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Intraductal Papillary Mucinous Neoplasm of the Pancreas: Can Benign Lesions Be Differentiated from Malignant Lesions with Multidetector CT?¹

¹ From the Russell H. Morgan Department of Radiology and Radiological Science (S.K., K.M.H., L.P.L., E.K.F.) and the Department of Pathology (R.H.H.), Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Hospital, Baltimore, Md. Presented as an education exhibit at the 2004 RSNA Annual Meeting. Received March 2, 2005; revision requested March 28 and received May 12; accepted May 13. All authors have no financial relationships to disclose.

View larger version (197K): [in a new window]   Figure 1a.  IPMN adenoma. Photomicrographs (original magnification, x 100 [a] and x 250 [b]; hematoxylineosin stain) of a surgical specimen. The papillae are architecturally simple, and the epithelium is composed of tall columnar cells with abundant apical cytoplasmic mucin and basally oriented nuclei without significant dysplasia. The epithelium maintains a high degree of differentiation.

 

View larger version (169K): [in a new window]   Figure 1b.  IPMN adenoma. Photomicrographs (original magnification, x 100 [a] and x 250 [b]; hematoxylineosin stain) of a surgical specimen. The papillae are architecturally simple, and the epithelium is composed of tall columnar cells with abundant apical cytoplasmic mucin and basally oriented nuclei without significant dysplasia. The epithelium maintains a high degree of differentiation.

 

View larger version (167K): [in a new window]   Figure 2a.  Carcinoma in situ arising in IPMN. Photomicrographs (original magnification, x 100 [a] and x 160 [b]; hematoxylineosin stain) of a surgical specimen show severe dysplastic epithelial changes in IPMN. There is cribri-form growth and budding of small clusters of epithelial cells into the lumen. Note the severe cytologic atypia including loss of polarity, loss of differentiated cytoplasmic features including diminished mucin content, cellular and nuclear pleomorphism, nuclear enlargement, and the presence of mitoses.

 

View larger version (212K): [in a new window]   Figure 2b.  Carcinoma in situ arising in IPMN. Photomicrographs (original magnification, x 100 [a] and x 160 [b]; hematoxylineosin stain) of a surgical specimen show severe dysplastic epithelial changes in IPMN. There is cribri-form growth and budding of small clusters of epithelial cells into the lumen. Note the severe cytologic atypia including loss of polarity, loss of differentiated cytoplasmic features including diminished mucin content, cellular and nuclear pleomorphism, nuclear enlargement, and the presence of mitoses.

 

View larger version (196K): [in a new window]   Figure 3.  Invasive carcinoma (colloid carcinoma) arising from IPMN. Photomicrograph (original magnification, x 100; hematoxylineosin stain) of a surgical specimen shows well-defined pools of mucin embedded in the stroma of the gland, with malignant epithelial cells floating within the mucin in clusters.

 

View larger version (156K): [in a new window]   Figure 4a.  Main duct type IPMN borderline lesion. Oblique axial (a) and oblique coronal (b) venous phase reformatted images show marked dilatation of the main duct in the pancreatic body and tail. Although there is significant dilatation of the main pancreatic duct, pathologic analysis demonstrated an IPMN borderline lesion. No invasive carcinoma was identified in the entire specimen.

 

View larger version (156K): [in a new window]   Figure 4b.  Main duct type IPMN borderline lesion. Oblique axial (a) and oblique coronal (b) venous phase reformatted images show marked dilatation of the main duct in the pancreatic body and tail. Although there is significant dilatation of the main pancreatic duct, pathologic analysis demonstrated an IPMN borderline lesion. No invasive carcinoma was identified in the entire specimen.

 

View larger version (136K): [in a new window]   Figure 5a.  Main duct type IPMN with associated invasive carcinoma. Oblique axial (a) and oblique coronal (b) venous phase reformatted images show a markedly dilated main duct in the pancreatic body and tail with an ill-defined soft-tissue mass in the pancreatic head (arrows). There is obstruction of the common bile duct by the mass; a common bile duct stent is in place. Pathologic analysis demonstrated an infiltrating moderately differentiated ductal adenocarcinoma associated with IPMN with carcinoma in situ. There was associated chronic pancreatitis and invasion of the duodenal wall and distal common bile duct. Metastases were found in four of 10 regional lymph nodes.

