Adult Chest Surgery

Chapter 68. Pancoast's Syndrome: Anterior Approach to Pancoast Tumor 

Approximately 5% of all non-small cell lung cancers (NSCLC) are located in the extreme apex of the lung, frequently with involvement of some combination of the first and second ribs, brachial plexus, subclavian vessels, and upper thoracic vertebral bodies. This phenomenon is referred to as a superior sulcus tumor, indicating tumor location in the uppermost portion of the costovertebral gutter within the chest. Pancoast's syndrome refers to superior sulcus tumors along with the triad of (1) shoulder and arm pain, (2) wasting of the hand muscles, and (3) ipsilateral Horner's syndrome (i.e., ptosis, miosis, and anhidrosis owing to invasion of the stellate ganglion). Henry Pancoast was a radiologist who described these findings in 1932 but failed to recognize the pulmonary origin of these tumors. Unaware of Pancoast's report, Tobias, an Argentine physician, described similar clinical findings and ascribed them to the presence of peripheral lung tumors. Pancoast-Tobias syndrome is perhaps a more appropriate eponym for this entity.

For the next 25 years, these tumors were considered unresectable and uniformly fatal. In 1961, Shaw and colleagues described successful outcomes in 18 patients undergoing 30 Gy of radiation, followed by resection, and this became the standard of care for the next 20–30 years.1 Recently, the Intergroup 0160 phase II trial demonstrated superior outcomes by using trimodality therapy for superior sulcus tumors, which now represents the standard of care.2

Surgical techniques have evolved considerably since the initial description of these tumors. By virtue of their location in proximity to the thoracic inlet, their resection represents one of the more challenging operations for thoracic surgeons. In addition to apical chest wall involvement, nerve roots, subclavian vessels, and vertebral bodies may be involved. Advances in surgical techniques have contributed significantly to improved outcomes in the last two decades—capabilities for vertebral resection and the development of anterior approaches to the thoracic inlet have provided a greater likelihood of obtaining a complete resection.


Factors that predict a favorable outcome after resection of superior sulcus tumors include R0 resection, absence of N2 or N3 metastases,3 lobectomy rather than limited pulmonary resection,4 and a complete pathologic response after induction chemoradiotherapy.5,6 Surprisingly, tumor stage (T3 versus T4 status) may be less important prognostically in this subset of patients; in the Intergroup 0160 study, this criterion was not a significant determinant of survival. The need for vertebral or subclavian vessel resection should not be considered an absolute contraindication to surgical treatment. Fadel and colleagues reported 5-year survival rates after resection of 36% in the presence of subclavian artery invasion.7

Limited survival benefit occurs with surgical resection alone. Local recurrences are common and extremely debilitating in terms of pain and limb function. Even with induction radiotherapy, complete resection is achieved in only 60% of patients, and overall 5-year survival is no better than 30%. Resectability, local control, and long-term survival have been positively affected by the addition of concurrent chemotherapy, as demonstrated by the long-term results of the phase II multicenter Intergroup 0160 trial.2 Two cycles of chemotherapy (i.e., cisplatin and etoposide) concurrent with 45 Gy of radiation to the primary tumor, followed by surgical resection 3–5 weeks later, with two adjuvant cycles of chemotherapy was well tolerated in 110 patients. This regimen resulted in R0 resection rates of 94% for T3 lesions, 96% for T4 lesions, an overall complete pathologic response rate of 56%, and 5-year survival of 44% (54% for R0 resection). Relapse occurred predominantly in the brain, with local failure in only 10 patients, a significant pattern shift in this disease. Ongoing questions exist about the optimal dose of radiation; our group6 has used higher radiation doses (median dose 56 Gy) with good tolerance and concomitant increased rates of complete pathologic response. Ideally, higher-dose regimens should be studied in a multicenter study protocol to make sure that these excellent results are generalizable.

Most superior sulcus tumors are approached posteriorly through a posterolateral thoracotomy extending up to the base of the neck, which is appropriate for posteriorly located tumors (Shaw-Paulson posterior approach; see Chap. 67). Exposure of tumors above the thoracic inlet is suboptimal with a posterior approach, however, and this may explain why there have been incomplete resections in the past. The anterior approach is preferable for more anteriorly and superiorly located tumors because it provides better access to the subclavian vessels and other cervical structures. Many surgeons favor an anterior exposure when there is a palpable supraclavicular mass, clinical involvement of the C7 or C8 nerve root, Horner's syndrome, proven or suspected vascular invasion, or any involvement of the thoracic inlet (or Sibson's fascia) and structures superior to it.8 It is important to be familiar with both the anterior and posterior exposures to permit maximum flexibility while operating.

