How is malignant mesothelioma treated?

How is malignant mesothelioma treated?
This information represents the views of the doctors and nurses serving on the American
Cancer Society’s Cancer Information Database Editorial Board. These views are based
on their interpretation of studies published in medical journals, as well as their own
professional experience.
The treatment information in this document is not official policy of the Society and is not
intended as medical advice to replace the expertise and judgment of your cancer care
team. It is intended to help you and your family make informed decisions, together with
your doctor.
Your doctor may have reasons for suggesting a treatment plan different from these
general treatment options. Don’t hesitate to ask him or her questions about your
treatment options. If you have mesothelioma, your cancer care team will recommend one
or more treatment options for you to consider. This is an important decision and you
should take time to think about all of your choices.
Making treatment decisions
After the cancer is found and staged, your cancer care team will discuss your treatment
options with you. The main factors in selecting treatment for mesotheliomas are the
location and extent of the tumor, whether it has spread to lymph nodes or other organs,
and your health and personal preferences. Based on these factors, your treatment options
may include:
• Surgery
• Radiation therapy
• Chemotherapy
In many cases, more than one of these treatments may be used.
Because mesothelioma is a rare cancer, it has been hard for doctors to compare the value
of different treatments. Only a few large clinical trials of treatments for mesothelioma
have been done. In addition, many doctors have little or no experience treating this disease. They usually refer patients with this cancer to specialists who treat large numbers
of mesothelioma patients at major medical centers.
You may have different types of doctors on your treatment team, depending on the stage
of your cancer and your treatment options. These doctors may include:
• A thoracic surgeon: a doctor who treats diseases of the lungs and chest with surgery.
• A radiation oncologist: a doctor who treats cancer with radiation therapy.
• A medical oncologist: a doctor who treats cancer with medicines such as
• A pulmonologist: a doctor who specializes in medical treatment of diseases of the
Many other specialists may be involved in your care as well, including nurse
practitioners, nurses, respiratory therapists, social workers, and other health professionals.
Mesothelioma is often hard to treat because it typically does not grow as a single tumor
mass. It tends to spread along nearby surfaces, nerves, and blood vessels. This often
makes it very hard to get rid of it completely with surgery and/or radiation.
Before deciding on a treatment plan, it’s very important to have an idea of the likely
benefits and possible risks. You will probably have many questions about the treatment
options suggested. Mesotheliomas are rare, so if time permits it is often a good idea to
seek a second opinion from a doctor who has a lot of experience in treating people with
these cancers. A second opinion can provide you with more information and help you
feel more confident about the treatment plan that you choose.
The next few sections describe the types of treatments used for mesotheliomas. This is
followed by a discussion of the most common treatments used, based on the extent of the
Surgery for malignant mesothelioma
Surgery for mesothelioma may be done for 1 of 2 reasons:
• To try to cure the cancer
• To relieve (palliate) pain and other symptoms caused by the tumor
Surgery to try to cure the cancer is known as potentially curative surgery. This type of
surgery may be an option if you are in otherwise good health and the cancer has not
spread too far to be removed completely. Unfortunately, even when the surgeon can
remove all of the cancer that can be seen, some cancer cells are often left behind. These
cells can grow and divide, causing the cancer to come back some time after surgery.
Because of this, not all doctors agree on the exact role of surgery. In most cases it is not
likely to cure you but may extend your life. Still, potentially curative surgery is being done in some major cancer centers, and a small number of patients who have had the
surgery have had long remissions of their disease.
Palliative surgery may be an option if the tumor has already spread beyond where it
started and is difficult to remove completely, or if you are too ill for a more extensive
operation. The goal of this surgery is to relieve or prevent symptoms, as opposed to
trying to cure the cancer.
Surgery for pleural mesothelioma
Surgery for pleural mesothelioma may be done either to help prevent or relieve
symptoms or to try to remove all of the cancer. Unfortunately, these tumors have often
spread too far to be removed completely. Sometimes, the surgeon may not be able to tell
the full extent of the cancer – and therefore which type of surgery might be best – until
the operation has started.
Extrapleural pneumonectomy (EPP): This surgery may offer the best chance to
remove all of the cancer, and it is most often used when the surgeon thinks a cure is
possible – typically in patients with resectable mesothelioma of the epithelioid type
whose cancer has not spread to the lymph nodes.