 

View larger version (144K): [in a new window]   Figure 5b.  Main duct type IPMN with associated invasive carcinoma. Oblique axial (a) and oblique coronal (b) venous phase reformatted images show a markedly dilated main duct in the pancreatic body and tail with an ill-defined soft-tissue mass in the pancreatic head (arrows). There is obstruction of the common bile duct by the mass; a common bile duct stent is in place. Pathologic analysis demonstrated an infiltrating moderately differentiated ductal adenocarcinoma associated with IPMN with carcinoma in situ. There was associated chronic pancreatitis and invasion of the duodenal wall and distal common bile duct. Metastases were found in four of 10 regional lymph nodes.

 

View larger version (153K): [in a new window]   Figure 6a.  Branch duct type IPMN adenoma. Axial (a) and oblique coronal (b) venous phase reformatted images show a small cystic mass with minimal septa in the uncinate process of the pancreas (arrow in a, large arrow in b). The main pancreatic duct (arrowhead in b) and common bile duct (small arrow in b) are not dilated. Pathologic analysis demonstrated a 1-cm-diameter branch duct type IPMN adenoma. No invasive carcinoma was identified.

 

View larger version (162K): [in a new window]   Figure 6b.  Branch duct type IPMN adenoma. Axial (a) and oblique coronal (b) venous phase reformatted images show a small cystic mass with minimal septa in the uncinate process of the pancreas (arrow in a, large arrow in b). The main pancreatic duct (arrowhead in b) and common bile duct (small arrow in b) are not dilated. Pathologic analysis demonstrated a 1-cm-diameter branch duct type IPMN adenoma. No invasive carcinoma was identified.

 

View larger version (148K): [in a new window]   Figure 7a.  Branch duct type IPMN adenoma. Axial (a) and coronal (b) venous phase reformatted images show a small unilocular cystic mass in the pancreatic body (arrow). There is no pancreatic duct dilatation. Pathologic analysis demonstrated a 1.2-cm-diameter IPMN adenoma. No invasive carcinoma was identified.

 

View larger version (159K): [in a new window]   Figure 7b.  Branch duct type IPMN adenoma. Axial (a) and coronal (b) venous phase reformatted images show a small unilocular cystic mass in the pancreatic body (arrow). There is no pancreatic duct dilatation. Pathologic analysis demonstrated a 1.2-cm-diameter IPMN adenoma. No invasive carcinoma was identified.

 

View larger version (143K): [in a new window]   Figure 8.  Branch duct type IPMN adenoma. Coronal venous phase reformatted image shows a unilocular cystic mass in the pancreatic head (large arrow). The main pancreatic duct (small arrow) and common bile duct (arrowhead) are not dilated. Pathologic analysis demonstrated a 1.4-cm-diameter branch duct type IPMN adenoma. No invasive carcinoma was identified.

 

View larger version (143K): [in a new window]   Figure 9a.  Combined type IPMN borderline lesions. Coronal venous phase reformatted images show multiple cystic lesions with multiple thin septa predominantly involving the pancreatic head and body (arrow). The main pancreatic duct is minimally dilated (arrowhead in b). Pathologic analysis demonstrated IPMN borderline lesions. No in situ or invasive carcinoma was identified.

 

View larger version (143K): [in a new window]   Figure 9b.  Combined type IPMN borderline lesions. Coronal venous phase reformatted images show multiple cystic lesions with multiple thin septa predominantly involving the pancreatic head and body (arrow). The main pancreatic duct is minimally dilated (arrowhead in b). Pathologic analysis demonstrated IPMN borderline lesions. No in situ or invasive carcinoma was identified.

 

View larger version (144K): [in a new window]   Figure 10a.  Combined type IPMN borderline lesion. Axial (a), coronal (b), and sagittal (c) venous phase reformatted images show dilatation of the main duct in the pancreatic tail (arrowhead in a) and a 3.5-cm-diameter cystic mass with multiple septa (arrows). An incidentally found old hematoma with peripheral calcification (* in a and b) is seen superior to the right kidney. Pathologic analysis demonstrated an IPMN borderline lesion. There was no invasive carcinoma.

