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Imaging-Based Scoring Systems for the Risk Stratification of Renal Tumors

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Diagnosis and Surgical Management of Renal Tumors

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Abstract

Individualizing the care of patients presenting with a renal mass requires the evaluation of a broad array of considerations including anatomic complexity of the patient’s tumor. In order to better objectify the description and classification of renal tumors, a number of imaging-based scoring systems have been developed. Several of these scoring systems have been comprehensively investigated and harnessed for reporting in the urologic literature, while others have seen more modest validation and adoption. The fundamental premise of each of these scoring systems is to allow the clinician to objectively assign a reproducible alphanumeric score to the salient characteristics of a renal mass as they relate to anatomic location. These scoring systems provide objective and reproducible tools for communication of patient selection and afford meaningful comparisons of outcomes and risks.

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References

  1. Kutikov A, Egleston BL, Wong YN, Uzzo RG. Evaluating overall survival and competing risks of death in patients with localized renal cell carcinoma using a comprehensive nomogram. J Clin Oncol. 2010;28(2):311–7.

    Article  PubMed  Google Scholar 

  2. Lane BR, Babineau D, Kattan MW, Novick AC, Gill IS, Zhou M, et al. A preoperative prognostic nomogram for solid enhancing renal tumors 7 cm or less amenable to partial nephrectomy. J Urol. 2007;178(2):429–34.

    Article  PubMed  Google Scholar 

  3. Ristau BT, Correa AF, Uzzo RG, Smaldone MC. Active surveillance for the small renal mass: growth kinetics and oncologic outcomes. Urol Clin North Am. 2017;44(2):213–22.

    Article  PubMed  Google Scholar 

  4. Lane BR, Kattan MW. Prognostic models and algorithms in renal cell carcinoma. Urol Clin North Am. 2008;35(4):613–25. vii

    Article  PubMed  Google Scholar 

  5. Hollingsworth JM, Miller DC, Daignault S, Hollenbeck BK. Rising incidence of small renal masses: a need to reassess treatment effect. J Natl Cancer Inst. 2006;98(18):1331–4.

    Article  PubMed  Google Scholar 

  6. Tang J, Qin Z, Li X, Han P, Wang F, Yang C, et al. Association between vascular endothelial growth factor gene polymorphisms and the risk and prognosis of renal cell carcinoma: a systematic review and meta-analysis. Oncotarget. 2017;8(30):50034–50.

    PubMed  PubMed Central  Google Scholar 

  7. Rabjerg M. Identification and validation of novel prognostic markers in renal cell carcinoma. Dan Med J. 2017;64(10):B5339.

    PubMed  Google Scholar 

  8. Kutikov A, Uzzo RG. The R.E.N.A.L. nephrometry score: a comprehensive standardized system for quantitating renal tumor size, location and depth. J Urol. 2009;182(3):844–53.

    Article  PubMed  Google Scholar 

  9. Ficarra V, Novara G, Secco S, Macchi V, Porzionato A, De Caro R, et al. Preoperative aspects and dimensions used for an anatomical (PADUA) classification of renal tumours in patients who are candidates for nephron-sparing surgery. Eur Urol. 2009;56(5):786–93.

    Article  PubMed  Google Scholar 

  10. Simmons MN, Ching CB, Samplaski MK, Park CH, Gill IS. Kidney tumor location measurement using the C index method. J Urol. 2010;183(5):1708–13.

    Article  PubMed  Google Scholar 

  11. Simmons MN, Hillyer SP, Lee BH, Fergany AF, Kaouk J, Campbell SC. Diameter-axial-polar nephrometry: integration and optimization of R.E.N.A.L. and centrality index scoring systems. J Urol. 2012;188(2):384–90.

    Article  PubMed  Google Scholar 

  12. Spaliviero M, Poon BY, Karlo CA, Guglielmetti GB, Di Paolo PL, Beluco Corradi R, et al. An Arterial Based Complexity (ABC) scoring system to assess the morbidity profile of partial nephrectomy. Eur Urol. 2016;69(1):72–9.

