Hegenscheid et al. Potentially relevant incidental findings on research whole-body MRI in the general adult
population: frequencies and management. EurRadiol 2012
SUPPLEMENTARY WEB APPENDIX
This appendix consists of online material only and includes an own reference list that
is independent from the journals’ article reference list. This appendix was provided by
the authors to give readers additional information on the decisions made by the
advisory board for the follow-up of incidental findings.
HEAD
BRAIN TUMOUR
Heterogeneous group of intra-axial and extra-axial tumours with benign or malignant
aspect. Management of incidental findings has been widely discussed for study MRI
of the head [1, 2].
Disclosed benign tumours were intraventricular tumours, large arachnoid cysts, large
meningiomas, and a vestibular schwannoma. All of these benign tumours were
disclosed due to perifocal oedema indicating space-occupying growth or location in a
region with high functional priority (e.g., brain stem, eloquent brain region). Disclosed
malignant tumours were suspicious for glioma or metastasis. One participant
presented with an extracranial soft tissue tumour with invasive intracranial growth. All
were disclosed due to their life-threatening nature [3, 4].
PITUITARY MICRO-/ MACROADENOMA
Pituitary microadenoma: intrasellar lesion with a maximum diameter < 10 mm.
Pituitary macroadenoma: sellar-suprasellar mass without separately identifiable
pituitary gland. Pituitary cyst: intrasellar or sellar-suprasellar cystic lesion.
All lesions suspicious for microadenoma were communicated due to a possible
hormone-producing state. Macroadenomas were disclosed due to possible
involvement of the optic chiasm and cavernous sinus, and affected study subjects
were recommended to undergo assessment of clinical symptoms as well as
ophthalmological/endocrinological evaluation [5].
ACUTE BRAIN INFARCTION
Acute cerebral infarction was diagnosed by diffusion-weighted imaging. Infarctions
encountered were silent cerebral infarctions (neurologically asymptomatic).
Silent cerebral infarction was found to more than double the risk of subsequent
stroke in both population- and hospital-based cohort studies, regardless of the
presence of cardiovascular risk factors [6-9]. This finding was communicated to allow
subjects with twice the normal risk of major stroke to undergo neurological check-up
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for identification of potentially treatable risk factors.
SUBDURAL HAEMATOMA
Crescentic, extra-axial convexity collection, crossing sutures but not dural
attachments.
One subdural haematoma was disclosed due to its space-occupying size.
NORMAL PRESSURE HYDROCEPHALUS (NPH)
NPH was suspected according to the evidence-based guidelines for the diagnosis of
NPH [10].
Diagnosis of NPH required correlation with clinical symptoms. Suspected NPH was
disclosed to allow neurological work-up since timely diagnosis and treatment by
ventricular shunting can reverse symptoms, while natural history of NPH leads to
chronic impairment [11].
NECK
CYSTIC OR SOLID PHARYNGEAL OR LARYNGEAL TUMOUR
Handling of cystic or solid oropharyngeal and laryngeal masses was difficult because
their diagnosis relied on only two unenhanced MR sequences of the neck.
The advisory board decided each case of asymmetry by interdisciplinary consensus.
Almost all asymmetries, excepting simple cysts, were disclosed since the incidence
and mortality of oropharyngeal and laryngeal cancer is highest in the state in which
the SHIP study was conducted compared to the other German states [12]. The
relatively low risk of complications associated with panendoscopy of the
nasopharyngeal and laryngeal cavities recommended for follow-up justified higher
follow-up rates.
CYSTIC OR SOLID SALIVARY GLAND TUMOUR
Handling of cystic or solid salivary gland masses was difficult because their diagnosis
relied on only two unenhanced MR sequences of the neck.
The advisory board decided by interdisciplinary consensus which masses should be
followed up by assessment of clinical signs and symptoms and ultrasonography.
GOITRE WITH TRACHEAL COMPRESSION
Diffuse, multinodular enlargement of the thyroid gland with tracheal compression.
Goitres were disclosed in case of tracheal compression since significant airway
compression indicates need for surgical treatment [13].
