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Hammad M, Hosny M, Khalil EM, Alfaar AS, Fawzy M. Pediatric ependymoma: A single-center experience from a developing country. Indian J Cancer 2020; 58:378-386. [PMID: 33402598 DOI: 10.4103/ijc.ijc_373_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Ependymomas are the third most common pediatric central nervous system (CNS) tumors, accounting for 6-12% of brain tumors in children. Management of these tumors remains challenging and recurrence occurs in over 50% of cases, mainly when complete resection is not achieved before radiotherapy. The 5-year overall survival (OS) ranges from 39 to 64%, with a 5-year progression-free survival (PFS) rate of 23-45%. The study aimed to describe the OS and PFS rates of cases of pediatric ependymoma. It also aimed to evaluate the effects of different variables on disease outcomes. Variables examined included patient age, the extent of surgical resection, radiotherapy and chemotherapy delivered, the histopathological subtype of the tumor, primary tumor location, and extent of the disease at presentation. Last, the challenges that potentially compromise treatment outcomes in resource-limited countries were to be highlighted. Methods This is a retrospective cohort study, representing a single-center experience that included 47 pediatric patients treated at the National Cancer Institute, Cairo University, between January 2009 and December 2014. Results Median follow-up stood at 23.5 months (range: 2-77 months). The average 3-year OS and PFS rates were 43.7 and 43.3%, respectively. Conclusion The extent of surgical excision (maximal resection) and the adequacy of postoperative radiotherapy were the only two factors that had significantly affected the outcome. Understandably, treatment outcomes for ependymomas in developing countries still lag behind best reported outcomes, mainly due to inadequate surgical excision and postoperative radiotherapy.
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Affiliation(s)
- Mahmoud Hammad
- Department of Pediatric Oncology and Hematology, National Cancer Institute (NCI), Cairo University; Department of Pediatric Oncology and Hematology, Children's Cancer Hospital of Egypt (CCHE/57357), Cairo, Egypt
| | - Maryhan Hosny
- Department of Pediatric Oncology and Hematology, National Cancer Institute (NCI), Cairo University; Department of Pediatric Oncology and Hematology, Children's Cancer Hospital of Egypt (CCHE/57357), Cairo, Egypt
| | - Ehab M Khalil
- Department of Radiation Oncology and Nuclear Medicine, National Cancer Institute (NCI), Cairo University, Cairo, Egypt
| | - Ahmad S Alfaar
- Department of Ophthalmology, Charité-Universtätsmedizin Berlin (Charité Medical University - Berlin), Berlin; Department of Ophthalmology, University of Leipzig, Leipzig, Sachsen, Germany
| | - Mohamed Fawzy
- Department of Pediatric Oncology and Hematology, National Cancer Institute (NCI), Cairo University; Department of Pediatric Oncology and Hematology, Children's Cancer Hospital of Egypt (CCHE/57357), Cairo, Egypt
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Routman DM, Raghunathan A, Giannini C, Mahajan A, Beltran C, Nagib MG, Nageswara Rao AA, Skrypek MM, Laack NNI. Anaplastic Ependymoma and Posterior Fossa Grouping in a Patient With H3K27ME3 Loss of Expression but Chromosomal Imbalance. Adv Radiat Oncol 2019; 4:466-472. [PMID: 31360801 PMCID: PMC6639753 DOI: 10.1016/j.adro.2019.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 02/14/2019] [Accepted: 03/04/2019] [Indexed: 11/17/2022] Open
Affiliation(s)
- David M Routman
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Caterina Giannini
- Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Chris Beltran
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Mahmoud G Nagib
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota
| | | | - Mary M Skrypek
- Department of Hematology Oncology, Children's Minnesota, Minneapolis, Minnesota
| | - Nadia N I Laack
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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Abstract
PURPOSE OF REVIEW This review discusses the evidence base behind current and emerging strategies of management of intracranial and spinal ependymomas in children, with a particular focus on aspects of surgical techniques, challenges and complications. RECENT FINDINGS The cornerstone of management remains maximal safe resective surgery, which has repeatedly been shown to correlate with improved survival. This is followed by focal conformal radiotherapy, although good results using proton beam therapy, with the potential for diminished side effects, are emerging. The role of chemotherapy remains largely unproven for paediatric ependymoma. Despite optimal management strategies, many children with ependymoma suffer from tumour recurrence. The standard of care for paediatric ependymoma comprises surgery and radiotherapy. Results of ongoing clinical trials will help shape its management in order to leverage our increasingly sophisticated understanding of the genetic drivers behind these tumours into survival benefit for this challenging group of patients.