This is an extensive operation that removes the pleura lining the chest wall, part of the
diaphragm, the pericardium (the sac around the heart), nearby lymph nodes, and the
whole lung on the side of the tumor. The diaphragm and the pericardium are then
reconstructed with man-made materials.
This is a difficult operation and is done only by surgeons in large medical centers. You
must be in good overall health with good lung function and no other serious illnesses to
tolerate this surgery. Several tests must be done beforehand to be sure you are healthy
enough for this surgery. Major complications occur in as many as 1 in 3 people who have
this operation.
Pleurectomy/decortication (P/D): This is a less extensive operation in which all of the
pleura lining the chest wall (on one side) is removed. The pleura coating the lung on that
same side is also removed, as is the pleura coating the mediastinum and the diaphragm.
The lung and diaphragm are not removed.
In a slightly more extensive version of this operation (known as a radical or extended
P/D), the diaphragm and pericardium are removed as well.
This surgery can be used to try to cure some cancers, but it is also used as a palliative
procedure to relieve symptoms in cases where the entire tumor cannot be removed. It can
help control the buildup of fluid, improve breathing, and decrease pain caused by the
Debulking: The goal of this surgery is to remove as much of the mesothelioma as
possible. In general, less tissue is removed in this operation than in a P/D procedure.
Possible side effects of surgery: Possible risks and side effects depend on the extent of
the surgery and the person’s health beforehand. Serious complications of EPP can includebleeding, blood clots, wound infections, changes in heart rhythm, pneumonia, and loss of
lung function. Most of these are less common with less extensive operations.
Because the surgeon must often spread the ribs during surgery, the incision will hurt for
some time afterward. Your activity will be limited for at least a month or two.
Surgery for peritoneal mesothelioma
Surgical treatment of peritoneal mesothelioma is often done either to help relieve
symptoms or to remove the tumor from the wall of the abdomen and digestive organs. As
with pleural mesothelioma, these tumors often have spread too far to be removed
Debulking: The goal of this surgery is to remove as much of the mesothelioma as
possible. Sometimes this means removing pieces of the intestine.
Omentectomy: The omentum is an apron-like layer of fatty tissue that drapes over the
contents of the abdomen. Cancers involving the peritoneum often spread to this tissue, so
it may be removed as part of surgery for peritoneal mesothelioma.
Surgery for pericardial mesothelioma
Surgery can be done to remove a mesothelioma from the pericardium (the sac around the
Surgery for mesothelioma of the tunica vaginalis testis
Surgery for mesothelioma of the tunica vaginalis testis, which occurs in the groin, rarely
cures this cancer. Most of the time surgery is done because the tumor resembles a hernia.
The surgeon attempts to treat a suspected hernia and only realizes the diagnosis after the
surgery has begun. This kind of mesothelioma typically can't be removed entirely.
Other palliative procedures
Several less invasive procedures can be used to control some of the symptoms caused by
mesothelioma, especially those due to the buildup of fluid.
Removal of fluid: Procedures such as thoracentesis, paracentesis, and pericardiocentesis
can be used to remove fluid that has built up and is causing symptoms. In these
procedures, a doctor uses a long, hollow needle to remove the fluid. These procedures are
described in the section, “How is malignant mesothelioma diagnosed?” The major
drawback with these techniques is that the fluid often builds up again, so they may need
to be repeated.
Pleurodesis: This procedure may be done to try to prevent fluid from building up in the
chest. A small cut is made in the skin of chest wall, and a hollow tube (called a chest
tube) is placed into the chest so that the fluid can drain out. Then the doctor uses the tube
to put a substance into the chest, such as talc mixed in a fluid (talc slurry), the antibiotic
doxycycline, or the chemotherapy drug bleomycin. Talc powder can also be sprayed into the chest cavity as an aerosol from a pressurized can. This causes the linings of the lung
(visceral pleura) and chest wall (parietal pleural) to stick together, sealing the space and
preventing further fluid buildup. The tube is generally left in for a day or two to drain any
new fluid that might accumulate. Pleurodesis can also be done at the time of
Shunt placement: A shunt is a device that allows fluid to move from one part of the
body to another. For example, a pleuro-peritoneal shunt lets fluid in the chest move into
the abdomen, where it is more likely to be absorbed by the body.
