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Zhao ZM, Jiang N, Gao YX, Yin ZZ, Zhao GD, Tan XL, Xu Y, Liu R. Clinical diagnosis and management of pancreatic mucinous cystadenoma and cystadenocarcinoma: Single-center experience with 82 patients. World J Gastrointest Oncol 2020; 12:642-650. [PMID: 32699579 PMCID: PMC7340995 DOI: 10.4251/wjgo.v12.i6.642] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/18/2020] [Accepted: 05/22/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Mucinous cystic neoplasm (MCN) of the pancreas is characterized by mucin-producing columnar epithelium and dense ovarian-type stroma and at risk for malignant transformation. Early diagnosis and treatment of MCN are particularly important.
AIM To investigate the clinical characteristics of and management strategies for pancreatic mucinous cystadenoma (MCA) and mucinous cystadenocarcinoma (MCC).
METHODS The clinical and pathological data of 82 patients with pancreatic MCA and MCC who underwent surgical resection at our department between April 2015 and March 2019 were retrospectively analyzed.
RESULTS Of the 82 patients included in this study, 70 had MCA and 12 had MCC. Tumor size of MCC was larger than that of MCA (P = 0.049). Age and serum levels of tumor markers carcinoembryonic antigen (CEA), carbohydrate antigen (CA) 19-9, and CA12-5 were significantly higher in MCC than in MCA patients (P = 0.005, 0.026, and 0.037, respectively). MCA tumor size was positively correlated with serum CA19-9 levels (r = 0.389, P = 0.001). Compared with MCC, MCA had a higher minimally invasive surgery rate (P = 0.014). In the MCA group, the rate of major complications was 5.7% and that of clinically relevant pancreatic fistula was 8.6%; the corresponding rates in the MCC group were 16.7% and 16.7%, respectively.
CONCLUSION Tumor size, age, and serum CEA, CA19-9, and CA12-5 levels may contribute to management of patients with MCN. Surgical resection is the primary treatment modality for MCC and MCA.
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Affiliation(s)
- Zhi-Ming Zhao
- Second Department of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - Nan Jiang
- Second Department of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - Yuan-Xing Gao
- Second Department of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - Zhu-Zeng Yin
- Second Department of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - Guo-Dong Zhao
- Second Department of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - Xiang-Long Tan
- Second Department of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - Yong Xu
- Second Department of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - Rong Liu
- Second Department of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
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[Duodenum-preserving total pancreatic head resection : an organ-sparing operation technique for cystic neoplasms and non-invasive malignant tumors]. Chirurg 2014; 84:412-20. [PMID: 23417612 DOI: 10.1007/s00104-012-2423-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Cystic neoplasms of the pancreas are being detected and surgically treated increasingly more frequently. Intraductal papillary mucinous neoplasms (IPMN) and mucinous cystic neoplasms (MCN) are primary benign lesions; however, the 5-year risk for malignant transformation has been estimated to be 63 % and 15 %, respectively. Surgical extirpation of a benign cystic tumor of the pancreas is a cancer preventive measure. The duodenum-preserving total pancreatic head resection technique (DPPHRt) is being used more frequently for cystic neoplasms of the pancreatic head. The complete resection of the pancreatic head can be applied as a duodenum-preserving technique or with segmental resection of the peripapillary duodenum. Borderline lesions, carcinoma in situ or T1N0 cancer of the papilla and the peripapillary common bile duct are also considered to be indications for segmental resection of the peripapillary duodenum. A literature search for cystic neoplastic lesions and DPPHRt revealed the most frequent indications to be IPMN, MCN and SCA lesions and 28 % suffered from a cystic neoplasm with carcinoma in situ or a peripapillary malignoma. The hospital mortality rate was 0.52 %. Compared to the Whipple type resection the DPPHRt exhibits significant benefits with respect to a low risk for early postoperative complications and a low hospital mortality rate of < 1 %. Exocrine and endocrine pancreatic functions after DPPHR are not impaired compared to the Whipple type resection.