    Article  PubMed  Google Scholar 

  13. Hakky TS, Baumgarten AS, Allen B, Lin HY, Ercole CE, Sexton WJ, et al. Zonal NePhRO scoring system: a superior renal tumor complexity classification model. Clin Genitourin Cancer. 2014;12(1):e13–8.

    Article  PubMed  Google Scholar 

  14. Leslie S, Gill IS, de Castro Abreu AL, Rahmanuddin S, Gill KS, Nguyen M, et al. Renal tumor contact surface area: a novel parameter for predicting complexity and outcomes of partial nephrectomy. Eur Urol. 2014;66(5):884–93.

    Article  PubMed  Google Scholar 

  15. Campbell S, Uzzo RG, Allaf ME, Bass EB, Cadeddu JA, Chang A, et al. Renal mass and localized renal cancer: AUA guideline. J Urol. 2017;198(3):520–9.

    Article  PubMed  Google Scholar 

  16. Withington J, Neves JB, Barod R. Surgical and minimally invasive therapies for the management of the small renal mass. Curr Urol Rep. 2017;18(8):61.

    Article  PubMed  Google Scholar 

  17. Hayn MH, Schwaab T, Underwood W, Kim HL. RENAL nephrometry score predicts surgical outcomes of laparoscopic partial nephrectomy. BJU Int. 2011;108(6):876–81.

    PubMed  Google Scholar 

  18. Simhan J, Smaldone MC, Tsai KJ, Canter DJ, Li T, Kutikov A, et al. Objective measures of renal mass anatomic complexity predict rates of major complications following partial nephrectomy. Eur Urol. 2011;60(4):724–30.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Waldert M, Waalkes S, Klatte T, Kuczyk MA, Weibl P, Schuller G, et al. External validation of the preoperative anatomical classification for prediction of complications related to nephron-sparing surgery. World J Urol. 2010;28(4):531–5.

    Article  PubMed  Google Scholar 

  20. Samplaski MK, Hernandez A, Gill IS, Simmons MN. C-index is associated with functional outcomes after laparoscopic partial nephrectomy. J Urol. 2010;184(6):2259–63.

    Article  PubMed  Google Scholar 

  21. Canter D, Kutikov A, Manley B, Egleston B, Simhan J, Smaldone M, et al. Utility of the R.E.N.A.L. nephrometry scoring system in objectifying treatment decision-making of the enhancing renal mass. Urology. 2011;78(5):1089–94.

    Article  PubMed  Google Scholar 

  22. Rosevear HM, Gellhaus PT, Lightfoot AJ, Kresowik TP, Joudi FN, Tracy CR. Utility of the RENAL nephrometry scoring system in the real world: predicting surgeon operative preference and complication risk. BJU Int. 2012;109(5):700–5.

    Article  PubMed  Google Scholar 

  23. Stroup SP, Palazzi K, Kopp RP, Mehrazin R, Santomauro M, Cohen SA, et al. RENAL nephrometry score is associated with operative approach for partial nephrectomy and urine leak. Urology. 2012;80(1):151–6.

    Article  PubMed  Google Scholar 

  24. Kruck S, Anastasiadis AG, Walcher U, Stenzl A, Herrmann TR, Nagele U. Laparoscopic partial nephrectomy: risk stratification according to patient and tumor characteristics. World J Urol. 2012;30(5):639–46.

    Article  PubMed  Google Scholar 

  25. Ellison JS, Montgomery JS, Hafez KS, Miller DC, He C, Wolf JS Jr, et al. Association of RENAL nephrometry score with outcomes of minimally invasive partial nephrectomy. Int J Urol. 2013;20(6):564–70.

    Article  PubMed  Google Scholar 

  26. Png KS, Bahler CD, Milgrom DP, Lucas SM, Sundaram CP. The role of R.E.N.A.L. nephrometry score in the era of robot-assisted partial nephrectomy. J Endourol. 2013;27(3):304–8.

