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A. Bánvölgyi Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Budapest, Hungary

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A. Görög Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Budapest, Hungary

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K. Gadó Faculty of Health Sciences, Department of Clinical Studies, Semmelweis University, Budapest, Hungary

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P. Holló Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Budapest, Hungary

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Abstract

The incidence of all types of malignant skin tumours, including both melanoma and non-melanoma types, has increased in recent decades, while basal cell carcinoma is the most common human malignancy in the Caucasian race. The aging of the skin is associated with an increase in both benign and malignant tumours. As the population ages and life expectancy extends, mostly in developed countries, dermatologists are likely to face growing numbers of patients seeking therapy for such abnormalities. It is primarily UV irradiation that is responsible for the development of skin cancers, although there are other risk factors, including air pollution and X-ray irradiation. Seborrhoeic keratosis, solar lentigo and other benign lesions, despite their harmless nature, may cause distress to patients, such as itching or aesthetic issues. This review article summarises the features of the most common benign and malignant lesions of aging skin.

Abstract

The incidence of all types of malignant skin tumours, including both melanoma and non-melanoma types, has increased in recent decades, while basal cell carcinoma is the most common human malignancy in the Caucasian race. The aging of the skin is associated with an increase in both benign and malignant tumours. As the population ages and life expectancy extends, mostly in developed countries, dermatologists are likely to face growing numbers of patients seeking therapy for such abnormalities. It is primarily UV irradiation that is responsible for the development of skin cancers, although there are other risk factors, including air pollution and X-ray irradiation. Seborrhoeic keratosis, solar lentigo and other benign lesions, despite their harmless nature, may cause distress to patients, such as itching or aesthetic issues. This review article summarises the features of the most common benign and malignant lesions of aging skin.

Introduction

The aging of the skin not only causes structural and subsequent physiological changes to the skin but also leads to the development of benign and malignant tumours in elderly people.

The most common benign lesion is the solar lentigo (SL), which appears as a brownish, flat mark. Also known as “age spots” [1], solar lentigines develop on skin surfaces that are exposed to sunlight. Seborrhoeic keratoses (SK) are also extremely frequent. These have a brownish, dark-coloured, verrucous surface that protrudes from the skin [1, 2]. Although these cannot develop into malignancy, many patients seek treatment due to potentially extreme itching or for aesthetic reasons [3]. In addition to benign changes in the skin, there are several precancerous and malignant lesions that emerge with the aging process. The incidence of all types of malignant skin tumours, both melanoma and non-melanoma types, as well as precancerous lesions, increases with age [4–6]. The most common precancerous lesion is actinic keratosis (AK, also referred to as solar keratosis), which may affect up to 25% of the elderly population [4]. Without adequate treatment, AK can transform into squamous cell carcinoma (SCC), which can metastasise [4]. Among malignant lesions, basal cell carcinoma (BCC) is the most prevalent and is the most common human malignancy in the Caucasian race [7].