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Shen X, Lu D, Xu X, Wang J, Wu J, Yan S, Zheng SS. A novel distinguishing system for the diagnosis of malignant pancreatic cystic neoplasm. Eur J Radiol 2013; 82:e648-54. [DOI: 10.1016/j.ejrad.2013.06.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Revised: 06/02/2013] [Accepted: 06/19/2013] [Indexed: 12/11/2022]
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Cho CS, Russ AJ, Loeffler AG, Rettammel RJ, Oudheusden G, Winslow ER, Weber SM. Preoperative classification of pancreatic cystic neoplasms: the clinical significance of diagnostic inaccuracy. Ann Surg Oncol 2013; 20:3112-9. [PMID: 23595223 DOI: 10.1245/s10434-013-2986-6] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND The potential for malignant transformation varies among pancreatic cystic neoplasms (PCN) subtypes. Imaging and cyst fluid analysis are used to identify premalignant or malignant cases that should undergo operative resection, but the accuracy of operative decision-making process is unclear. The objective of this study was to characterize misdiagnoses of PCN and determine how often operations are undertaken for benign, non-premalignant disease. METHODS A retrospective analysis of patients undergoing pancreatic resection for the preoperative diagnosis of PCN was undertaken. Preoperative and pathological diagnoses were compared to measure diagnostic accuracy. RESULTS Between 1999 and 2011, 74 patients underwent pancreatic resection for the preoperative diagnosis of PCN. Preoperative classification of mucinous vs. non-mucinous PCN was correct in 74%. The specific preoperative PCN diagnosis was correct in 47%, but half of incorrect preoperative diagnoses were clinically equivalent to the pathological diagnoses. The likelihood that the pathological diagnosis was of higher malignant potential than the preoperative diagnosis was 7%. In 20% of cases, the preoperative diagnosis was premalignant or malignant, but the pathological diagnosis was benign. Diagnostic accuracy and the rate of undercall diagnoses and overcall operations did not change with the use of EUS or during the time period of this analysis. CONCLUSIONS Precise, preoperative classification of PCN is frequently incorrect but results in appropriate clinical decision-making in three-quarters of cases. However, one in five pancreatic resections performed for PCN was for benign disease with no malignant potential. An appreciation for the rate of diagnostic inaccuracies should inform our operative management of PCN.
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Affiliation(s)
- Clifford S Cho
- Section of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, J4/703 Clinical Sciences Center, 600 Highland Avenue, Madison, WI, USA.
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Abstract
OBJECTIVE Pancreatic cysts are being detected more frequently with advances in abdominal imaging. We designed this study to identify the characteristics of pancreatic cysts upon long-term follow-up and to define the proper management of them. METHODS We identified 1386 patients diagnosed with pancreatic cysts at our hospital from 1999 to 2010 and analyzed clinicopathologic data including radiological findings. RESULTS At initial diagnosis, 515 patients (37.2%) were classified as being at high-risk for malignancy, and 247 patients (17.8%) underwent surgery identifying 128 borderline or malignant cysts (51.8%). Borderline or malignant cysts were associated with older age, male sex, elevated serum level of lipase, carcinoembryonic antigen (CEA) or carbohydrate antigen 19-9 (CA 19-9), and a dilated pancreatic duct. Long-term follow-up for at least 24 months revealed that most of cystic lesions unchanged in size but malignant transformation was observed in 7 patients. CONCLUSIONS Most lesions with low or indeterminate risk did not changed in size during follow-up period, but one fifth of high-risk lesions were identified as borderline or malignant after surgery. Surgical resection should be performed in patients with high-risk cysts considering their clinical condition, and radiological follow-up of nonsurgically managed cysts should be continued for more than 6 years.