 

View larger version (143K): [in a new window]   Figure 10b.  Combined type IPMN borderline lesion. Axial (a), coronal (b), and sagittal (c) venous phase reformatted images show dilatation of the main duct in the pancreatic tail (arrowhead in a) and a 3.5-cm-diameter cystic mass with multiple septa (arrows). An incidentally found old hematoma with peripheral calcification (* in a and b) is seen superior to the right kidney. Pathologic analysis demonstrated an IPMN borderline lesion. There was no invasive carcinoma.

 

View larger version (142K): [in a new window]   Figure 10c.  Combined type IPMN borderline lesion. Axial (a), coronal (b), and sagittal (c) venous phase reformatted images show dilatation of the main duct in the pancreatic tail (arrowhead in a) and a 3.5-cm-diameter cystic mass with multiple septa (arrows). An incidentally found old hematoma with peripheral calcification (* in a and b) is seen superior to the right kidney. Pathologic analysis demonstrated an IPMN borderline lesion. There was no invasive carcinoma.

 

View larger version (150K): [in a new window]   Figure 11a.  Combined type IPMN borderline lesions. Oblique axial (a) and coronal (b, c) venous phase reformatted images show diffuse moderate dilatation of the main pancreatic duct (arrowheads) and multiple cystic lesions communicating with the main duct throughout the pancreas. Pathologic analysis demonstrated IPMN borderline lesions. No in situ or invasive carcinoma was identified.

 

View larger version (152K): [in a new window]   Figure 11b.  Combined type IPMN borderline lesions. Oblique axial (a) and coronal (b, c) venous phase reformatted images show diffuse moderate dilatation of the main pancreatic duct (arrowheads) and multiple cystic lesions communicating with the main duct throughout the pancreas. Pathologic analysis demonstrated IPMN borderline lesions. No in situ or invasive carcinoma was identified.

 

View larger version (155K): [in a new window]   Figure 11c.  Combined type IPMN borderline lesions. Oblique axial (a) and coronal (b, c) venous phase reformatted images show diffuse moderate dilatation of the main pancreatic duct (arrowheads) and multiple cystic lesions communicating with the main duct throughout the pancreas. Pathologic analysis demonstrated IPMN borderline lesions. No in situ or invasive carcinoma was identified.

 

View larger version (152K): [in a new window]   Figure 12a.  Small invasive carcinoma associated with IPMN with extensive carcinoma in situ. Axial (a) and oblique coronal (b) venous phase reformatted images show a small cystic mass in the pancreatic head (arrowhead) with diffuse mild dilatation of the main pancreatic duct. Pathologic analysis demonstrated a 1.1-cm-diameter IPMN with extensive carcinoma in situ and an associated infiltrating moderately differentiated ductal adenocarcinoma (0.6 cm in diameter) just proximal to the ampulla.

 

View larger version (153K): [in a new window]   Figure 12b.  Small invasive carcinoma associated with IPMN with extensive carcinoma in situ. Axial (a) and oblique coronal (b) venous phase reformatted images show a small cystic mass in the pancreatic head (arrowhead) with diffuse mild dilatation of the main pancreatic duct. Pathologic analysis demonstrated a 1.1-cm-diameter IPMN with extensive carcinoma in situ and an associated infiltrating moderately differentiated ductal adenocarcinoma (0.6 cm in diameter) just proximal to the ampulla.

 

View larger version (138K): [in a new window]   Figure 13a.  Invasive carcinoma associated with IPMN. Axial (a) and coronal (b) venous phase images show an apparent solid mass in the pancreatic head (large arrow in b) that involves the distal common bile duct. A biliary stent is in place. There is diffuse dilatation of the main pancreatic duct (small arrow in b) and a large pseudocyst in the lesser sac (*), which is secondary to pancreatitis and compresses the stomach. Pathologic analysis demonstrated an infiltrating moderately differentiated ductal adenocarcinoma arising in IPMN. The carcinoma infiltrated into the wall of the distal common bile duct. Metastatic carcinoma was found in six of 14 lymph nodes.

