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Manual of Cardio-oncology pp 191–213Cite as

Radiotherapy: Clinical Aspects and Cardiotoxicity

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Abstract

Radiation therapy (RT) causes inflammation, activation of pro-fibrotic cytokines, and endothelial and microvascular damage. Radiation increases oxidative stress through free radical production and results in recruitment of matrix metalloproteinases and pro-inflammatory mediators. These changes may lead to acute toxicity (evident during or shortly after radiotherapy) and start a chronic process leading to delayed dysfunction that is evident several years later. Acute changes largely result from direct radiation damage and the immediate inflammatory response, while long-term changes are due to stem cell loss and late and persistent tissue fibrosis. Thus, chronic radiation-induced damage is irreversible and can affect multiple cardiac structures including the coronary arteries, myocardium, pericardium, cardiac valves, and the conduction system. The incidence of acute pericarditis has decreased over time from 20 % to 2.5 % with modern radiation techniques; therapy is the same as for acute viral or idiopathic pericarditis. Ventricular dysfunction is a rare event. It is more frequent when an anthracycline or high-dose chemotherapy is administered concurrently, or shortly before RT, since radiation interacts synergistically to induce myocardial damage.Delayed radiation-induced heart disease (RIHD) is a significant problem, especially in long-term survivors of lymphoma and breast cancer. The median time from RT to appearance of clinically significant RIHD is 15 years, with the incidence increasing progressively over time. All the patients treated with mediastinal or chest radiotherapy more than 10 years ago should be object of an active program of prevention and follow-up. The follow-up should last lifelong. Many cancer patients who achieved complete remission are dismissed by the oncological follow-up after 5–10 years. Few patients have the opportunity to be included in a cancer survivor clinic for long-term follow-up of treatment-related disease. The general practitioners and the cardiologists should take care of this problem. The group at highest risk is represented by childhood cancer survivors, and this problem has been addressed in Chap. 16. Coronary Artery Disease (CAD) is the most frequent and relevant form of RIHD. The risk of death due to acute myocardial infarction (AMI) is two- to fourfold higher in patients treated for Hodgkin lymphoma compared with age-matched controls, but can be increased sevenfold or higher in some subgroups. The mechanism involved in plaque formation is thought to mirror spontaneous atherosclerosis; however, plaques in irradiated patients have been found to be more fibrous with decreased lipid content, and the lesions are consistently more proximal, smoother, concentric, tubular, and longer. Left ventricular (LV) dysfunction is a frequent complication of chest RT, and may be due to: macroscopic CAD leading to chronic ischemia; decrease in capillary density resulting in myocyte hypoxia; direct myocyte damage and necrosis, more evident in synergy with anthracycline cardiotoxicity, with progressive fibrosis replacing viable myocardial tissue; increase in type I collagen rather than type III collagen, leading to reduced myocardial distensibility. Valvular heart disease (VHD) ranges from sclerosis to severe, often calcific, valvular stenosis and/or regurgitation. It is more common after mediastinal RT in comparison to chest wall RT for breast cancer. Among breast cancer patients, it is more common after left-sided RT in comparison to right-sided RT. Chronic pericarditis may develop as a consequence of acute pericarditis seen during or shortly after RT and as a delayed complication. Most patients have a combination of restrictive and constrictive disease and pericardial stripping does not afford similar benefits in RT patients compared to those with constriction due to other causes. Arrhythmias can be seen as a consequence of RT, and may be both hyperkinetic and hypokinetic. Inappropriate sinus tachycardia, both at rest and during effort, is common after thoracic RT and is felt to be a consequence of autonomic dysfunction. Bundle branch and atrio-ventricular blocks may also be observed. Radiation-induced carotid disease produces carotid lesions that are more extensive than the traditional bifurcation stenosis and often involves atypical areas such as long segments of the carotid artery. The global risk of cerebrovascular events is increased and the common atherosclerosis risk factors and preexisting atherosclerotic lesions are exacerbating factors In patients presenting with symptoms of dyspnea, fatigue, and reduced exercise tolerance, it is important to consider other organs that may be affected by RT or chemotherapy in the differential diagnosis: acute, chronic and recall radiation pneumonitis should be ruled out; chemotherapyinduced lung disease may be observed with several agents, mostly with bleomycin; radiation fields including the neck (such as mantle field used for HL) may cause thyroid dysfunction, most frequently hypothyroidism..

