Durable Regression of Primary Cutaneous B-Cell Lymphoma Following Fever-inducing Mistletoe Treatment: Two Case Reports

Abstract

Background: Mistletoe is a complementary cancer treatment that is widely used, usually in addition to and alongside recommended conventional cancer therapy. However, little is known about its use, effectiveness, and safety in the treatment of cutaneous lymphoma.

Case Report: Two patients with primary cutaneous B-cell lymphoma (pT2bcNxM0 follicle center and pT2ac-NxM0 marginal zone) either declined or postponed recommended conventional treatment and received high-dose, fever-inducing mistletoe treatment; a combination of intratumoral, subcutaneous, and intravenous application was given; and one patient also underwent whole-body hyperthermia. The lymphoma regressed over a period of 12 and 8 months, respectively, and after administration of a cumulative dose of 12.98 g and 4.63 g mistletoe extract, respectively. The patients are in remission to date, 3.5 years after commencement of treatment. Neither patient received conventional cancer treatment during the entire observation period.

Key Words: Mistletoe treatment, Lymphoma, primary cutaneous B-cell lymphoma, fever, PCBCL, PCFCL, PCMZL, cancer, tumor

摘要

背景:槲寄生疗法是一种广泛使 用的补充性癌症治疗方法,通常 作为常规癌症治疗的补充疗法, 或伴随常规疗法共同使用。然 而, 在皮肤淋巴瘤的治疗过程 中,人们对该疗法的使用、有效 性和安全性知之甚少。

病例报告:两名原发性皮肤B-细 胞淋巴瘤患者(pT2bcNxM0滤泡 中心和pT2acNxM0边缘区域)取 消或推迟推荐的常规治疗,并接 受高剂量、可引起发热的槲寄生 疗法;通过瘤内、皮下和静脉注 射方式进行组合给药,其中一名 患者还接受了全身过热疗法。这 两名患者在分别接受12.98 g 和 4.63g累积剂量的槲寄生提取物 治疗后,分别在12个月和8个月后 淋巴瘤出现退化。迄今为止,即 在开始治疗的3年半之后,患者病 情正处于缓解期。在整个观察期 期间,两名患者都未接受常规癌 症治疗。

RESUMEN

Antecedentes: El muérdago es una planta que se utiliza ampliamente como tratamiento oncológico complementario, por lo general, en forma concomitante con la terapia convencional recomendada. Sin embargo, no se sabe mucho sobre su uso, efectividad y seguridad en el tratamiento del linfoma cutáneo.

Caso clínico: Dos pacientes diagnosticados con linfoma cutáneo primario de células B (centro folicular pT2bcNxM0 y zona marginal pT2acNxM0) habían rechazado o pospuesto el tratamiento convencional recomendado para estos casos, y recibieron dosis altas de tratamiento con muérdago, que provoca fiebre. Se administró una combinación de inyección intratumoral, subcutánea e intravenosa (IV), y uno de los pacientes también sufrió hipertermia en todo el cuerpo. Se registró un retroceso del linfoma en un período de 12 y 8 meses, respectivamente. Esto sucedió luego de que se administrara una dosis acumulativa de 12,98 g y 4,63 g de extracto de muérdago, respectivamente. A la fecha, los pacientes se encuentran en etapa de remisión, luego de transcurridos 3 años y medio desde el inicio del tratamiento. Ninguno de ellos recibió tratamiento oncológico convencional durante todo el período de observación.

CASE 1: PRIMARY CUTANEOUS FOLLICLE CENTER B-CELL LYMPHOMA

A 51-year-old female presented with 2 lesions on the left lower leg in May 2008 at the oncology department of a large tertiary hospital (Aberdeen Royal Infirmary [ARI]). She had first noticed in the summer of 2007 a lesion in the left upper Achilles region, which increased in size and became red. In autumn 2007, a similar lesion developed over the mid shin of the same leg, and in the weeks leading up to presentation, a couple of much smaller satellite lesions appeared around the anterior lesion.

