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[en] The current study aimed to compare contouring of glandular tissue only (gCTV) with the clinical target volume (CTV) as defined according to European Society for Radiotherapy and Oncology (ESTRO) guidelines (eCTV) and historically treated volumes (marked by wire and determined by palpation and anatomic landmarks) in breast cancer radiotherapy. A total of 56 consecutive breast cancer patients underwent treatment planning based solely on anatomic landmarks/wire markings ("wire based"). From these treatment plans, the 50% and 95% isodoses were transferred as structures and compared to the following CT-based volumes: eCTV; a Hounsfield unit (HU)-based automatic contouring of the gCTV; and standardized planning target volumes (PTVs) generated with 1-cm safety margins (resulting in the ePTVs and gPTVs, respectively). The 95% isodose volume of the wire-based plan was larger than the eCTV by 352.39 ± 176.06 cm but smaller than the ePTV by 157.58 ± 189.32 cm. The 95% isodose was larger than the gCTV by 921.20 ± 419.78 cm and larger than the gPTV by 190.91 ± 233.49 cm. Patients with larger breasts had significantly less glandular tissue than those with small breasts. There was a trend toward a lower percentage of glandular tissue in older patients. Historical wire and anatomic landmarks-based treatment planning sufficiently covers the glandular tissue and the theoretical gPTV generated for the glandular tissue. Modern CT-based CTV and PTV definition according to ESTRO results in a larger treated volume than the historical wire-based techniques. HU-standardized glandular tissue contouring results in a significantly smaller CTV and might be an option for reducing the treatment volume and improving reproducibility of contouring between institutions.
Journal
[en] The aim of this review was to analyze the respective efficacy of various heart-sparing radiotherapy techniques. Heart-sparing can be performed in three different ways in breast cancer radiotherapy: by seeking to keep the heart out of treated volumes (i.e. by prone position or specific breathing techniques such as deep inspiration breath-hold [DIBH] and/or gating), by solely irradiating a small volume around the lumpectomy cavity (partial breast irradiation, PBI), or by using modern radiation techniques like intensity-modulated radiation therapy (IMRT), volumetric modulated arc therapy (VMAT) or protons. This overview presents the available data on these three approaches. Studies on prone position are heterogeneous and most trials only refer to patients with large breasts; therefore, no definitive conclusion can be drawn for clinical routine. Nonetheless, there seems to be a trend toward better sparing of the left anterior descending artery in supine position even for these selected patients. The data on the use of DIBH for heart-sparing in breast cancer patients is consistent and the benefit compared to free-breathing is supported by several studies. In comparison with whole breast irradiation (WBI), PBI has an advantage in reducing the heart dose. Of note, DIBH and PBI with multicatheter brachytherapy are similar with regard to the dose reduction to heart structures. WBI by IMRT/VMAT techniques without DIBH is not an effective strategy for heart-sparing in breast cancer patients with “standard” anatomy. A combination of DIBH and IMRT may be used for internal mammary radiotherapy. Based on the available findings, the DEGRO breast cancer expert panel recommends the use of DIBH as the best heart-sparing technique. Nonetheless, depending on the treatment volume and localization, other techniques may be employed or combined with DIBH when appropriate.
Journal
[en] The aim of the study was to assess the importance of surrounding tissues for the delineation of moving targets in tissue-specific phantoms and to find optimal settings for lung, soft tissue, and liver tumors. Tumor movement was simulated by a water-filled table tennis ball (target volume, TV). Three phantoms were created: corkboards to simulate lung tissue (lung phantom, LunPh), animal fat as fatty soft tissue (fatty tissue phantom, FatPh), and water enhanced with contrast medium as the liver tissue (liver phantom, LivPh). Slow planning three-dimensional compute tomography images (3D-CTs) were acquired with and without phantom movements. One-dimensional tumor movement (1D), three-dimensional tumor movement (3D), as well as a real patient's tumor trajectories were simulated. The TV was contoured using two lung window settings, two soft-tissue window settings, and one liver window setting. The volumes were compared to mathematical calculated values. TVs were underestimated in all phantoms due to movement. The use of soft-tissue windows in the LivPh led to a significantunderestimation of the TV (70.8 % of calculated TV). When common window settings [LunPh + 200 HU/-1,000 HU (upper window/lower window threshold); FatPh: + 240 HU/-120 HU; LivPh: + 175 HU/+ 50 HU] were used, the contoured TVs were: LivPh, 84.0 %; LunPh, 93.2 %, and FatPh, 92.8 %. The lower window threshold had a significant impact on the size of the delineated TV, whereas changes of the upper threshold led only to small differences. The decisive factor for window settings is the lower window threshold (for adequate TV delineation in the lung and fatty-soft tissue it should be lower than density values of surrounding tissue). The use of a liver window should be considered. (orig.)
