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Ghosh Laskar S, Sinha S, Kumar A, Samanta A, Mohanty S, Kale S, Khan F, Lewis Salins S, Murthy V. Reducing Salivary Toxicity with Adaptive Radiotherapy (ReSTART): A Randomized Controlled Trial Comparing Conventional IMRT to Adaptive IMRT in Head and Neck Squamous Cell Carcinomas. Clin Oncol (R Coll Radiol) 2024; 36:353-361. [PMID: 38575432 DOI: 10.1016/j.clon.2024.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 02/14/2024] [Accepted: 03/13/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND The utility of Adaptive Radiotherapy (ART) in Head and Neck Squamous Cell Carcinoma (HNSCC) remains to be ascertained. While multiple retrospective and single-arm prospective studies have demonstrated its efficacy in decreasing parotid doses and reducing xerostomia, adequate randomized evidence is lacking. METHODS AND ANALYSIS ReSTART (Reducing Salivary Toxicity with Adaptive Radiotherapy) is an ongoing phase III randomized trial of patients with previously untreated, locally advanced HNSCC of the oropharynx, larynx, and hypopharynx. Patients are randomized in a 1:1 ratio to the standard Intensity Modulated Radiotherapy (IMRT) arm {Planning Target Volume (PTV) margin 5 mm} vs. Adaptive Radiotherapy arm (standard IMRT with a PTV margin 3 mm, two planned adaptive planning at 10th and 20th fractions). The stratification factors include the primary site and nodal stage. The RT dose prescribed is 66Gy in 30 fractions for high-risk PTV and 54Gy in 30 fractions for low-risk PTV over six weeks, along with concurrent chemotherapy. The primary endpoint is to compare salivary toxicity between arms using salivary scintigraphy 12 months' post-radiation. To detect a 25% improvement in the primary endpoint at 12 months in the ART arm with a two-sided 5% alpha value and a power of 80% (and 10% attrition ratio), a sample size of 130 patients is required (65 patients in each arm). The secondary endpoints include acute and late toxicities, locoregional control, disease-free survival, overall survival, quality of life, and xerostomia scores between the two arms. DISCUSSION The ReSTART trial aims to answer an important question in Radiation Therapy for HNSCC, particularly in a resource-limited setting. The uniqueness of this trial, compared to other ongoing randomized trials, includes the PTV margins and the xerostomia assessment by scintigraphy at 12 months as the primary endpoint.
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Affiliation(s)
- S Ghosh Laskar
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India.
| | - S Sinha
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India.
| | - A Kumar
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India.
| | - A Samanta
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India.
| | - S Mohanty
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India.
| | - S Kale
- Department of Medical Physics, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India.
| | - F Khan
- Clinical Research Secretariat (CRS), Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India.
| | - S Lewis Salins
- Department of Radiation Oncology, Kasturba Medical College, Manipal, India.
| | - V Murthy
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India.
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Wang E, Yen A, Hrycushko B, Wang S, Lin J, Zhong X, Dohopolski M, Nwachukwu C, Iqbal Z, Albuquerque K. The accuracy of artificial intelligence deformed nodal structures in cervical online cone-beam-based adaptive radiotherapy. Phys Imaging Radiat Oncol 2024; 29:100546. [PMID: 38369990 PMCID: PMC10869256 DOI: 10.1016/j.phro.2024.100546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 01/31/2024] [Accepted: 02/01/2024] [Indexed: 02/20/2024] Open
Abstract
Background and Purpose Online cone-beam-based adaptive radiotherapy (ART) adjusts for anatomical changes during external beam radiotherapy. However, limited cone-beam image quality complicates nodal contouring. Despite this challenge, artificial-intelligence guided deformation (AID) can auto-generate nodal contours. Our study investigated the optimal use of such contours in cervical online cone-beam-based ART. Materials and Methods From 136 adaptive fractions across 21 cervical cancer patients with nodal disease, we extracted 649 clinically-delivered and AID clinical target volume (CTV) lymph node boost structures. We assessed geometric alignment between AID and clinical CTVs via dice similarity coefficient, and 95% Hausdorff distance, and geometric coverage of clinical CTVs by AID planning target volumes by false positive dice. Coverage of clinical CTVs by AID contour-based plans was evaluated using D100, D95, V100%, and V95%. Results Between AID and clinical CTVs, the median dice similarity coefficient was 0.66 and the median 95 % Hausdorff distance was 4.0 mm. The median false positive dice of clinical CTV coverage by AID planning target volumes was 0. The median D100 was 1.00, the median D95 was 1.01, the median V100% was 1.00, and the median V95% was 1.00. Increased nodal volume, fraction number, and daily adaptation were associated with reduced clinical CTV coverage by AID-based plans. Conclusion In one of the first reports on pelvic nodal ART, AID-based plans could adequately cover nodal targets. However, physician review is required due to performance variation. Greater attention is needed for larger, daily-adapted nodes further into treatment.