Benign lesions of the aging skin: characteristics and treatment options

During the aging process, the skin not only loses its constituent components but also reacts to UV and other environmental impacts, such as air pollution. These combined factors result in an increasing number of pigmented and non-pigmented benign tumours, as well as lesions of vascular origin. Seborrhoeic keratoses, which can vary widely in size from a few millimetres to several centimetres, are the most common benign lesions [3] (Fig. 1). They develop from keratinocytes and can take many different clinical forms. They may present as light brown to black in colour and can have an almost flat or extensively verrucous surface [3]. The diagnosis of SK is in general uncomplicated with the use of a dermatoscope. However, in the case of forms that are more darkly pigmented, or even black, it is important to distinguish SK from melanoma. In cases where no clear diagnosis can be established, surgical excision and histological examination are recommended [8]. Seborrhoeic keratoses can easily be removed using a variety of techniques, such as electrocautery or curettage with a Volkmann spoon or carbon dioxide (CO2) laser device [9]. Where histological examination is needed, curettage or in toto excision are the preferred procedures. In the case of the possible differential diagnosis of malignant melanoma (MM) versus SK, in toto excision is the only applicable technique [8]. However, in the event of a clear diagnosis it is not necessary to remove SK, as malignant transformation does not occur. If itching, inflammation, or other symptomatic issues develop, or if the patient requests the removal of SK due to aesthetic reasons, the need for treatment may be validated [10]. In outpatient care in the elderly population, the above techniques are equally applicable. In nursing homes, chronic general wards, or specialised units for elderly patients, cryotherapy is preferred. With this method, the chances of secondary infection are minimal, no wounds develop, and it can even be applied as a bedside procedure [11]. The differential diagnosis of SL (primarily the lentigo maligna subtype) versus melanoma can also give rise to issues [12]. In the event of a definite diagnosis, if the patient requests the removal of SL for aesthetic reasons, chemical peeling or retinoid creams with an exfoliating effect can be used in addition to the above-mentioned techniques [13]. Another common benign lesion of vascular origin is senile angioma, also known as cherry angioma or Campbell de Morgan spots, which likewise have no malignant transformation potential [14]. These lesions thus require no action, other than for aesthetic reasons, in which case they can be removed by electrocautery, CO2 lasers, and especially vascular lasers, such as diode, pulse dye (PDL) or Nd:YAG lasers [14]. In skin folds, such as the axilla, groin and neck area, irritation makes the skin vulnerable to the development of soft fibromas (also called skin tags or acrochordons). These are non-pigmented, benign lesions with no malignant potential. However, because of irritation and inflammation, and also for aesthetic reasons, many patients seek treatment for this condition [15]. These lesions can also be removed using electrocautery, CO2 laser or cryotherapy. Smaller lesions can even be removed with scissors, in which case the bleeding can be effectively controlled using a high concentration solution of ferric chloride or aluminium chloride [16].

Fig. 1.
Fig. 1.

Seborrhoeic keratosis, a benign skin growth on the ear, characterised by a light brown waxy, scaly, and raised verrucous surface

Citation: Developments in Health Sciences 4, 4; 10.1556/2066.2022.00055

Precancerous lesions of the skin: characteristics and treatment options

The most common precancerous lesion is AK, which may affect up to 25% of the elderly population [4]. Actinic keratosis appears as an erythematous, generally scaly, slightly infiltrated plaque. It is occasionally accompanied by subjective symptoms, such as itching or pain, but does not usually cause any complaints. As it can transform into SCC [17], it does require treatment. There are many therapeutic options available [18], including removal by cryotherapy or physical destruction using electrocautery or CO2 laser. Photodynamic therapy (PDT), as well as the “daylight” version of this technique, are being used increasingly to treat AK, and several lesions can be treated during a single session [19]. Topical therapies are also available, such as creams containing 5-fluorouracil (5-FU) or imiquimod (Aldara®), a Toll-like receptor 7 (TLR7) agonist, both of which are excellent options for the treatment of AK [19]. Cryotherapy offers the same advantage as in the case of SK, as it can be used as a bedside procedure. The topical creams referred to above can be applied by the patients themselves, supposing an adequate level of compliance. In the event of inadequate compliance, the cream can be administered by nursing staff, thus the medical human resources required for this procedure are minimal.

Other precancerous lesions of the skin, such as Bowen's disease and erythroplasia of Queyrat can also be treated using the same therapeutic modalities [20, 21].

Malignant lesions of the skin: characteristics and treatment options

The most aggressive and dangerous skin malignancy is MM, the incidence of which has increased significantly in recent decades, reaching 68.6 per 100,000 people in the U.S. in 2006 [22]. Malignant melanoma affects disproportionately more men than women in the U.S. (107 versus 41 cases per 100,000 people) [22]. In Hungary, the incidence almost doubled (12 versus 23 cases per 100,000 people) between 2001 and 2012, although MM affected moderately more women than men [23].

In cases of melanoma, surgical excision with an adequate safety margin is required. Depending on the depth of the melanoma lesion, known as the Breslow thickness, staging and further oncological treatment may be necessary [24]. In the presence of features identified on the basis of the ABCD rule — that is, asymmetry, irregular border, multiple colours, and a diameter greater than 6 mm — it is feasible to establish a suspected diagnosis of melanoma (Fig. 2). This should subsequently be confirmed by a dermatologist via dermoscopic examination. Furthermore, all newly formed pigmented lesions or existing pigmented lesions showing changes should be treated as potential melanomas. However, caution is required even in the case of newly formed “pinkish” non-pigmented lesions, which should be considered as melanomas and checked by dermoscopic examination [25, 26].

Fig. 2.
Fig. 2.