Histopathology confirmed grade 1 follicular B-cell lymphoma (Figures 1 and and2).2). Staging computed tomography (CT) scan (chest, abdomen, pelvis) reported no intraabdominal or pelvic lymphadenopathy but showed one 2.7 × 1.7 inguinal lymph node, which was not biopsied. Stage was pT2bcNxM0. Hematology, biochemistry, and trephine bone marrow biopsy were essentially normal. IgH gene rearrangement analysis found clonality, confirming B-cell lymphoma; T-cell receptor (TCR)-β–ve; TCR-γ very weakly polyclonal. Cytogenetics: t(11;14) and t(14;18) translocations were not tested.

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Cellular lymphoid tumor. The pattern is largely diffuse with focal nodular areas (H&E ×10). Image courtesy of Dr Ghada Bashat, Pathology, Aberdeen Royal Infirmary.

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Cellular lymphoid tumor. The pattern is largely diffuse with focal nodular areas (H&E ×20). Image courtesy of Dr Ghada Bashat, Pathology, Aberdeen Royal Infirmary.

The patient was generally well; she had no history of injury or infection and no B symptoms, such as fatigue, night sweats, weight loss, or pruritus. She had longstanding assumptive skin lipomas in different areas of the body but had been generally healthy, had a grown daughter, worked as a movement therapist, was a non-smoker, drank no alcohol, took no regular medications, and reported no allergies.

In view of the multicentric lesions, with satellites and possible regional node involvement indicative of advancement, it was recommended she undergo systemic immuno-chemotherapy with 6 cycles of cyclophosphamide, vincristine, and prednisone plus rituximab (R-CVP) and involved-field radiotherapy on completion of the cycles. Although the patient was not opposed to this treatment in principle, she decided to keep it in reserve and improve her immunity with ME treatment first.

On presentation for ME treatment in June 2008, the patient had a posterior lesion in the left proximal Achilles region measuring 5 cm × 4 cm (Figure 3) and an anterior mid shin tumor measuring 4 cm × 2 cm (Figure 4), with a number of surrounding satellites, each < 1.5 cm. The 2 large lesions were raised, red, and warm to the touch. The overlying skin was thinned but intact. There were no signs of deep tissue infiltration; she reported no pain, and no neurological deficits were ascertained. The left leg was well perfused, but there was pitting edema around the lesions and the ankle.

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Primary cutaneous B-cell lymphoma in July 2008. Posterior lesion left lower leg.

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Primary cutaneous B-cell lymphoma in July 2008. Anterior lesion left lower leg; surrounding satellites not showing clearly.

Treatment

Treatment with ME (using Abnobaviscum fraxini) comprised a combination of IV, intratumoral (IT), and subcutaneous (SC) applications over 12.3 months and IV and SC application over another 8 months. Details are shown in Table 1. Treatment was subdivided in an induction phase, wherein febrile reactions to ME are elicited, and a postinduction phase. ME treatment was combined with whole-body hyperthermia (WBHT)—a technique to increase core temperature to 39° to 39.5°C for 2 to 5 hours with water-filtered infrared A radiation under controlled conditions. The skin lesions were not directly targeted. She had no other cancer treatments and was not taking any medications.

Table 1

Treatment Schedule (06/02/08–06/08/09) of Patient With PCBCLa

Month Day or Interval ME Dosage (mg) Per Application WBHT
IV Treatmentb IT Treatment SC Treatment (no. of sessions, if > 1)
Induction phase
0 1 40
2 80 1
3 160 1 10
4 4 20
8 160 10 30
11 160 20 20
15 160 40
Post-induction phase
16 40 40
18 160
21–28c (3 ×) 40
25 200
1 29–35 (2 ×) 40
32 200
36–42 40
36 200 80
37 40 No. 1
42 200 120 No. 2
43–49 (2 ×) 40
46 200
50–56 (2 ×) 40
53 200 80
2 57 240d
58 200 No. 3
61
64–70 (2 ×) 40
67 200 320d
71–77 (2 ×) 40
74 200
78 320d 40
79 200 No. 4
3 85–91 40
88 200 320d
92–98 (2 ×) 40
95 200
99 320d
100 200 No. 5
103–112 (2 ×) 40
109 200
113–119 (2 ×) 40
116 200
4 120 320d 20
127–140 (4 ×) 40
135 200 No. 7
5 141–161 (5 ×) 40
162 360d
163 200 No. 8
6 169–182 (3 ×) 40
178 200
183–189 (2 ×) 40
190 400d
191 200 No. 9
197–210 (4 ×) 40
204 200
211–231 (6 ×) 40
233 400d
234 200 No. 10
237–271 (12 ×) 20
254 200
272 400d
279–369 (13 ×) 40
338 200
12 370 240d
371 200 No. 12
372 End of IT treatment; subsequent IV and SC treatment and WBHT not shown.
Total
No. of applications 33 19 81 12 ×
ME dosage 6120 3950 2901

