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Mercado M, Abreu C, Vergara-López A, González-Virla B, Espinosa-de-Los-Monteros AL, Sosa-Eroza E, Cadena-Obando D, Cuevas-Ramos D, Portocarrero-Ortiz LA, Pérez-Reyes SP, Mercado-Cherem A, Ibarra-Salce R, Talavera JO. Surgical and Pharmacological Outcomes in Acromegaly: Real-Life Data From the Mexican Acromegaly Registry. J Clin Endocrinol Metab 2020; 105:5908275. [PMID: 32944780 DOI: 10.1210/clinem/dgaa664] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/16/2020] [Indexed: 02/13/2023]
Abstract
CONTEXT Acromegaly registries constitute a valuable source of therapeutic outcome information in real-life. OBJECTIVE The objective of this work is to analyze surgical and pharmacological outcomes in the Mexican Acromegaly Registry (MAR). DESIGN AND METHODS Data were extracted from the MAR informatic platform. Surgical remission was defined by a postoperative postglucose (GH) of less than 1 ng/mL and an insulin-like growth factor 1 (IGF-1) of less than 1.2 × upper limit of normal (ULN). Pharmacological remission was defined by a basal GH of less than 1 ng/mL and an IGF-1 of less than 1.2 × ULN. RESULTS A total of 650 surgical outcomes were analyzed (94.6% transsphenoidal). Surgical remission was achieved in 40.15%, whereas 44.15% remained biochemically active. Persistently active disease after surgery was significantly associated with harboring an invasive macroadenoma, a basal GH of greater than 10 ng/mL, and/or an IGF-1 of greater than 2 × ULN at diagnosis on bivariate and multivariate analysis. The outcome of monotherapy with first-generation somatostatin analogs (SSAs) was evaluated in 267 patients (adjunctive in 65%), of whom 28.4% achieved remission. Persistently active disease was significantly associated with harboring an invasive macroadenoma as well as with pretreatment basal GH and IGF-1 levels of greater than 10 ng/mL and greater than 2 × ULN, respectively, on bivariate and multivariate analysis. Combined therapy with SSA and cabergoline was analyzed in 100 patients, of whom 19% achieved remission and 44% remained active; in this subset of patients, only a pretreatment IGF-1 of greater than 2 × ULN was significantly associated with persistent disease activity. CONCLUSION Surgical and pharmacological outcomes in acromegaly are highly dependent on tumor size/invasiveness as well as on the degree of hypersomatotropinemia.
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Affiliation(s)
- Moisés Mercado
- Endocrinology Service and Research Unit in Endocrine Diseases, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, IMSS, México City, Mexico
| | - Coralys Abreu
- Endocrinology Service, Centro Médico Nacional 20 de noviembre, ISSSTE, México City, Mexico
| | - Alma Vergara-López
- Endocrinology Service, Centro Médico Nacional 20 de noviembre, ISSSTE, México City, Mexico
| | - Baldomero González-Virla
- Endocrinology Service and Research Unit in Endocrine Diseases, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, IMSS, México City, Mexico
| | - Ana-Laura Espinosa-de-Los-Monteros
- Endocrinology Service and Research Unit in Endocrine Diseases, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, IMSS, México City, Mexico
| | - Ernesto Sosa-Eroza
- Endocrinology Service and Research Unit in Endocrine Diseases, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, IMSS, México City, Mexico
| | - Diego Cadena-Obando
- Endocrinology Service and Research Unit in Endocrine Diseases, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, IMSS, México City, Mexico
| | - Daniel Cuevas-Ramos
- Neuroendocrinology Clinic, Department of Endocrinology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México City, Mexico
| | | | | | - Abraham Mercado-Cherem
- Endocrinology Service and Research Unit in Endocrine Diseases, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, IMSS, México City, Mexico
| | - Raúl Ibarra-Salce
- Endocrinology Service and Research Unit in Endocrine Diseases, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, IMSS, México City, Mexico
| | - Juan O Talavera
- División of Education and Research, American British Cowdray Medical Center, México City, Mexico