Malignant melanoma, a pigmented asymmetric tumour on the lower limb

Citation: Developments in Health Sciences 4, 4; 10.1556/2066.2022.00055

Squamous cell carcinoma (or so-called spinalioma) is the second most common human skin cancer after BCC and is able to metastasise [27]. The typical clinical features of SCC are a slowly or rapidly growing scaly or crusted plaque, nodule, or tumour, which is erythematous or greyish white in colour. As previously discussed, AK can transform into SCC and must therefore be treated early. The treatment of SCC follows the same principles as the treatment of melanoma, although a narrower safety margin of 5 mm is generally suitable [27]. Staging examinations are also required because of its metastatic potential [28]. Basal cell carcinoma has the highest prevalence among skin cancers and is also the most common human malignancy in the Caucasian race [7]. It is essentially non-metastatic, although its locally advanced form (laBCC) can lead to the severe destruction of surrounding tissue, and even to the death of the patient [29–32]. The clinical presentation is generally an erythematous, occasionally ulcerated, bleeding plaque or bump with a pearly shine [29] (Fig. 3). With the use of a dermatoscope, arborising telangiectasias can be observed and pigmented BCC can be distinguished from melanoma [33]. It can occasionally be difficult to diagnose BCC, mostly in the case of subtypes such as superficial or sclerodermiform BCC [34]. Careful observation and dermatological examination are therefore crucial for all wounds that do not heal after six weeks, especially in areas exposed to sunlight [7]. The gold standard treatment is surgical excision. Radiotherapy, cryotherapy, curettage combined with chemical surgery, electrocautery or CO2 laser, photodynamic therapy, or imiquimod topical therapy can also be used to remove BCCs [27]. In the facial area, and especially around the eyes, nose and ears, prompt and adequate treatment is of paramount importance. The basic principle is that if the BCC can be removed surgically or otherwise, this is the recommended option even where there is a chance of causing a moderate aesthetic defect. Although BCC lesions generally grow slowly, they can become enormous and laBCCs can develop, which represent a therapeutic challenge [29–31]. In several cases, surgical excision is not feasible or would result in severe functional and aesthetic issues. In such cases, the targeted small-molecule SMO inhibitors vismodegib or sonidegib may be the only choice of treatment. If the general condition of an elderly patient permits, this may be a good therapeutic option with significant, but in most cases manageable, side effects [30, 31]. Nevertheless, laBCCs can present a serious oncological dilemma in the elderly population. The optimal therapy must be determined taking into account a number of factors, including the size, the histological type of the BCC, comorbidities, and the life expectancy of the patient independent of the BCC. The severity and danger of the disease should not be underestimated solely because of the age of the patient, as this is a tumour that gradually and relentlessly destroys the surrounding organs, including the eyes, nose and ears, or even as far as the cranial bone. Tumours accompanied by regular bleeding and secondary superinfection cause a serious deterioration in quality of life over many years.

Fig. 3.
Fig. 3.

Basal cell carcinoma, an erythematous, ulcerated, pearly, shiny tumour on the forehead

Citation: Developments in Health Sciences 4, 4; 10.1556/2066.2022.00055

Conclusions

The prevention, prompt detection, and appropriate treatment of skin tumours are of particular importance in the elderly population. Essentially, annual screening is sufficient and requires only a dermatoscope, which is easily portable. Screening can thus be performed locally in nursing homes or in the chronic care units of hospitals, which is an important consideration for a significant proportion of the elderly patient population. Adequate dermato-oncological care can significantly reduce mortality and morbidity in the elderly population, thus its further development will remain an important objective in the future. However, in addition to malignant lesions, there may still be a significant need for the treatment of benign lesions in elderly patients. Whether for functional or aesthetic reasons, the importance of such treatment should be considered from a quality of life perspective.

Conflicts of interest/Funding

The authors declare no conflict of interest. No financial support was received for the preparation of this manuscript.

Authors' contribution

AB - writing original draft. Preparation, creation of the published work, specifically writing the initial draft. AG - writing original draft. Preparation, creation of the published work, specifically writing the initial draft. KG - preparation of the published work, contributed to the critical revision of the manuscript. PH - Critical review, including pre- or post-publication stages, supervised the study and finalized the manuscript.