Abbreviations: IT, intratumoral; IV, intravenous; ME, mistletoe extract; PCBCL, primary cutaneous B-cell lymphoma; SC, subcutaneous; WBHT, whole-body hyperthermia.

aMonth and day (interval) of treatment; mode, dose, and number of ME applications; application of WBHT.
bInfused in 250 mL sodium chloride 0.9%, over 60–90 minutes.
cTreatment periods of 1 or more weeks during which SC injections were given.
dIT distributed over both lesions.

During induction, the patient had 4 febrile responses of ≥38.5°C lasting < 24 hours with maximum readings of 38.5°C (after day 3); 38.7°C (after day 4); 39.1°C (after day 8); and 38.6°C (after day 11). For the IT approach, the lesions were injected from the healthy skin margins to avoid breaking the paper-thin skin overlying the bulging tumors. The volume of ME fluid often exceeded 20 mL (20 mg/mL/ampoule) and was injected evenly intraand perilesional while repositioning the needle during injection.

After IT treatment, the lesions responded with immediate postinjection swelling and inflammation, followed by clinical resolution of inflammation, and over the course of treatment, the lesions successively appeared less inflamed. The rate of regression seemed slightly accelerated after starting WBHT (day 37), and after 4 months, there was a clear overall improvement. The lesions continued to show injection-associated fluctuations, and the posterior lesion resolved first.

The lesions steadily decreased in volume, consistency, and redness. The remission was assessed by visual inspection and palpation and confirmed by 3 independent clinicians from 3 different clinical settings, including the ARI. The overall fitness and stamina of the patient improved. Re-scanning in May 2009 reflected “No significant supraclavicular, axillary or mediastinal … retroperitoneal or pelvic lymphadenopathy; as before, there are inguinal nodes the largest of which is on the left and measuring 1.3 × 1.8 cm. This node was documented as 2.7 × 1.7 cm on staging.” Routine full blood count and biochemistry were normal. Given the favorable clinical signs of control, the IT injections were discontinued at 12.3 months. Combined IV and SC ME treatment with WBHT continued for another 8 months, and the lesions continued to regress. The areas blanched eventually, leaving depressed (posterior, Figure 5) and level (anterior lesion, Figure 6) hyperpigmented areas. Conventional therapy was deferred indefinitely. At last review in December 2011, the patient was doing well and remained in remission; the appearances were similar to those from June 2011 (Figures 7 and and88).

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Primary cutaneous B-cell lymphoma in May 2010. Posterior left lower leg; posttreatment pigmentation and depression.

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Primary cutaneous B-cell lymphoma in May 2010. Anterior left lower leg showing pigmentation changes.

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Primary cutaneous B-cell lymphoma in June 2011. Posterior left lower leg.

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Primary cutaneous B-cell lymphoma in June 2011. Anterior left lower leg.

Tolerability

Fever was associated with sickness (grade 1) and grade 2 to 3 fatigue. The subsequent combined IV/IT administrations elicited fatigue (grade 1–2) for 1 to 3 days. No hypersensitivity was observed. SC injections elicited site responses of 4 cm to 5 cm erythema for < 2 days. The intralesional injections with concentrated ME were uncomfortable, with fluid pressure and pain for a few minutes, but did not require analgesia. Inflammatory responses (erythema, swelling, tenderness) and (transient) increase of edema of the lower leg lasted for < 2 days and were treated with cooling applications. The patient had no phlebitis at cannulation sites.