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Abreu C, Guinto G, Mercado M. Surgical-pharmacological interactions in the treatment of acromegaly. Expert Rev Endocrinol Metab 2019; 14:35-42. [PMID: 30595057 DOI: 10.1080/17446651.2019.1559729] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 12/13/2018] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Acromegaly requires a multimodal treatment approach that includes surgery by an expert pituitary neurosurgeon, pharmacological treatment with one or more of the available drugs and radiation therapy. These treatment alternatives are not mutually exclusive but rather complement each other when properly indicated in the individual patient. In this review, we summarize and analyze the available data concerning the choice of the surgical approach (microscopy vs. endoscopy) and the interactions between medical treatment with somatostatin analogs and pituitary surgery. AREAS COVERED Technical aspects, complications and outcome of transsphenoidal surgery (TSS); Advantages and disadvantages of the microscopic and endoscopic approaches; Safety and efficacy of somatostatin analogs (SSA); Primary pharmacological therapy versus primary TSS; Benefits of the preoperative treatment with SSA; and the effect of surgical tumor debulking in the therapeutic response to SSA. EXPERT COMMENTARY Continuing efforts at improving surgical techniques and at generating more efficacious pharmacological therapies for acromegaly are likely to improve the outcome of these patients. However, an integral approach of the patient aimed not only at achieving biochemical criteria of cure but also at treating the individual comorbidities is mandatory to improve the quality of life of these patients and to reduce their mortality rate.
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Affiliation(s)
- Coralys Abreu
- a Endocrinology Service , Centro Medico Nacional 20 de Noviembre, ISSSTE , Mexico City , Mexico
| | - Gerardo Guinto
- b Neurological Center , American British Cowdray Medical Center , Mexico City , Mexico
| | - Moisés Mercado
- c Experimental Endocrinology Unit , Hospital de Especialidades, Centro Medico Nacional S. XXI, IMSS , Mexico City , Mexico
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Microsurgical versus endoscopic transsphenoidal resection for acromegaly: a systematic review of outcomes and complications. Acta Neurochir (Wien) 2017; 159:2193-2207. [PMID: 28913667 DOI: 10.1007/s00701-017-3318-6] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 08/28/2017] [Indexed: 12/16/2022]
Abstract
PURPOSE The aim of this systematic review is to evaluate the long-term endocrine outcomes and postoperative complications following endoscopic vs. microscopic transsphenoidal resection (TSR) for the treatment of acromegaly. METHODS A literature review was performed, and studies with at least five patients who underwent TSR for acromegaly, reporting biochemical remission criteria and long-term remission outcomes were included. Data extracted from each study included surgical technique, perioperative complications, biochemical remission criteria, and long-term remission outcomes. RESULTS Fifty-two case series from 1976 to 2016 met the inclusion criteria, comprising 4375 patients. Thirty-six reports were microsurgical (n = 3144) and 13 were endoscopic (n = 940). Three studies compared microsurgical (n = 111) to endoscopic TSR outcomes (n = 180). The overall initial and long-term remission rates were 58.2 vs. 57.4% and 69.2 vs. 70.2% for the microsurgical and endoscopic groups, respectively. For microadenomas, the initial and long-term remission rates were 77.6 vs. 82.2% and 76.9 vs. 73.5% for microsurgical and endoscopic approaches, respectively. For macroadenomas, the initial and long-term remission rates were 46.9 vs. 60.0% and 40.2 vs. 61.5% for microsurgical and endoscopic approaches, respectively. The rates of postoperative CSF leak were 3.0 vs. 2.3% for the microscopic and endoscopic groups, respectively. The rates of hypopituitarism and transient diabetes insipidus were 6.7 vs. 6.4% and 9.0 vs. 7.8% for the microscopic and endoscopic groups, respectively. CONCLUSIONS Both endoscopic and microsurgical approaches for TSR of growth hormone-secreting adenomas are viable treatment options for patients with acromegaly, and yield similarly high rates of remission under the most current consensus criteria.