    Article  PubMed  Google Scholar 

  27. Li M, Gao Y, Cheng J, Qu L, Chen J, Cai C, et al. Diameter-axial-polar nephrometry is predictive of surgical outcomes following partial nephrectomy. Medicine (Baltimore). 2015;94(30):e1228.

    Article  Google Scholar 

  28. Bylund JR, Gayheart D, Fleming T, Venkatesh R, Preston DM, Strup SE, et al. Association of tumor size, location, R.E.N.A.L., PADUA and centrality index score with perioperative outcomes and postoperative renal function. J Urol. 2012;188(5):1684–9.

    Article  PubMed  Google Scholar 

  29. Okhunov Z, Rais-Bahrami S, George AK, Waingankar N, Duty B, Montag S, et al. The comparison of three renal tumor scoring systems: C-index, P.A.D.U.A., and R.E.N.A.L. nephrometry scores. J Endourol. 2011;25(12):1921–4.

    Article  PubMed  Google Scholar 

  30. Tomaszewski JJ, Smaldone MC, Mehrazin R, Kocher N, Ito T, Abbosh P, et al. Anatomic complexity quantitated by nephrometry score is associated with prolonged warm ischemia time during robotic partial nephrectomy. Urology. 2014;84(2):340–4.

    Article  PubMed  Google Scholar 

  31. Kopp RP, Mehrazin R, Palazzi KL, Liss MA, Jabaji R, Mirheydar HS, et al. Survival outcomes after radical and partial nephrectomy for clinical T2 renal tumours categorised by R.E.N.A.L. nephrometry score. BJU Int. 2014;114(5):708–18.

    Article  PubMed  Google Scholar 

  32. Joshi SS, Uzzo RG. Renal tumor anatomic complexity: clinical implications for urologists. Urol Clin North Am. 2017;44(2):179–87.

    Article  PubMed  Google Scholar 

  33. Broughton GJ, Clark PE, Barocas DA, Cookson MS, Smith JA Jr, Herrell SD, et al. Tumour size, tumour complexity, and surgical approach are associated with nephrectomy type in small renal cortical tumours treated electively. BJU Int. 2012;109(11):1607–13.

    Article  PubMed  Google Scholar 

  34. Tobert CM, Kahnoski RJ, Thompson DE, Anema JG, Kuntzman RS, Lane BR. RENAL nephrometry score predicts surgery type independent of individual surgeon’s use of nephron-sparing surgery. Urology. 2012;80(1):157–61.

    Article  PubMed  Google Scholar 

  35. Esen T, Acar O, Musaoglu A, Vural M. Morphometric profile of the localised renal tumors managed either by open or robot-assisted nephron-sparing surgery: the impact of scoring systems on the decision making process. BMC Urol. 2013;13:63.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Tomaszewski JJ, Uzzo RG, Kocher N, Li T, Manley B, Mehrazin R, et al. Patients with anatomically “simple” renal masses are more likely to be placed on active surveillance than those with anatomically “complex” lesions. Urol Oncol. 2014;32(8):1267–71.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Hew MN, Baseskioglu B, Barwari K, Axwijk PH, Can C, Horenblas S, et al. Critical appraisal of the PADUA classification and assessment of the R.E.N.A.L. nephrometry score in patients undergoing partial nephrectomy. J Urol. 2011;186(1):42–6.

    Article  CAS  PubMed  Google Scholar 

  38. Mayer WA, Godoy G, Choi JM, Goh AC, Bian SX, Link RE. Higher RENAL nephrometry score is predictive of longer warm ischemia time and collecting system entry during laparoscopic and robotic-assisted partial nephrectomy. Urology. 2012;79(5):1052–6.

    Article  PubMed  Google Scholar 

  39. Lavallee LT, Desantis D, Kamal F, Blew B, Watterson J, Mallick R, et al. The association between renal tumour scoring systems and ischemia time during open partial nephrectomy. Can Urol Assoc J. 2013;7(3–4):E207–14.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Altunrende F, Laydner H, Hernandez AV, Autorino R, Khanna R, White MA, et al. Correlation of the RENAL nephrometry score with warm ischemia time after robotic partial nephrectomy. World J Urol. 2013;31(5):1165–9.