THYROID TUMOUR
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Thyroid mass suspicious of malignancy: irregular demarcation from surrounding
structures, invasion, metastatic cervical lymphadenopathy.
Management of incidental thyroid masses on MRI/CT has been discussed
controversially [14]. Assessment required risk stratification by history, physical
examination, and ancillary tests (serum TSH, ultrasonography) [13, 15]. Since the
SHIP study provided thyroid ultrasonography and serum TSH values for each
participant in the internal branch of the study, the advisory board only disclosed
masses with high propability of malignancy, whereas all nondisclosed nodules were
automatically evaluated in the normal course of the SHIP study protocol.
CHEST
LUNG NODULE
Lung lesion completely surrounded by lung parenchyma < 3 cm in diameter [16].
Pulmonary nodules were reported according to the guidelines of the Fleischner
Society [17, 18]. Subjects with nodules > 4 mm were recommended to undergo initial
CT. If CT confirmed the nodule seen on MRI, further follow-up was recommended
following the guidelines of the Fleischner Society.
PNEUMONIA
Segmental/lobar consolidation of the lung due to inflammatory infiltration in
asymptomatic/ oligosymptomatic participants (silent infection) [19].
Asymptomatic/oligosymptomatic pneumonia was disclosed since, especially in the
elderly, pneumonia can present as silent infection with atypical features (deteriorating
general condition, confusion, and lethargy) but is nevertheless a major cause of
morbidity and mortality [20]. Poststenotic pneumonias in central lung carcinomas are
mostly subclinical infections [21]. Consequently, an underlying carcinoma should be
ruled out.
PLEURAL EFFUSION
Fluid accumulation in the pleural space replacing the pulmonary volume.
Pleural effusion was disclosed if effusion was so largeof such a volume that
respiratory restriction seemed likely, indicated by pulmonary dystelectasis or
atelectasis.
LIVER
LIVER LESION
A benign lesion (cyst, haemangioma, adenoma, focal nodular hyperplasia (FNH)) or
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malignant lesion (hepatocellular carcinoma) was assumed when the respective
imaging criteria were present. Lesions were classified as unclear if morphology on
plain imaging was not definitively benign and criteria for malignancy (destructive or
invasive growth) were not fulfilled.
(1) FNHs have few complications, and there is no evidence of malignant
transformation [22]. Disclosure of FNH was based on their responsiveness to
oestrogens with larger, more vascular tumours occurring in women on oral
contraceptives. Therefore, FNH was communicated in premenopausal women to
allow affected women and their gynaecologists to discuss discontinuation of oral
contraceptives [23].
(2) Large cysts were disclosed on the basis of their higher rate of complications such
as spontaneous haemorrhage, rupture, infection, or mechanical compression of
adjacent structures to allow correlation with clinical symptoms [24].
(3) Most hepatic haemangioma remain stable over time and require no treatment.
Treatment or follow-up is not indicated for lesions <5 cm in diameter, whereas
lesions >15 cm in diameter may need resection and were therefore disclosed
[25].
(4) All adenomas were communicated because of an approx. 10% risk of malignant
transformation to hepatocellular carcinoma (HCC) [26].
(5) Unclear liver lesions need further imaging evaluation (MRI with liver-specific
contrast medium/ ultrasonography) for reliable characterization.
(6) Liver lesions highly suspicious for hepatocellular carcinoma or metastasis were
communicated due to their malignant nature.
CIRRHOSIS OR HEMOCHROMATOSIS
Cirrhosis: chronic liver disease characterized by diffuse parenchymal injury, fatty and
fibrotic tissue changes, and formation of abnormal nodules.
Haemochromatosis: iron overload disorder with structural and functional impairment
of involved organs. Decreased signal intensity of the liver on T1- and T2-weighted
images.
Haemochromatosis and cirrhosis are severe pathologies shortening life expectancy
and lowering quality of life [27, 28]. These conditions were disclosed to allow
evaluation of etiology and risk factors as well as to facilitate possible treatment.
BILIARY SYSTEM
CHOLESTASIS
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Dilatation of the choledochal duct > 7mm/10mm or of intrahepatic bile ducts > 3mm
in participants without/after cholecystectomy, respectively.