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Liu W, Xie L, He M, Shen M, Zhu J, Yang Y, Wang M, Hu J, Ye H, Li Y, Zhao Y, Zhang Z. Expression of Somatostatin Receptor 2 in Somatotropinoma Correlated with the Short-Term Efficacy of Somatostatin Analogues. Int J Endocrinol 2017; 2017:9606985. [PMID: 28396686 PMCID: PMC5370518 DOI: 10.1155/2017/9606985] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 01/23/2017] [Indexed: 11/17/2022] Open
Abstract
The expression of somatostatin receptor subtypes (SSTRs) in pituitary growth hormone- (GH-) secreting adenomas may predict the response to somatostatin analogues (SSA). Our aim was to evaluate the value of the immunohistochemical (IHC) scores of 2 subtypes, SSTR2 and SSTR5, in predicting the short-term efficacy of SSA therapy in patients with active acromegaly. Ninety-three newly diagnosed acromegalic patients were included in our study. These patients were categorized into either a SSA-pretreated group (SA, n = 63) or a direct-surgery group (DS, n = 30), depending on whether or not presurgical SSA treatment was received. IHC analysis, using a 12-grade scoring system, with rabbit monoclonal antibodies against SSTR2 and SSTR5, was performed on all adenoma tissues. The reduction of GH, IGF-1, and tumor size after treatment with SSA for 3 months was measured. Compared with that in the DS group, SSTR2 expression was lower in the SA group. Additionally, in the SA group, SSTR2 expression was positively correlated with the reduction of IGF-1 and tumor volume. However, there was no correlation between the SSTR5 score and the efficacy of SSA. In conclusion, the protein expression of SSTR2, but not of SSTR5, is a valuable indicator in predicting biochemical and tumor size response to short-term SSA treatment in acromegalic patients.
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Affiliation(s)
- Wenjuan Liu
- Division of Endocrinology and Metabolism, Huashan Hospital, Fudan University, Shanghai 200040, China
- Institute of Endocrinology and Diabetology, Fudan University, Shanghai 200040, China
| | - Lina Xie
- Department of Endocrinology, Kunshan Rehabilitation Hospital, Suzhou, Jiangsu 215314, China
| | - Min He
- Division of Endocrinology and Metabolism, Huashan Hospital, Fudan University, Shanghai 200040, China
- Institute of Endocrinology and Diabetology, Fudan University, Shanghai 200040, China
| | - Ming Shen
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai 200040, China
- Shanghai Pituitary Tumor Center, Shanghai 200040, China
| | - Jingjing Zhu
- Department of Pathology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Yeping Yang
- Division of Endocrinology and Metabolism, Huashan Hospital, Fudan University, Shanghai 200040, China
- Institute of Endocrinology and Diabetology, Fudan University, Shanghai 200040, China
| | - Meng Wang
- Division of Endocrinology and Metabolism, Huashan Hospital, Fudan University, Shanghai 200040, China
- Institute of Endocrinology and Diabetology, Fudan University, Shanghai 200040, China
| | - Ji Hu
- Department of Endocrinology, The Second Affiliated Hospital, Soochow University, Suzhou, Jiangsu 215004, China
| | - Hongying Ye
- Division of Endocrinology and Metabolism, Huashan Hospital, Fudan University, Shanghai 200040, China
- Shanghai Pituitary Tumor Center, Shanghai 200040, China
| | - Yiming Li
- Division of Endocrinology and Metabolism, Huashan Hospital, Fudan University, Shanghai 200040, China
- Institute of Endocrinology and Diabetology, Fudan University, Shanghai 200040, China
- Shanghai Pituitary Tumor Center, Shanghai 200040, China
| | - Yao Zhao
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai 200040, China
- Shanghai Pituitary Tumor Center, Shanghai 200040, China
| | - Zhaoyun Zhang
- Division of Endocrinology and Metabolism, Huashan Hospital, Fudan University, Shanghai 200040, China
- Institute of Endocrinology and Diabetology, Fudan University, Shanghai 200040, China
- Shanghai Pituitary Tumor Center, Shanghai 200040, China
- *Zhaoyun Zhang:
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Abstract
OBJECTIVE Acromegaly is a rare disease characterized by hypersecretion of growth hormone (GH), typically from a benign pituitary somatotroph adenoma, that leads to subsequent hypersecretion of insulin-like growth factor 1 (IGF-1). Patients with acromegaly have an increased risk of mortality and progressive worsening of comorbidities. Surgery, medical therapy, and radiotherapy are currently available treatment approaches for patients with acromegaly, with overall therapeutic goals of lowering GH levels and achieving normal IGF-1 levels, reducing tumor size, improving comorbidities, and minimizing mortality risk. Although surgery can lead to biochemical remission in some patients with acromegaly, many patients will continue to have uncontrolled disease and require additional treatment. METHODS We reviewed recently published reports and present a summary of the safety and efficacy of current treatment modalities for patients with acromegaly. RESULTS A substantial proportion of patients who receive medical therapy or radiotherapy will have persistently elevated GH and/or IGF-1. Because of the serious health consequences of continued elevation of GH and IGF-1, there is a need to improve therapeutic approaches to optimize biochemical control, particularly in high-need patient populations for whom current treatment options provide limited benefit. CONCLUSION This review discusses current treatment options for patients with acromegaly, limitations associated with each treatment approach, and areas within the current treatment algorithm, as well as patient populations for which improved therapeutic options are needed. Novel agents in development were also highlighted, which have the potential to improve management of patients with uncontrolled or persistent acromegaly.