[de]
Das Ziel dieser Arbeit war es, den Einfluss des umgebenden Gewebes auf die Konturierung bewegter Objekte zu untersuchen. Um die optimalen CT-Fensterungen fuer Lungen-, Weichteil- und Lebertumoren zu bestimmen, wurden gewebespezifische Phantome verwendet. Die Tumorbewegung wurde mit einem mit Wasser gefuellten Tischtennisballs (''target volume'', TV) simuliert. Dieser Ball wurde als Tumor in 3 Phantomen verwendet: Korkplatten zur Simulation von Lungengewebe (''lung phantom'', LunPh), Schweineschmalz als fetthaltiges Weichteilgewebe (''fatty-tissue phantom'', FatPh) und kontrastmittelversetztes Wasser als Lebergewebe (''liver phantom'', LivPh). Langsame dreidimensionale Planungs-CTs (3-D-CT) wurde ohne und mit Phantombewegungen aufgenommen, wobei eindimensionale (1-D), 3-D- und Patiententumorbewegungen simuliert wurden. Das TV wurde in 2 verschiedenen Lungenfenstern, 2 Weichteilfenstern und einem Leberfenster konturiert. Die konturierten Volumina wurden mit den mathematisch berechneten verglichen. Aufgrund der Bewegung wurden die TVs in allen Phantomen unterschaetzt. Die Weichteilfenster fuehrten im LivPh zu einer drastischen Unterschaetzung des TV (70,8 % des berechneten TV). Fuer die Standardfensterungen [LunPh: + 200 HU/-1000 HU (unterer/oberer Fenstergrenzwert); FatPh: + 240 HU/-120 HU; LivPh: + 175 HU/+ 50 HU] ergab sich fuer das TV: LivPh 84 %, LunPh 93,2 % und FatPh 92,8 %. Der untere Fenstergrenzwert hat entscheidenden Einfluss auf die Groesse des konturierten TV. Aenderungen des oberen Fenstergrenzwertes fuehrten lediglich zu geringen Differenzen. Abhaengig vom umgebenden Gewebe erscheint die Groesse eines TVs unterschiedlich. Der entscheidende Faktor bei der CT-Fensterung ist der untere Fenstergrenzwert. Fuer eine adaequate TV-Konturierung in Lungen- und fetthaltigem Weichteilgewebe sollte er niedriger sein als die Dichtewerte (HU-Werte) des umgebenden Gewebes. Fuer Lebertumoren sollte ein Leberfenster verwendet werden. (orig.)Journal
[en] The goal of this study was to assess the impact of different setup approaches in image-guided radiotherapy (IMRT) of the prostatic gland. In all, 28 patients with prostate cancer were enrolled in this study. After the placement of an endorectal balloon, the planning target volume (PTV) was treated to a dose of 70 Gy in 35 fractions. A simultaneously integrated boost (SIB) of 76 Gy (2.17 Gy per fraction and per day) was delivered to a smaller target volume. All patients underwent daily prostate-aligned IGRT by megavoltage CT (MVCT). Retrospectively, three different setup approaches were evaluated by comparison to the prostate alignment: setup by skin alignment, endorectal balloon alignment, and automatic registration by bones. A total of 2,940 setup deviations were analyzed in 980 fractions. Compared to prostate alignment, skin mark alignment was associated with substantial displacements, which were ≥ 8 mm in 13 %, 5 %, and 44 % of all fractions in the lateral, longitudinal, and vertical directions, respectively. Endorectal balloon alignment yielded displacements ≥ 8 mm in 3 %, 19 %, and 1 % of all setups; and ≥ 3 mm in 27 %, 58 %, and 18 % of all fractions, respectively. For bone matching, the values were 1 %, 1 %, and 2 % and 3 %, 11 %, and 34 %, respectively. For prostate radiotherapy, setup by skin marks alone is inappropriate for patient positioning due to the fact that, during almost half of the fractions, parts of the prostate would not be targeted successfully with an 8-mm safety margin. Bone matching performs better but not sufficiently for safety margins ≤ 3 mm. Endorectal balloon matching can be combined with bone alignment to increase accuracy in the vertical direction when prostate-based setup is not available. Daily prostate alignment remains the gold standard for high-precision radiotherapy with small safety margins. (orig.)