Abbreviations

AK

actinic keratosis

BCC

basal cell carcinoma

CO2

carbon dioxide

laBCC

locally advanced basal cell carcinoma

MM

malignant melanoma

PDT

photodynamic therapy

SCC

squamous cell carcinoma

SL

solar lentigo

SK

seborrhoeic keratosis

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    Moscarella E , Brancaccio G , Briatico G , Ronchi A , Piana S , Argenziano G . Differential diagnosis and management on seborrheic keratosis in elderly patients. Clin Cosmet Investig Dermatol 2021;14:395406. https://doi.org/10.2147/CCID.S267246.

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    Karadag AS , Parish LC . The status of the seborrheic keratosis. Clin Dermatol 2018;36:275277. https://doi.org/10.1016/j.clindermatol.2017.09.011.

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    • Search Google Scholar
    • Export Citation
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    Fleming P , Zhou S , Bobotsis R , Lynde C . Comparison of the treatment guidelines for actinic keratosis: a critical appraisal and review. J Cutan Med Surg 2017;21:408417. https://doi.org/10.1177/1203475417708166.

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    Rogers HW , Weinstock MA , Feldman SR , Coldiron BM . Incidence estimate of nonmelanoma skin cancer (Keratinocyte Carcinomas) in the U.S. Population, 2012. JAMA Dermatol 2015;151:10811086. https://doi.org/10.1001/jamadermatol.2015.1187.

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    • Export Citation
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    Cameron MC , Lee E , Hibler BP , Barker CA , Mori S , Cordova M , et al.. Basal cell carcinoma: epidemiology; pathophysiology; clinical and histological subtypes; and disease associations. J Am Acad Dermatol 2019;80:303317. Erratum in: J Am Acad Dermatol. 2021;85:535 https://doi.org/10.1016/j.jaad.2018.03.060.

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    • Crossref
    • Search Google Scholar
    • Export Citation
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    Kao S , Kiss A , Efimova T , Friedman AJ . Managing seborrheic keratosis: evolving strategies and optimal therapeutic outcomes. J Drugs Dermatol 2018;17(9):933940.

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    • Export Citation
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    • Export Citation
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    Clebak KT , Mendez-Miller M , Croad J . Cutaneous cryosurgery for common skin conditions. Am Fam Physician 2020;101:399406.

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    Tanaka M , Sawada M , Kobayashi K . Key points in dermoscopic differentiation between lentigo maligna and solar lentigo. J Dermatol 2011;38:5358. https://doi.org/10.1111/j.1346-8138.2010.01132.x.

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    Ortonne JP , Pandya AG , Lui H , Hexsel D . Treatment of solar lentigines. J Am Acad Dermatol 2006;54:S262S271. https://doi.org/10.1016/j.jaad.2005.12.043.

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    Buslach N , Foulad DP , Saedi N , Mesinkovska NA . Treatment modalities for cherry angiomas: a systematic review. Dermatol Surg 2020;46:16911697. https://doi.org/10.1097/DSS.0000000000002791.

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    Coakley A , Wu MJ , Kumar J , Dadrass F , Tao J , Moy L , et al.. A comparison of ferric subsulfate solution, silver nitrate, and aluminum chloride for pain assessment, time to hemostasis, and cosmesis in acrochordon snip excision. J Clin Aesthet Dermatol 2020;13:3237.

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    • Export Citation
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Senior Editors

Editor-in-Chief: Zoltán Zsolt NAGY
Vice Editors-in-Chief: Gabriella Bednárikné DÖRNYEI, Ákos KOLLER
Managing Editor: Johanna TAKÁCS