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Beger HG, Schwarz M, Poch B. Duodenum-preserving total pancreatic head resection for benign cystic neoplastic lesions. J Gastrointest Surg 2012; 16:2160-6. [PMID: 22790582 DOI: 10.1007/s11605-012-1929-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Accepted: 05/30/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Cystic neoplasms of the pancreas are diagnosed frequently due to early use of abdominal imaging techniques. Intraductal papillary mucinous neoplasm, mucinous cystic neoplasm, and serous pseudopapillary neoplasia are considered pre-cancerous lesions because of frequent transformation to cancer. Complete surgical resection of the benign lesion is a pancreatic cancer preventive treatment. OBJECTIVES The application for a limited surgical resection for the benign lesions is increasingly used to reduce the surgical trauma with a short- and long-term benefit compared to major surgical procedures. Duodenum-preserving total pancreatic head resection introduced for inflammatory tumors in the pancreatic head transfers to the patient with a benign cystic lesion located in the pancreatic head, the advantages of a minimalized surgical treatment. PATIENTS Based on the experience of 17 patients treated for cystic neoplastic lesions with duodenum-preserving total pancreatic head resection, the surgical technique of total pancreatic head resection for adenoma, borderline tumors, and carcinoma in situ of cystic neoplasm is presented. A segmental resection of the peripapillary duodenum is recommended in case of suspected tissue ischemia of the peripapillary duodenum. In 305 patients, collected from the literature by PubMed search, in about 40% of the patients a segmental resection of the duodenum and 60% a duodenum and common bile duct-preserving total pancreatic head resection has been performed. RESULTS Hospital mortality of the 17 patients was 0%. In 305 patients collected, the hospital mortality was 0.65%, 13.2% experienced a delay of gastric emptying and a pancreatic fistula in 18.2%. Recurrence of the disease was 1.5%. Thirty-two of 175 patients had carcinoma in situ. CONCLUSION Duodenum-preserving total pancreatic head resection for benign cystic neoplastic lesions is a safe surgical procedure with low post-operative morbidity and mortality.
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Cystic lesions of the pancreas: changes in the presentation and management of 1,424 patients at a single institution over a 15-year time period. J Am Coll Surg 2011; 212:590-600; discussion 600-3. [PMID: 21463795 DOI: 10.1016/j.jamcollsurg.2011.01.016] [Citation(s) in RCA: 178] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Accepted: 01/11/2011] [Indexed: 12/18/2022]
Abstract
BACKGROUND Cystic lesions of the pancreas are being identified more frequently, and a selective approach to resection is now recommended. The aim of this study was to assess the change in presentation and management of pancreatic cystic lesions evaluated at a single institution over 15 years. STUDY DESIGN A prospectively maintained registry of patients evaluated between 1995 and 2010 for the ICD-9 diagnosis of pancreatic cyst was reviewed. The 539 patients managed from 1995 to 2005 were compared with the 885 patients managed from 2005 to 2010. RESULTS A total of 1,424 patients were evaluated, including 1,141 with follow-up >6 months. Initial management (within 6 months of first assessment) was operative in 422 patients (37%) and nonoperative in 719 patients (63%). Operative mortality in patients initially submitted to resection was 0.7% (n = 3). Median radiographic follow-up in patients initially managed nonoperatively was 28 months (range 6 to 175 months). Patients followed radiographically were more likely to have cysts that were asymptomatic (72% versus 49%, p < 0.001), smaller (1.5 versus 3 cm, p < 0.001), without solid component (94% versus 68%, p < 0.001), and without main pancreatic duct dilation (88% versus 61%, p < 0.001). Changes prompting subsequent operative treatment occurred in 47 patients (6.5%), with adenocarcinoma identified in 8 (17%) and pancreatic endocrine neoplasm in 4 (8.5%). Thus, of the 719 patients initially managed nonoperatively, invasive malignancy was identified in 12 (1.7%), with adenocarcinoma seen in 1.1%. CONCLUSION Cystic lesions of the pancreas are being identified more frequently, yet are less likely to present with concerning features of malignancy. Carefully selected patients managed nonoperatively had a risk of malignancy that was equivalent to the risk of operative mortality in those patients who initially underwent resection.