    Article  PubMed  Google Scholar 

  41. Liu ZW, Olweny EO, Yin G, Faddegon S, Tan YK, Han WK, et al. Prediction of perioperative outcomes following minimally invasive partial nephrectomy: role of the R.E.N.A.L nephrometry score. World J Urol. 2013;31(5):1183–9.

    Article  PubMed  Google Scholar 

  42. Kobayashi K, Saito T, Kitamura Y, Nobushita T, Kawasaki T, Hara N, et al. The RENAL nephrometry score and the PADUA classification for the prediction of perioperative outcomes in patients receiving nephron-sparing surgery: feasible tools to predict intraoperative conversion to nephrectomy. Urol Int. 2013;91(3):261–8.

    Article  PubMed  Google Scholar 

  43. Borgmann H, Reiss AK, Kurosch M, Filmann N, Frees S, Mager R, et al. R.E.N.A.L. score outperforms PADUA score, C-index and DAP score for outcome prediction of nephron sparing surgery in a selected cohort. J Urol. 2016;196(3):664–71.

    Article  PubMed  Google Scholar 

  44. Tanagho YS, Kaouk JH, Allaf ME, Rogers CG, Stifelman MD, Kaczmarek BF, et al. Perioperative complications of robot-assisted partial nephrectomy: analysis of 886 patients at 5 United States centers. Urology. 2013;81(3):573–9.

    Article  PubMed  Google Scholar 

  45. Bruner B, Breau RH, Lohse CM, Leibovich BC, Blute ML. Renal nephrometry score is associated with urine leak after partial nephrectomy. BJU Int. 2011;108(1):67–72.

    Article  PubMed  Google Scholar 

  46. Tomaszewski JJ, Cung B, Smaldone MC, Mehrazin R, Kutikov A, Viterbo R, et al. Renal pelvic anatomy is associated with incidence, grade, and need for intervention for urine leak following partial nephrectomy. Eur Urol. 2014;66(5):949–55.

    Article  PubMed  Google Scholar 

  47. Jung S, Min GE, Chung BI, Jeon SH. Risk factors for postoperative hemorrhage after partial nephrectomy. Korean J Urol. 2014;55(1):17–22.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Schmit GD, Thompson RH, Kurup AN, Weisbrod AJ, Boorjian SA, Carter RE, et al. Usefulness of R.E.N.A.L. nephrometry scoring system for predicting outcomes and complications of percutaneous ablation of 751 renal tumors. J Urol. 2013;189(1):30–5.

    Article  PubMed  Google Scholar 

  49. Reyes J, Canter D, Putnam S, Simhan J, Smaldone MC, Kutikov A, et al. Thermal ablation of the small renal mass: case selection using the R.E.N.A.L.-Nephrometry score. Urol Oncol. 2013;31(7):1292–7.

    Article  PubMed  Google Scholar 

  50. Chang X, Ji C, Zhao X, Zhang F, Lian H, Zhang S, et al. The application of R.E.N.A.L. nephrometry scoring system in predicting the complications after laparoscopic renal radiofrequency ablation. J Endourol. 2014;28(4):424–9.

    Article  PubMed  Google Scholar 

  51. Okhunov Z, Shapiro EY, Moreira DM, Lipsky MJ, Hillelsohn J, Badani K, et al. R.E.N.A.L. nephrometry score accurately predicts complications following laparoscopic renal cryoablation. J Urol. 2012;188(5):1796–800.

    Article  PubMed  Google Scholar 

  52. Sisul DM, Liss MA, Palazzi KL, Briles K, Mehrazin R, Gold RE, et al. RENAL nephrometry score is associated with complications after renal cryoablation: a multicenter analysis. Urology. 2013;81(4):775–80.

    Article  PubMed  Google Scholar 

  53. Lagerveld BW, Brenninkmeijer M, van der Zee JA, van Haarst EP. Can RENAL and PADUA nephrometry indices predict complications of laparoscopic cryoablation for clinical stage T1 renal tumors? J Endourol. 2014;28(4):464–71.