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Affiliation(s)
- Sebastian M Toescu
- Developmental Imaging and Biophysics Section, UCL-GOS Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK.,Department of Neurosurgery, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK
| | - Kristian Aquilina
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK.
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4
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Neurocognitive, academic and functional outcomes in survivors of infant ependymoma (UKCCSG CNS 9204). Childs Nerv Syst 2019; 35:411-420. [PMID: 30554263 DOI: 10.1007/s00381-018-4015-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 11/28/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE This is the first UK multi-centre case-controlled study with follow-up in excess of 10 years to report the neurocognitive, academic and psychological outcomes of individuals diagnosed with a brain tumour in early childhood. Children enrolled into the UKCCSG CNS 9204 trial, diagnosed with intracranial ependymoma when aged ≤ 36 months old, who received a primary chemotherapy strategy to defer or avoid radiotherapy, were recruited. METHODS Outcomes of those who relapsed and subsequently received radiotherapy (n = 13) were compared to those enrolled who did not relapse (n = 16), age-matched controls-diagnosed with solid non-central nervous system (SN-CNS; n = 15) tumours or low-grade posterior fossa pilocytic astrocytoma (PFPA; n = 15), and normative data. Analyses compared nine neurocognitive outcomes as primary measures with quality of survival as secondary measures. RESULTS Relapsed ependymoma participants performed significantly worse than their non-relapsed counterparts on measures of Full Scale IQ, Perceptual Reasoning, Word Reading and Numerical Operations. The relapsed ependymoma group performed significantly worse than SN-CNS controls on all primary measures, whereas non-relapsing participants only differed significantly from SN-CNS controls on measures of Processing Speed and General Memory. Relapsed ependymoma participants fared worse than all groups on measures of quality of survival. CONCLUSIONS The relapsed irradiated ependymoma group demonstrated the most significantly impaired neurocognitive outcomes at long-term follow-up. Non-relapsing participants demonstrated better outcomes than those who relapsed. Results tentatively suggest avoiding radiotherapy helped preserve neurocognitive and learning outcomes of individuals diagnosed with ependymoma when aged ≤ 36 months old. Prospective neurocognitive surveillance is required. Recommendations for clinical and research practice are provided.
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Tsang D, Laperriere N. Re-irradiation for Paediatric Tumours. Clin Oncol (R Coll Radiol) 2019; 31:191-198. [DOI: 10.1016/j.clon.2018.10.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 05/29/2018] [Accepted: 06/11/2018] [Indexed: 12/25/2022]
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Pollack IF, Agnihotri S, Broniscer A. Childhood brain tumors: current management, biological insights, and future directions. J Neurosurg Pediatr 2019; 23:261-273. [PMID: 30835699 PMCID: PMC6823600 DOI: 10.3171/2018.10.peds18377] [Citation(s) in RCA: 158] [Impact Index Per Article: 31.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 10/29/2018] [Indexed: 02/06/2023]
Abstract
Brain tumors are the most common solid tumors in children, and, unfortunately, many subtypes continue to have a suboptimal long-term outcome. During the last several years, however, remarkable advances in our understanding of the molecular underpinnings of these tumors have occurred as a result of high-resolution genomic, epigenetic, and transcriptomic profiling, which have provided insights for improved tumor categorization and molecularly directed therapies. While tumors such as medulloblastomas have been historically grouped into standard- and high-risk categories, it is now recognized that these tumors encompass four or more molecular subsets with distinct clinical and molecular characteristics. Likewise, high-grade glioma, which for decades was considered a single high-risk entity, is now known to comprise multiple subsets of tumors that differ in terms of patient age, tumor location, and prognosis. The situation is even more complex for ependymoma, for which at least nine subsets of tumors have been described. Conversely, the majority of pilocytic astrocytomas appear to result from genetic changes that alter a single, therapeutically targetable molecular pathway. Accordingly, the present era is one in which treatment is evolving from the historical standard of radiation and conventional chemotherapy to a more nuanced approach in which these modalities are applied in a risk-adapted framework and molecularly targeted therapies are implemented to augment or, in some cases, replace conventional therapy. Herein, the authors review advances in the categorization and treatment of several of the more common pediatric brain tumors and discuss current and future directions in tumor management that hold significant promise for patients with these challenging tumors.