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References

  1. Taunk NK, Haffty BG, Kostis JB, Goyal S. Radiation-induced heart disease: pathologic abnormalities and putative mechanisms. Front Oncol. 2015;5:39.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Murthy SC, Rozas MS, Adelstein DJ, et al. Induction chemoradiotherapy increases pleural and pericardial complications after esophagectomy for cancer. J Thorac Oncol. 2009;4:395–403.

    Article  PubMed  Google Scholar 

  3. Murdych T, Weisdorf DJ. Serious cardiac complications during bone marrow transplantation at the University of Minnesota, 1977-1997. Bone Marrow Transplant. 2001;28:283–7.

    Article  CAS  PubMed  Google Scholar 

  4. de Ville de Goyet M, Brichard B, et al. Prospective cardiac MRI for the analysis of biventricular function in children undergoing cancer treatments. Pediatr Blood Cancer. 2015;62:867–74.

    Article  Google Scholar 

  5. Marks LB, Yu X, Prosnitz RG, et al. The incidence and functional consequences of RT-associated cardiac perfusion defects. Int J Radiat Oncol Biol Phys. 2005;63(1):214–23.

    Article  PubMed  Google Scholar 

  6. Gayed I, Gohar S, Liao Z, et al. The clinical implications of myocardial perfusion abnormalities in patients with esophageal or lung cancer after chemoradiation therapy. Int J Cardiovasc Imaging. 2009;25:487–95.

    Article  PubMed  Google Scholar 

  7. Galper SL, Yu JB, Mauch PM, et al. Clinically significant cardiac disease in patients with Hodgkin lymphoma treated with mediastinal irradiation. Blood. 2011;117:412–8.

    Article  CAS  PubMed  Google Scholar 

  8. Darby SC, Ewertz M, McGale P, et al. Risk of ischemic heart disease in women after radiotherapy for breast cancer. N Engl J Med. 2013;368:987–98.

    Article  CAS  PubMed  Google Scholar 

  9. Adams MJ, Hardenbergh PH, Constine LS, Lipshultz SE. Radiation-associated cardiovascular disease. Crit Rev Oncol Hematol. 2003;45:55–75. Review.

    Article  PubMed  Google Scholar 

  10. Gaya AM, Ashford RF. Cardiac complications of radiation therapy. Clin Oncol (R Coll Radiol). 2005;17:153–9. Review.

    Article  CAS  Google Scholar 

  11. van Nimwegen FA, Schaapveld M, Janus CP, et al. Cardiovascular disease after hodgkin lymphoma treatment: 40-year disease risk. JAMA Intern Med. 2015;175:1007–17.

    Article  PubMed  Google Scholar 

  12. Swerdlow AJ, Higgins CD, Smith P, et al. Myocardial infarction mortality risk after treatment for Hodgkin disease: a collaborative British cohort study. J Natl Cancer Inst. 2007;99:206–14.

    Article  PubMed  Google Scholar 

  13. Duma MN, Molls M, Trott KR. From heart to heart for breast cancer patients-cardiovascular toxicities in breast cancer radiotherapy. Strahlenther Onkol. 2014;190:5–7.

    Article  CAS  PubMed  Google Scholar 

  14. Daniëls LA, Krol AD, de Graaf MA, et al. Screening for coronary artery disease after mediastinal irradiation in Hodgkin lymphoma survivors: phase II study of indication and acceptance†. Ann Oncol. 2014;25:1198–203.

    Article  PubMed  Google Scholar 

  15. Heidenreich PA, Hancock SL, Vagelos RH, et al. Diastolic dysfunction after mediastinal irradiation. Am Heart J. 2005;150:977–82.

