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Q: Treatment of Unknown Primary cancer ( Answered 3 out of 5 stars,   2 Comments )
Subject: Treatment of Unknown Primary cancer
Category: Health > Conditions and Diseases
Asked by: ravibattula-ga
List Price: $51.00
Posted: 31 Aug 2005 21:10 PDT
Expires: 30 Sep 2005 21:10 PDT
Question ID: 562942
I would like to know if there is any case of successful treatment for
unknown primary cancer with secondary cancer in Liver.
I found that there are few std treatments like
chemotherapy,Radiotherapy etc as mentioned in the below link

What i am looking for is any institute,Doctor,medication,Therapy
anywhere in the world that is available or anyone who has recovered
throughly(even 90%), having liver cancer of secondary type with
unknown primary cancer.
Also if the chemotherapy is started very early after diagonising then
how long can one survive ?
I understand that without knowing the primary the treatment is very
difficult and limited,but there should be some alternative or
treatment or drug etc maybe under research.

Appreciate any effort in this regard.

Request for Question Clarification by welte-ga on 14 Sep 2005 15:22 PDT
Hi ravibattula-ga,  

When you ask for an institute, etc., that has experience with 90%
recovery, do  you mean that some individual patient had 90% regression
of their metestatic (secondary) tumor of unknown primary, or that 90%
or more of their patients completely recovered?

Either of these categories is likely to yield few or no results.  I
can give you an outline of the current approach to cancers of unknown
primary that have spread to the liver if that would be helpful and
suffice as an answer to your question.


Clarification of Question by ravibattula-ga on 15 Sep 2005 17:48 PDT
What I mean is any of the individual patient with more than 90%
recovery.Obviously that would totally dependant on the individual and
his/her symptoms,but still.
Also if you could let me know about some medicine or some treatment
even herbal that is helpful in preventing or spreading fast that would
be helpful.
Subject: Re: Treatment of Unknown Primary cancer
Answered By: welte-ga on 17 Sep 2005 10:32 PDT
Rated:3 out of 5 stars
Hi again ravibattula-ga,

My condolences on your difficult diagnosis.  As usual, the following
is not a substitute for medical advice or direct examination and

Having an unknown primary is very difficult to treat, as I'm sure you
know, primarily because treatment regimens are aimed at specific tumor
types.  As a bit of an aside, in terms of finding out what the primary
tumor is, a relatively recent modality for detection of tumors is PET
(Positron Emission Tomography).

PET is a nuclear medicine study where a type of sugar is tagged with a
radionuclide.  Metabolically active cells preferentially consume sugar
and therefore accumulate radionuclide.  PET images these cells and
therefore gives (roughly, not taking various artifacts into
consideration) a map of metabolic activity in the body.  It is more
sensitive for detection of cancers than CT alone.  Here is a very
compelling case, similar to your case, where PET made a significant
difference in diagnosis and management for a patient with liver
metastases from a primary tumor of unknown origin:

Here is a brief description of  a group who examined multiple studies
looking at PET's utility in identifying unknown primary tumors:

The overall sensitivity in this study was 87%, meaning that 87% of
unknown primary tumors were identified.  By comparison, CT is about
40% sensitive for detecting unknown primary tumors.  Most of the
tumors identified by CT are ovarian.

Dr. Gutzeit, et al., recently published a paper looking at the utility
of PET-CT for detection of tumors of unknown primary.  This is a new
modality that combines PET and CT (using a single machine).  This was
initially done to provide higher quality PET images, but can also give
anatomic imaging information via CT for better localization of PET
information.  Here's their abstract and the reference:

"PURPOSE: To retrospectively evaluate fused positron emission
tomography (PET)/computed tomography (CT) in depicting the primary
lesion in cancer of an unknown primary tumor, compared with PET, CT,
and PET and CT side-by-side evaluation. MATERIALS AND METHODS:
Institutional review board approval and informed consent were
obtained. Forty-five patients (26 men and 19 women) with metastatic
cervical adenopathy (n = 18) or extracervical metastases (n = 27) of
unknown primary tumor were included. The mean age of the patients was
57 years (range, 29-95 years). PET/CT imaging was performed in all
patients 1 hour after administration of 350 MBq of fluorodeoxyglucose
with a whole-body field of view. Contrast agents were administered
orally and intravenously in all patients to ensure diagnostic CT data.
PET/CT data sets were evaluated for the primary tumor, and imaging
results were compared with those of CT, PET, and PET and CT
side-by-side evaluation. Differences in diagnostic performance were
assessed by using the McNemar test with Bonferroni correction, which
accounts for multiple comparisons. RESULTS: PET/CT depicted the
primary tumor in 15 (33%) of 45 patients. In 30 (67%) patients, the
primary tumor site remained occult (P > .05). PET and CT side-by-side
evaluation depicted 13 (29%) of 45 tumors (P > .05). PET alone
revealed the primary tumor in 11 (24%) of 45 patients (P > .05), while
CT alone helped in the correct diagnosis in eight (18%) of 45 patients
(P > .05). There were no significant differences between the
diagnostic accuracies of PET/CT and the other imaging modalities.
CONCLUSION: PET/CT was able to depict more primary tumors, though not
significantly, than either of the other imaging modalities, but larger
patient cohorts are required to finally judge its value for revealing
the primary tumor site."

Gutzeit A. Antoch G. Kuhl H. Egelhof T. Fischer M. Hauth E. Goehde S.
Bockisch A. Debatin J. Freudenberg L. Unknown primary tumors:
detection with dual-modality PET/CT--initial experience. [Journal
Article] Radiology. 234(1):227-34, 2005 Jan.
UI: 15564390

A reprint can be requested from Dr. Gutzeit:

Please note too that the eMedicine article does not include a good
discussion of PET or PET-CT.


Unknown primary tumors (UPT), aka Cancers of Unknown Primary (CUP),
comprise about 2-4% of all cancers according to one source (see NIH
site below) and 5-15% according to the eMedicine site below.

Here is a nice summary of the condition from eMedicine:

"Tumor of unknown origin is a distinct clinicopathological entity
defined as the presence of a metastatic cancer without a known primary
site of origin. This entity can be diagnosed only if the histology of
the tumor is not consistent with the known tumors of the organ from
which the biopsy was taken.

This entity is a diagnostic dilemma and a therapeutic challenge. It
creates anxiety among not only patients and their families but also
physicians, who feel uncomfortable informing patients that they have
an advanced disease of unknown origin."

The National Cancer Institute summarizes the current thought on the
types of tumors CUP could likely represent:

"The majority of CUP are adenocarcinomas or undifferentiated tumors;
less commonly, squamous cell carcinoma, melanoma, sarcoma, and
neuroendocrine tumors can also present with a primary site of origin
that cannot be determined. In approximately 15% to 25% of patients the
primary site cannot be identified even at postmortem examination.[7]"

And further in the article:
"The distribution of primary sites that are likely to result in CUP
contrasts with the distribution of major primary adenocarcinomas as
reported in the Surveillance, Epidemiology, and End Results data. Most
large studies have shown that carcinoma of the lung and pancreas are
the most common primary carcinomas that initially present as CUP.
Other common malignancies such as colorectal, breast, and prostate
cancers infrequently present as CUP.[7-10]"

The above NCI site has a good deal of additional peer-reviewed
information regarding CUP, along with multiple references for more

The following site also has a good deal of information on CUP/UPT,
with a more patient oriented focus:

The above site includes information on alternative therapies.

Treatment Options
The NIH Cancer site sums up the current thinking on treatment for CUP as follows:

"CUP is a term that refers to many different cancers. For that reason,
treatment depends on where the cancer is found, what the cancer cells
look like under a microscope, and the patient?s age and overall
physical condition. No method is standard, but chemotherapy, radiation
therapy, hormone therapy, and surgery may be used alone or in
combination to treat patients who have CUP. Even when the cancer is
unlikely to be cured, treatment may help the patient live longer or
improve the patient?s quality of life. However, the potential side
effects of the treatment must be considered along with the potential

eMedicine has an excellent frequently updated article on CUP.  Their
site includes details on current treatment options, which I'll talk
about below.

One group in Japan tried using two chemotherapy agents (Paclitaxel and
Cisplatin) to treat a group of patients with unfavorable types of CUP.
 Here are their results:
"Of the 37 patients, 31 had adenocarcinoma subtypes. The overall
response rate of 26 patients with measurable lesions was 42% [95%
confidence interval (CI) 23?61%]. Stable disease was seen in six
patients and progressive disease in nine. Median time to progression
was 4 months (95% CI 1.3?6.8). Median overall survival was 11 months
(95% CI 8.3?13.5). The major toxicities were neuropathy and
neutropenia. Grade 4 neutropenia occurred in 10 patients, but febrile
neutropenia was seen in four."

