisions may be required. It is generally felt that with small, well-circumscribed tumors, margins of 3 to 5 mm are adequate while large tumors, those with poorly defined borders or recurrent tumors should have a wider excision.
The carbon dioxide laser has been used with some success in the excision of cutaneous tumors from patients with cardiac disease or other medical illnesses that place them at high risk for the use of epinephrine. Laser excision allows bloodless excision without the need for vasoconstrictive agents. Laser vaporization is also useful in the case of multiple small lesions that do not require reconstruction. Lesions up to 7-8 mm may be resected and left with a physiologic dressing to heal with excellent cosmetic results. Laser excision has also been applied for the palliation of multiple lesions in elderly debilitated patients or those with more threatening medical conditions where cure is either unrealistic or impossible.
Mohs surgery was the subject of a recent Grand Rounds presentation and will be mentioned here only for completeness. The reader is referred to that presentation for thorough discussion of the history and technique. The concept was introduced in 1930 with initial published results in 1941. In recent years it has come to be the treatment method of choice for the cure of high risk BCCa and SCCa of the skin. Using a rapid fixation or fresh tissue technique, the excision specimen is mapped so that re-excision can be directed only to the precise area where tumor remains. The cure rates have proven to be high, 96% to 99%. The advantages of the technique lie in its ability to precisely locate any residual tumor and remove additional tissue only where necessary. This allows for the greatest assurance of complete tumor removal while preserving all uninvolved tissue. Using the fresh tissue technique, resulting defects may be immediately reconstructed. The most significant advantage is the high cure rate that can be attained in the management of advanced, high-risk or recurrent lesions. This includes larger lesions (0.6 cm to 1 cm) and those with a morpheaform growth pattern with ill-defined borders. The disadvantages include the special expertise required to perform the procedure, time and expense.
Radiation therapy (XRT) has been used in the past to treat cutaneous malignancy with some success. It has fallen out of favor for several reasons. It requires a prolonged course of treatment and radiodermatitis with the risk of carcinogenesis occur in the treated area. Serious complications including radiation chondritis and osteoradionecrosis also helped to limit its usefulness. XRT still finds application in the treatment of elderly patients or those with co-morbid conditions that make them poor surgical risks. Due to the potential for carcinogenesis, it is relatively contraindicated in young patients. Tissue for histological examination and control of the margins are unavailable, which makes it impossible to ensure the adequacy of treatment. In addition, recurrent tumors after XRT tend to be aggressive and difficult to manage. The recurrence rate after XRT ranges from 4.4% to 9.5% dependent upon the size of the primary lesion. Given the other options currently available for the treatment of BCCa and SCCa, XRT has a limited role in their management.
Photodynamic therapy (PDT) utilizes a photosensitizing drug that is selectively concentrated in tumors and that, after being activated by exposure to light, induces preferential tumor necrosis. Porphyrin has been the drug used most often in the head and neck. The argon ion dye pump laser has been the most commonly used light source. There has been a wide variation in the drug and light source used however, making the evaluation of the results difficult. It therefore remains an experimental treatment that may gain further acceptance in the future. Research is needed to determine the best treatment regimens and proper indications for its application.
Another investigational treatment modality is Interferon-a (IFN-a ). Initial investigation has revealed excellent results in the treatment of nodular and superficial BCCa. IFN-a is administered intralesionally at low doses three times a week. The exact mechanism of action is not clear, but it is believed to be due to the anti-proliferative and immunomodulating effects of IFN-a . It is known to cause an increased response to neoplastic tissues by stimulating macrophages and natural killer cells. Side effects include local erythema and pain. Some patients have a flu-like illness that is relatively mild and responsive to anti-pyretics. Leukopenia and thrombocytopenia may also complicate therapy.
Retinoids have had limited use in the treatment of cutaneous malignancy, most often in patients with basal cell nevus syndrome. Partial regression of BCCa has been noted using isotretinoin and etretinate. Isotretinoin in high-doses has shown a preventative effect, but compliance is often compromised due to unacceptable side effects.
Chemotherapy has some usefulness for locally aggressive or metastatic disease. It may be combined with radiation therapy for palliation of extensive metastatic disease. Cis-platin, bleomycin, cyclophosphamide, 5-fluorouracil and vinblastine have all been studied. Cis-platin has been the most widely used and associated with the longest remissions. Cis-platin, doxorubicin and XRT can achieve palliation in widely disseminated or inoperable disease.
Treatment of the regional lymphatics is indicated in certain cases of SCCa and BCCa of the head and neck. This is more often the case with advanced tumors that invade deep tissues such muscle, bone, cartilage or nerve. Elective parotidectomy is indicated for the complete removal of deeply invasive tumors of the periauricular region or when any lymphadenectomy is to be performed for tumors arising superior to the mandible. Larger SCCa (>2 cm), recurrent tumors and those arising in scarred areas (Marjolins ulcer) all behave more aggressively and are more likely to require regional lymphadenectomy.
When dissection of the lymphatics is required, the nodal groups that must be removed are dependent on the location of the primary tumor. For tumors arising in the periauricular region, the preauricular, parotid and postauricular nodes are all at risk. The preauricular nodes receive drainage from the anterior parietal scalp, forehead, temple, ear, eyelids, skin overlying the zygoma, and in some cases the nasal ala. The parotid nodes drain a similar area and may be located superficial or deep to the facial nerve. If both are involved, a total parotidectomy may be required to removal all nodes. The facial nerve is spared unless involved with tumor. The postauricular nodes are rarely involved, but must be remembered in dealing with tumors in the posterior parietal scalp, ear and mastoid.