Given the magnitude of the surgical resections, especially following concurrent chemoradiation, it is important to select patients with satisfactory performance status, as well as adequate cardiac, pulmonary, and renal function (especially for platinum-based regimens). Smoking cessation is also critical. Marginal respiratory status in conjunction with pulmonary and chest wall resection increases perioperative risk. Careful neurologic assessment is critical to determine the extent of brachial plexus involvement. Any neurologic dysfunction higher than the lower trunk of the plexus is likely to lead to significant limb dysfunction after resection; in some rare cases, forequarter amputation may be considered a better palliative option.9,10 In addition, long-track neurologic symptoms may indicate extensive spinal cord involvement owing to vertebral invasion.


Initial assessment is similar to that for any lung cancer resection. Tissue is almost always obtainable by transthoracic needle aspiration.11 Of note, tuberculosis and lymphoma have been reported to mimic Pancoast tumors. Tissue diagnosis therefore is critical before commencing multimodality therapy. In addition to chest and upper abdomen CT scanning and CT/PET, it is often helpful to include a neck CT scan to better image the thoracic inlet. To better delineate involvement of the brachial plexus, subclavian vessels, vertebral bodies, or neural foramina, MRI with contrast enhancement is the preferred imaging modality for this region. Involvement of the lower trunks of the brachial plexus may be considered a contraindication to resection because of limb dysfunction; however, resection of the T1 and C8 nerve roots can be easily accomplished. Brain imaging, using CT scanning or MRI, is also recommended as part of a thorough metastatic assessment. Extrathoracic metastases or persistent N2 or N3 disease after induction therapy is considered an absolute oncologic contraindication by most. It is critical to perform a thorough mediastinoscopic evaluation as part of the initial workup12 or after induction chemoradiation.6 If persistent postoperative N2 or N3 disease is documented, surgery should be attempted when it is the only satisfactory way to palliate pain because cure cannot be achieved.13

Extensive involvement of the subclavian and carotid arteries is not an absolute contraindication to resection (Table 68-1). Doppler ultrasound of the neck vessels and great vessels, including the vertebral artery, is helpful not only for assessment of tumor invasion but also to look for atherosclerotic changes that may affect clamp placement or critical stenoses.13 Careful neurologic examination and, in some cases, electromyography can help to define brachial plexus involvement, phrenic nerve involvement, and cord involvement. Preoperative neurosurgical consultation is highly recommended if there is any question of brachial plexus involvement or vertebral invasion; a team approach can be very useful intraoperatively (Table 68-2).

Table 68-1. Contraindications to Surgery

Inadequate cardiopulmonary reserve

Distant metastases

Persistent N2 or N3 disease after induction therapy

Involvement of trunks of the brachial plexus

Involvement of nerve roots higher than C8


Table 68-2. Additional Preoperative Tests Recommended for Superior Sulcus Tumors

Contrast-enhanced MRI of thoracic inlet/brachial plexus

Doppler ultrasound of neck and great vessels

Electromyography in selected patients



Routine measures for lung resection should be requested, such as preoperative antibiotics, deep vein thrombosis prophylaxis, and a double-lumen endotracheal tube. Central venous line placement is prudent for reliable IV access and central venous pressure monitoring and in most patients should be placed on the contralateral side to keep the line out of the surgical field. Radial arterial pressure monitoring is also recommended and also should be placed on the nonoperative side in case subclavian artery manipulation is required. It is also wise to coordinate surgical scheduling with a spine specialist for backup in case of vertebral body or other neurologic involvement.

Before embarking on a complex resection using the anterior approach to the thoracic inlet, it is helpful to review the relevant anatomy (Fig. 68-1). Starting from the anterior-most structures, the sternocleidomastoid muscle is affixed to the manubrium and medial clavicle. Inferior to the clavicle, the subclavius muscle is attached to the medial first rib and posterolateral aspect of the clavicle. The costoclavicular ligament is situated more medially and is connected to the medial clavicle and first rib. Immediately behind the subclavius muscle lies the subclavian vein. The omohyoid courses in front of the internal jugular vein, attaching to the hyoid bone superiorly and the upper border of the scapula posterolaterally. The phrenic nerve is posterior to the subclavian vein and lies on the anterior surface of the anterior scalene muscle. The thoracic duct enters the confluence of internal jugular vein and subclavian vein on the left side.