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Duan L, Huang M, Yan H, Zhang Y, Gu F. Cost-effectiveness analysis of two therapeutic schemes in the treatment of acromegaly: a retrospective study of 168 cases. J Endocrinol Invest 2015; 38:717-23. [PMID: 25783618 DOI: 10.1007/s40618-015-0242-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 01/09/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE This study aimed to estimate the cost effectiveness of two therapeutic schemes, including preoperative medical therapy and surgery as primary therapy. METHODS A total of 168 acromegaly cases were retrospectively investigated for a comparative evaluation of surgery and preoperative medical therapy. A Markov model was developed to simulate treatment cost-effectiveness and progression of acromegaly. RESULTS Overall effectiveness of preoperative medical therapy was significantly higher than surgery in acromegalic patients with macroadenoma. In addition, life expectancy, and cost per life-year gained were slightly higher in the preoperative medical therapy group than in the initial surgery group when patients received surgery as a secondary treatment. Interestingly, preoperative medical therapy achieved a significant increase in life expectancy and reduced cost for patients who received long-term medical therapy as secondary treatment. CONCLUSIONS In acromegalic patients with macroadenoma, the cost-effectiveness analysis revealed more satisfactory outcomes in preoperative therapy, compared with primary surgery.
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Affiliation(s)
- L Duan
- Key Laboratory of Endocrinology, Ministry of Health, Department of Endocrinology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 100730, Beijing, China
| | - M Huang
- The Cardiology Department, Nanfang Hospital, 510515, Guangzhou, China
| | - H Yan
- Orthopedic Department, The Third Affiliated Hospital of Southern Medical University, 510630, Guangzhou, China
| | - Y Zhang
- Department of National Health Accounts and Policy Studies, China National Health Development Research Center, 100191, Beijing, China
| | - F Gu
- Key Laboratory of Endocrinology, Ministry of Health, Department of Endocrinology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 100730, Beijing, China.
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Matchekhina LV, Belaya ZE, Melnichenko GA, Shestakova MV. [Carbohydrate metabolism in patients with acromegaly and Itsenko-Cushing disease]. TERAPEVT ARKH 2015. [PMID: 28635800 DOI: 10.17116/terarkh2015871098-104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The relevance of investigating carbohydrate metabolism (CM) in patients with acromegaly and Itsenko-Cushing disease is attributable to frequent glucose metabolic disturbances, on the one hand, and to difficulties in choosing sugar-lowering therapy in these categories of patients, on the other. The efficiency of hyperglycemia treatment in these patients may be reduced due to problems in achieving remission/cure of the underlying disease and to specific therapy favoring hyperglycemia. The top-priority tasks are to search for ways of reducing the frequency of CM abnormalities in patients with neuroendocrine diseases and to elaborate sugar-lowering therapy regimens. There is a growing interest in studies of the role of the incretin system in the pathogenesis of secondary hyperglycemias associated with neuroendocrine diseases. Nevertheless, few works have been published on this subject matter because of its novelty. There is a need for a further closer study of the specific features of incretin system function and the pharmacodynamics of incretin mimetics that are potential candidates as first-line drugs to treat secondary hyperglycemias. This paper attempts to summarize the available data obtained from studies into CM in neuroendocrine diseases.