[de]
Das Ziel dieser Studie bestand darin, den Einfluss verschiedener Herangehensweisen bei der Einstellung einer bildgesteuerten (IGRT) Prostatabestrahlung zu ueberpruefen. Es wurden 28 Patienten in die Studie eingeschlossen. Vor jeder Fraktion erfolgte die Anlage eines endorektalen Ballons. Das Planungszielvolumen (PTV) wurde normofraktioniert bis zu einer Dosis von 70 Gy bestrahlt. Eine simultan integrierte Dosiserhoehung (SIB) mit 2,17 Gy tgl. bis zu einer Gesamtdosis von 76 Gy wurde auf ein kleineres Zielvolumen appliziert. Alle Bestrahlungen erfolgten bildgesteuert (IGRT) mit Hilfe eines Megavolt-CT (MVCT). Retrospektiv wurden drei verschiedene Einstellungsmoeglichkeiten mit der Uebereinstimmung bezogen auf das Prostatavolumen verglichen: manuelle Anpassung anhand der Koerperoberflaeche (Haut), manuelle Bildfusion anhand des endorektalen Ballons und computergesteuerte Fusion anhand der knoechernen Strukturen. In 980 Fraktionen wurden 2940 Lageabweichungen der Prostata registriert und ausgewertet. Im Vergleich zur Einstellung nach dem Prostatavolumen fanden sich bei Einstellung anhand der Koerperoberflaeche erhebliche Abweichungen ≥ 8 mm in 13 %, 5 % und 44 % aller Fraktionen in der lateralen, longitudinalen und vertikalen Richtung. Die Einstellung durch Bildfusion anhand des Rektumballons zeigte Abweichungen ≥ 8 mm in 3 %, 19 % und 1 % sowie ≥ 3 mm in 27 %, 58 % und 18 % aller Fraktionen. Bei der automatischen Anpassung an die knoechernen Strukturen lagen die Werte bei 1 %, 1 % und 2 % fuer ≥ 8 mm sowie bei 3 %, 11 % und 34 % fuer ≥ 3 mm. Bei der Strahlentherapie der Prostata ist die Einstellung mittels alleiniger Abgleichung der Koerperoberflaechenmarkierungen ungenuegend, da in fast der Haelfte der Fraktionen, unter Annahme eines Sicherheitssaums von 8 mm, Teile der Prostata nicht suffizient therapiert werden wuerden. Die automatische Bildfusion anhand der knoechernen Strukturen erreicht bessere Ergebnisse, allerdings ist diese immer noch inadaequat fuer die Therapie mit einem Sicherheitssaum von ≤ 3 mm. Eine zusaetzliche Fusionierung des Rektumballons verbessert die Zielgenauigkeit vor allem in der vertikalen Richtung und bietet sich somit als Alternative an, wenn eine prostatabasierte Einstellung nicht moeglich ist. Letztendlich bleibt die taegliche Angleichung an das Prostatagewebe der Goldstandard in der Hochpraezisionsstrahlentherapie mit kleinen Sicherheitssaeumen. (orig.)Journal
[en] The purpose of this study is to evaluate the tumor movement and accuracy of patient immobilization in stereotactic body radiotherapy of liver tumors with low pressure foil or abdominal compression. Fifty-four liver tumors treated with stereotactic body radiotherapy were included in this study. Forty patients were immobilized by a vacuum couch with low pressure foil, 14 patients by abdominal compression. We evaluated the ratio of gross tumor volume/internal target volume, the tumor movement in 4D-computed tomography scans and daily online adjustments after cone beam computed tomography scans. The ratio of gross tumor volume/internal target volume was smaller with low pressure foil. The tumor movement in 4D-computed tomography scans was smaller with abdominal compression, the cranial movement even significantly different (p = 0.02). The mean online adjustments and their mean absolute values in the vertical, lateral and longitudinal axis were smaller with abdominal compression. The online adjustments were significantly different (p < 0.013), their absolute values in case of the longitudinal axis (p = 0.043). There was no significant difference of the adjustments’ 3D vectors. In comparison to low pressure foil, abdominal compression leads to a reduction of the tumor movement. Online adjustments decreased significantly, thus leading to higher accuracy in patient positioning.