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Sakorafas GH, Mahairas A, Smyrniotis V. Potential pitfalls in the management of primary pancreatic cystic neoplasms. ONKOLOGIE 2011; 34:332-336. [PMID: 21625189 DOI: 10.1159/000328791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Primary pancreatic cystic neoplasms (PCN) have been increasingly recognized over the last 2 decades, mainly as a result of the widespread use of modern imaging techniques in patients with abdominal complaints. Biological behavior and management greatly differ between subgroups of PCN. Accurate preoperative diagnosis is required to select the optimal management strategy for each individual patient with PCN. An in-depth knowledge of the biological, imaging, macroscopic/microscopic features, and laboratory findings of each subtype of PCN is required on the part of the clinician, in order to select a cost-effective diagnostic evaluation of the patient. Clinical judgment is also required on the part of the surgeon to select the optimal procedure and to avoid severe pitfalls in the surgical management of these neoplasms.
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Affiliation(s)
- George H Sakorafas
- 4th Department of Surgery, Athens University Medical School, ATTIKON University Hospital, Athens, Greece.
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Sakorafas GH, Smyrniotis V, Reid-Lombardo KM, Sarr MG. Primary pancreatic cystic neoplasms revisited. Part III. Intraductal papillary mucinous neoplasms. Surg Oncol 2011; 20:e109-18. [PMID: 21396811 DOI: 10.1016/j.suronc.2011.01.004] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Revised: 01/04/2011] [Accepted: 01/27/2011] [Indexed: 12/11/2022]
Abstract
Intraductal papillary mucinous neoplasms (IPMNs) represent about 25% of all primary pancreatic cystic neoplasms and are increasingly recognized during the last two decades. They are characterized by intraductal proliferation of neoplastic mucinous cells forming papillary projections into the pancreatic ductal system, which is typically dilated and contains globules of mucus. IPMNs may be multifocal and have malignant potential. Modern imaging is essential in establishing preoperative diagnosis and in differentiating different subtypes of IPMNs (i.e., main-duct vs. branch-type disease). Endoscopic retrograde or magnetic resonance cholangiopancreatography accurately delineate the morphologic changes of the pancreatic ductal system. Endoscopic ultrasonography (usually used in conjunction with image-guided FNA and analysis of the aspirated material) is commonly used for differential diagnosis of IPMNs from other pancreatic cystic lesions. Surgical resection (usually anatomic pancreatectomy, depending on the location of the disease) is the treatment of choice. Total pancreatectomy may occasionally be required in selected patients, but is associated with formidable long-term morbidity. A conservative approach has recently been proposed for carefully selected patients with branch-duct IPMNs. Recurrences following surgical resection can be observed, especially in patients with multifocal disease or in the presence of underlying malignancy.
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Affiliation(s)
- George H Sakorafas
- 4th Department of Surgery, Medical School, University of Athens, Attikon University Hospital, Arkadias 19-21, Athens 12462, Greece.
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Sakorafas GH, Smyrniotis V, Reid-Lombardo KM, Sarr MG. Primary pancreatic cystic neoplasms revisited: part II. Mucinous cystic neoplasms. Surg Oncol 2011; 20:e93-101. [PMID: 21251815 DOI: 10.1016/j.suronc.2010.12.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2010] [Accepted: 12/14/2010] [Indexed: 02/08/2023]
Abstract
Mucinous cystic neoplasms (MCNs) of the pancreas represent one of the most common primary pancreatic cystic neoplasms, accounting for approximately half of these cases. MCNs are observed almost exclusively in women, and most commonly are located in the body/tail of the pancreas. In contrast to SCNs, MCNs have malignant potential. Proliferative changes (hyperplasia with or without atypia, borderline changes, non-invasive or carcinomas in-situ, and invasive carcinomas) can often be observed within the same neoplasm. Several risk factors for the presence of underlying malignancy within an MCN have recently been recognized. Cross-sectional imaging is of key importance for the diagnostic evaluation of patients with a cystic pancreatic lesion. Cyst fluid examination (cytology, biochemical/genetic analysis) is possible by using fine needle aspiration of the MCN, usually under endoscopic guidance, and may provide useful information for the differential diagnosis. Since MCNs have malignant potential, surgical resection is the treatment of choice.