 

View larger version (148K): [in a new window]   Figure 13b.  Invasive carcinoma associated with IPMN. Axial (a) and coronal (b) venous phase images show an apparent solid mass in the pancreatic head (large arrow in b) that involves the distal common bile duct. A biliary stent is in place. There is diffuse dilatation of the main pancreatic duct (small arrow in b) and a large pseudocyst in the lesser sac (*), which is secondary to pancreatitis and compresses the stomach. Pathologic analysis demonstrated an infiltrating moderately differentiated ductal adenocarcinoma arising in IPMN. The carcinoma infiltrated into the wall of the distal common bile duct. Metastatic carcinoma was found in six of 14 lymph nodes.

 

View larger version (137K): [in a new window]   Figure 14a.  Invasive carcinoma associated with IPMN. Axial (a), coronal (b, c), and sagittal (d) venous phase images show a large cystic mass with a solid component (arrowheads in b and c) in the pancreatic head. There are fistulous tracts between the mass and duodenum (large arrow in b, arrow in d) and between the mass and common bile duct (small arrow in b). In addition, there are small air bubbles within the mass and diffuse dilatation of the main pancreatic duct. Pathologic analysis demonstrated an infiltrating moderately differentiated adenocarcinoma with prominent extracellular mucin production arising in association with IPMN with carcinoma in situ. The infiltrating carcinoma involved the wall of the duodenum.

 

View larger version (151K): [in a new window]   Figure 14b.  Invasive carcinoma associated with IPMN. Axial (a), coronal (b, c), and sagittal (d) venous phase images show a large cystic mass with a solid component (arrowheads in b and c) in the pancreatic head. There are fistulous tracts between the mass and duodenum (large arrow in b, arrow in d) and between the mass and common bile duct (small arrow in b). In addition, there are small air bubbles within the mass and diffuse dilatation of the main pancreatic duct. Pathologic analysis demonstrated an infiltrating moderately differentiated adenocarcinoma with prominent extracellular mucin production arising in association with IPMN with carcinoma in situ. The infiltrating carcinoma involved the wall of the duodenum.

 

View larger version (148K): [in a new window]   Figure 14c.  Invasive carcinoma associated with IPMN. Axial (a), coronal (b, c), and sagittal (d) venous phase images show a large cystic mass with a solid component (arrowheads in b and c) in the pancreatic head. There are fistulous tracts between the mass and duodenum (large arrow in b, arrow in d) and between the mass and common bile duct (small arrow in b). In addition, there are small air bubbles within the mass and diffuse dilatation of the main pancreatic duct. Pathologic analysis demonstrated an infiltrating moderately differentiated adenocarcinoma with prominent extracellular mucin production arising in association with IPMN with carcinoma in situ. The infiltrating carcinoma involved the wall of the duodenum.

 

View larger version (147K): [in a new window]   Figure 14d.  Invasive carcinoma associated with IPMN. Axial (a), coronal (b, c), and sagittal (d) venous phase images show a large cystic mass with a solid component (arrowheads in b and c) in the pancreatic head. There are fistulous tracts between the mass and duodenum (large arrow in b, arrow in d) and between the mass and common bile duct (small arrow in b). In addition, there are small air bubbles within the mass and diffuse dilatation of the main pancreatic duct. Pathologic analysis demonstrated an infiltrating moderately differentiated adenocarcinoma with prominent extracellular mucin production arising in association with IPMN with carcinoma in situ. The infiltrating carcinoma involved the wall of the duodenum.

 

View larger version (149K): [in a new window]   Figure 15a.  Invasive carcinoma associated with IPMN. (a) Oblique coronal venous phase reformatted image shows a markedly dilated main duct in the pancreatic body and tail (arrow). (b–d) Axial (b), oblique coronal (c), and sagittal (d) venous phase reformatted images show that the dilatation of the main duct abruptly ends at the pancreatic body, where there is a soft-tissue mass (arrow in c, white arrows in d). There is also irregularity and narrowing of the adjacent splenic vein (arrows in b, black arrow in d). Pathologic analysis demonstrated an invasive poorly differentiated adenocarcinoma with anaplastic features arising in association with IPMN. The carcinoma invaded the splenic vein. Metastatic carcinoma was found in one of 14 lymph nodes.