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Affiliation(s)
- Ethan Wang
- University of Texas Southwestern Medical Center, Department of Radiation Oncology, Dallas, TX, United States
| | - Allen Yen
- University of Texas Southwestern Medical Center, Department of Radiation Oncology, Dallas, TX, United States
| | - Brian Hrycushko
- University of Texas Southwestern Medical Center, Department of Radiation Oncology, Dallas, TX, United States
| | - Siqiu Wang
- University of Texas Southwestern Medical Center, Department of Radiation Oncology, Dallas, TX, United States
| | - Jingyin Lin
- University of Texas Southwestern Medical Center, Department of Radiation Oncology, Dallas, TX, United States
| | - Xinran Zhong
- University of Texas Southwestern Medical Center, Department of Radiation Oncology, Dallas, TX, United States
| | - Michael Dohopolski
- University of Texas Southwestern Medical Center, Department of Radiation Oncology, Dallas, TX, United States
| | - Chika Nwachukwu
- University of Texas Southwestern Medical Center, Department of Radiation Oncology, Dallas, TX, United States
| | - Zohaib Iqbal
- University of Texas Southwestern Medical Center, Department of Radiation Oncology, Dallas, TX, United States
| | - Kevin Albuquerque
- University of Texas Southwestern Medical Center, Department of Radiation Oncology, Dallas, TX, United States
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Yoganathan S, Aouadi S, Ahmed S, Paloor S, Torfeh T, Al-Hammadi N, Hammoud R. Generating synthetic images from cone beam computed tomography using self-attention residual UNet for head and neck radiotherapy. Phys Imaging Radiat Oncol 2023; 28:100512. [PMID: 38111501 PMCID: PMC10726231 DOI: 10.1016/j.phro.2023.100512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 11/09/2023] [Accepted: 11/09/2023] [Indexed: 12/20/2023] Open
Abstract
Background and purpose Accurate CT numbers in Cone Beam CT (CBCT) are crucial for precise dose calculations in adaptive radiotherapy (ART). This study aimed to generate synthetic CT (sCT) from CBCT using deep learning (DL) models in head and neck (HN) radiotherapy. Materials and methods A novel DL model, the 'self-attention-residual-UNet' (ResUNet), was developed for accurate sCT generation. ResUNet incorporates a self-attention mechanism in its long skip connections to enhance information transfer between the encoder and decoder. Data from 93 HN patients, each with planning CT (pCT) and first-day CBCT images were used. Model performance was evaluated using two DL approaches (non-adversarial and adversarial training) and two model types (2D axial only vs. 2.5D axial, sagittal, and coronal). ResUNet was compared with the traditional UNet through image quality assessment (Mean Absolute Error (MAE), Peak-Signal-to-Noise Ratio (PSNR), Structural Similarity Index (SSIM)) and dose calculation accuracy evaluation (DVH deviation and gamma evaluation (1 %/1mm)). Results Image similarity evaluation results for the 2.5D-ResUNet and 2.5D-UNet models were: MAE: 46±7 HU vs. 51±9 HU, PSNR: 66.6±2.0 dB vs. 65.8±1.8 dB, and SSIM: 0.81±0.04 vs. 0.79±0.05. There were no significant differences in dose calculation accuracy between DL models. Both models demonstrated DVH deviation below 0.5 % and a gamma-pass-rate (1 %/1mm) exceeding 97 %. Conclusions ResUNet enhanced CT number accuracy and image quality of sCT and outperformed UNet in sCT generation from CBCT. This method holds promise for generating precise sCT for HN ART.