The free full text of this article is available:

Treatment of true CUP, where the primary tumor or tumor type is never
identified, is largely based on educated guessing about the primary
tumor type, based on the type of presentation (age, gender, secondary
symptoms, etc.).  This approach is somewhat limited in that these
tumors are by their very nature atypical - they metastasize very early
and likely behave atypically from other primary cancers of the same

A recent article gives a good overview of the current means by which
this "educated guessing" takes place, going through the various
presentations that can be encountered and treatment options for each.

Mintzer DM. Warhol M. Martin AM. Greene G. Cancer of unknown primary:
changing approaches. A multidisciplinary case presentation from the
Joan Karnell cancer center of pennsylvania hospital. [Case Reports.
Clinical Conference. Journal Article] Oncologist. 9(3):330-8, 2004.
UI: 15169988

This article is available for free from this page:

Table 4 of the above article lists the scenarios with the greatest
potential for long-term survival:
"Axillary nodal adenocarcinoma
Peritoneal carcinomatosis
Unrecognized extragonadal germ cell tumors
Squamous cell cancer involving cervical lymph nodes
Poorly differentiated neuroendocrine carcinoma"

Patients with these so-called "therapy responsive subtypes" of CUP
have the greatest chance at long term survival, which I would include
in the "90% recovery" that you specify.  The authors of the above
paper give a somewhat more hopeful view than that held in the past,
particularly because of improved molecular and radiological methods
that help guide the educated guessing portion of the diagnosis, which
then leads to more appropriate treatment and improved survival.  Here
is their comment in this regard:

"The scenario of cancer of unknown primary where a lesion was
recognized as cancer but not otherwise discernible as carcinoma,
lymphoma, sarcoma, or melanoma is all but gone. While a few cases may
still defy categorization, the use of immunoperoxidase staining for
keratins, vimentin, and common leukocyte antigen, as well as the
availability of molecular genetic assays for immunoglobulin and T-cell
receptor rearrangements has allowed categorization of most of these
entities to at least a broad group of tumors, helping to focus workup
and therapy."

Additional information on gathering information to narrow the primary
tumor type to help identify therapy responsive subtypes in CUP can be
found in these articles:

Hillen HF.	 Unknown primary tumours.  Postgrad Med J. 2000
Nov;76(901):690-3. Review.
PMID: 11060142
Free full text available:

Dennis JL, Hvidsten TR, Wit EC, Komorowski J, Bell AK, Downie I,
Mooney J, Verbeke C, Bellamy C, Keith WN, Oien KA.	Markers of
adenocarcinoma characteristic of the site of origin: development of a
diagnostic algorithm. Clin Cancer Res. 2005 May 15;11(10):3766-72.
PMID: 15897574 
Full text is not freely available, but a full text reprint can be
requested from Karen Oein (the Principle Investigator):
Based on their algorithm, 88% of these tumors were correctly
classified, which may lead to improved therapy and survival.

While the previous discussion described the patients with the best
chance of greater than 90% recover, or for that matter any significant
response to therapy, it is likely of at least psychological benefit to
know of someone who has survived for a significant period of time. 
There is a case report in the literature describing just such an

"An 18-year-old male presented in 1979 with a gastrinoma of unknown
primary origin. Massive upper-digestive haemorrhage led to total
gastrectomy, at which histology evidenced liver metastases, confirmed
9 months later at reoperation for an intestinal occlusion.
Postoperative morphological evidence of liver metastases was
repeatedly negative using abdominal ultrasound and computerized
tomography (CT) scans and magnetic resonance imaging (MRI), but a
recent somatostatin-receptor-specific scintigraphy (Octreoscan) was
positive only in the liver area. Twenty-two years after diagnosis, the
primary tumour has not been identified, the patient leads a normal
life, and his circulating gastrin levels, although still elevated at
317?550 pg/ml (normal < 127 pg/ml), have fallen over recent years from
> 1000 pg/ml. We discuss the relevance of the described prognostic