 

View larger version (157K): [in a new window]   Figure 15b.  Invasive carcinoma associated with IPMN. (a) Oblique coronal venous phase reformatted image shows a markedly dilated main duct in the pancreatic body and tail (arrow). (b–d) Axial (b), oblique coronal (c), and sagittal (d) venous phase reformatted images show that the dilatation of the main duct abruptly ends at the pancreatic body, where there is a soft-tissue mass (arrow in c, white arrows in d). There is also irregularity and narrowing of the adjacent splenic vein (arrows in b, black arrow in d). Pathologic analysis demonstrated an invasive poorly differentiated adenocarcinoma with anaplastic features arising in association with IPMN. The carcinoma invaded the splenic vein. Metastatic carcinoma was found in one of 14 lymph nodes.

 

View larger version (149K): [in a new window]   Figure 15c.  Invasive carcinoma associated with IPMN. (a) Oblique coronal venous phase reformatted image shows a markedly dilated main duct in the pancreatic body and tail (arrow). (b–d) Axial (b), oblique coronal (c), and sagittal (d) venous phase reformatted images show that the dilatation of the main duct abruptly ends at the pancreatic body, where there is a soft-tissue mass (arrow in c, white arrows in d). There is also irregularity and narrowing of the adjacent splenic vein (arrows in b, black arrow in d). Pathologic analysis demonstrated an invasive poorly differentiated adenocarcinoma with anaplastic features arising in association with IPMN. The carcinoma invaded the splenic vein. Metastatic carcinoma was found in one of 14 lymph nodes.

 

View larger version (142K): [in a new window]   Figure 15d.  Invasive carcinoma associated with IPMN. (a) Oblique coronal venous phase reformatted image shows a markedly dilated main duct in the pancreatic body and tail (arrow). (b–d) Axial (b), oblique coronal (c), and sagittal (d) venous phase reformatted images show that the dilatation of the main duct abruptly ends at the pancreatic body, where there is a soft-tissue mass (arrow in c, white arrows in d). There is also irregularity and narrowing of the adjacent splenic vein (arrows in b, black arrow in d). Pathologic analysis demonstrated an invasive poorly differentiated adenocarcinoma with anaplastic features arising in association with IPMN. The carcinoma invaded the splenic vein. Metastatic carcinoma was found in one of 14 lymph nodes.

 

View larger version (142K): [in a new window]   Figure 16a.  Invasive carcinoma arising in IPMN. Axial (a, b), coronal (c), and sagittal (d) venous phase reformatted images show a large complex cystic mass with calcifications and an apparent solid component (arrowhead in a, top arrowhead in b, arrowheads in c and d) in the pancreatic body and tail. The main pancreatic duct is markedly dilated. An enlarged, hypoattenuating celiac lymph node is also seen (black arrow in a). There is a small peripancreatic fluid collection and ascites. There is also splenic vein occlusion with gastroepiploic collateral veins (white arrows in a) and a small splenic infarct (bottom arrowhead in b). Pathologic analysis demonstrated colloid carcinoma arising in IPMN and extending into the peripancreatic soft tissue. Multiple metastatic carcinoma involved peripancreatic and celiac lymph nodes. There was mucinous and necrotic debris with focal calcifications within the mass.

 

View larger version (139K): [in a new window]   Figure 16b.  Invasive carcinoma arising in IPMN. Axial (a, b), coronal (c), and sagittal (d) venous phase reformatted images show a large complex cystic mass with calcifications and an apparent solid component (arrowhead in a, top arrowhead in b, arrowheads in c and d) in the pancreatic body and tail. The main pancreatic duct is markedly dilated. An enlarged, hypoattenuating celiac lymph node is also seen (black arrow in a). There is a small peripancreatic fluid collection and ascites. There is also splenic vein occlusion with gastroepiploic collateral veins (white arrows in a) and a small splenic infarct (bottom arrowhead in b). Pathologic analysis demonstrated colloid carcinoma arising in IPMN and extending into the peripancreatic soft tissue. Multiple metastatic carcinoma involved peripancreatic and celiac lymph nodes. There was mucinous and necrotic debris with focal calcifications within the mass.