Editorial Board

  • Zoltán BALOGH (Department of Nursing, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • Klára GADÓ (Department of Clinical Studies, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • István VINGENDER (Department of Social Sciences, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • Attila DOROS (Department of Imaging and Medical Instrumentation, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • Judit Helga FEITH (Department of Social Sciences, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • Mónika HORVÁTH (Department of Physiotherapy, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • Illés KOVÁCS (Department of Clinical Ophthalmology, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • Ildikó NAGYNÉ BAJI (Department of Applied Psychology, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • Tamás PÁNDICS (Department for Epidemiology, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • József RÁCZ (Department of Addictology, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • Lajos A. RÉTHY (Department of Family Care Methodology, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • János RIGÓ (Department of Clinical Studies in Obstetrics and Gynaecology, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • Andrea SZÉKELY (Department of Oxyology and Emergency Care, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • Márta VERESNÉ BÁLINT (Department of Dietetics and Nutritional Sicences, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • Gyula DOMJÁN (Department of Clinical Studies, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • Péter KRAJCSI (Department of Morphology and Physiology, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • György LÉVAY (Department of Morphology and Physiology, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • Csaba NYAKAS (Department of Morphology and Physiology, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • Vera POLGÁR (Department of Morphology and Physiology, InFaculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • László SZABÓ (Department of Family Care Methodology, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • Katalin TÁTRAI-NÉMETH (Department of Dietetics and Nutrition Sciences, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • Katalin KOVÁCS ZÖLDI (Department of Social Sciences, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • Gizella ÁNCSÁN (Library, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary)
  • András FALUS (Department of Genetics, Cell- and Immunbiology, Faculty of Medicine, Semmelweis University, Budapest, Hungary)
  • Zoltán UNGVÁRI (Department of Public Health, Faculty of medicine, Semmelweis University, Budapest, Hungary)
  • Romána ZELKÓ (Faculty of Pharmacy, Semmelweis University, Budapest, Hungary)
  • Mária BARNAI (Faculty of Health Sciences and Social Studies, University of Szeged, Szeged, Hungary)
  • László Péter KANIZSAI (Department of Emergency Medicine, Medical School, University of Pécs, Pécs, Hungary)
  • Bettina FŰZNÉ PIKÓ (Department of Behavioral Sciences, Faculty of Medicine, University of Szeged, Szeged, Hungary)
  • Imre SEMSEI (Faculty of Health, University of Debrecen, Debrecen, Hungary)
  • Teija-Kaisa AHOLAAKKO (Laurea Universities of Applied Sciences, Vantaa, Finland)
  • Ornella CORAZZA (University of Hertfordshire, Hatfield, Hertfordshire, United Kingdom)
  • Oliver FINDL (Department of Ophthalmology, Hanusch Hospital, Vienna, Austria)
  • Tamás HACKI (University Hospital Regensburg, Phoniatrics and Pediatric Audiology, Regensburg, Germany)
  • Xu JIANGUANG (Shanghai University of Traditional Chinese Medicine, Shanghai, China)
  • Paul GM LUITEN (Department of Molecular Neurobiology, University of Groningen, Groningen, Netherlands)
  • Marie O'TOOLE (Rutgers School of Nursing, Camden, United States)
  • Evridiki PAPASTAVROU (School of Health Sciences, Cyprus University of Technology, Lemesos, Cyprus)
  • Pedro PARREIRA (The Nursing School of Coimbra, Coimbra, Portugal)
  • Jennifer LEWIS SMITH (Collage of Health and Social Care, University of Derby, Cohehre President, United Kingdom)
  • Yao SUYUAN (Heilongjiang University of Traditional Chinese Medicine, Heilongjiang, China)
  • Valérie TÓTHOVÁ (Faculty of Health and Social Sciences, University of South Bohemia, České Budějovice, Czech Republic)
  • Tibor VALYI-NAGY (Department of Pathology, University of Illonois of Chicago, Chicago, IL, United States)
  • Chen ZHEN (Central European TCM Association, European Chamber of Commerce for Traditional Chinese Medicine)

2020  

CrossRef
Documents

9
CrossRef Cites 8
CrossRef H-index 2
Days from submission to acceptance 219
Days from acceptance to publication 176
Acceptance
Rate
47%

 

 

2019  
CrossRef
Documents
13
Acceptance
Rate
83%

 

Developments in Health Sciences
Publication Model Online only Gold Open Access
Submission Fee none
Article Processing Charge none
Subscription Information Gold Open Access

Developments in Health Sciences
Language English
Size A4
Year of
Foundation
2018
Volumes
per Year
1
Issues
per Year
2
Founder Semmelweis Egyetem
Founder's
Address
H-1085 Budapest, Hungary Üllői út 26.
Publisher Akadémiai Kiadó
Publisher's
Address
H-1117 Budapest, Hungary 1516 Budapest, PO Box 245.
Responsible
Publisher
Chief Executive Officer, Akadémiai Kiadó
ISSN 2630-9378 (Print)
ISSN 2630-936X (Online)

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