The suboccipital nodes lie along the occipital artery and may be involved with tumors arising on the scalp posterior to an imaginary line drawn through the external auditory canal. The external jugular node lies superficial to the sternocleidomastoid adjacent to the greater auricular nerve and drains the lateral face, ear and upper neck. The facial artery nodal group lies along the nasolabial portion of the facial artery from the nose to the mandible and drains the lateral nose, upper lip, medial face and nasolabial fold. The submental nodes lie between the anterior bellies of the digastric and drain the lips, nasal vestibule and chin. The lymphatics of the posterior triangle of the neck (level V) may be involved with cancers of the neck, ear and scalp. The submandibular nodes (level I) drain the cheek, chin, nose and nasolabial regions. The anterior jugular nodes (levels II-IV) receive drainage from throughout the head and neck and are potentially involved in cancers arising in any location. The supraclavicular nodes located along the transverse cervical artery may be involved in cancers of the lower neck or upper chest.
The same principles of neck dissection for cancers of the upper aerodigestive tract apply in dissection for skin malignancy. This includes the sparing of uninvolved structures, but sacrificing those vessels or nerves that are involved with tumor. Post-operative XRT is indicated for multiple positive nodes, extracapsular spread and lymphovascular invasion.
Prognosis and Recurrence
The recurrence rate of primary BCCa varies from 1% to 39%. These rates vary depending on the histologic type. Nodular BCCa has a low recurrence rate in the range of 1% to 6%, while morpheaform tumors have much higher rate of 12% to 30%. Larger tumors arising in the midface, morpheaform or keratotic types and deep invasion all have higher recurrence rates. Some evidence suggests that women and younger patients have a higher rate of recurrence suggesting a reluctance to obtain wide margins in favor of cosmesis rather than adhere to sound oncologic principle. The majority of tumors will recur within 3 years of initial treatment, and the risk of subsequent recurrences increases after initial treatment failure.
The risk of recurrence for SCCa varies widely dependent on investigator. Seventy five percent of patients who develop recurrences do so within 2 years of initial treatment and 95% do so within 5 years. Tumors located on the midface, size over 2 cm and perineural invasion all carry a higher rate of recurrence. Perineural invasion carries a much higher risk of recurrence (47.2%) and metastasis (34.8%). Treatment of such neurotrophic SCCa with Mohs micrographic surgery and XRT dropped the rate of recurrence to 0% with a metastatic rate of 5.9% in one study.
Weber reports a higher risk of recurrence with aggressive skin cancers that are greater than 2 cm in greatest diameter, invade muscle, cartilage, bone, or nerves, or have regional lymphatic metastasis. Of the 134 patients in his study (45 with SCCa and 89 with BCCa), 70% with any one of these factors recurred, while only 20% of those patients without one of these features had a recurrence. Complete resection with frozen section confirmation of adequate margins successfully controlled 88 of 89 patients with BCCa. Of the 45 patients with SCCa, 14 had a recurrence.
The exact mortality from non-melanoma cutaneous malignancies is difficult to accurately determine. This is because they are not often reported to cancer registries within large centers in the U.S. One study revealed a death rate of 0.44 per 100,000 persons per year with the most deaths resulting from widespread SCCa arising in the periauricular region. Approximately 2,000 to 3,000 deaths per year in the United States can be attributed to BCCa and SCCa of the skin. Patients from 65 to 70 years of age seem to be particularly at risk. While mortality is not high when compared to other tumors, the impact on health care is significant given the prevalence of the disease and non-negligible recurrence rate.
Cutaneous malignancies are common disorders that are encountered by physicians in all medical specialties. There are multiple treatment options that offer a high success rate. Lesions that are advanced are more difficult to treat however. Thus early recognition, diagnosis and treatment offer the best chance for cure. Even more importantly, prevention through patient education regarding the harmful effects of ultraviolet radiation can prevent significant morbidity with its resultant socioeconomic and psychosocial impact. Perhaps further investigation will reveal mechanisms to reverse the damage inflicted in skin by radiation. As the head and neck is the most common location for these neoplasms, the otolaryngologist must be ever vigilant so that these lesions may be treated expeditiously with the greatest chance for cure.
Strom SS. Epidemiology of basal and squamous cell carcinomas of the skin. In Weber RS, Miller MJ, Goepfert H, eds. Basal and Squamous Cell Skin Cancers of the Head and Neck. Baltimore: Williams & Wilkins, 1996:1.
Weber RS, Callender DL. Clinical assessment and staging. In Weber RS, Miller MJ, Goepfert H, eds. Basal and Squamous Cell Skin Cancers of the Head and Neck. Baltimore: Williams & Wilkins, 1996:65.
Byers RM. Regional lymphadenectomy for metastatic skin cancer. In Weber RS, Miller MJ, Goepfert H, eds. Basal and Squamous Cell Skin Cancers of the Head and Neck. Baltimore: Williams & Wilkins, 1996:141.
Stucker FJ, Nathan C-AO. Cutaneous malignancy. In Bailey BJ, ed. Head and Neck Surgery-Otolaryngology, 2nd ed. Philadelphia: Lippincott-Raven, 1998:1415.
Swanson NA, Grekin RC. Recognition and treatment of skin lesions. In Cummings CW et al., eds. Otolaryngology-Head&Neck Surgery, 3rd ed. St. Louis: Mosby, 1999:413.
Swanson NA, Johnson TM. Management of basal and squamous cell carcinoma. In Cummings CW et al., eds. Otolaryngology-Head&Neck Surgery, 3rd ed. St. Louis: Mosby, 1999:486.
Friedman RJ, Rigel DS, Nossa R, Dorf R. Basal cell and squamous cell carcinoma of the skin. In Murphy GP, Lawrence W, Lenhard RE, eds. American Cancer Society Textbook of Clinical Oncology, 2nd ed. Atlanta: American Cancer Society, 1995:330.
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Posted 02/14/2000


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