    Article  PubMed  Google Scholar 

  16. McGale P, Darby SC, Hall P, et al. Incidence of heart disease in 35,000 women treated with radiotherapy for breast cancer in Denmark and Sweden. Radiother Oncol. 2011;100:167–75.

    Article  PubMed  Google Scholar 

  17. Cella L, Liuzzi R, Conson M, et al. Dosimetric predictors of asymptomatic heart valvular dysfunction following mediastinal irradiation for Hodgkin’s lymphoma. Radiother Oncol. 2011;101:316–32.

    Article  PubMed  Google Scholar 

  18. Wethal T, Lund MB, Edvardsen T, et al. Valvular dysfunction and left ventricular changes in Hodgkin's lymphoma survivors. A longitudinal study. Br J Cancer. 2009;101:575–81.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Handa N, McGregor CG, Danielson GK, et al. Valvular heart operation in patients with previous mediastinal radiation therapy. Ann Thorac Surg. 2001;71:1880–4.

    Article  CAS  PubMed  Google Scholar 

  20. Schellong G, Riepenhausen M, Bruch C, et al. Late valvular and other cardiac diseases after different doses of mediastinal radiotherapy for Hodgkin disease in children and adolescents: report from the longitudinal GPOH follow-up project of the German-Austrian DAL-HD studies. Pediatr Blood Cancer. 2010;55:1145–52.

    Article  PubMed  Google Scholar 

  21. Cutter DJ, Schaapveld M, Darby SC, et al. Risk of valvular heart disease after treatment for Hodgkin lymphoma. J Natl Cancer Inst. 2015;107(4)

    Google Scholar 

  22. Groarke JD, Tanguturi VK, Hainer J, et al. Abnormal exercise response in long-term survivors of hodgkin lymphoma treated with thoracic irradiation: evidence of cardiac autonomic dysfunction and impact on outcomes. J Am Coll Cardiol. 2015;65:573–83.

    Article  PubMed  Google Scholar 

  23. Slama MS, Le Guludec D, Sebag C, et al. Complete atrioventricular block following mediastinal irradiation: a report of six cases. Pacing Clin Electrophysiol. 1991;14:1112–8.

    Article  CAS  PubMed  Google Scholar 

  24. Orzan F, Brusca A, Gaita F, et al. Associated cardiac lesions in patients with radiation-induced complete heart block. Int J Cardiol. 1993;39:151–6.

    Article  CAS  PubMed  Google Scholar 

  25. Heidenreich PA, Hancock SL, Lee BK, et al. Asymptomatic cardiac disease following mediastinal irradiation. J Am Coll Cardiol. 2003;42:743–9.

    Article  PubMed  Google Scholar 

  26. Chargari C, Riet F, Mazevet M, et al. Complications of thoracic radiotherapy. Presse Med. 2013;42:e342–51.

    Article  PubMed  Google Scholar 

  27. Ding X, Ji W, Li J, Zhang X, Wang L. Radiation recall pneumonitis induced by chemotherapy after thoracic radiotherapy for lung cancer. Radiat Oncol. 2011;6:24.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Levy A, Hollebecque A, Bourgier C, et al. Targeted therapy-induced radiation recall. Eur J Cancer. 2013;49:1662–8.

    Article  PubMed  Google Scholar 

  29. Limper AH. Chemotherapy-induced lung disease. Clin Chest Med. 2004;25:53–64.

    Article  PubMed  Google Scholar 

  30. Della Latta V, Cecchettini A, Del Ry S, Morales MA. Bleomycin in the setting of lung fibrosis induction: From biological mechanisms to counteractions. Pharmacol Res. 2015;97:122–30.

    Article  CAS  PubMed  Google Scholar 

  31. Hancock SL, Cox RS, McDougall IR. Thyroid Diseases after Treatment of Hodgkin's Disease. N Engl J Med. 1991;325:599–605.

    Article  CAS  PubMed  Google Scholar 

  32. Jereczek-Fossa BA, Alterio D, Jassem J, et al. Radiotherapy-induced thyroid disorders. Cancer Treat Rev. 2004;30:369–84. Review.