Natural history of chronic cholestasis leads to secondary biliary cirrhosis of the liver.
Patients with this condition require evaluation of etiology and management of
treatable causes. Recommendations included assessment of paraclinical and clinical
signs as well as ultrasonographic correlation.
CHRONIC CHOLECYSTITIS
Chronic cholecystitis: diffuse gall bladder wall thickening and presence of gallstones.
Chronic cholecystitis was often seen and was only disclosed in case of acute
exacerbation: pericholecystic fluid and adjacent fat signal intensity changes [29].
PANCREAS
CHRONIC PANCREATITIS
Chronic pancreatitis: pancreatic atrophy, pancreatic duct dilatation and side branch
dilatation, irregularity of the pancreatic ducts, calcifications, pseudocysts, and biliary
obstruction.
Chronic pancreatitis was disclosed due to a natural history with exocrine/endocrine
insufficiency and chronic pain syndrome to allow evaluation and enable management
of treatable causes [30]. Recommendations included assessment of paraclinical and
clinical signs as well as ultrasonographic correlation.
PANCREATIC TUMOUR
Unclear pancreatic lesions disclosed were suspicious for malignancy but could also
be tumour-simulating benign lesions such as inflammatory pseudotumours or
complex pseudocysts.
Since unenhanced imaging with a single modality does not differentiate cancer and
focal pancreatitis, disclosure allowed correlation with additional imaging findings
(contrast-enhanced CT and ERCP with biopsy) [31, 32]. The follow-up regimen was
based on the White Paper of the ACR incidental findings committee [33].
SPLEEN & LYMPHATIC SYSTEM
SPLENOMEGALY
Splenomegaly: craniocaudal length of the spleen exceeding 12 cm.
Splenomegaly was disclosed if suggestive of systemic diseases of the lymphatic
system (e.g., generalized lymphadenopathy with concomitant splenomegaly),
metastasis (e.g., abdominal lymphadenopathy in conjunction with suspicious
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intestinal, hepatic, or pancreatic mass), or reactive lymphadenopathy with
concomitant inflammation suggested by severe tissue oedema. All of these cases
were presented to the advisory board with disclosure being decided on a case-bycase basis.
SPLENIC TUMOUR
Splenic lesions were classified as lesions with a distinct MRI appearance
(cyst/hemangioma, calcification, infarction) and unclear lesions.
Unclear lesions could not be reliably characterized on the basis of the available plain
MR sequences. Correlation with other imaging modalities was suggested to rule out
inflammatory and infectious disease, hematologic disorders, and solid malignancies
[34].
INTESTINE
GASTROINTESTINAL TUMOR
Solid soft tissue mass of the intestinal wall, which reproduced in at least two different
sequences to exclude peristalsis as cause of intestinal wall thickening.
Available MR images were limited, not least because no contrast agent was used.
Cases in question were presented to the advisory board with disclosure being
decided on a case-by-case basis.
LARGE HERNIATION
Opening or weakness in the muscular structure of the abdominal wall with protrusion
of an organ or part of an organ out of the abdominal cavity.
Large herniations with protrusion of organs were disclosed due the risk of
incarceration [35].
KIDNEY
RENAL CYST OR TUMOUR
We adopted the Bosniak classification system to grade cystic renal lesions [36,37].
The differential diagnosis of renal masses includes angiomyolipoma and renal cell
carcinoma.
Category I cysts were disclosed > 8 cm in diameter due to the increased risk of
hemorrhage especially in individuals undergoing anticoagulation therapy [38, 39].
Simple category II cysts are benign, but cyst category IIF (a cystic lesion with multiple
thin septa, or septa thicker than hairline, or a thick calcification) are not invariably
benign [40, 41]. Disclosure was implemented for cysts category ≥ IIF with follow-up
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according to the recommendations of the White Paper of the ACR incidental findings
committee [33]. Although benign, renal angiomyolipomas were always disclosed
since angiomyolipoma was found to be the most frequent misdiagnosis for renal cell
carcinoma [42]. Renal angiomyolipomas were also disclosed because they are
associated with an increased risk of tumoural haemorrhage when their size exceeds
4 cm [43]. Kidney masses with an invasive and/or destructive growth pattern are
highly suspicious for renal cell carcinoma and were disclosed due to their probably
malignant nature.
