PSa 0, radiation?

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mr bill
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Date Joined Sep 2010
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   Posted 12/2/2010 12:58 PM (GMT -6)   
Had my 12 week follow up yesterday at Cleveland Clinic. PSA was 000 on their equipment that measures small amounts.
The med oncologist obviously said, wait till we have something to treat.
The radiation oncologist said he could go either way wait, or give it a shot now, even though there is no PSa.
The surgeon said he would like to see me have radiation within a month or so. He fed all the numbers into some sort of geonome (not sure if that is correct name) program. From that he determined that I have a 98% chance of recurrence.  Thusly, radiation with 0 PSa.  He also minimized the side affects of the treatment.  Obviously it would be pelvic RT, especially the lymph nodes; which may lead to temporary bowel issues.
 
I have a great deal of confidence in this surgeon, which I hope is rightfully placed. He went in with PSa of 30, Gleason 9 and came out with PSa of 0.00.  He really seems to know his stuff.
 
I had received some sidebar feedback from another member of the forum, but was wondering how others felt about going ahead with the radiation at this time? The other member mentioned that others, that have pretty much the same signature,
only aprox 50% have experienced recurrence. I mentioned that to the radiation onc. who thought it might be as low as 20%, but with my 0 PSa he would venture about 30 to 40% that I would not have recurrence without radiation.  He did explain that there are no statistics/numbers/studies to back up what the surgeon proposed. They are pretty much going by gut feeling.
 
I was wondering what other members of the forum thought?
 
Mr Bill
Age 66
BPH since 1996. at least three negative biopsies Erie. Uro did not prescribe finasteride
2007 acute urine retention photoselective vaporize Clev. Clinic
8-9-10 PSA rose to 10.14 with finasteride positive biopsy Cleveland gleason 9, cat & bone scan negative
9-8-10 Robotic prostatectomy at Cleveland. Biopsy 9 nodes, 2 positive,seminal & vas deferens
PSA 3 wk .06, 6 wk <.03

Jerry L.
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Date Joined Feb 2010
Total Posts : 3072
   Posted 12/2/2010 1:36 PM (GMT -6)   
Mr. Bill,

That is good news on your current PSA. I couldn't tell from your signature, but was there lymph node invovlement?

I went the radiation road right after surgery because I thought there was good data showing it was beneficial.

Below is an article that may be of interest to you: "Even With Undetectable PSA, Men With Locally Advanced Prostate Cancer Benefit From Adjuvant Radiation".

http://www.medscape.com/viewarticle/704911

Jerry L.
Nov. 2009 Dx at Age 44
Dec. 2009 DaVinci Robotic Surgery
Jan. 2010 T3b, Gleason 9
Feb. 2010 Adjuvant Radiation

PSA History:
-----------------
Nov. 2009 4.30
Feb. 2010 <.05
May 2010 <.05
Aug. 2010 <.05
Nov. 2010 <.05

BB_Fan
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Date Joined Jan 2010
Total Posts : 1011
   Posted 12/2/2010 1:59 PM (GMT -6)   
Since you are asking for opinions, I guess that if I was in your shoes I would go for the adjuvant radiation. IMO you should attack the PCa where ever you find it. If it is detected in then nodes I would hit them with RT. It way not cure you, but it would slow down progression.
Dx PCa Dec 2008 at 56, PSA 3.4
Biopsy: T1c, Geason 7 (3+4) - 8 cores, 4 positive, 30% of all 4 cores.
Robotic Surgery March 2009 Hartford Hospital, Dr Wagner
Pathology Report: T2c, Geason 8, organ confined, negitive margins, lymph nodes negitive - tumor volume 9%, nerves spared, no negitive side effects of surgery.
PSA's < .01, .01, .07, .28, .50. HT 5/10. IMRT 9/10.
PSA's post HT .01, < .01

daveshan
Regular Member


Date Joined Jan 2010
Total Posts : 363
   Posted 12/2/2010 3:06 PM (GMT -6)   
Mr Bill,
This is a tough decision. I was faced with the same one recently, my Dr held off 'till I was back very close to normal in ED and urinary continence then suggested it might be time to do adjuvant radiation just in case. I had been pushing her for it as I was quite scared of a recurrence.

After a lot of research I decided to wait and hit it if my PSA became detectable, in my lab's case this would be >0.04. at 0.05 we get ready and will do a test sooner than the next cycle (currently 3 months) if it shows a trend we hit it.

My decision would have been different if I had ANY positive lymph nodes or more than the very small positive margin I ended up with. I'm also 56 and my wife is 47, if we were 10 years older it may have changed my thinking a bit.