Journal
Radiation Oncology (Online); ISSN 1748-717X; 
; v. 13; vp
; v. 13; vp
[en] The aim of this study was to analyze differences in couch shifts (setup errors) resulting from image registration of different CT datasets with free breathing cone beam CTs (FB-CBCT). As well automatic as manual image registrations were performed and registration results were correlated to tumor characteristics. FB-CBCT image registration was performed for 49 patients with lung lesions using slow planning CT (PCT), average intensity projection (AIP), maximum intensity projection (MIP) and mid-ventilation CTs (MidV) as reference images. Both, automatic and manual image registrations were applied. Shift differences were evaluated between the registered CT datasets for automatic and manual registration, respectively. Furthermore, differences between automatic and manual registration were analyzed for the same CT datasets. The registration results were statistically analyzed and correlated to tumor characteristics (3D tumor motion, tumor volume, superior-inferior (SI) distance, tumor environment). Median 3D shift differences over all patients were between 0.5 mm (AIPvsMIP) and 1.9 mm (MIPvsPCT and MidVvsPCT) for the automatic registration and between 1.8 mm (AIPvsPCT) and 2.8 mm (MIPvsPCT and MidVvsPCT) for the manual registration. For some patients, large shift differences (>5.0 mm) were found (maximum 10.5 mm, automatic registration). Comparing automatic vs manual registrations for the same reference CTs, ∆AIP achieved the smallest (1.1 mm) and ∆MIP the largest (1.9 mm) median 3D shift differences. The standard deviation (variability) for the 3D shift differences was also the smallest for ∆AIP (1.1 mm). Significant correlations (p < 0.01) between 3D shift difference and 3D tumor motion (AIPvsMIP, MIPvsMidV) and SI distance (AIPvsMIP) (automatic) and also for 3D tumor motion (∆PCT, ∆MidV; automatic vs manual) were found. Using different CT datasets for image registration with FB-CBCTs can result in different 3D couch shifts. Manual registrations achieved partly different 3D shifts than automatic registrations. AIP CTs yielded the smallest shift differences and might be the most appropriate CT dataset for registration with 3D FB-CBCTs.
Journal
Radiation Oncology (Online); ISSN 1748-717X; ; v. 11; vp
; v. 11; vp
[en] Aim of the present analysis was to evaluate the movement and dose variability of the different lymph node levels of node-positive breast cancer patients during adjuvant radiotherapy (RT) with regional nodal irradiation (RNI) in deep-inspiration breath hold (DIBH). Thirty-five consecutive node-positive breast cancer patients treated from October 2016 to February 2018 receiving postoperative RT of the breast or chest wall including RNI of the supra-/infraclavicular lymph node levels (corresponding to levels IV, III, Rotter LN (interpectoral), and some parts of level II) were analyzed. To evaluate the lymph node level movement, a center of volume (COV) was obtained for each lymph node level for free-breathing (FB) and DIBH plans. Geometric shifts and dose differences between FB and DIBH were analyzed. A significant movement of the COV in anterior (y) and cranial (z) dimensions was observed for lymph node levels I-II and Rotter lymph nodes (p < 0.001) due to DIBH. Only minor changes in the lateral dimension (x axis) were observed, without reaching significance for levels III, IV, and internal mammary. There was a significant difference in the mean dose of level I (DIBH vs. FB: 38.2 Gy/41.3 Gy, p < 0.001) and level II (DIBH vs. FB: 45.9 Gy/47.2 Gy, p < 0.001), while there was no significant difference in level III (p = 0.298), level IV (p = 0.476), or internal mammary nodes (p = 0.471). A significant movement of the axillary lymph node levels was observed during DIBH in anterior and cranial directions for node-positive breast cancer patients in comparison to FB. The movement leads to a significant dose reduction in level I and level II. (orig.)