Figure 68-1.


Relevant anatomy for anterior approach to the thoracic inlet anterior-most structures.


The middle compartment of the thoracic inlet is situated between the anterior and middle scalene muscles, which insert on the first rib and contain the subclavian artery and its branches (from medial to lateral, the vertebral artery and internal mammary artery, the thyrocervical trunk, and then the costocervical trunk) and the brachial plexus trunks (Fig. 68-2). The posterior scalene muscle inserts on the second rib and lies just posterior to the brachial plexus. The long thoracic nerve emanates from the brachial plexus and weaves between the posterior and middle scalene muscles. The nerve roots, stellate ganglion, and vertebral bodies are the most posterior structures in the thoracic inlet.

Figure 68-2.


The middle compartment of the thoracic inlet.

Dartevelle Transclavicular Technique

For the anterior approach as described by Dartevelle and colleagues (1993),14 the patient is positioned supine with the neck hyperextended and turned away from the tumor. A rolled towel behind the shoulders helps with exposure of the operative site.15 The arms can be tucked at the sides, but it may be wise to leave access to the anterolateral chest on the operative side in case an anterolateral thoracotomy is necessary. The patient should be sterilely prepared from the angle of the mandible to below the costal margin and from the midclavicular line of the contralateral chest to the midaxillary line on the side of the tumor and beyond the shoulder superiorly. An L-shaped incision is performed along the anterior border of the sternocleidomastoid muscle, extending horizontally a few centimeters below and parallel to the clavicle into the deltopectoral groove (Fig. 68-3). Depending on the planned area of entry into the thoracic cavity, this transverse incision can be placed over the second, third, or fourth intercostal space.

Figure 68-3.


A. An L-shaped incision is performed along the anterior border of the sternocleidomastoid muscle. Note that the incision is extended horizontally a few centimeters below and parallel to the clavicle into the deltopectoral groove. B. Intraoperative photograph.


The sternal attachments of the sternocleidomastoid muscles are divided, as are the upper digitations of the pectoral muscle on the clavicle; a myocutaneous flap now can be pulled back to expose the thoracic inlet (Figs. 68-4 and 68-5). The medial half of the clavicle is removed (the sternal or Gigli saw works well for this). The omohyoid is divided, if necessary, and the scalene fat pad is removed and checked for metastases. The subclavian vein and its branches, as well as the distal internal jugular vein (depending on the cephalad extent of tumor), are dissected and controlled proximally and distally. On the left it is often necessary to ligate the thoracic duct as it enters the vein. In general, veins should be resected and not reconstructed, realizing that the patient may have edema in that extremity, which can be managed with arm elevation and compression garments. As collaterals develop, the end result is usually not significantly morbid. It can be helpful to divide the anterior, external, and even internal jugular vein to facilitate mobilization and resection of the subclavian vein.

Figure 68-4.


After dividing the sternal attachments of the sternocleidomastoid muscles and upper digitations of the pectoral muscle on the clavicle, the myocutaneous flap created by the incision can be pulled back to expose the thoracic inlet.


Figure 68-5.


Same exposure of the thoracic inlet presented in the intraoperative photograph in Fig. 68-3.


The pleural cavity is entered one interspace below the tumor to assess its intrathoracic extent. Next, the anterior scalene muscle can be divided at the first rib, unless it is grossly invaded, in which case it is better to divide it as proximally as possible, taking care to preserve the phrenic nerve (Fig. 68-6). This is followed by dissection of the subclavian artery and its branches, which all can be divided to facilitate mobilization. The exception is that the vertebral artery should be preserved when possible, but if it is invaded by tumor and there is no significant extracranial carotid vascular disease by preoperative duplex study, it should be taken en bloc with the tumor. If it is not possible to free the tumor from the subclavian artery in a subadventitial plane, then preparations should be made to resect and reconstruct it (see below). Next, the middle scalene muscle is taken as high as necessary to better expose the brachial plexus. It may be helpful to have the neurosurgical team assist with neurolysis of the plexus. Nerve roots can be divided but should not be taken higher than C8 (see Fig. 68-6, inset). It is important to ligate the roots to avoid a cerebrospinal fluid leak. If necessary for an R0 resection, the prevertebral muscles along with the paravertebral sympathetic chain and stellate ganglion can be resected safely as well. Many of these patients will have preexisting Horner's syndrome, but if not, this possibility should be mentioned when obtaining informed written consent for the operation.