Patient’s Description of Treatment

The patient in this case described the treatment experience as follows:

With the initial fevers and fluctuating energy levels, my treatment was intense, exhausting and it was the only thing I could do during that time: but not a burden and a meaningful experience. During one of the high fevers an old traumatic experience became disentangled and I have felt freed up since; I now feel better than before my cancer, physically and emotionally. I also felt empowered by the working together with my doctors to develop the best treatment for me. I am very grateful for my new health!

CASE 2: PRIMARY CUTANEOUS MARGINAL ZONE B-CELL LYMPHOMA

A 52-year-old flight attendant was diagnosed at the same oncology department (ARI) with stage 2A, pT2ac-NxM0 primary cutaneous marginal zone B-cell lymphoma (PCMZL). In December 2007, 2 to 3 days after venapunction, he developed a lesion in the left antecubital fossa, which was excised in May 2008. The histopathology showed nodal marginal zone lymphoma (Figure 9). A staging CT scan of the neck, chest, abdomen, and pelvis showed no signs of systemic disease; trephine bone marrow biopsy, biochemistry, and hematology were normal. Shortly after excision, the patient developed a second lesion on the right anterior chest wall, medial to the right anterior axillary fold. The lesion was only palpable (no photographs). The patient was asymptomatic, had no recent weight loss or fatigue. Several treatment options were recommended: R-CVP, 10 fractions of involved-field radiotherapy of the 2 sites, or 6 months’ pulsed chlorambucil; he declined these options.

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Nodular marginal zone lymphoma. The architecture of the node is diffusely effaced by a population of lymphoid, plasmacytic, and histiocytic cells (H&E ×10). Image courtesy of Dr Ghada Bashat, Pathology, Aberdeen Royal Infirmary.

The patient had a history of rosacea with keratitis; actinic keratoses of upper back (treated with occasional cryotherapy); 2 basal cell carcinomas—one of the upper back (excised 1999) and one of the left leg (excised early 2007)—and an uncertain diagnosis of facial cutaneous scleroderma with no visceral involvement, but raised titres of antinuclear factor, which was unresponsive to azathioprine and oral prednisolone (2004). He used nicotine and alcohol moderately. Apart from emollients, he used no other regular conventional medications, reported no formal allergies, and was mistletoe-naïve. He had had no recent infections and no soft tissue trauma.

On presentation at PAC in August 2008, the patient was in good general health, with a Karnofsky Performance Scale status of > 90%. There was one soft and mobile lymph node in the left axilla. The right upper thoracic lesion was 2 × 3 cm palpable and mobile. There were no other abnormal findings.

Treatment

Combined IV, IT, and SC treatment with ME (Abnobaviscum fraxini) was provided over a period of 8.5 months. Details are shown in Table 2. During informed consent, it was explained to the patient that his underlying autoimmune condition theoretically could be aggravated. He received no other anticancer treatments.

Table 2

Treatment Schedule (08/09/08–04/20/09) and Tumor Size of Patient With PCMZLa

Month Day or Interval ME Dosage (mg) Per Application Tumor Size (cm) Palpation
IV Treatmentb IT Treatment SC Treatment (no. of sessions, if > 1)
Induction phase
0 1 40 3 × 2
2 80 0.2
3 160
4 200 2 0.2
5 10
7 200 20
10 200 40 2
13 200 80 4
Post-induction phase
22 12
1 26–47 (7 ×) 20 5 × 4
52 100 40
2 54–64 (3 ×) 20
66 140 40
71–85 (5 ×) 20
3 87 120 40
93–107 (4 ×) 20
109 160 40
4 114–128 (5 ×) 20
130 180 100
132–149 (6 ×) 20
5 151 180 100
153–170 (6 ×) 20
172 200 100 Reducing
6 176–191 (5 ×) 20
193 160 80
7 195–219 (8 ×) 20
221 160 80 0.5 × 0.5 × 0.3
223–254 (10 ×) 20
8 256 160 20 Impalpable
257 End of IT treatment; subsequent IV and SC treatment not shown. CR
Total
No. of applications 17 × 15 × 64 ×
ME dose 2 640 792 1 198.4

Abbreviations: CR, complete response; IT, intratumoral; IV, intravenous; ME, mistletoe extract; PCMZL, primary cutaneous marginal zone lymphoma; SC, subcutaneous.

aMonth and day (interval) of treatment; mode, dose, and number of ME applications.
bInfused in 250 mL sodium chloride 0.9% over 60–90 minutes.