ADRENAL TUMOUR
Adrenal lesion ≥ 1 cm.
All adrenal masses ≥ 1 cm were disclosed. Follow-up was recommended according
to the White Paper of the ACR incidental findings committee to allow correlation with
prior imaging and/or follow-up by MRI or CT [33].
CHRONIC URINARY OBSTRUCTION
We differentiated chronic urinary retention with dilatation of the calicopelvic system
with concomitant atrophy of renal parenchyma from acute urinary retention with
dilatation of the calicopelvic system and normal renal parenchyma.
Chronic and acute urinary retention was always disclosed since both will lead to
chronic kidney disease if untreated and persisting [44, 45].
URINARY BLADDER MASS
Localized circumscribed urinary bladder masses were differentiated from global
thickening of the urinary bladder wall. The first is suspicious for urinary bladder
malignancy, the second is a sign of chronic bladder damage.
Since the acquired MR sequences are limited regarding evaluation of the urinary
bladder, among others because evaluation depends on bladder filling at the time of
imaging, circumscribed or diffuse wall thickening was always disclosed to enable
further diagnostic work-up (ultrasonography, cystoscopy) and correlation with
possible clinical symptoms.
MALE GENITAL SYSTEM
PROSTATIC HYPERPLASIA OR TUMOUR
Probably benign enlargement of the prostate due to nodular hyperplasia causing
progressive urinary obstruction was distinguished from
enlargement
of
the
prostate
(asymmetric
enlargement,
probably malignant
invasive
growth,
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lymphadenopathy) suggestive of prostatic cancer.
Volumetry of the prostate was performed in all men ([transverse diameter in cm]3 x
/6) [46]. Prostatic enlargement  60 ml was disclosed to allow urological risk
stratification
for
urinary
obstruction
and
prostate
cancer
(transabdominal/
transurethral ultrasound and biopsy, correlation with clinical symptoms and
paraclinical parameters) [47].
INGUINAL TESTIS
Incomplete testicular descent into the scrotum with testis in the inguinal canal.
An inguinal testis has an increased risk of malignant transformation and infertility and
was disclosed depending on the participant’s age [48-50].
TESTICULAR AND EPIDIDYMAL MASS
Cystic or solid testicular or epididymal mass with benign or malignant aspect.
Simple scrotal cysts (epididymal/ testicular/ tunica albuginea cyst, spermatocele] are
benign and were not disclosed. Solid scrotal masses were generously disclosed with
recommendation for urological clarification. For scrotal masses there are multiple
differential diagnoses, and differentiation requires correlation with clinical signs and
symptoms, paraclinical parameters and alternate imaging modalities, espescially
ultrasonography, and ultimativley inguinal exploration [51-53].
SEMINAL VESICLE MASS
Generalized enlargement of the seminal vesicles was distinguished from focal
lesions.
Diffuse enlargement was not disclosed since underlying conditions are benign
(inflammation, radiotherapy-induced changes, amyloidosis). Focal lesions suggesting
tumor invasion (cancer of the prostate, bladder or rectum) were disclosed [54].
FEMALE GENITAL SYSTEM
UTERINE OR CERVICAL TUMOUR
Benign masses of the uterus and cervix (leiomyoma, adenomyoma/ adenomyosis,
endometrial hyperplasia, polyp, Nabothian cysts) and probably malignant masses
(endometrial or cervical carcinoma, endometrial sarcoma) were differentiated.
None of the definitely benign uterine lesions listed above were disclosed. For unclear
uterine and cervical masses, the interdisciplinary advisory board decided on a caseby-case basis which masses to follow up. The relatively low risk of complications of
colposcopy and ultrasonography recommended for follow-up justified higher follow-
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up rates [55, 56].
COMPLEX OVARIAN CYST OR TUMOUR
Ovarian masses were differentiated into benign (functional cysts, haemorrhagic
cysts), unclear, and probably malignant (solid tumours or mixed solid and cystic
tumours, size > 8 cm, local invasion, peritoneal fluid, and adenopathy).