 

View larger version (156K): [in a new window]   Figure 16c.  Invasive carcinoma arising in IPMN. Axial (a, b), coronal (c), and sagittal (d) venous phase reformatted images show a large complex cystic mass with calcifications and an apparent solid component (arrowhead in a, top arrowhead in b, arrowheads in c and d) in the pancreatic body and tail. The main pancreatic duct is markedly dilated. An enlarged, hypoattenuating celiac lymph node is also seen (black arrow in a). There is a small peripancreatic fluid collection and ascites. There is also splenic vein occlusion with gastroepiploic collateral veins (white arrows in a) and a small splenic infarct (bottom arrowhead in b). Pathologic analysis demonstrated colloid carcinoma arising in IPMN and extending into the peripancreatic soft tissue. Multiple metastatic carcinoma involved peripancreatic and celiac lymph nodes. There was mucinous and necrotic debris with focal calcifications within the mass.

 

View larger version (164K): [in a new window]   Figure 16d.  Invasive carcinoma arising in IPMN. Axial (a, b), coronal (c), and sagittal (d) venous phase reformatted images show a large complex cystic mass with calcifications and an apparent solid component (arrowhead in a, top arrowhead in b, arrowheads in c and d) in the pancreatic body and tail. The main pancreatic duct is markedly dilated. An enlarged, hypoattenuating celiac lymph node is also seen (black arrow in a). There is a small peripancreatic fluid collection and ascites. There is also splenic vein occlusion with gastroepiploic collateral veins (white arrows in a) and a small splenic infarct (bottom arrowhead in b). Pathologic analysis demonstrated colloid carcinoma arising in IPMN and extending into the peripancreatic soft tissue. Multiple metastatic carcinoma involved peripancreatic and celiac lymph nodes. There was mucinous and necrotic debris with focal calcifications within the mass.

 

View larger version (151K): [in a new window]   Figure 17a.  Invasive carcinoma associated with IPMN. Axial (a) and oblique coronal (b) venous phase reformatted images show a cystic mass with peripheral enhancement in the pancreatic head (arrow). There is minimal amorphous soft-tissue attenuation within the mass (arrowhead in a). Pathologic analysis demonstrated in situ and infiltrating moderately differentiated adenocarcinoma of the pancreas associated with IPMN. Metastatic carcinoma was found in two of 10 lymph nodes.

 

View larger version (154K): [in a new window]   Figure 17b.  Invasive carcinoma associated with IPMN. Axial (a) and oblique coronal (b) venous phase reformatted images show a cystic mass with peripheral enhancement in the pancreatic head (arrow). There is minimal amorphous soft-tissue attenuation within the mass (arrowhead in a). Pathologic analysis demonstrated in situ and infiltrating moderately differentiated adenocarcinoma of the pancreas associated with IPMN. Metastatic carcinoma was found in two of 10 lymph nodes.

 

View larger version (150K): [in a new window]   Figure 18a.  Invasive ductal carcinoma with prominent extracellular mucin deposition arising from IPMN with carcinoma in situ. Axial (a), coronal (b), and sagittal (c) venous phase reformatted images show a complex cystic mass with a thick septum (arrow in a and c) in the pancreatic head. There is moderate dilatation of the main duct in the pancreatic body and tail (arrowheads in b) with atrophy of the body and tail. Pathologic analysis demonstrated invasive ductal carcinoma with prominent extracellular mucin deposition (colloid carcinoma) arising from IPMN with carcinoma in situ.

 

View larger version (166K): [in a new window]   Figure 18b.  Invasive ductal carcinoma with prominent extracellular mucin deposition arising from IPMN with carcinoma in situ. Axial (a), coronal (b), and sagittal (c) venous phase reformatted images show a complex cystic mass with a thick septum (arrow in a and c) in the pancreatic head. There is moderate dilatation of the main duct in the pancreatic body and tail (arrowheads in b) with atrophy of the body and tail. Pathologic analysis demonstrated invasive ductal carcinoma with prominent extracellular mucin deposition (colloid carcinoma) arising from IPMN with carcinoma in situ.

 

View larger version (164K): [in a new window]   Figure 18c.  Invasive ductal carcinoma with prominent extracellular mucin deposition arising from IPMN with carcinoma in situ. Axial (a), coronal (b), and sagittal (c) venous phase reformatted images show a complex cystic mass with a thick septum (arrow in a and c) in the pancreatic head. There is moderate dilatation of the main duct in the pancreatic body and tail (arrowheads in b) with atrophy of the body and tail. Pathologic analysis demonstrated invasive ductal carcinoma with prominent extracellular mucin deposition (colloid carcinoma) arising from IPMN with carcinoma in situ.

 

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