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Affiliation(s)
- L V Matchekhina
- Endocrinology Research Centre, Ministry of Health of Russia, Moscow, Russia
| | - Zh E Belaya
- Endocrinology Research Centre, Ministry of Health of Russia, Moscow, Russia
| | - G A Melnichenko
- Endocrinology Research Centre, Ministry of Health of Russia, Moscow, Russia
| | - M V Shestakova
- Endocrinology Research Centre, Ministry of Health of Russia, Moscow, Russia
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de los Monteros ALE, Carrasco CA, Albarrán AAR, Gadelha M, Abreu A, Mercado M. The role of primary pharmacological therapy in acromegaly. Pituitary 2014; 17 Suppl 1:S4-10. [PMID: 24166706 PMCID: PMC3906545 DOI: 10.1007/s11102-013-0530-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND OBJECTIVES Primary pharmacological therapy may be the only viable treatment option for many patients with acromegaly, especially those presenting with advanced disease with large inoperable tumors. Long-acting somatostatin analogs are currently the first-line treatment of choice in this setting, where they provide biochemical control and reduce tumor size in a significant proportion of patients. We herein present a brief overview of the role of primary pharmacological therapy in the treatment of acromegaly within the context of Latin America and support this with a representative case study. CASE DESCRIPTION A 20 year old male presented with clinical and biochemical evidence of acromegaly. The glucose-suppressed growth hormone (GH) was 5.3 μg/L, his insulin-like growth factor-1(IGF-1) was 3.5 times the ULN and serum prolactin greater than 4,000 μg/L. Pituitary MRI revealed a large and invasive mass, extending superiorly into the optic chiasm and laterally into the left cavernous sinus. He was treated with a combination of octreotide and cabergoline with remarkable clinical improvement, normalization of GH and IGF-1 values and striking shrinkage of the adenoma. CONCLUSION This case illustrates how effective the pharmacological therapy of acromegaly can be and yet at the same time, raises several important issues such as the need for life-long treatment with costly medications such as the somatostatin analogs. Access to these agents may be limited in regions where resources are restricted and clinicians face challenges in order to make the most efficient use of available options.
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Affiliation(s)
| | - Carmen A. Carrasco
- Endocrinology Department, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Alfredo Adolfo Reza Albarrán
- Endocrinology and Metabolism Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Mônica Gadelha
- Endocrinology Section, Hospital Universitário Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Alin Abreu
- Endocrinology Department, Hospital Imbanaco, Cali, Colombia
| | - Moisés Mercado
- Faculty of Medicine, Universidad Nacional Autónoma de México, Mexico City, Mexico
- Endocrine Service, and Experimental Endocrinology Unit, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, MD Aristóteles 68 Polanco, 11560 Mexico City, Mexico
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Abstract
INTRODUCTION Acromegaly is a rare disease that severely impacts patients' health all the while, being a slowly progressing illness. In the past decades, advancements in treatment modalities, especially development of new drugs, as well as focused guidelines has improved management of acromegaly. Still, many patients are considered not sufficiently treated and there remains an ongoing need for further development. AREAS COVERED This article reviews new medical treatments currently under clinical investigation (such as pasireotide, oral octreotide and somatoprim) and under experimental development (such as octreotide implants, CAM2029 and ATL-1103). EXPERT OPINION As it seems unlikely that one single agent may achieve cure in 100% of cases, there is an urgent need for new agents that help patients where current medication fails. Imperatively, this means we have to improve our understanding of the underlying pathogenetic and molecular mechanisms.
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Affiliation(s)
- Sylvère Störmann
- Klinikum der Universität München, Medizinische Klinik und Poliklinik IV , Ziemssenstr. 1, 80336 München , Germany +49 0 89 5160 2111 ; +49 0 89 5160 2194 ;
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