He had 6 febrile responses (38° to 39.2°C) between days 5 and 87. There were no signs of concomitant infection. After IT injections, the lymphoma lesion each time showed a similar response pattern of inflammatory swelling and erythema for up to 2 days, then resolution. The lesion increased in size over the first month to 4 × 5 cm, then remained unchanged for 3 months, and after the IT dose was increased to 100 mg ME, the lesion steadily diminished to become impalpable at 8.5 months (Table 2). This complete response (CR) was clinically verified by 3 clinicians in 2 separate institutions, including the ARI. The ITs were ceased in April 2009, and SC and IV treatment was continued until November 2010. A CT scan in March 2010 was unre-markable. The patient was last reviewed in December 2011 and was doing well and in remission; no new lesions had developed.

Tolerability

During the first 3 months, treatment was challenging. The fever episodes in particular were accompanied by sickness and grade 1 to 2 fatigue. Once, grade 2 phlebitis developed at an IV cannulation site and resolved spontaneously; interestingly, no local relapse resulted from this. The SC and IT doses were followed by typical inflammatory site reactions that resolved without scarring or subcutaneous fibrosis. No hypersensitivity and no signs or symptoms of autoimmune reactivation were observed. After 6 months, the patient consistently reported improved vitality and well-being.

Patient’s Description of Treatment

The patient in this case described the treatment experience as follows:

When I was offered chemo-/radiotherapy, this seemed aggressive to me like a sledge hammer [sic] to crack a nut. My understanding of mistletoe therapy felt gentler and simply like the right thing to do. The treatment itself, whilst challenging, confirmed my feeling that it was the bedrock, the main stay [sic] of being healed.

DISCUSSION

The primary cutaneous B-cell lymphoma of 2 patients regressed after administration of a combination of SC, IV, and IT applications of high-dose, fever-inducing ME treatment. The rationale for the combination was to optimize immune responses as currently understood to elicit fever and to apply the principle of “in situ” vaccination with IT application. In one patient, WBHT was added to draw on the benefits of improved immune competence that is associated with fever-range hyperthermia. Three and a half years since commencement, the patients remain in clinical remission.

With high dosage, especially local ME applications, tumor remissions have been reported repeatedly in a number of tumor types, including breast cancer, Merkel cell cancer, primary liver cancer, pancreatic cancer, and cutaneous squamous cell cancer. Still, high-dose and combined IT, IV, and SC administration that aims to elicit febrile induction is uncommon and underreported.

The literature on ME treatment of lymphoma is limited compared to that of other tumor types. One retrospective study describes favorable outcomes, including a few remissions in a group of 61 patients with follicular non-Hodgkin’s lymphoma treated with a lowlectin ME (Iscador Pini) either alone or combined with or on completion of chemotherapy. Another retrospective study primarily investigated safety aspects of ME treatment in Hodgkin’s and non-Hodgkin’s lymphoma and found no risks. Some case reports describe remission of non-Hodgkin’s lymphoma under ME monotherapy, including 2 in cutaneous T-cell lymphoma in children., In these cases, the dosage was lower than in the cases reported here and applied mainly subcutaneously and only partly intravenously and intratumorally. At least one fever reaction was reported.

Preclinical studies with lymphoma cells and murine lymphoma models treated with ME, isolated MLs, recombinant ML, and other ME peptides have consistently shown antitumoral effects with tumor inhibition, inhibition of metastases, and survival benefit., ME contain several cytotoxic ingredients, among them lectins and viscotoxins, which are particularly abundant in Abnobaviscum fraxini. When lec-tins are applied systemically, their cytotoxicity is moderated by serum proteins and later by the occur-rence of anti-ML antibodies; hence, their cytotoxicity is to be expected, primarily with IT administration. However, a disease response could also be effected by an immunological mechanism, as has been demonstrated for ME repeatedly., Furthermore, fever seems to have a role in tumor defense. The impact of ME treatment cannot be easily ascertained when used concurrently with mainstream cancer therapy. Occasionally, however, patients postpone or decline recommended conventional treatment in favor of ME, and such cases allow evaluation of ME treatment alone. Two of these patients are described above; these are the only two cutaneous lymphoma cases treated at PAC with ME alone and are therefore unselected. The cases of 2 other patients from PAC who had cancer at other sites and were treated with ME monotherapy have been published previously.