[de]
Ziel der vorliegenden Analyse war es, die Bewegungs- und Dosisvariabilitaet der verschiedenen Lymphknotenstationen nodalpositiver Brustkrebspatientinnen waehrend der adjuvanten Bestrahlung inklusive regionaler Lymphabflussbestrahlung (RNI) in tiefer Inspiration (''deep inspiration breath hold'', DIBH) zu bewerten. Von Oktober 2016 bis Februar 2018 wurden 35 nodalpositive Brustkrebspatientinnen mit postoperativer RT der Brust oder Brustwand einschliesslich RNI der supra-/infraklavikulaeren Lymphknotenregionen (entsprechend Level IV, III, Rotter-Lymphknoten interpektoral und Anteile von Level II) untersucht. Zur Beurteilung der Bewegung der Lymphknotenstationen wurde fuer jedes Lymphknotenlevel der geometrische Volumenmittelpunkt (''center of volume'', COV) in freier Atmung (''free breathing'', FB) und DIBH ermittelt. Die raeumlichen Bewegungen und Dosisunterschiede zwischen FB und DIBH wurden analysiert. Eine signifikante Bewegung des COV in anteriorer (y) und kranialer (z) Richtung wurde fuer die Lymphknotenlevel I-II sowie fuer die Rotter-Lymphknoten (p < 0,001) in DIBH beobachtet. Es wurden nur geringe Veraenderungen im Bereich der lateralen Dimension (x-Achse) beobachtet, welche fuer die Level III, IV und die Mammaria-interna-Lymphknoten nicht signifikant waren. Es zeigten sich ausserdem signifikante Dosisunterschiede fuer das Lymphknotenlevel I (DIBH vs. FB: 38,2 Gy/41,3 Gy; p < 0,001) und II (DIBH vs. FB: 45,9 Gy/47,2 Gy; p < 0,001), waehrend es keinen signifikanten Unterschied fuer das Level III (p = 0,298), IV (p = 0,476) und Mammaria interna (p = 0,471) gab. Eine signifikante Bewegung der axillaeren Lymphknotenstationen waehrend DIBH wurde vorwiegend in anteriorer und kranialer Richtung im Vergleich zu FB beobachtet. Die Bewegung fuehrte zu einer signifikanten Dosisreduktion innerhalb der Lymphknotenlevel I und II. (orig.)Journal
[en] Radiation-induced fibrosis (RIF) is one of the severe long-term side effects of radiation therapy (RT) with a crucial impact on the development of postoperative wound healing disorders (WHD). The grades of fibrosis vary between mild to severe depending on individual radiosensitivity. In this study, we have investigated the molecular pathways that influence RIF and have correlated data from immunohistochemistry (IHC) for von –Willebrand Factor (vWF) and from Real-Time Polymerase Chain Reaction (RT-PCR) concerning markers such as Transforming Growth Factor (TGF)-β_1, and vWF, with clinical data concerning the occurrence of WHD during follow-up. Expression profiles of the genes encoding TGF-β_1, vWF, and α-procollagen (PC) were analyzed, by RT-PCR, in specimens from patients with (n = 20; 25.6 %) and without (n = 58; 74.4 %) a history of previous RT to the head and neck. Moreover, IHC against vWF was performed. Clinical data on the occurrence of cervical WHDs were analyzed and correlated. A statistically significant increase in the expression profiles of α-PC and TGF-β_1 was observed in previously irradiated skin samples (occurrence of RT >91 days preoperatively). vWF showed a statistically significant increase in non-irradiated tissue. Moreover, analysis of expression profiles in patients with and without WHDs during follow-up was performed. IHC showed a reduced amount of vessels and structural changes in epidermal tissue post-RT. The expression of markers of fibrosis and angiogenesis was analyzed in order to gain insight into molecular pathways that account for structural changes in irradiated skin and that eventually lead to WHDs. The results are congruent with reports from the literature and are a possible starting point for further research, as anti-TGF-β_1 treatment, for example, could represent new therapeutic opportunities in the management of previously irradiated patients
Journal
Radiation Oncology (Online); ISSN 1748-717X; ; v. 10; vp
; v. 10; vp