The shunt is a long, thin, flexible tube with a small pump in the middle. In the operating
room, the doctor inserts one end of the shunt into the chest cavity and the other end into
the peritoneum. (The pump is placed just under the skin over the ribs.) Once the shunt is
in place, the patient uses the pump several times a day to move the fluid from the chest to
the abdomen. This approach may be used if pleurodesis or other techniques are not
Catheter placement: This is another approach sometimes used to control the buildup of
fluid. One end of the catheter (a thin, flexible tube) is placed in the chest or abdomen
through a small cut in the skin, and the other end is left outside the body. This is done in a
doctor’s office or hospital. Once in place, the catheter can be attached to a special bottle
or other device to allow the fluid to drain out on a regular basis.
For more general information about surgery, please see our document, Understanding
Cancer Surgery: A Guide for Patients and Families .
Radiation therapy for malignant mesothelioma
Radiation therapy uses high-energy x-rays or particles to kill cancer cells. Mesotheliomas
are often hard to treat with radiation therapy. They are not usually contained as single,
discrete tumors, so aiming radiation at them while avoiding nearby normal tissues is
difficult. But new radiation therapy techniques may make this form of treatment more
Uses of radiation therapy
Radiation therapy may be used in different ways to treat mesothelioma:
• It can be used after surgery to try to kill any small areas of cancer that could not be
seen and removed during surgery. This is called adjuvant radiation therapy .
• It can be used as a palliative procedure to ease symptoms of mesothelioma such as
shortness of breath, pain, bleeding, and trouble swallowing.
Types of radiation therapy
Two main types of radiation therapy can be used to treat mesothelioma: External beam radiation therapy (EBRT): This type of radiation therapy uses x-rays
from a machine outside the patient’s body to kill cancer cells. It is the most common
form of radiation therapy for mesothelioma.
The treatment is much like getting an x-ray, but the radiation is more intense. The
procedure itself is painless. Before your treatments start, the medical team will take
careful measurements to find the correct angles for aiming the radiation beams and the
proper dose of radiation. Each treatment lasts only a few minutes, although the setup time
– getting you into place for treatment – usually takes longer. Most often, radiation
treatments are given 5 days a week for several weeks.
With newer techniques, doctors can more accurately treat mesotheliomas while reducing
the radiation reaching nearby healthy tissues such as the lungs. This may offer a better
chance of increasing the success rate and reducing side effects.
For example, intensity-modulated radiation therapy (IMRT) is an advanced form of 3-
dimensional radiation therapy. It uses a computer-driven machine that moves around the
patient as it delivers radiation. It shapes the radiation beams to fit the tumor and aims
them at the tumor from several angles, as well as adjusting the intensity (strength) of the
beams to limit the dose reaching nearby normal tissues.
Brachytherapy: For this type of radiation therapy, a radiation source is placed inside the
body. For mesothelioma, the doctor places radioactive material directly into the chest or
the abdomen at the site of the cancer. The radiation given off travels only a very short
distance, which limits the possible damage to nearby healthy tissues. Brachytherapy is
seldom used for this type of cancer.
Possible side effects
Side effects of external radiation therapy may include fatigue and sunburn-like skin
problems and hair loss where the radiation enters the body. These usually go away once
treatment is finished. Chest radiation therapy may cause lung damage and lead to trouble
breathing and shortness of breath. Abdominal radiation therapy may cause nausea,
vomiting, diarrhea, and a loss of appetite.
If radiation therapy is used together with chemotherapy, it may make the side effects of
chemotherapy worse.
If you are having any side effects from radiation therapy, talk with your doctor. There are
often ways to help control these symptoms.
For more general information about radiation therapy, please see our document,
Understanding Radiation Therapy: A Guide for Patients and Families .
Chemotherapy for malignant mesothelioma
Chemotherapy (chemo) is treatment with anti-cancer drugs. There are 2 main ways that
chemotherapy can be given to treat mesothelioma.  In systemic therapy, chemotherapy is injected into a vein. The drug enters the
bloodstream and travels throughout the body to reach and destroy the cancer cells
wherever they may be.