Webb SM, Mones J.	Twenty-two years' survival of metastatic gastrinoma
evidenced recently by somatostatin-receptor-specific scintigraphy. 
Eur J Gastroenterol Hepatol. 2002 Mar;14(3):333-6.
PMID: 11953703
The article is not freely available, but you may request a reprint from Dr. MonÚs:

One paper from Ireland looked at CUP with liver metastases found an
almost universally bleak outcome:

"AIM: The objectives of this study were to identify prognostic
features for patients with hepatic metastases and unknown primary
neoplasms (UPN), determine the common primary tumours, assess the
value of diagnostic tests in finding these tumours, and evaluate the
impact of therapy and knowledge of the primary tumour on patient
survival. MATERIALS AND METHODS: Eighty-eight patients with UPN and
liver biopsy proven hepatic metastases over a 10-year period were
reviewed (M:F, 58:30; age range 27-91 years, median 64.5 years).
Histopathology, diagnostic investigations and success at identifying
the primary neoplasm were recorded. In addition, in 70 patients with
adenocarcinoma histology (M:F, 48:22; age range 27-91 years, median 65
years), treatment and survival data from the date of biopsy were
recorded. RESULTS: The histological spectrum included adenocarcinoma
in 70, neuroendocrine in four, squamous cell carcinoma in four, small
cell carcinoma in four, carcinoid in two, hepatoma in one and three
others. Extensive investigation identified a primary neoplasm in 16/88
patients (18%) including colorectal in six, gastric in two, lung in
four, oesophageal in two, prostate in one and carcinoid in one. In the
adenocarcinoma group survival data were available for 62/70 patients.
Sixteen of 62 patients received active treatment with either surgery,
chemotherapy, radiotherapy or a combination protocol. Forty-six of 62
patients received palliative care alone. Median survival for the
adenocarcinoma group overall was 49 days. The median survival for
treated patients (49 days) versus untreated patients (52 days) was not
significantly different (P=0.128). Patients <65 years were more likely
to receive active treatment than those >65 years (P=0.006). Age with a
hazard ratio (HR) of 1.01 (P=0.178), active treatment
(HR=0.65;P=0.194), knowledge of the primary neoplasm (HR=0.60;P=0.213)
and male gender (HR=0.88;P=0.642) had no significant effect on
survival. CONCLUSION: Although hepatic metastases are associated with
poor prognosis, it is essential that a liver biopsy be performed to
obtain a histological diagnosis. Adenocarcinoma metastases carry a
dismal prognosis, and no prognostic factors, including knowledge of
the primary tumour, are significant for patient survival. Extensive
investigation is not warranted in patients with adenocarcinoma liver

I should point out that a median survival of, for example, 49 days in
the treated patients means that half of the patients survived longer
and some may have survived to the end of the studies followup period. 
Because CUP is such a heterogeneous mix of diseases, it's hard to
predict who will respond and be in the small group of patients who
respond to therapy.  This is why the methods discussed earlier are
important to determine who should be treated.

Hogan BA, Thornton FJ, Brannigan M, Browne TJ, Pender S, O'Kelly P,
Lyon SM, Lee MJ.  Hepatic metastases from an unknown primary neoplasm
(UPN): survival, prognostic indicators and value of extensive
investigations.  Clin Radiol. 2002 Dec;57(12):1073-7.

A second paper confirms the poor outcome of patients with CUP
metastatic to the liver:
"Carboplatin plus paclitaxel combination chemotherapy is effective in
patients with predominantly nodal/pleural metastases of unknown
primary carcinoma and in women with peritoneal carcinomatosis.
However, in patients with liver, bone, or multiple organ involvement,
the combination offers limited benefit. The investigation of novel
treatment approaches is highly warranted for this group of patients."

Briasoulis E, Kalofonos H, Bafaloukos D, Samantas E, Fountzilas G,
Xiros N, Skarlos D, Christodoulou C, Kosmidis P, Pavlidis N. 
Carboplatin plus paclitaxel in unknown primary carcinoma: a phase II
Hellenic Cooperative Oncology Group Study.  J Clin Oncol. 2000

Both of these articles are a few years old, and this is a rapidly
progressing field, so I wouldn't take either of these as the final
word on the subject.  That being said, the latest treatment
recommendations typically arise from clinical trials investigating
various treatment options (see below).