I am taking a chance and I'm not advising you to do the same. For me the chance of retaining the use of my little friend against the possibility of taking an ED setback was the deciding factor. May seem silly to some but that was my choice.

Looking at your stat's I'd really think about playing it safe.

Best of luck whatever you decide
Dave in Durango CO
Diagnosed 12-09 age 55
07-06 PSA 2.5
01-08 PSA 5.5 (PCP did not tell me of increase or schedule follow-up!!!!)
09-09 PSA 6.5 Sent for consult with Urologist
11-09 Consult, scheduled for biopsy, found out about PSA from '08 (yes I was pissed)
12-09 Biopsy, initial Gleason 9 (4+5) later reduced to 8 with tertiary 5, ain't much but I'll take it.
01-10 Bone Scan, "appears negative"
03-01-10 RRP in Durango CO by Dr Sejal Quale and Dr Shandra Wilson, no naked eye evidence of spread, Vesicles and lymph nodes taken for microscopic exam.

03-16-10 Removal of cath' and pathology results of samples.
Multifocal carcinoma with areas of Gleason pattern 3, 4 and 5, Overall Gleason grade 4+4 with tertiary 5, Bilateral involving 21% of left lobe, 3% of right lobe, Invasion of left Seminal vesicle, Tumor focally present at left resection margin, 9 lymph nodes removed all negative, Tumor staging pT3b NO MX

04-23-10 PSA <0.04....... 06-07-10 PSA <0.04..... 08-03-10 <0.04
05-03-10 1 week without pads
06-28-10 ;-)

mr bill
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Date Joined Sep 2010
Total Posts : 709
   Posted 12/2/2010 3:25 PM (GMT -6)   
Jerry,
Yes, I did have 2 of 9 lymph nodes positive.  That is an excellent article, and seems to fit my circumstancs. I just wonder if waiting pas the eighteen weeks will negate any positive benefits.
 
Mr. Bill

Casey59
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Date Joined Sep 2009
Total Posts : 3172
   Posted 12/2/2010 4:12 PM (GMT -6)   
mr bill said...
I have a great deal of confidence in this surgeon, which I hope is rightfully placed. He went in with PSa of 30, Gleason 9 and came out with PSa of 0.00.  He really seems to know his stuff.
 
It's important to have confidence in your surgeon, but at 12 weeks after surgery with undetectable PSA probably isn't an indicator as to whether he "knows his stuff" or not.
 
Your likelihood of recurrence is high...I believe you already know this.  You had Gleason 9.  You had positive lymph nodes.  From your signature, I think you also had seminal vesicle involvement (SVI).  (Have you entered your case results into one of the nomograms to get a history-based prediction of recurrence based on others with similar case characteristics?)  Look up the percent involvement of Gleason 4 and 5 tissue in your pathology report, and then look up the chart at this site to see the likelihood of recurrence based on high Gleason results alone (Link).
 
With a high likelihood of recurrence, at 12-weeks post op with undetectable PSA, all you really know now is that you probably do not have much, or possibly any, systemic PC (because having systemic PC would likely result in detectable levels, especially if it's been around for a while).
 
The responses you got make sense to me:
  • "med oncologist obviously said, wait till we have something to treat" -- he provides hormone therapy treatment, which is primarily for systemic PC (don't know if you have), although it would also affect local PC
  • "radiation oncologist said he could go either way wait, or give it a shot now, even though there is no PSa" --based, I imagine, on the high likelihood of recurrence
  • "surgeon said he would like to see me have radiation within a month or so" -- probably also based on high likelihood of recurrence, but giving yourself more time for healing/recovery from surgery

Here's another good article for you, which includes discussion on combination of RT and HT. 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2848745/

best wishes...


Piano
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Date Joined Apr 2008
Total Posts : 847
   Posted 12/2/2010 4:15 PM (GMT -6)   
I was Gleason 8 (PSA 5.7) and didn't have adjuvant radiation. My PSA dropped to undetectable for six months, but since then has been rising, and now I am facing salvage radiation, nearly 3 years out from surgery, with reduced chance of a "cure".

A 98% chance of recurrence is close to certainly, so I'd run with what your doctors recommend.

Jerry L.
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Date Joined Feb 2010
Total Posts : 3072
   Posted 12/3/2010 1:33 AM (GMT 0)   
Mr. Bill,
 
I think there is good data to support doing radiation early.  It is probably debatable whether HT should begin before and after radiation vs. when PSA begins to rise.  Hopefully, others will chime in and give you data about doing the HT now versus later.  I would at least learn what you can about it so you can make an informed decision.
 
Jerry L.
 