Chemo drugs can also be placed directly into the body cavity where the cancer is – either
intrapleurally (directly into the chest) or intraperitoneally (into the abdomen) – with a
small catheter (tube) placed through a small cut in the chest or abdominal wall. Chemo
drugs given this way are still absorbed into the bloodstream, but most of the drug goes
directly to where the cancer cells are. This approach may let doctors give higher doses to
the tumor while limiting the side effects to the rest of the body. Chemo drugs given this
way are sometimes heated first (called hyperthermic chemotherapy), which may help
them work better. Sometimes this treatment is given as a single dose in the operating
room, right after surgery to remove the cancer.
For mesotheliomas that can be treated with surgery, chemotherapy may be given before
surgery to try to shrink the cancer and lower the risk of spread. This is called neoadjuvant
therapy. Chemo can also be given after surgery to try to try to kill any cancer cells that
were left behind because they were too small to be seen. This type of treatment, called
adjuvant therapy, may help delay or prevent the cancer from growing back.
For cancers that are not resectable, chemotherapy may be the main treatment (alone or
along with radiation therapy). Chemotherapy may slow the progression of the disease, but
it is very unlikely to make it go away completely.
Doctors usually give chemotherapy in cycles, with each period of treatment followed by a
rest period to allow the body time to recover. Chemo cycles generally last about 3 to 4
weeks. Chemotherapy is often not recommended for patients in poor health, but advanced
age by itself is not a barrier to getting it.
Several chemo drugs have been used to treat mesothelioma. Most doctors now use a
combination of the drugs pemetrexed (Alimta
) and cisplatin. Pemetrexed lowers levels
of folic acid and vitamin B12 in the body, so patients get these as well to help avoid
certain side effects.
Other drugs used to treat mesothelioma include:
• Gemcitabine (Gemzar
• Carboplatin
• Methotrexate
• Vinorelbine
• Mitomycin
• Doxorubicin (Adriamycin
• Epirubicin (Ellence
• Cyclophosphamide (Cytoxan
) • Ifosfamide (Ifex
These may be given as combinations of 2 drugs, but single drugs can be used in people
who may not be able to tolerate more than one drug. Several other drugs are also being
studied for use against mesothelioma.
Possible side effects
Chemo drugs attack cells that are dividing quickly, which is why they work against
cancer cells. But other cells in the body, such as those in the bone marrow, the lining of
the mouth and intestines, and the hair follicles, also divide quickly. These cells are also
likely to be affected by chemotherapy, which can lead to side effects.
The side effects of chemotherapy depend on the type and dose of drugs you are given and
how long they are used for. Common side effects include:
• Hair loss
• Mouth sores
• Loss of appetite
• Nausea and vomiting
• Diarrhea
• Increased chance of infections (from too few white blood cells)
• Easy bruising or bleeding (from too few blood platelets)
• Fatigue (from too few red blood cells)
These side effects are usually short-term and go away after treatment is finished. There
are often ways to lessen these side effects. For example, drugs can be given to help
prevent or reduce nausea and vomiting. Be sure to ask your doctor or nurse about
medicines to help reduce side effects, and let him or her know if you have side effects, so
they can be managed effectively.
Some drugs can have other side effects. For example, cisplatin and carboplatin can
damage nerves (called neuropathy). This can sometimes lead to hearing loss or symptoms
in the hands and feet such as pain, burning or tingling sensations, sensitivity to cold or
heat, or weakness. In most cases this goes away once treatment is stopped, but it may last
a long time in some people.
Be sure to report any side effects or changes you notice while getting chemotherapy to
your medical team so that you can get prompt treatment for them. In some cases, the
doses of the drugs may need to be reduced or treatment may need to be delayed or
stopped to prevent the effects from getting worse.
For more general information about chemotherapy, please see our document,
Understanding Chemotherapy: A Guide for Patients and Families . Clinical trials for malignant mesothelioma
You may have had to make a lot of decisions since you’ve been told you have cancer.
One of the most important decisions you will make is choosing which treatment is best
for you. You may have heard about clinical trials being done for your type of cancer. Or
maybe someone on your health care team has mentioned a clinical trial to you.