[en] Purpose: To assess the impact of interfractional variations of shape and setup uncertainties on the dose to the parotid glands (PGs) in head-and-neck cancer intensity-modulated radiotherapy and image-guided radiotherapy (IGRT). Methods and Materials: Two scenarios were analyzed retrospectively for 10 head-and-neck cancer patients, treated with helical TomoTherapy (TomoTherapy Inc., Madison, WI): the IGRT scenario and the non-IGRT scenario. The initial dose-volume histograms derived from the planning computed tomography (PCT) scan and 120 recalculated dose-volume histograms of the PGs of each scenario and of corresponding fractions were compared. Setup errors, cumulative median doses (CMDs) for 6 fractions, overall volumes of the PGs, and volumes that received less than 1 Gy or more than 1.6 Gy per fraction were analyzed. Results: The mean decrease in the PG volume was 0.13 cm3/d. There was a significantly higher CMD than initially predicted (mean increase for 6 fractions, 1.13 Gy for IGRT and 0.96 Gy for non-IGRT). The volume that received less than 1 Gy per fraction decreased (mean difference to PCT, 1.36 cm3 for IGRT [p = 0.003] and 1.35 cm3 for non-IGRT [p = 0.003]) and the volume that received more than 1.6 Gy per fraction increased with increasing fraction number (mean difference to PCT, 1.14 cm3 for IGRT [p = 0.01] and 1.16 cm3 for non-IGRT [p = 0.006]). There was no statistically significant difference between the two scenarios (CMD, p = 0.095; volume that received <1 Gy per fraction, p = 0.896; and volume that received >1.6 Gy per fraction, p = 0.855). Conclusions: In the analyzed group the actual delivered dose to the PGs does not differ significantly between an IGRT and a non-IGRT approach. However, IGRT in head-and-neck cancer intensity-modulated radiotherapy is strongly recommended to improve patient setup.
Journal
International Journal of Radiation Oncology, Biology and Physics; ISSN 0360-3016; ; CODEN IOBPD3; v. 77(4); p. 1266-1273
; CODEN IOBPD3; v. 77(4); p. 1266-1273
[en] Purpose: To quantify the actual delivered dose to the cervical spinal cord with different image-guided radiotherapy (IGRT) approaches during head and neck (HN) cancer helical tomotherapy. Methods and Materials: Twenty HN patients (HNpts) treated with bilateral nodal irradiation were analyzed. Daily megavoltage computed tomography MVCT) scans were performed for setup purposes. The maximum dose on the planning CT scan (plan-Dmax) and the magnitude and localization of the actual delivered Dmax (a-Dmax) were analyzed for four scenarios: daily image-guided radiotherapy (dIGRT), twice weekly IGRT (2×WkIGRT), once weekly IGRT (1×WkIGRT), and no IGRT at all (non-IGRT). The spinal cord was recontoured on 236 MVCTs for each scenario (total, 944 fractions), and the delivered dose was recalculated for each fraction (fx) separately. Results: Fifty-one percent of the analyzed fx for dIGRT, 56% of the analyzed fx for the 2×WkIGRT, 62% of the analyzed fx for the 1×WkIGRT, and 63% of the analyzed fx for the non-IGRT scenarios received a higher a-Dmax than the plan-Dmax. The median increase of dose in these fx was 3.3% more for dIGRT, 5.8% more for 2×WkIGRT, 10.0% more for 1×WkIGRT, and 9.5% more for non-IGRT than the plan-Dmax. The median spinal cord volumes receiving a higher dose than the plan-Dmax were 0.02 cm3 for dIGRT, 0.11 cm3 for 2×WkIGRT, 0.31 cm3 for 1×WkIGRT, and 0.22 cm3 for non-IGRT. Differences between the dIGRT and all other scenarios were statistically significant (p < 0.05). Conclusions: Compared to the Dmax of the initial plan, daily IGRT had the smallest increase in dose. Furthermore, daily IGRT had the lowest proportion of fractions and the smallest volumes affected by a dose that was higher than the planned dose. For patients treated with doses close to the tolerance dose of the spinal cord, we recommend daily IGRT. For all other cases, twice weekly IGRT is sufficient.
Journal
International Journal of Radiation Oncology, Biology and Physics; ISSN 0360-3016; ; CODEN IOBPD3; v. 84(1); p. 283-288
; CODEN IOBPD3; v. 84(1); p. 283-288
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