    Article  CAS  PubMed  Google Scholar 

  33. Lancellotti P, Nkomo VT, Badano LP, et al.; European Society of Cardiology Working Groups on Nuclear Cardiology and Cardiac Computed Tomography and Cardiovascular Magnetic Resonance; American Society of Nuclear Cardiology; Society for Cardiovascular Magnetic Resonance; Society of Cardiovascular Computed Tomography. Expert consensus for multi-modality imaging evaluation of cardiovascular complications of radiotherapy in adults: a report from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. Eur Heart J Cardiovasc Imaging. 2013;14:721–40.

    Google Scholar 

  34. Jaworski C, Mariani JA, Wheeler G, Kaye DM. Cardiac complications of thoracic irradiation. J Am Coll Cardiol. 2013;61:2319–28.

    Article  PubMed  Google Scholar 

  35. Heidenreich P, Schnittger I, Strauss H, et al. Screening for coronary artery disease after mediastinal irradiation for Hodgkin's disease. J Clin Oncol. 2007;25:43–9.

    Article  PubMed  Google Scholar 

  36. Kupeli S, Hazirolan T, Varan A, et al. Evaluation of coronary artery disease by computed tomography angiography in patients treated for childhood Hodgkin's lymphoma. J Clin Oncol. 2010;28:1025–30.

    Article  PubMed  Google Scholar 

  37. Schwitter J, Arai AE. Assessment of cardiac ischaemia and viability: role of cardiovascular magnetic resonance. Eur Heart J. 2011;32:799–809.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Greenwood JP, Maredia N, Younger JF, et al. Cardiovascular magnetic resonance and single-photon emission computed tomography for diagnosis of coronary heart disease (CE-MARC): a prospective trial. Lancet. 2012;379:453–60.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Machann W, Beer M, Breunig M, et al. Cardiac magnetic resonance imaging findings in 20-year survivors of mediastinal radiotherapy for Hodgkin's disease. Int J Radiat Oncol Biol Phys. 2011;79:1117–23.

    Article  PubMed  Google Scholar 

  40. Pierga J, Maunoury C, Valette H, et al. Follow-up thallium-201 scintigraphy after mantle field radiotherapy for Hodgkin's disease. Int J Radiat Oncol Biol Phys. 1993;25:871–6.

    Article  CAS  PubMed  Google Scholar 

  41. Mulrooney DA, Nunnery SE, Armstrong GT, et al. Coronary artery disease detected by coronary computed tomography angiography in adult survivors of childhood Hodgkin lymphoma. Cancer. 2014;120:3536–44.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Grothues F, Smith G, Moon JC, et al. Comparison of interstudy reproducibility of cardiovascular magnetic resonance with two-dimensional echocardiography in normal subjects and in patients with heart failure or left ventricular hypertrophy. Am J Cardiol. 2002;90:29–34.

    Article  PubMed  Google Scholar 

  43. Caudron J, Fares J, Bauer F, Dacher JN. Evaluation of left ventricular diastolic function with cardiac MR imaging. Radiographics. 2011;31:239–59.

    Article  PubMed  Google Scholar 

  44. Brouwer C, Postma A, Vonk J, et al. Systolic and diastolic dysfunction in long-term adult survivors of childhood cancer. Eur J Cancer. 2011;47:2453–62.

    Article  PubMed  Google Scholar 

  45. Nagueh S, Appleton C, Gillebert T, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography. Eur J Echocardiogr. 2009;10:165–93.

    Article  PubMed  Google Scholar 

  46. Dickerson JA, Raman SV, Baker PM, Leier CV. Relationship of cardiac magnetic resonance imaging and myocardial biopsy in the evaluation of nonischemic cardiomyopathy. Congest Heart Fail. 2013;19:29–38.

    Article  PubMed  Google Scholar 

  47. Zurick A, Bolen M, Kwon D, et al. Pericardial delayed hyperenhancement with CMR imaging in patients with constrictive pericarditis undergoing surgical pericardiectomy: a case series with histopathological correlation. JACC Cardiovasc Imaging. 2011;4:1180–91.