Fairwind
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Date Joined Jul 2010
Total Posts : 3895
   Posted 12/2/2010 7:45 PM (GMT -6)   
This is a VERY tough call...Zero is zero, right?? Why treat zero?? But positive lymph nodes and Gleason 9 are screaming DO IT....

A very tough hand indeed...Work the odds between doing it now and waiting...Are they talking adding on HT also??
Age 68.
PSA at age 55: 3.5, DRE normal. Advice, "Keep an eye on it".
age 58: 4.5
" 61: 5.2
" 64: 7.5, DRE "Abnormal"
" 65: 8.5, " normal", biopsy, 12 core, negative...
" 66 9.0 "normal", 2ed biopsy, negative, BPH, Proscar
" 67 4.5 DRE "normal"
" 68 7.0 third biopsy positive, 4 out of 12, G-6,7, 9
RRP Sept 3 2010, pos margin, one pos vesicle nodes neg. Post Op PSA 0.9 SRT, HT, Dec

NCOBJIM
Regular Member


Date Joined Dec 2010
Total Posts : 35
   Posted 12/2/2010 8:13 PM (GMT -6)   
I had RP in 2006 after Gleason 3+4=7 Stage III PC
PSA went down to 0.05 & stayed that way till 2009.
Went to 0.1, 0.2 then 0.4.
June 2010 decided right then to go for IMRT.
38 treatments plus 6 month HT
PSA now at 0.04 & hoping for continued decline.
 

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 12/2/2010 8:31 PM (GMT -6)   
Mr. Bill,

It is a tough call in your situation. One side (your pathology) cries do it now, and other side, the zero, says wait, heal some more from your surgery, and wait and see. Others in your situation have recurrance right away, some further out, and some not at all. Where are you on the incontinence front? If you go for radiation, it tends to put a damper on your incontinence improvements, though, like all things PC, not always.

David in SC
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06 11/10 Not taking it
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/23/10

mr bill
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Date Joined Sep 2010
Total Posts : 709
   Posted 12/2/2010 8:52 PM (GMT -6)   
The incontinence issues are certainly an something to be considered. Dry all night, maybe get up once, sometimes twice. Mornings are dry, then the afternoon dribble starts. Early evening goes back to dry.  Maybe the afternoon leakage is related to the cup of early morning coffee and two cups of tea.  It will probably be a month before I would start RT. Maybe things will be better by then. Trying to find a place in the south for RT. Clinic oncologist is OK with that. Radiation oncologist lkes ht with rt but says we can wait on the ht to see if it is ever necessary down the road.
 
Does anyone know anything about oncology at University of Alabama Birmingham http://hemonc.dom.uab.edu/?
 
Thank you for all the input, nothing beats experience.
 
Mr. Bill

Post Edited (mr bill) : 12/2/2010 6:56:50 PM (GMT-7)


compiler
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Date Joined Nov 2009
Total Posts : 7270
   Posted 12/2/2010 11:40 PM (GMT -6)   
Wow. It was a tough call in my situation and I chose to wait (followed the advice of my Ford team).
 
Your pathology is worse than mine, but an amazing PSA.
 
What about just waiting and doing SRT IMMEDIATELY if you get a detectable PSA? Might be a good compromise?
 
Tough decision.
 
Good luck
 
Mel

tarhoosier
Regular Member


Date Joined Mar 2010
Total Posts : 496
   Posted 12/3/2010 10:47 AM (GMT -6)   
Bill:
Your pathology says high chance of recurrence, with significant possibility of systemic disease. Those two things together mean that radiation has a smaller likelihood of cure. Your psa says excellent results with no indication of residual disease. So what to make of the apparent contradiction? I say First accomplish all the healing that you can. Any radiation now compromises return of continence and potency. The trial SWOG 8794 (available online in full) shows radiation within 180 days was helpful compared to waiting until recurrence was confirmed by rising psa. Node positive status compromises the results. In any case, your surgeon accomplished everything that he could and deserves a round of applause. At this point his work is done. I say that your advice from the med oncologist and rad onco is where you should place your bet: Immediate or delayed? Without evidence of disease or upon recurrence? What opportunity is lost if you delay until the appearance of psa? What is the trigger the onco would consider? What dose and target? Nodes too? With Anti-hormone therapy or no? Have you read and completely understand all of the pathology report? Are you otherwise healthy and accepting of radiation without contra-indications? Have side effects been fully explained and explored?
I think you have a while to consider, read and discuss everything. The WORST thing you could do is to rush to treatment without fully exploring the options.