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Affiliation(s)
- S.A. Yoganathan
- Department of Radiation Oncology, National Center for Cancer Care & Research (NCCCR), Hamad Medical Corporation, Doha, Qatar
| | - Souha Aouadi
- Department of Radiation Oncology, National Center for Cancer Care & Research (NCCCR), Hamad Medical Corporation, Doha, Qatar
| | - Sharib Ahmed
- Department of Radiation Oncology, National Center for Cancer Care & Research (NCCCR), Hamad Medical Corporation, Doha, Qatar
| | - Satheesh Paloor
- Department of Radiation Oncology, National Center for Cancer Care & Research (NCCCR), Hamad Medical Corporation, Doha, Qatar
| | - Tarraf Torfeh
- Department of Radiation Oncology, National Center for Cancer Care & Research (NCCCR), Hamad Medical Corporation, Doha, Qatar
| | - Noora Al-Hammadi
- Department of Radiation Oncology, National Center for Cancer Care & Research (NCCCR), Hamad Medical Corporation, Doha, Qatar
| | - Rabih Hammoud
- Department of Radiation Oncology, National Center for Cancer Care & Research (NCCCR), Hamad Medical Corporation, Doha, Qatar
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Gupta A, Dunlop A, Mitchell A, McQuaid D, Nill S, Barnes H, Newbold K, Nutting C, Bhide S, Oelfke U, Harrington KJ, Wong KH. Online adaptive radiotherapy for head and neck cancers on the MR linear Accelerator: Introducing a novel modified Adapt-to-Shape approach. Clin Transl Radiat Oncol 2022; 32:48-51. [PMID: 34849412 PMCID: PMC8608651 DOI: 10.1016/j.ctro.2021.11.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 11/02/2021] [Accepted: 11/04/2021] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION The Elekta Unity MR-Linac (MRL) has enabled adaptive radiotherapy (ART) for patients with head and neck cancers (HNC). Adapt-To-Shape-Lite (ATS-Lite) is a novel Adapt-to-Shape strategy that provides ART without requiring daily clinician presence to perform online target and organ at risk (OAR) delineation. In this study we compared the performance of our clinically-delivered ATS-Lite strategy against three Adapt-To-Position (ATP) variants: Adapt Segments (ATP-AS), Optimise Weights (ATP-OW), and Optimise Shapes (ATP-OS). METHODS Two patients with HNC received radical-dose radiotherapy on the MRL. For each fraction, an ATS-Lite plan was generated online and delivered and additional plans were generated offline for each ATP variant. To assess the clinical acceptability of a plan for every fraction, twenty clinical goals for targets and OARs were assessed for all four plans. RESULTS 53 fractions were analysed. ATS-Lite passed 99.9% of mandatory dose constraints. ATP-AS and ATP-OW each failed 7.6% of mandatory dose constraints. The Planning Target Volumes for 54 Gy (D95% and D98%) were the most frequently failing dose constraint targets for ATP. ATS-Lite median fraction times for Patient 1 and 2 were 40 mins 9 s (range 28 mins 16 s - 47 mins 20 s) and 32 mins 14 s (range 25 mins 33 s - 44 mins 27 s), respectively. CONCLUSIONS Our early data show that the novel ATS-Lite strategy produced plans that fulfilled 99.9% of clinical dose constraints in a time frame that is tolerable for patients and comparable to ATP workflows. Therefore, ATS-Lite, which bridges the gap between ATP and full ATS, will be further utilised and developed within our institute and it is a workflow that should be considered for treating patients with HNC on the MRL.