    Article  PubMed  Google Scholar 

  48. Feng D, Glockner J, Kim K, et al. Cardiac magnetic resonance imaging pericardial late gadolinium enhancement and elevated inflammatory markers can predict the reversibility of constrictive pericarditis after antiinflammatory medical therapy: a pilot study. Circulation. 2011;124:1830–7.

    Article  CAS  PubMed  Google Scholar 

  49. Francone M, Dymarkowski S, Kalantzi M, et al. Assessment of ventricular coupling with real-time cine MRI and its value to differentiate constrictive pericarditis from restrictive cardiomyopathy. Eur Radiol. 2006;16:944–51.

    Article  PubMed  Google Scholar 

  50. Thavendiranathan P, Verhaert D, Walls M, et al. Simultaneous right and left heart real-time, free-breathing CMR flow quantification identifies constrictive physiology. JACC Cardiovasc Imaging. 2012;5:15–24.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Johansen S, Tjessem KH, Fosså K, et al. Dose Distribution in the Heart and Cardiac Chambers Following 4-field Radiation Therapy of Breast Cancer: a Retrospective Study. Breast Cancer (Auckl). 2013;7:41–9.

    Google Scholar 

  52. Tian S, Hirshfield KM, Jabbour SK, et al. Serum biomarkers for the detection of cardiac toxicity after chemotherapy and radiation therapy in breast cancer patients. Front Oncol. 2014;4:277.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Schömig K, Ndrepepa G, Mehilli J, et al. Thoracic radiotherapy in patients with lymphoma and restenosis after coronary stent placement. Catheter Cardiovasc Interv. 2007;70:359–65.

    Article  PubMed  Google Scholar 

  54. Brown ML, Schaff HV, Sundt TM. Conduit choice for coronary artery bypass grafting after mediastinal radiation. J Thorac Cardiovasc Surg. 2008;136:1167–71.

    Article  PubMed  Google Scholar 

  55. Ling LH, Oh JK, Schaff HV, et al. Constrictive pericarditis in the modern era: evolving clinical spectrum and impact on outcome after pericardiectomy. Circulation. 1999;100:1380–6.

    Article  CAS  PubMed  Google Scholar 

  56. Bertog SC, Thambidorai SK, Parakh K, et al. Constrictive pericarditis: etiology and cause specific survival after pericardiectomy. J Am Coll Cardiol. 2004;43:1445–52.

    Article  PubMed  Google Scholar 

  57. Crestanello JA, McGregor CG, Danielson GK, et al. Mitral and tricuspid valve repair in patients with previous mediastinal radiation therapy. Ann Thorac Surg. 2004;78:826–31.

    Article  PubMed  Google Scholar 

  58. Handa N, McGregor CG, Danielson GK, et al. Coronary artery bypass grafting in patients with previous mediastinal radiation therapy. J Thorac Cardiovasc Surg. 1999;117:1136–42.

    Article  CAS  PubMed  Google Scholar 

  59. Uriel N, Vainrib A, Jorde UP, et al. Mediastinal radiation and adverse outcomes after heart transplantation. J Heart Lung Transplant. 2010;29(3):378–81.

    Article  PubMed  Google Scholar 

  60. Saxena P, Joyce LD, Daly RC, et al. Cardiac transplantation for radiation-induced cardiomyopathy: the Mayo Clinic experience. Ann Thorac Surg. 2014;98:2115–21.

    Article  PubMed  Google Scholar 

  61. Chang AS, Smedira NG, Chang CL, et al. Cardiac surgery after mediastinal radiation: extent of exposure influences outcome. J Thorac Cardiovasc Surg. 2007;133:404–13.

    Article  PubMed  Google Scholar 

  62. Wu W, Masri A. Popovic ZBet al. Long-term survival of patients with radiation heart disease undergoing cardiac surgery: a cohort study. Circulation. 2013;127:1476–85.

    Article  PubMed  Google Scholar 

  63. Desai MY, Karunakaravel K, Wu W, et al. Pulmonary fibrosis on multidetector computed tomography and mortality in patients with radiation-associated cardiac disease undergoing cardiac surgery. J Thorac Cardiovasc Surg. 2014;148:475.e3–81.