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7
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Thorp N, Gandola L. Management of Ependymoma in Children, Adolescents and Young Adults. Clin Oncol (R Coll Radiol) 2019; 31:162-170. [PMID: 30616927 DOI: 10.1016/j.clon.2018.12.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 11/18/2018] [Accepted: 11/22/2018] [Indexed: 12/20/2022]
Abstract
Paediatric ependymomas are rare, malignant tumours arising throughout the central nervous system, but most frequently (in children) the posterior fossa. The standard of care for localised disease is gross total resection and focal radiotherapy, resulting in overall survival rates of up to 85%. Despite improvements in survival, treatment remains challenging, with persistently high rates of (rarely curable) relapse alongside risks of significant tumour and treatment-related toxicity. Systemic therapy is currently used to delay radiotherapy in very young children and in the management of metastatic or recurrent disease. Its use in the adjuvant setting is the subject of ongoing studies. Current research efforts are aimed at eliciting a better understanding of molecular biology, correlating this with tumour behaviour and defining targets for potential new agents. Prognosis seems to be related to the extent of surgical resection and the age at presentation. This article reviews clinical aspects of ependymoma management in children and young people.
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Affiliation(s)
- N Thorp
- Clatterbridge Cancer Centre, Wirral, UK.
| | - L Gandola
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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Yecies D, Azad TD, Esparza R, Quon JL, Forkert ND, MacEachern SJ, Bruckert L, Maleki M, Edwards MSB, Grant GA, Yeom KW. Long-Term Supratentorial Radiologic Effects of Surgery and Local Radiation in Children with Infratentorial Ependymoma. World Neurosurg 2018; 122:e1300-e1304. [PMID: 30448581 DOI: 10.1016/j.wneu.2018.11.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 11/03/2018] [Accepted: 11/07/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Current standard of care for children with infratentorial ependymoma includes maximal safe resection and local radiation of 54-59 Gray. High-dose local radiation has been associated with declines in multiple cognitive domains. The anatomic and physiologic correlates of this cognitive decline remain undefined, and there have been no radiographic studies on the long-term effects of this treatment paradigm. METHODS A comprehensive database of pediatric brain tumor patients treated at Stanford Children's from 2004-2016 was queried. Seven patients with posterior fossa ependymoma who were treated with surgery and local radiation alone, who had no evidence of recurrent disease, and had imaging suitable for analysis were identified. Diffusion-weighted magnetic resonance imaging datasets were used to calculate apparent diffusion coefficient maps for each subject, while arterial spin labeling datasets were used to calculate maps of cerebral blood flow. Diffusion-weighted imaging and arterial spin labeling datasets of 52 age-matched healthy children were analyzed in the same fashion to enable group comparisons. RESULTS Several statistically significant differences were detected between the 2 groups. Cerebral blood flow was lower in the caudate and pallidum and higher in the nucleus accumbens in the ependymoma cohort compared with controls. Apparent diffusion coefficient was increased in the thalamus and trended toward decreased in the amygdala. CONCLUSIONS Surgery and local radiation for posterior fossa ependymoma are associated with supratentorial apparent diffusion coefficient and cerebral blood flow alterations, which may represent an anatomic and physiologic correlate to the previously published decline in neurocognitive outcomes in this population.
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Affiliation(s)
- Derek Yecies
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA.