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Affiliation(s)
- Amit Gupta
- The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, Head & Neck Unit, 15 Cotswold Road, Sutton, London SM2 5NG, United Kingdom
| | - Alex Dunlop
- The Joint Department of Physics, The Royal Marsden Hospital and the Institute of Cancer Research; Downs Road, Sutton SM2 5PT, United Kingdom
| | - Adam Mitchell
- The Joint Department of Physics, The Royal Marsden Hospital and the Institute of Cancer Research; Downs Road, Sutton SM2 5PT, United Kingdom
| | - Dualta McQuaid
- The Joint Department of Physics, The Royal Marsden Hospital and the Institute of Cancer Research; Downs Road, Sutton SM2 5PT, United Kingdom
| | - Simeon Nill
- The Joint Department of Physics, The Royal Marsden Hospital and the Institute of Cancer Research; Downs Road, Sutton SM2 5PT, United Kingdom
| | - Helen Barnes
- The Royal Marsden NHS Foundation Trust; Downs Road, Sutton SM2 5PT, United Kingdom
| | - Kate Newbold
- The Royal Marsden NHS Foundation Trust; Downs Road, Sutton SM2 5PT, United Kingdom
| | - Chris Nutting
- The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, Head & Neck Unit, 15 Cotswold Road, Sutton, London SM2 5NG, United Kingdom
| | - Shreerang Bhide
- The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, Head & Neck Unit, 15 Cotswold Road, Sutton, London SM2 5NG, United Kingdom
| | - Uwe Oelfke
- The Joint Department of Physics, The Royal Marsden Hospital and the Institute of Cancer Research; Downs Road, Sutton SM2 5PT, United Kingdom
| | - Kevin Joseph Harrington
- The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, Head & Neck Unit, 15 Cotswold Road, Sutton, London SM2 5NG, United Kingdom
| | - Kee Howe Wong
- The Royal Marsden NHS Foundation Trust; Downs Road, Sutton SM2 5PT, United Kingdom
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Barnes H, Alexander S, Bower L, Ehlers J, Gani C, Herbert T, Lawes R, Møller PK, Morgan T, Nowee ME, Smith G, van Triest B, Tyagi N, Whiteside L, McNair H. Development and results of a patient-reported treatment experience questionnaire on a 1.5 T MR-Linac. Clin Transl Radiat Oncol 2021; 30:31-37. [PMID: 34307911 PMCID: PMC8283148 DOI: 10.1016/j.ctro.2021.06.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 06/02/2021] [Accepted: 06/23/2021] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION With the implementation of new radiotherapy technology, it is imperative that patient experience is investigated alongside efficacy and outcomes. This paper presents the development of a specifically designed validated questionnaire and a first report of international multi-institutional preliminary patient experience of MRI-guided adaptive radiotherapy (MRgART) on the 1.5 T MR-Linac (MRL). METHODS A patient experience questionnaire was developed and validated before being distributed to the Elekta MRL Consortium, to gather first patient-reported experience from participating centres worldwide. The final version of the questionnaire contains 18 questions covering a range of themes and was scored on a Likert scale of 0-3. Responses were post-processed so that a score of 0 represents a negative response and 3 represents the most favourable response. These results were analysed for patient-reported experience of treatment on the MRL. Results were also analysed for internal consistency of the questionnaire using Chronbach's Alpha and the questionnaire contents were validated for relevance using content validity indexes (CVI). RESULTS 170 responses were received from five centres, representing patients with a wide range of tumour treatment sites from four different countries. MRgART was well tolerated with an 84% favourable response across all questions and respondents. When analysed by theme, all reported the highest percentage of results in the favourable categories (2 and 3). Internal consistency in the questionnaire was high (Cronbach's α = 0.8) and the item-level CVI for each question was 0.78 or above and the Scale-level CVI was 0.93, representing relevant content. CONCLUSION The developed questionnaire has been validated as relevant and appropriate for use in reporting experience of patients undergoing treatment on the MRL. The overall patient-reported experience and satisfaction from multiple centres within the Elekta MRL Consortium was consistently high. These results can reinforce user confidence in continuing to expand and develop MRL use in adaptive radiotherapy.