    Article  PubMed  Google Scholar 

  54. Kutikov A, Smaldone MC, Egleston BL, Manley BJ, Canter DJ, Simhan J, et al. Anatomic features of enhancing renal masses predict malignant and high-grade pathology: a preoperative nomogram using the RENAL nephrometry score. Eur Urol. 2011;60(2):241–8.

    Article  PubMed  PubMed Central  Google Scholar 

  55. Satasivam P, Sengupta S, Rajarubendra N, Chia PH, Munshey A, Bolton D. Renal lesions with low R.E.N.A.L nephrometry score are associated with more indolent renal cell carcinomas (RCCs) or benign histology: findings in an Australian cohort. BJU Int. 2012;109(Suppl 3):44–7.

    Article  PubMed  Google Scholar 

  56. Wang HK, Zhu Y, Yao XD, Zhang SL, Dai B, Zhang HL, et al. External validation of a nomogram using RENAL nephrometry score to predict high grade renal cell carcinoma. J Urol. 2012;187(5):1555–60.

    Article  PubMed  Google Scholar 

  57. Gorin MA, Ball MW, Pierorazio PM, Tanagho YS, Bhayani SB, Kaouk JH, et al. Outcomes and predictors of clinical T1 to pathological T3a tumor up-staging after robotic partial nephrectomy: a multi-institutional analysis. J Urol. 2013;190(5):1907–11.

    Article  PubMed  Google Scholar 

  58. Weight CJ, Atwell TD, Fazzio RT, Kim SP, Kenny M, Lohse CM, et al. A multidisciplinary evaluation of inter-reviewer agreement of the nephrometry score and the prediction of long-term outcomes. J Urol. 2011;186(4):1223–8.

    Article  PubMed  Google Scholar 

  59. Matsumoto R, Abe T, Shinohara N, Murai S, Maruyama S, Tsuchiya K, et al. RENAL nephrometry score is a predictive factor for the annual growth rate of renal mass. Int J Urol. 2014;21(6):549–52.

    Article  PubMed  Google Scholar 

  60. Kriegmair MC, Mandel P, Moses A, Lenk J, Rothamel M, Budjan J, et al. Defining renal masses: comprehensive comparison of RENAL, PADUA, NePhRO, and C-index score. Clin Genitourin Cancer. 2016;15(2):248–55.

    Article  PubMed  Google Scholar 

  61. Kopp RP, Liss MA, Mehrazin R, Wang S, Lee HJ, Jabaji R, et al. Analysis of renal functional outcomes after radical or partial nephrectomy for renal masses >/=7 cm using the RENAL score. Urology. 2015;86(2):312–9.

    Article  PubMed  Google Scholar 

  62. Kim SP, Campbell SC, Gill I, Lane BR, Van Poppel H, Smaldone MC, et al. Collaborative review of risk benefit trade-offs between partial and radical nephrectomy in the management of anatomically complex renal masses. Eur Urol. 2017;72(1):64–75.

    Article  PubMed  Google Scholar 

  63. Bagrodia A, Harrow B, Liu ZW, Olweny EO, Faddegon S, Yin G, et al. Evaluation of anatomic and morphologic nomogram to predict malignant and high-grade disease in a cohort of patients with small renal masses. Urol Oncol. 2014;32(1):37.e17–23.

    Article  Google Scholar 

  64. Antonelli A, Furlan M, Sandri M, Minervini A, Cindolo L, Parma P, et al. The R.E.N.A.L. nephrometric nomogram cannot accurately predict malignancy or aggressiveness of small renal masses amenable to partial nephrectomy. Clin Genitourin Cancer. 2014;12(5):366–72.

    Article  PubMed  Google Scholar 

  65. Tyritzis SI, Papadoukakis S, Katafigiotis I, Adamakis I, Anastasiou I, Stravodimos KG, et al. Implementation and external validation of Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score for predicting complications in 74 consecutive partial nephrectomies. BJU Int. 2012;109(12):1813–8.