    Article  Google Scholar 

  64. De Bruin ML, Dorresteijn LD, van't Veer MB, et al. Increased risk of stroke and transientischemic attack in 5-year survivors of Hodgkin lymphoma. J Natl Cancer Inst. 2009;101(13):928–37.

    Article  PubMed  Google Scholar 

  65. Plummer C, Henderson RD, O'Sullivan JD, Read SJ. Ischemic stroke and transientischemic attack after head and neck radiotherapy: a review. Stroke. 2011;42:2410–8.

    Article  PubMed  Google Scholar 

  66. Acker JC. Serial in vivo observation of cerebral vasculature after treatment with a large single fraction of radiation. Radiat Res. 1998;149:350.

    Article  CAS  PubMed  Google Scholar 

  67. Ye J, Rong X, Xiang Y, et al. A study of radiation-induced cerebral vascular injury in nasopharyngeal carcinoma patients with radiation-induced temporal lobe necrosis. PLoS One. 2012;7(8), e42890.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  68. Louis EL, McLoughlin MJ, Wortzman G. Chronic damage to medium and large arteries following irradiation. J Can Assoc Radiol. 1974;25(2):94–104.

    CAS  PubMed  Google Scholar 

  69. Hull MC, Morris CG, Pepine CJ, Mendenhall NP. Valvular dysfunction and carotid, subclavian, and coronary artery disease in survivors of Hodgkin lymphoma treated with radiation therapy. JAMA. 2003;290:2831–7.

    Article  CAS  PubMed  Google Scholar 

  70. Cheng SW. Carotid stenosis after radiotherapy for nasopharyngeal carcinoma. Arch Otolaryngol Head Neck Surg. 2000;126:517.

    Article  CAS  PubMed  Google Scholar 

  71. Steele SR, Martin MJ, Mullenix PS, et al. Focused high-risk population screening for carotid arterial stenosis after radiation therapy for head and neck cancer. Am J Surg. 2004;187:594–8.

    Article  PubMed  Google Scholar 

  72. Jurado JA, Bashir R, Burket MW. Radiation-induced peripheral artery disease. Catheter Cardiovasc Interv. 2008;72:563–8.

    Article  PubMed  Google Scholar 

  73. Zagar TM, Marks LB. Breast cancer radiotherapy and coronary artery stenosis: location, location, location. J Clin Oncol. 2012;30:350.

    Article  PubMed  Google Scholar 

  74. Mousavi N, Nohria A. Radiation-induced cardiovascular disease. Curr Treat Opt Cardiovasc Med. 2013;15:507–17.

    Article  Google Scholar 

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Authors and Affiliations

  1. Cardiology Unit, IRCCS CRO-National Cancer Institute, Aviano (PN), Italy

    Chiara Lestuzzi

  2. Division of Cardiovascular Medicine, Cardio-Oncology Program, Department of Medicine, Dana-Farber Cancer Institute and Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

    Anju Nohria

  3. Cardiology ASL TO 3, Regione Piemonte, Italy

    Riccardo Asteggiano

  4. Cardiology IV Unit, Niguarda Ca’ Granda Hospital, Milan, Italy

    Paola Vallerio

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  1. Cardiology Unit, IRCCS CRO-National Cancer Institute, Aviano (PN), Italy

    Chiara Lestuzzi

  2. Cardiology Unit, National Cancer Institute “Giovanni Paolo II”, Bari, Italy

    Stefano Oliva

  3. Medical Oncology Unit, Ospedale San Vincenzo, Taormina, Italy

    Francesco Ferraù

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Lestuzzi, C., Nohria, A., Asteggiano, R., Vallerio, P. (2017). Radiotherapy: Clinical Aspects and Cardiotoxicity. In: Lestuzzi, C., Oliva, S., Ferraù, F. (eds) Manual of Cardio-oncology. Springer, Cham. https://doi.org/10.1007/978-3-319-40236-9_12

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