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Affiliation(s)
- George H Sakorafas
- 4th Department of Surgery, Medical School, University of Athens, Attikon University Hospital, Arkadias 19-21, Athens 12462, Greece.
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Sakorafas GH, Smyrniotis V, Reid-Lombardo KM, Sarr MG. Primary pancreatic cystic neoplasms revisited. Part I: serous cystic neoplasms. Surg Oncol 2011; 20:e84-92. [PMID: 21237638 DOI: 10.1016/j.suronc.2010.12.002] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2010] [Revised: 12/13/2010] [Accepted: 12/14/2010] [Indexed: 12/12/2022]
Abstract
Primary pancreatic cystic neoplasms have been recognized increasingly during the two recent decades and include mainly serous cystic neoplasms, mucinous cystic neoplasms, and intraductal papillary mucinous neoplasms. Serous cystic neoplasms represent about 30% of all cystic neoplasms of the pancreas and are characterized by their microcystic appearance (on imaging, macroscopically, and microscopically) and their benign biologic behavior. Modern diagnostic methodology allows the preoperative diagnosis with an acceptable accuracy. Currently, indications for resection of serous cystic neoplasms of the pancreas include the presence of symptoms, size > 4 cm (because these 'large' neoplasms have a more rapid growth rate and probably will soon become symptomatic), and any uncertainty about the diagnosis of a serous versus a mucinous cystic neoplasm. Resection should also be considered for lesions in the body/tail of the pancreas. Conservative treatment is a reasonable option in selected patients (for example in the presence of small, asymptomatic lesions in the pancreatic head, especially in the frail or elderly patient).
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Affiliation(s)
- George H Sakorafas
- 4th Department of Surgery, Medical School, University of Athens, Attikon University Hospital, Arkadias 19-21, Athens 12462, Greece.
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Abstract
The discovery of a pancreatic cyst in an asymptomatic patient presents an immediate challenge to the interpreting radiologist, the clinician who manages the patient, and patients themselves. When a cyst is discovered on imaging in a patient without symptoms directly referable to the pancreas, the following questions are immediately raised: can the lesion be accurately diagnosed or is the appropriate management clear from the examination, is the best management approach to suggest watchful waiting with follow-up imaging, what is the best method for imaging follow-up, and what is the optimal frequency of follow-up? This article recommends an approach to analyzing patients with incidental pancreatic cysts.
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Affiliation(s)
- Alec J Megibow
- Department of Radiology, New York University Langone Medical Center, New York, NY, USA.
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Abstract
PURPOSE OF REVIEW To summarize published research on pancreatic surgery over the past year. RECENT FINDINGS Improvements in the treatment of patients with acute gallstone pancreatitis with regards to the timing of ERCP and cholecystectomy as well as management of pancreatic pseudocysts have been reported. It is often difficult to detect malignancy in neoplastic pancreatic cysts; however, a detailed cyst fluid analysis for protein and genetic markers may improve this accuracy. In order to continue to improve pancreatic cancer care in the United States, a standardized reporting system must be developed, and this was a focus of the American Hepato-Pancreatico-Biliary Association Consensus Conference on Resectable and Borderline Resectable Disease. The conference examined pretreatment assessment, surgical treatment, and combined modality treatment for pancreatic cancer. A multi-institutional randomized clinical trial revealed that routine preoperative decompression of malignant biliary obstruction is associated with a higher frequency of complications. Pancreatic fistulas are the most common source of perioperative morbidity following pancreatic surgery. Fortunately, most of these can be managed nonoperatively via interventional radiology techniques. SUMMARY There is a broad spectrum of pancreatic diseases, which often require surgical treatment. Fortunately, the morbidity and mortality from each of them continues to decrease with more accurate diagnosis, improved management techniques, and standardized reporting systems.
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Affiliation(s)
- Timothy R Donahue
- Department of Surgery, Division of General Surgery, David Geffen School of Medicine at University of California, UCLA, Los Angeles, California 90095-6904, USA
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