    Article  PubMed  Google Scholar 

  66. Wang L, Li M, Chen W, Wu Z, Cai C, Xiang C, et al. Is diameter-axial-polar scoring predictive of renal functional damage in patients undergoing partial nephrectomy? An evaluation using technetium Tc 99m ((9)(9)Tcm) diethylene-triamine-penta-acetic acid (DTPA) glomerular filtration rate. BJU Int. 2013;111(8):1191–8.

    Article  CAS  PubMed  Google Scholar 

  67. Kriegmair MC, Hetjens S, Mandel P, Wadle J, Budjan J, Michel MS, et al. Tumor size and invasiveness matters for partial nephrectomy: external validation and modification of the arterial based complexity score. J Surg Oncol. 2017;115:768–74.

    Article  PubMed  Google Scholar 

  68. Kriegmair MC, Mandel P, Moses A, Bolenz C, Michel MS, Pfalzgraf D. Zonal NephRo score: external validation for predicting complications after open partial nephrectomy. World J Urol. 2016;34(4):545–51.

    Article  CAS  PubMed  Google Scholar 

  69. Hsieh PF, Wang YD, Huang CP, Wu HC, Yang CR, Chen GH, et al. A mathematical method to calculate tumor contact surface area: an effective parameter to predict renal function after partial nephrectomy. J Urol. 2016;196(1):33–40.

    Article  PubMed  Google Scholar 

  70. Haifler M, Higgins A, Ristau BT, Smaldone MC, Kutikov A, Zisman A, et al. External validation of contact surface area as a predictor of post-operative renal function in patients undergoing partial nephrectomy. In: Center FCC, editor. In peer review; 2017.

    Google Scholar 

  71. Davidiuk AJ, Parker AS, Thomas CS, Leibovich BC, Castle EP, Heckman MG, et al. Mayo adhesive probability score: an accurate image-based scoring system to predict adherent perinephric fat in partial nephrectomy. Eur Urol. 2014;66(6):1165–71.

    Article  PubMed  Google Scholar 

  72. Martin L, Rouviere O, Bezza R, Bailleux J, Abbas F, Schott-Pethelaz AM, et al. Mayo adhesive probability score is an independent computed tomography scan predictor of adherent perinephric fat in open partial nephrectomy. Urology. 2017;103:124–8.

    Article  PubMed  Google Scholar 

  73. Thiel DD, Davidiuk AJ, Meschia C, Serie D, Custer K, Petrou SP, et al. Mayo adhesive probability score is associated with localized renal cell carcinoma progression-free survival. Urology. 2016;89:54–60.

    Article  PubMed  Google Scholar 

  74. Meeks JJ, Zhao LC, Navai N, Perry KT Jr, Nadler RB, Smith ND. Risk factors and management of urine leaks after partial nephrectomy. J Urol. 2008;180(6):2375–8.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Urology, Temple University Hospital, Temple Health, Philadelphia, PA, USA

    Andrew G. McIntosh

  2. Department of Surgical Oncology, Fox Chase Cancer Center, Temple Health, Philadelphia, PA, USA

    Shreyas Joshi, Robert G. Uzzo & Alexander Kutikov

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  1. Andrew G. McIntosh
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  2. Shreyas Joshi
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  3. Robert G. Uzzo
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  4. Alexander Kutikov
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Editors and Affiliations

  1. The James Buchanan Brady Urological, Institute and Department of Urology, Johns Hopkins University School of Medic, Baltimore, MD, USA

    Michael A. Gorin

  2. The James Buchanan Brady Urological, Institute and Department of Urology, Johns Hopkins University School of Medic, Baltimore, MD, USA

    Mohamad E. Allaf

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McIntosh, A.G., Joshi, S., Uzzo, R.G., Kutikov, A. (2019). Imaging-Based Scoring Systems for the Risk Stratification of Renal Tumors. In: Gorin, M., Allaf, M. (eds) Diagnosis and Surgical Management of Renal Tumors. Springer, Cham. https://doi.org/10.1007/978-3-319-92309-3_6

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