Clinical trials are carefully controlled research studies that are done with patients who
volunteer for them. They are done to get a closer look at promising new treatments or
If you would like to take part in a clinical trial, you should start by asking your doctor if
your clinic or hospital conducts clinical trials. You can also call our clinical trials
matching service for a list of clinical trials that meet your medical needs. You can reach
this service at 1-800-303-5691 or on our Web site at You
can also get a list of current clinical trials by calling the National Cancer Institute's
Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237) or by
visiting the NCI clinical trials Web site at
There are requirements you must meet to take part in any clinical trial. If you do qualify
for a clinical trial, it is up to you whether or not to enter (enroll in) it.
Clinical trials are one way to get state-of-the art cancer treatment. Sometimes they may
be the only way to get access to some newer treatments. They are also the only way for
doctors to learn better methods to treat cancer. Still, they are not right for everyone.
You can get a lot more information on clinical trials in our document called Clinical
Trials: What You Need to Know. You can read it on our Web site or call our toll-free
number (1-800-227-2345) and have it sent to you.
Complementary and alternative therapies for malignant
When you have cancer you are likely to hear about ways to treat your cancer or relieve
symptoms that your doctor hasn’t mentioned. Everyone from friends and family to
Internet groups and Web sites may offer ideas for what might help you. These methods
can include vitamins, herbs, and special diets, or other methods such as acupuncture or
massage, to name a few.
What exactly are complementary and alternative therapies?
Not everyone uses these terms the same way, and they are used to refer to many different
methods, so it can be confusing. We use complementary to refer to treatments that are
used along with your regular medical care. Alternative treatments are used instead of a
doctor’s medical treatment.
Complementary methods: Most complementary treatment methods are not offered as
cures for cancer. Mainly, they are used to help you feel better. Some methods that are used along with regular treatment are: meditation to reduce stress, acupuncture to help
relieve pain, or peppermint tea to relieve nausea. Some complementary methods are
known to help, while others have not been tested. Some have been proven not be helpful,
and a few have even been found harmful.
Alternative treatments: Alternative treatments may be offered as cancer cures. These
treatments have not been proven safe and effective in clinical trials. Some of these
methods may pose danger, or have life-threatening side effects. But the biggest danger in
most cases is that you may lose the chance to be helped by standard medical treatment.
Delays or interruptions in your medical treatments may give the cancer more time to
grow and make it less likely that treatment will help.
Finding out more
It is easy to see why people with cancer think about alternative methods. You want to do
all you can to fight the cancer, and the idea of a treatment with few or no side effects
sounds great. Sometimes medical treatments like chemotherapy can be hard to take, or
they may no longer be working. But the truth is that most of these alternative methods
have not been tested and proven to work in treating cancer.
As you consider your options, here are 3 important steps you can take:
• Look for “red flags” that suggest fraud. Does the method promise to cure all or most
cancers? Are you told not to have regular medical treatments? Is the treatment a
“secret” that requires you to visit certain providers or travel to another country?
• Talk to your doctor or nurse about any method you are thinking about using.
• Contact us at 1-800-227-2345 to learn more about complementary and alternative
methods in general and to find out about the specific methods you are looking at.
The choice is yours
Decisions about how to treat or manage your cancer are always yours to make. If you
want to use a non-standard treatment, learn all you can about the method and talk to your
doctor about it. With good information and the support of your health care team, you may
be able to safely use the methods that can help you while avoiding those that could be
Treatment of mesothelioma based on the extent of the
The stage (extent) of a mesothelioma is an important factor in determining treatment
options. But other factors, such as whether the doctor feels the cancer is resectable (all
visible cancer can be removed by surgery), as well as a person’s general health and
preferences, also play a role.  Mesotheliomas can be hard to treat, whether the cancer is resectable or not. It’s very
important that you understand the goal of treatment before it starts – whether it is to try to
cure the cancer or to help relieve symptoms – as well as the possible benefits and risks.
This can help you make an informed decision when looking at your treatment options.
Resectable mesotheliomas
In general, most stage I and some stage II and III pleural mesotheliomas are potentially
resectable, but there are exceptions. Whether a tumor is resectable is based on the subtype
(most doctors believe only epithelioid and mixed/biphasic tumors are potentially
resectable), where it is located, how far it has grown into nearby tissues, and whether or
not a person is healthy enough to have surgery.