No alternative therapies have been proven to be effective, which
doesn't mean that they don't work.  Here is a site (mentioned above)
that discusses alternative and complimentary therapies for cancer
patients.  These are not particularly specific to CUP, but are likely
to be beneficial.  There is an increasing amount of data to support
that one's mental state can have an effect on survival, although this
area is research is still developing.

Clinical Trials
The prognosis of CUP is improving, but is still poor for patients with
CUP metastatic to the liver.  The latest treatment options are being
tested for efficacy and toxicity in various clinical trials. Any
future successful treatment regimen is highly likely to originate from
a successful clinical trial.  While a therapy is undergoing a clinical
trial, one can't tell if it is effective or not, but the thought of
many patients is that it can't do any harm to try something.  One of
the problems is that it's also unknown if some therapy may actually
cause more harm than good, which is why clinical trials are conducted.
 That being said, a lot of thought and review goes into the design of
clinical trials to avoid treatment regimens likely to be more harmful
than beneficial.

Here is a link to a continuously updated page from the National Cancer
Institute, listing all of the current clinical trials in the country
for patients around the world with CUP:

There are currently 13 trials running, the first 5 are the most
relevant to CUP.  Details of each of these trials, along with contact
information, can be found at the above link.  Select a study, click
the check box, and then click on "Display Selected Studies."

I hope this information was useful.  I wish you the best in the
management and treatment of this difficult condition.  Please feel
free to request any clarification.


Search Terms used alone and in combination via Google and the
Ovid/PubMed medical database.  Additional references were gleaned from
various bibliographies of papers found using the above resources.

unknown primary
clinical trials
alternative therapy
complimentary therapy

Request for Answer Clarification by ravibattula-ga on 27 Sep 2005 19:48 PDT
Sorry for a late response.I was actually waiting for one of the test
result 'PLASMA CHROMOGANIN A'.The results came out today and it looks
like its a carcinoid cancer now.
I checked the link and its very useful.

And it seems that there are few treatment options as compared to Primary Unknown.

If you could please elaborate this in detail that will be very helpful.


Clarification of Answer by welte-ga on 28 Sep 2005 08:15 PDT
Hi Ravibattula-ga,

I'm sorry to hear of your likely diagnosis of carcinoid tumor, but
glad that you finally have a diagnosis.  It's certainly better to know
what type of tumor you're up against than resorting to "educated
guessing," as I outlined previously.

eMedicine has some good peer-reviewed articles on carcinoid tumors. 
Here's one discussing carcinoid syndrome, seen in patients with
metastatic carcinoid tumors secreting excess amounts of serotonin:

The above article is very detailed and is nicely divided into
sections.  Of note, the article mentions the frequency of location of
carcinoid primaries:

"In order of frequency, carcinoids may occur in the appendix (35%),
ileum (28%), rectum (13%), and bronchi (13%). Incidence is less than
1% in the pancreas, gallbladder, liver, larynx, testes, and ovaries;
however, these tumors have a high incidence of metastases and spread
through the mesenterial lymph nodes (see Image 3) and portal vein.
Carcinoids do not produce the malignant carcinoid syndrome until they
are no longer confined to the small bowel or mesentery, perhaps
because of the liver breakdown of tumor products. After spreading to
the liver, carcinoids can metastasize to the lungs, bone, skin, or
almost any organ. Ovarian carcinoids may be considered exceptions. In
fact, a patient with ovarian teratomas, whose secretory products enter
into the systemic circulation, may present with this syndrome without
liver metastasis."

Carcinoids presenting as CUP probably represent more aggressive tumors
that metastasize early.  Again, PET (or preferably PET-CT) may help in
localizing the location of the primary tumor, but there is limited
experience with carcinoid tumors.  Knowing that this is a carcinoid
tumor also helps guide the type of imaging that should be done.  For
these types of tumors, the most sensitive and specific imaging study
is Nuclear Medicine imaging using Indium-111 DTPA (diethylenetriamine
pentaacetic acid) aka OctreoScan.  This is a somatostatin analogue
that binds to receptors on carcinoid tumors.  About 2% of carcinoid
tumors don't express these receptors, so there is about a 2% false
negative rate with this test.  A positive results suggests a better
response to treatment with octreotide.  The above eMedicine article
discusses the utility or other imaging modalities under the Imaging

Chromogranin-A is one of the polypeptides that carcinoids can produce.
 Others are listed in the Pathophysiology section of the above
article.  These polypeptides (PPs) are responsible for the symptoms
causing the carcinoid syndrome in advanced carcinoid cancers.