In premenopausal women, complex cysts with suspected haemorrhage and cystic
tumours were disclosed, while simple cystic lesions (functional cysts) were not. In
postmenopausal women, cysts were disclosed if diameter exceeded 2 cm due to the
increased risk of ovarian cancer to allow correlation with ultrasound and paraclinical
parameters (Ca-125) [57, 58]. All unclear ovarian masses and those with signs of
malignancy (solid tumour or mixed solid and cystic tumour, size > 8 cm, local
invasion, peritoneal fluid, adenopathy) were disclosed [59-61].
BREAST LESION (≥ BI-RADS 3)
Breast lesions in women who underwent the contrast-enhanced MR mammography
module were classified according to the Breast Imaging Reporting and Data System
(BI-RADS).
Breast lesions classified  BI-RADS 3 were disclosed. For category 3 lesions, close
follow-up was recommended [62, 63] as well as ultrasonographic correlation [64]. For
category 4 or 5 lesions, biopsy was recommended.
SPINE AND MUSCULOSKELETAL SYSTEM
ABSOLUTE SPINAL CANAL STENOSIS WITH MYELOPATHY
Acquired stenosis of the cervical/lumbar spinal canal secondary to degenerative
changes
with
intramedullary
T2-hyperintensity
representing
myelomalacia,
demyelination, or oedema.
Natural history of cervical/lumbar spinal canal stenosis is progressive and dynamic
with mainly irreversible damage to the spinal cord/cauda equina. Disclosure allowed
diagnostic and therapeutic interruption of the progressive disabling process [65, 66].
INTRASPINAL TUMOUR
Intraspinal
lesions
were
classified
into
intramedullary
lesions,
intradural
extramedullary lesions, and extradural lesions. There are many differential diagnoses
depending on many features including lesion site, signal intensities, and clinical and
paraclinical parameters [67, 68].
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Without contrast-enhanced MR images, differentiation of benign and malignant
lesions was not possible. Therefore all intraspinal lesions were disclosed to allow
further diagnostic steps.
BONE LESION
Bone lesions encountered were bone cysts, chondrogenic bone tumors (with benign
aspect], and unclear bone lesions not classifiable on the basis of plain MR images.
Bone cysts were disclosed if size and location suggested risk of fracture (e.g.,
femoral neck, case-by-case decision by the advisory board]. Most chondrogenic
bone tumours were assumed to be enchondromas, which are primary benign
tumours with little potential of malignant transformation. The risk of secondary
malignant transformation is increased for endochondromas located in the axial
skeleton and > 5 cm in diameter [69]. Enchondroma cannot reliably be differentiated
from low-grade chondrosarcoma by MRI alone [70, 71]. Chondrogenic bone tumours
were disclosed if located in the axial skeleton and diameter > 5cm for short-time
follow-up and correlation with clinical signs and other imaging modalities.
SEVERE BONE EDEMA
Differential diagnoses for bone marrow oedema vary widely depending on
localization, age, clinical symptoms, and radiographic appearance (osteoarthritis,
osteonecrosis, traumatic bone bruise, bone infarction, insufficiency/stress fracture,
metastasis, transient bone marrow oedema syndrome, septic joint, osteomyelitis,
leukaemia, and lymphoma) [72].
Bone oedema was not disclosed if it was most likely due to osteoarthritis, traumatic
bone bruise, bone infarction, or early osteonecrosis. Bone
oedema was
communicated when it was assumed to be associated with fracture, osteomyelitis,
osteonecrosis with destruction of the joint surface, and possible malignancy.
HEART AND VESSELS
HEART FAILURE
Left ventricular ejection fraction (LVEF) was obtained for participants who underwent
the cardiac MR module. If LVEF was < 35% heart failure was diagnosed.
Community-dwelling elderly persons with impaired LVEF have a substantial risk of
death from congestive heart failure [73]. Therefore LVEF < 35% was disclosed.
MYOCARDIAL TUMOUR
One participant presented with a cardiac mass most likely originating from the
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myocardium.