English Alf
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Date Joined Oct 2009
Total Posts : 2218
   Posted 12/3/2010 11:18 AM (GMT -6)   
Bill: I can't quite tell from your signature if you also had positive seminal vesicles and positive vas deferens, if so that is another reason they may be thinking you need RT sooner rather than later as it meant the PCa was already moving away from the prostate. Also the Gleason 9 is not a wonderful sign (that's the sort of thing that makes mathematical models suggest a recurrence is likely too), but there have been plenty of 9s here who have done okay.
The zero PSA does however seem like very good news, and should at least enable you to take a while to make up your mind. How soon before your next PSA test? Is retesting in just 3 moinths perhaps an idea rather than waiting 3 months?

Alf

mr bill
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Date Joined Sep 2010
Total Posts : 709
   Posted 12/3/2010 1:39 PM (GMT -6)   
Next PSA is three months. However, the one link posted above suggested radiation be started 18 weeks after RP.  I agree I do not want to rush things.
Yes, did have positive seminal and vas deferen.
 
Kind of up in air right now.
 
Mr Bill
Age 66
BPH since 1996. at least three negative biopsies Erie. Uro did not prescribe finasteride
2007 acute urine retention photovaporize Clev. Clinic prscb finasteride
8-9-10 PSA rose to 10.14 with finasteride positive biopsy Cleveland gleason 9, cat & bone scan negative
9-8-10 RP at Cleveland. Biopsy 9 nodes 2 positive, 2 positive,seminal & vas deferens
PSA 3 wk .06, 6 wk <.03, 12wk 0.0

John T
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Date Joined Nov 2008
Total Posts : 4269
   Posted 12/3/2010 1:58 PM (GMT -6)   
Bill,
Let's look at the facts, you have a gleason 9 with a psa of 30. Since high gleason grades give off low psa this would put you into a very, very high risk catagory. You have seminal vessical invasion which is highly indicative of lympnode spread and your positive lymphnodes confirm this. Every indication, but your low psa post op indicates a systemic spread which surgery will not cure. There is every indication that your surgeon is correct in his assessment of a 99% chance of a reoccurrance. Did anyone mention HT along with the pelvic radiation? Radiation plus a 2 years course of HT is probably the best course of action at this time. There are micro mets in your system that can only be killed or slowed by HT.
JohnT
65 years old, rising psa for 10 years from 4 to 40; 12 biopsies and MRIS all negative. Oct 2009 DXed with G6 <5%. Color Doppler biopsy found 2.5 cm G4+3. Combidex clear. Seeds and IMRT, no side affects and psa .1 at 1.5 years.

Carlos
Regular Member


Date Joined Nov 2009
Total Posts : 486
   Posted 12/3/2010 2:34 PM (GMT -6)   
Mr. Bill,  You asked about UAB.  UAB is a respected major treatment center in our region.  However, I don't have any personal knowledge about their radiation oncology department.  I made the 250 mile trip from Pensacola to Birmingham for PCa surgery but will stay in Pensacola for SRT.  I have an experienced radiation oncologist with a recently upgraded facility that includes state of the art imaging and of course the new Varian equipment.  I'm starting SRT on the 15th.  I wish you good luck with your decision and treatment.
 
Carlos

Diagnosed 2/2008 at age 71, PSA 9.1, G8 (5+3), stage T1c.
Robotic surgery 5/2008, LFPF at 6 wks.,nerves spared, stg. pT2c, N0, MX, R0, G8 (5+3)
PSA .12 at 2.5 years, rechk 2 wks later 0.2. All prior tests <0.1.

Jerry L.
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Date Joined Feb 2010
Total Posts : 3072
   Posted 12/3/2010 5:02 PM (GMT -6)   
John T.,

I agree with going the radiation route and I would encourage Mr. Bill to check into the HT option as well.
Do you have any good data/links suggesting doing HT at the same time as radiation vs. waiting until a rise in PSA?

Hang in there Mr. Bill. HW is a great place for information and support. There are a lot of guys that are traveling down the same road as you. Once you get a plan, it gets better.

Thanks,
Jerry L.
Nov. 2009 Dx at Age 44
Dec. 2009 DaVinci Robotic Surgery
Jan. 2010 T3b, Gleason 9
Feb. 2010 Adjuvant Radiation

PSA History:
-----------------
Nov. 2009 4.30
Feb. 2010 <.05
May 2010 <.05
Aug. 2010 <.05
Nov. 2010 <.05

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4269
   Posted 12/3/2010 5:23 PM (GMT -6)   
Jerry,
There is a lot of disagreement as to when to add HT. Studies in High risk patients have shown a combination of radiation and HT is superior to either radiation or HT used alone. There is a lot of disagreement as to the duration of the HT.
New England Journal of Medicine, June 2009 showed an increased survival for men given 30 months of HT with radiation over those given 6 months.
Other studies for combining HT with Radiation:
Bolla: The Lancet July 2002
D"Amico: Journal of the American Medcal Association Aug 2004
Pilepch: Urology, April 1995
I think ther is definately a survival benefit, but HT has to be given for somewhere between 13 and 24 months and probably closer to 24 months to get the best benefits.