In terms of treatment, the current standard of care is surgical resection:

"Complete surgical removal of all tumor tissues is the best treatment
when feasible because this may result in a complete and permanent
cure. The aim of surgical therapy is to reduce the tumor mass and
obtain symptom remission. Performing a curative resection, mass
debulking, or hepatic embolization is possible. Although palliation
often is brief and frequently associated with substantial morbidity,
debulking hepatic metastases may palliate systemic symptoms."

Again, localizing the primary carcinoid tumor is required to guide
surgical planning.  Liver transplant has also been performed with
promising results, but is still in the experimental stage in this

"Hepatic transplantation also has been attempted in selected patients,
with promising results; however, generalization for this treatment
option, because it is extremely expensive and debilitating, is not
possible without more long-term studies."

An experimental technique is to administer "a radioactive somatostatin
analogue (In-111 DTPA-D-Phe1 octreotide) [MIBG] is a form of internal
radiation therapy, which hopefully is strong enough to kill the tumor

There are also multiple chemotherapy agents and regimens that may be
tried, which are described in detail in the eMedicine article above.

The Oncology Channel has a good summary of treatment options aimed at
the nonprofessional:

[Note, the site says "cancer" malignancy, which is probably a
programming error - the title of the site is "carcinoid" malignancy. 
The link I provided is correct.]

Investigation of new treatments for carcinoid tumors is ongoing.  Here
is a link to a continuously updated list of clinical trials dealing
with carcinoid tumors:

You can also browse or search for these (or limit by geographic area)
from the main site here:

Here is a different eMedicine article on carcinoid tumors, focusing on
imaging issues:

Although written by a pediatrician (and aimed at the evaluation and
treatment of carcinoid tumors in children), this eMedicine article
also addresses issues in adults and nicely outlines the
chemotherapeutic agents that may be used for treatment:

If the carcinoid tumor is localized to the GI tract, this article may
be of some utility:

Carcinoid tumors are uncommonly found in the lungs.  Here is an
article describing this rare entity, written by a cardiothoracic
surgeon at Louisiana State University:

The online Merck Manual is another resource for information on
carcinoid tumors.  Here's the top level page for carcinoids:

The NIH MedLine Plus page has answers to many questions from multiple
national agencies:

For a somewhat different perspective, the UK BACUP group has a
carcinoid page, somewhat similar to the NIH page:

You can find the British Columbia info page here:

You can get additional information from the Carcinoid Cancer Foundation:

As you are aware, the Cancer Links USA site has many additional links
to resources on carcinoids.  I have included additional ones above
(for example, there are multiple good eMedicine sites to look at).  
This site also has several links to support groups.


Again, I wish you the best with combatting this difficult illness. 
Please feel free to request any additional clarification.

ravibattula-ga rated this answer:3 out of 5 stars and gave an additional tip of: $2.00
Thanks for the research and the information provided,it was helpful
little bit but very few options were feasible.

Subject: Re: Treatment of Unknown Primary cancer
From: tech00-ga on 13 Sep 2005 21:50 PDT
try the essiac,

read this link

My grandmother had Cervical Cancer 5 years final step.

now, she hasn┤t any trace of the cancer...

a similar product is distributed all over the word by:

the name is flor essence. flor essence is the product we used.

I hope this info being useful. thank you.
Subject: Re: Treatment of Unknown Primary cancer
From: otti7021-ga on 28 Sep 2005 05:23 PDT
I think that cancer is a disease of the mind that spreads throughout
the body as the mind becomes intolerate of negativity of thoughts  and
abuse of the body and the only way is change of thinking habits and
more importantly diet. ross horne has written very compelling books on
this subject that goes right back to the origins of our cellular
construction. I find modern medicine the very opposite from which it
derives(to give care and help to the sick) now it is just a mechanism
of the corporate curruption, especially cancer treatment.
my father strugled for years with screwed up cholerstrol and through
his own initiative got long term blance of it with no help from modern
medicine. Many other radical therapys especially frugality applied to
living and eating you can cure most things inexpensively and
effectively. the dietians of today will be the doctors of tomorrow.

regards jes

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