| | - Tej D Azad
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Rogelio Esparza
- Department of Neurosurgery, NYU School of Medicine, New York, New York, USA
| | - Jennifer L Quon
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Nils D Forkert
- Department of Radiology and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Sarah J MacEachern
- Department of Radiology and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Lisa Bruckert
- Division of Developmental-Behavioral Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Maryam Maleki
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Michael S B Edwards
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Gerald A Grant
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Kristen W Yeom
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
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De B, Khakoo Y, Souweidane MM, Dunkel IJ, Patel SH, Gilheeney SW, De Braganca KC, Karajannis MA, Wolden SL. Patterns of relapse for children with localized intracranial ependymoma. J Neurooncol 2018; 138:435-445. [PMID: 29511977 DOI: 10.1007/s11060-018-2815-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 02/23/2018] [Indexed: 10/17/2022]
Abstract
We examined patterns of relapse and prognostic factors in children with intracranial ependymoma. Records of 82 children diagnosed with localized intracranial ependymoma were reviewed. 52% first presented to our institution after relapse. Median age at initial diagnosis was 4 years (range 0-18 years). Gender was 55% male. Initial tumor location was infratentorial in 71% and supratentorial in 29%. Histology was WHO Grade II in 32% and Grade III in 68%. As part of definitive management, 99% had surgery, 70% received RT (26% 2D/3D-conformal RT[CRT], 22% intensity-modulated RT [IMRT], 22% proton), and 37% received chemotherapy. Median follow-up was 4.6 years (range 0.2-32.9). Overall, 74% of patients relapsed (50% local, 17% distant, 7% local + distant) at a median 1.5 (range 0.1-17.5) years. Five-year OS and FFS for patients presenting prior to relapse are 70% (95% confidence interval [CI], 50-83%) and 48% (95% CI 30-64%), respectively. On log-rank, superior overall survival (OS) was demonstrated for gross total resection (p = 0.03). Superior failure-free survival (FFS) was demonstrated for age < 5 years (p = 0.04). No difference in OS or FFS was found between 2D/3D-CRT versus IMRT/proton (p > 0.05). On multivariate analysis, age ≤ 5 was independently associated with a lower risk of death and failure versus older patients (p < 0.05). Contrary to previous reports, young age may not be a poor prognostic factor in patients who can tolerate intensive treatment. Future studies examining patients stratified by clinical and molecular attributes are warranted.
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Affiliation(s)
- Brian De
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Yasmin Khakoo
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA.,Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mark M Souweidane
- Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA.,Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Neurological Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Ira J Dunkel
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA
| | - Suchit H Patel
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Stephen W Gilheeney
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kevin C De Braganca
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Suzanne L Wolden
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
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Snider CA, Yang K, Mack SC, Suh JH, Chao ST, Merchant TE, Murphy ES. Impact of radiation therapy and extent of resection for ependymoma in young children: A population-based study. Pediatr Blood Cancer 2018; 65. [PMID: 29115718 DOI: 10.1002/pbc.26880] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 09/29/2017] [Accepted: 10/02/2017] [Indexed: 11/09/2022]
Abstract
BACKGROUND Young children with posterior fossa ependymoma (PF-EPN) have a worse prognosis than older children, and they have a unique molecular profile (PF-EPN-A subtype). Alternative treatment strategies are often used in these young patients, and their prognostic factors are less clear. METHODS We characterized the prognostic factors and treatment outcomes of 482 patients between ages 0 and 3 years with the diagnosis of ependymoma identified from the Surveillance, Epidemiology, and End Results registry (1973-2013). RESULTS Radiation therapy (RT) was delivered to 52.3% of patients, and gross total resection (GTR) was performed in 51.0% of patients. Overall survival (OS) at 10 years was 48.4% with median follow-up of 3.3 years. WHO grade was not predictive of OS. Extent of resection was significant for survival; the 10-year OS with GTR was 61.0%, and with subtotal resection (STR) and biopsy was 38.2% and 35.0%, respectively (P < 0.001). RT significantly benefitted OS for both grades II and III. The 10-year OS for grade II was 50.5% with RT and 43.4% without (P = 0.030); 10-year OS for grade III was 66.0% with RT and 40.0% without (P = 0.002). Multivariate analysis showed significantly improved OS with RT (hazard ratio [HR] 0.601, 95% CI: 0.439-0.820, P = 0.001) and GTR (HR 0.471, 95% CI: 0.328-0.677, P < 0.0001). CONCLUSIONS Ependymoma outcomes in patients within 0-3 years of age significantly improved with RT and GTR. Histopathologic grading of ependymoma demonstrated no prognostic significance. Given the poor OS for this population and unique genetic profile, future prospective studies with molecular-based stratification should be performed to evaluate additional prognostic factors.
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Affiliation(s)
- C A Snider
- Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - K Yang
- Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio.,Department of Stem Cell Biology and Regenerative Medicine, Cleveland Clinic, Cleveland, Ohio
| | - S C Mack
- Department of Stem Cell Biology and Regenerative Medicine, Cleveland Clinic, Cleveland, Ohio
| | - J H Suh
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
| | - S T Chao
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
| | - T E Merchant
- Department of Radiological Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - E S Murphy
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
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Proton therapy for paediatric CNS tumours — improving treatment-related outcomes. Nat Rev Neurol 2016; 12:334-45. [DOI: 10.1038/nrneurol.2016.70] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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