The advisory board agreed upon disclosure since cardiac tumours are rare entities
requiring special expertise and further diagnostic steps.
PERICARDIAL EFFUSION
One participant presented with pericardial effusion impairing diastolic ventricular
filling.
The advisory board agreed upon disclosure since further increase in intrapericardial
fluid volume was expected to cause decompensation.
VASCULAR STENOSIS
Arterial stenosis of the (1) renal artery and (2) aortic isthmus was identified.
(1) Renal artery stenosis causes hypertension and progressive renal failure. The
need for revascularization and its benefits have been discussed controversly
[74,75]. Disclosure allowed individual assessment of the need for treatment.
(2) One participant presented with aortic coarctation. The advisory board agreed
upon disclosure due to the severely reduced life expectancy in untreated aortic
coarctation [76].
VASCULAR ANEURYSM
Arterial aneurysms of the (1) splenic artery, (2) renal artery, (3) abdominal aorta
(AAA), and (4) thoracic aorta were identified.
(1) No consensus has been reached regarding intervention in asymptomatic patients
with splenic artery aneurysm. The smallest aneurysm that ruptured over a 4-year
observation period at the Mayo Clinic was 2 cm [77]. It has been recommended to
treat asymptomatic aneurysms greater than 2 cm in patients with a reasonable
operative risk and life expectancy greater than 2 years [77, 78]. Therefore all
splenic aneurysms were disclosed.
(2)While the majority of renal artery aneurysms are asymptomatic, they are
associated with hypertension in up to 73% of cases. A diameter greater than 1.5
cm requires repair. Aneurysm repair cures hypertension in 20-50% of cases [79].
Therefore, the single case encountered was disclosed.
(3)An AAA is a focal dilation of the abdominal aorta ≥ 1.5 times its normal diameter,
by convention infrarenal aorta ≥ 3 cm [80]. The risk of rupture correlates with
diameter of the aneurysm: 5-5.9 cm: 11% per year and ≥ 6 cm: 25% per year [81].
All AAAs were disclosed with recommendations: 3-4 cm: yearly ultrasound
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examination, 4-4.5 cm: ultrasound examination every 6 months, ≥ 4.5 cm: referral
to a vascular specialist [82].
(4)An aneurysm of the thoracic aorta is considered if diameter exceeds > 4.5 cm. All
aneurysms need follow-up with regular imaging to monitor growth [83]. With regard
to aneurysm size and risk of rupture or dissection, an annual rate of 2% for
aneurysms < 5 cm, 3% for aneurysms 5 to 5.9 cm, and 7% for aneurysms > 6 cm
was found [84]. Surgery is indicated for a diameter of > 5.5 cm or 6 cm in patients
with an increased operative risk [83].
INTRACRANIAL ANEURYSM
Intracranial aneurysm: saccular or fusiform dilatation of an intracranial artery.
Whether incidental aneurysms should be treated preventively has been discussed
controversially
[85-87].
All
findings
were
disclosed
after
neurosurgical/neuroradiological assessment by the advisory board with individualized
recommendations for diagnosis, follow-up, and treatment.
CAVERNOUS MALFORMATION
Cavernous malformations (CMs) are benign vascular hamartomas with intralesional
haemorrhages of different ages.
CMs can cause seizures or intracranial haemorrhage, yet 40% of cases are
asymptomatic. Asymptomatic persons need not be treated. Therefore all CMs were
discussed in the advisory board. Disclosure was decided on a case-by-case basis
taking into account age, localization, and size of the malformation (region with high
functional priority, e.g., brain stem, eloquent brain regions).
INTERNAL CAROTID ARTERY STENOSIS
Internal carotid artery (ICA) stenosis was classified according to the NASCET
method: % stenosis = (normal lumen - minimal residual lumen) / (normal lumen x
100) [88].
ICA stenosis  50% was disclosed to allow further individual assessment since in
asymptomatic patients younger than 75 with carotid diameter reduction ≥ 70%
carotid, endarterectomy was shown to halve the 5-year stroke risk [89].
Note–. Gray-shaded cells indicate precedents.
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