JT
65 years old, rising psa for 10 years from 4 to 40; 12 biopsies and MRIS all negative. Oct 2009 DXed with G6 <5%. Color Doppler biopsy found 2.5 cm G4+3. Combidex clear. Seeds and IMRT, no side affects and psa .1 at 1.5 years.

mr bill
Veteran Member


Date Joined Sep 2010
Total Posts : 709
   Posted 12/3/2010 5:58 PM (GMT -6)   
I believe Dr. Walsh indicates that Adjunct RT is not the best course of action. However, he goes on to say that HT enhances Radiation therapy.  There are just to many things to consider.  Surgeon does not believe my PC is systemic. I really hope he is right.  He is a very agressive personality, but he is good.
 
Glad to hear that UAB is well respected. I just have to find a place for treatment in a warmer climate. After all these years of living in Erie, working in the cold a great deal of the time before retirement, and now throwing PC on the fire, how much can an old toot put up with?
 I know the clinic is near the top according to U.S. News, but I am not sure if I need the top right now.  Anybody know anymore good places in the south?
 
Mr Bill

Post Edited (mr bill) : 12/4/2010 8:41:57 AM (GMT-7)


Fairwind
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Date Joined Jul 2010
Total Posts : 3895
   Posted 12/3/2010 6:00 PM (GMT -6)   
I REALLY did not want to do the trifecta, surgery, RT, HT, so I consulted with 3 different doctors, one of them a honcho at a university research center.. They all agreed, in my case, doing all three was the way to go...This was before the post-op PSA (0.9) came back..After that, all resistance from me faded...
Age 68.
PSA at age 55: 3.5, DRE normal. Advice, "Keep an eye on it".
age 58: 4.5
" 61: 5.2
" 64: 7.5, DRE "Abnormal"
" 65: 8.5, " normal", biopsy, 12 core, negative...
" 66 9.0 "normal", 2ed biopsy, negative, BPH, Proscar
" 67 4.5 DRE "normal"
" 68 7.0 third biopsy positive, 4 out of 12, G-6,7, 9
RRP Sept 3 2010, pos margin, one pos vesicle nodes neg. Post Op PSA 0.9 SRT, HT, Dec

142
Forum Moderator


Date Joined Jan 2010
Total Posts : 7087
   Posted 12/3/2010 8:34 PM (GMT -6)   
Mr. Bill,
 
You will have seen in other postings that I did the adjunct IGRT at about 25 weels after DaVinci, with an "undetectable" PSA, G 4+5, multiple EPE. My wait was in hopes of a little more incontinence improvement.
My uro has an 18-week minimum wait stance on starting RT.
 
The Rad. Oncologist wanted HT in tandem, but my uro/surgeon agreed with my aversion for HT in this case.
 
My choice was to do it sooner than later. Having already had the incontinence and ED side-effects, it made more sense to me to do it (I am 57) rather than find that it came back in two or three years.
 
DaVinci 10/2009
My IGRT journey (2010) -
www.healingwell.com/community/default.aspx?f=35&m=1756808

mr bill
Veteran Member


Date Joined Sep 2010
Total Posts : 709
   Posted 12/3/2010 9:01 PM (GMT -6)   
Veteran,
How did you do with the RT and incontinence issue after 18 weeks?
 
Mr. Bill
Age 66
BPH since 1996. at least three negative biopsies Erie. Uro did not prescribe finasteride
2007 acute urine retention photovaporize Clev. Clinic prscb finasteride
8-9-10 PSA rose to 10.14 with finasteride positive biopsy Cleveland gleason 9, cat & bone scan negative
9-8-10 RP at Cleveland. Biopsy 9 nodes 2 positive, 2 positive,seminal & vas deferens
PSA 3 wk .06, 6 wk <.03, 12wk 0.0

142
Forum Moderator


Date Joined Jan 2010
Total Posts : 7087
   Posted 12/3/2010 9:24 PM (GMT -6)   
At 18 weeks I was at 1 pad per day. That did not get any better/worse out to 25 weeks. Later in the RT sessions I started having a bit of a setback, and now, just over 5 months out from finishing RT, I am at 2-3 pads per day.
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