In lymphoma, spontaneous remission is estimated to occur in 5% to 20% of cases. It is sometimes of long duration,,, and often is associated with reducing an immunosuppressive treatment or condition; following fever, viral or bacterial infections, or vaccination; or after biopsy and following eradication of helicobacter in gastric lymphoma. In a small follow-up study observing patients over many years, spontaneous remissions were reported in 4 of 16 patients with PCFCL (one of them complete) and in 4 of 8 patients with PCMZL (none of them complete), all of whom had a relapse. Although spontaneous remission could have played a role in the cases presented here, in the first of the cases presented, the lesions had grown progressively until commencement of ME treatment and then steadily decreased, with fluctuating treatment-related inflammatory responses. In the second case, the lesion resolved after initial treatment-related increase and with some delay, which is a known response pattern in ME-associated tumor remissions., Therefore, a mere coincidence is unlikely, especially as the 2 cases are unselected (meaning that they were not selected from a larger group of patients with cutaneous lymphomas treated with ME but were the only patients with cutaneous lymphonas treated in this way) and represent the only patients with PCBCL from PAC that had been treated with ME monotherapy. One also has to consider that the fever-induction ME treatment is likely to upregulate just those mechanisms implicated in the frequent spontaneous remission described for lymphoma.

Two further case publications on ME treatment of a related entity, CD30+ T-cell lympho-proliferation, reported complete regression of multiple and active cutaneous and nodal disease., In one case, treatment consisted of low-dose IV (3 infusions of 0.02 mg, 0.2 mg, and 2 mg) and SC (up to 2 mg twice a week) without fever or site responses, with a noticeable disease response within 1 week and durable (30 months) complete response (CR) within 4 weeks. The second case was treated with primary fever intent (38°C), IT, and SC, and had a dose-dependent partial response and CR that relapsed with a lower-dose ME but regressed again with dose increase.

A differentiated appreciation of the singular components of the combined ME treatment—the specific role of fever and each of the specific contributions of SC, IT, and IV—and of the synergies is not possible given the current knowledge and require further research.

Although treatment was well tolerated and the safety observed is in accordance with other investigations on the safety of ME treatment in higher dosage, this treatment should be reserved for use by physicians who have experience with ME application in higher dosages and IT/IV until further investigations have explored the role of high-dose, fever-inducing ME in cancer and its safety in more detail.

CONCLUSION

High-dose, fever-inducing mistletoe treatment seems to have beneficial effects in two cases of primary cutaneous B-cell lymphoma. Further research is needed to investigate antitumor effects, potential mechanisms of action, best mode of application, and the associated safety and efficacy.

Consent

Written informed consent was obtained from both patients for publication of the report and the accompanying Figures. They both read the final version of the paper and confirmed its contents.

Contributor Information

Maurice Orange, Maurice Orange, MSc, is a general practitioner, formerly medical director at Park Attwood Clinic, United Kingdom, and currently senior hospital doctor integrative oncology at the Ita Wegman Klinik, Arlesheim.

Maria P. Fonseca, Maria P. Fonseca was formerly an assistant general practitioner at Park Attwood Clinic and currently is in private practice at Emerson College, United Kingdom.

Broder H. von Laue, Broder H. von Laue, Dr med, is senior doctor, oncology focused practice, Niefern-Oeschelbronn, Germany.

Stefan Geider, Stefan Geider, Dr med, is a general practitioner at Camphill Medical Practice NHS, St John’s, Aberdeen, United Kingdom.

Gunver S. Kienle, Gunver S. Kienle, Dr med, is senior research scientist at the Institute for Applied Epistemology and Medical Methodology at the University of Witten/Herdecke in Freiburg, Germany.

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