Many patients with resectable pleural mesothelioma have their cancer removed by
pleurectomy/decortication (P/D) or extrapleural pneumonectomy (EPP). Surgery is more
likely to result in long-term benefit in stage I cancers, where there is a better chance that
most or all of the cancer can be removed. For these early-stage cancers, EPP may be a
good option if it can be done. It offers the best chance to remove the cancer, but it is a
complex and extensive operation that can also have major side effects. Patients with
early-stage peritoneal mesotheliomas might also benefit from surgery. Some patients can
have long remissions after extensive surgery by experts. Surgery may still be helpful for
later-stage cancers, but the benefits are more likely to be short term.
Sometimes, the surgeon may think the cancer is resectable based on imaging tests (such
as CT scans) done before surgery, but once the operation starts it becomes clear that not
all of the cancer can be removed. In these cases the surgeon may switch to a less
extensive operation (which is less likely to cause side effects) or even stop the surgery
altogether if it is not likely to be helpful. Treatment would then be the same as for
unresectable mesotheliomas (see below).
Doctors are still studying whether giving chemotherapy before surgery (neoadjuvant
therapy) or giving chemotherapy or radiation therapy after surgery (adjuvant therapy) is
helpful. Some doctors prefer to give neoadjuvant chemotherapy, and many doctors advise
adjuvant chemotherapy or radiation therapy, but not all doctors agree on what the best
course of treatment is.
If you are not healthy enough to have a major operation, radiation therapy and/or
chemotherapy may be used instead. While these treatments may shrink or slow the
growth of the cancer for a time, they are not likely to result in a cure.
If you have symptoms because of fluid buildup in the chest or abdomen, other approaches
such as thoracentesis/paracentesis or pleurodesis (described in the “Surgery” section)
may be helpful.
Because these cancers can be hard to treat, taking part in a clinical trial of a newer form
of treatment may be a reasonable option. These types of studies are usually done in large
medical centers.  Unresectable mesotheliomas
Stage IV mesotheliomas, as well as many earlier-stage mesotheliomas, can’t be removed
completely by surgery either because of the extent or subtype of the disease or because a
person may not be healthy enough for an operation. Chemotherapy and/or radiation
therapy may shrink or slow the growth of the cancer for a time. But these treatments are
very unlikely to result in a cure and can have their own side effects. Before starting such
treatments, the goals of treatment should be clear to you and your family.
In people with early-stage mesotheliomas that are likely to grow slowly and are not
causing any symptoms, watching them closely at first may be a reasonable option.
Treatment can then be started if there are signs that the cancer is growing quickly or if it
starts to cause symptoms.  
Because these cancers can be hard to treat, taking part in a clinical trial of a newer form
of treatment may be a reasonable option.
In many cases, treatment aimed at relieving symptoms and making you more comfortable
may be a good choice. This could include treatments that prevent or reduce fluid buildup
in the body, which could affect your breathing or ability to take in nutrition.
Pain management is another important aspect of your care. Some minor operations and
types of radiation therapy can help relieve pain if needed. Doctors can also prescribe
strong pain-relieving drugs. Some people with cancer may hesitate to use opioid drugs
(such as morphine) for fear of being sleepy all the time or becoming addicted to them.
But many people get very effective pain relief from these medicines without serious side
effects. It’s very important to let your cancer care team know if you are having pain so
that it can be treated effectively.
Recurrent mesotheliomas
Cancer is called recurrent when it come backs after treatment. Recurrence can be local
(in or near the same place it started) or distant (spread to organs such as the brain or
liver). Mesotheliomas often come back after the initial treatment. If this happens, further
treatment options depend on where the cancer is, what treatments have already been used,
and a person’s general health.
In most cases the options will be similar to those listed above for unresectable
mesotheliomas. For example, chemotherapy may be used to try to shrink or slow the
growth of the cancer and to relieve any symptoms. Because recurrent cancers can often
be hard to treat, clinical trials of new types of treatment may be a good option.
More treatment information for malignant mesothelioma
For more details on treatment options – including some that may not be addressed in this
document – the National Cancer Institute (NCI) and the National Comprehensive Cancer
Network (NCCN) are good sources of information.  The NCI provides treatment guidelines via its telephone information center (1-800-4-
CANCER) and its Web site ( Detailed guidelines intended for use by
cancer care professionals are also available on
The NCCN, made up of experts from many of the nation's leading cancer centers,
develops cancer treatment guidelines for doctors to use when treating patients. These are
available on the NCCN Web site (

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