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Affiliation(s)
- Helen Barnes
- Royal Marsden NHS Foundation Trust, United Kingdom
| | | | - Lorna Bower
- Royal Marsden NHS Foundation Trust, United Kingdom
- Institute of Cancer Research, United Kingdom
| | - Jakob Ehlers
- Department for Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
| | - Cihan Gani
- Department for Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
| | | | | | | | - Toby Morgan
- Royal Marsden NHS Foundation Trust, United Kingdom
- Institute of Cancer Research, United Kingdom
| | | | | | | | - Neelam Tyagi
- Memorial Sloan Kettering Cancer Centre, United States
| | | | - Helen McNair
- Royal Marsden NHS Foundation Trust, United Kingdom
- Institute of Cancer Research, United Kingdom
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Eccles C, Adair Smith G, Bower L, Hafeez S, Herbert T, Hunt A, McNair H, Ofuya M, Oelfke U, Nill S, Huddart R. Magnetic resonance imaging sequence evaluation of an MR Linac system; early clinical experience. Tech Innov Patient Support Radiat Oncol 2019; 12:56-63. [PMID: 32095556 PMCID: PMC7033780 DOI: 10.1016/j.tipsro.2019.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 11/06/2019] [Accepted: 11/11/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To systematically identify the preferred magnetic resonance imaging (MRI) sequences following volunteer imaging on a 1.5 Tesla (T) MR-Linear Accelerator (MR Linac) for future protocol development. METHODS Non-patient volunteers were recruited to a Research and Ethics committee approved prospective MR-only imaging study on a 1.5T MR Linac system. Volunteers attended 1-3 imaging sessions that included a combination of mDixon, T1w, T2w sequences using 2-dimensional (2D) and 3-dimensional (3D) acquisitions. Each sequence was acquired over 2-7 minutes and reviewed by a panel of 3 observers to evaluate image quality using a visual grading analysis based on a 4-point Likert scale. Sequences were acquired and modified iteratively until deemed fit for purpose (online image matching or re-planning) and all observers agreed they were suitable in 3 volunteers. RESULTS 26 volunteers underwent 31 imaging sessions of six general anatomical regions. Images were acquired in one or two of six general anatomical regions: male pelvis (n = 9), female pelvis (n = 4), chestwall/breast (n = 5), lung/oesophagus (n = 5), abdomen (n = 3) and head and neck (n = 5). Images were acquired using a pre-defined exam-card that on average, included six sequences (range 2-10), with a maximum scan time of approximately one hour. The majority of observers preferred T2-weighted sequences. The thorax teams were the only groups to prefer T1-weighted imaging. CONCLUSIONS An iterative process identified sequence agreement in all anatomical regions. These sequences will now be evaluated in patient volunteers. ADVANCES IN KNOWLEDGE This manuscript is the first publication sharing the results of the first systematic selection of MRI sequences for use in on-board MRI-guided radiotherapy by end-users (therapeutic radiographers and clinical oncologists) in healthy volunteers.
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Affiliation(s)
- C.L. Eccles
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
- The Christie NHS Foundation Trust, and the University of Manchester, Manchester, United Kingdom
| | - G. Adair Smith
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - L. Bower
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
- The Institute of Cancer Research/The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - S. Hafeez
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
- The Institute of Cancer Research/The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - T. Herbert
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - A. Hunt
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
- The Institute of Cancer Research/The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - H.A. McNair
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
- The Institute of Cancer Research/The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Mercy Ofuya
- Clinical Trials and Statistic Unit, The Institute for Cancer Research, London, United Kingdom
| | - Uwe Oelfke
- Joint Department of Physics at the Royal Marsden and The Institute of Cancer Research, United Kingdom
| | - Simeon Nill
- Joint Department of Physics at the Royal Marsden and The Institute of Cancer Research, United Kingdom
| | - R.A. Huddart
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
- The Institute of Cancer Research/The Royal Marsden NHS Foundation Trust, London, United Kingdom
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