Figure 68-6.


The pleural cavity is entered one interspace below the tumor to assess its intrathoracic extent. Assistance from the neurosurgical team is recommended for neurolysis of the plexus. (Inset) Nerve roots higher than C8 should not be taken.

At this point, the first rib can be divided at the transverse process posteriorly and a few centimeters anterior to the tumor or at the costosternal junction. The second and third ribs also can be resected en bloc with the tumor as needed. This provides an entry point into the pleural space through which the upper lobectomy can be performed. In the past, an accessory anterior or in some cases posterolateral thoracotomy (after repositioning and reprepping the patient) has been made, but with videothoracoscopy assistance, the additional incisions are less often necessary.

This approach, pioneered by Dartevelle and colleagues, revolutionized the ability to achieve a complete resection for tumors centered in the middle to anterior aspect of the thoracic inlet. The downside to this approach is the suboptimal exposure of the hilum, which requires additional incisions, but this problem may be obviated by adjunct use of thoracoscopy. In addition, there have been functional deficits in shoulder mobility and cervical posture associated with clavicular resection and an inability to stabilize the sternoclavicular articulation.16 The latter concern motivated the following alterations of Dartevelle's technique.

Osteomuscular-Sparing Approach

This technique differs from the above-described operation in that the sternoclavicular joint is preserved. The same skin incision is made, and the sternocleidomastoid is mobilized, but the pectoral muscle is split along the fibers a few centimeters below the clavicle rather than separating it from the clavicle (Fig. 68-7). An L-shaped incision is made in the manubrium with the sternal saw to release the upper outer corner adjacent to the sternoclavicular joint. The proximal internal mammary artery is ligated, and the first costal cartilage is resected. Now the clavicle, with attached pectoral and sternocleidomastoid muscles, can be elevated as an "osteomuscular flap" (Fig. 68-8). The remainder of the resection is carried out as described earlier. For closure, the manubrium is reapproximated with two sternal wires. Aesthetic and functional results are reportedly superior to those of claviculectomy16 owing to preservation of the shoulder girdle architecture. The negative aspects of this technique are again the suboptimal exposure for lung resection and the fact that the vascular dissection deep to the scalene muscles can be more challenging than with the standard Dartevelle incision.15

Figure 68-7.


Osteomuscular-sparing approach with preservation of the sternoclavicular joint. The pectoral muscle is split along the fibers a few centimeters below the clavicle rather than separating it from the clavicle.


Figure 68-8.


The clavicle, with attached pectoral and sternocleidomastoid muscles, is elevated as an osteomuscular flap.

Hemiclamshell or Trapdoor Incision

The hemiclamshell or trapdoor incision (when extended above the clavicle or along the sternocleidomastoid) was proposed originally for trauma to the great vessels or for mediastinal tumors. It provides excellent exposure of the anterior mediastinum and chest apex and has been used with some success for superior sulcus tumors as well. The basic incision consists of a median sternotomy down to the fourth interspace with lateral extension through the intercostals (Fig. 68-9). A standard sternal retractor then may be used to elevate the sternum, or a mammary retractor can be helpful to elevate sternal and intercostal aspects of the incision. Several modifications have been suggested, including extension along the sternocleidomastoid or superior to the clavicle. In this case, the mammary artery should be ligated proximally. Some surgeons recommend resection of the medial clavicle, as in the Dartevelle approach.15 Another alternative is to resect the first costal cartilage and costoclavicular ligament to preserve the architecture of the shoulder girdle while allowing improved mobility of the anterior chest wall and better exposure and control of the distal subclavian vessels.17 The incision is closed by wiring the sternum, reapproximating the intercostal space, and then suturing the pectoral muscles if disturbed during the dissection. A major advantage to this incision is better exposure of the pulmonary hilum. However, the posterior aspect of the thoracic inlet is difficult to dissect with this technique; also, the incision maybe excessive for a smaller, anterior, truly apical tumor.

Figure 68-9.


Hemiclamshell or trapdoor incision provides excellent exposure of the anterior mediastinum and chest apex. Incision consists of a median sternotomy down to the fourth interspace with lateral extension through the intercostals.

Vascular Resection

Before deciding on the need for vascular resection, the artery should be properly exposed. The vein should be mobilized as described earlier and divided proximal and distal to the tumor if invaded. Next, the artery should be prepared for proximal and distal control by dividing the anterior scalene muscle, preserving the phrenic nerve if not invaded by tumor. The internal mammary artery and ascending cervical artery are divided; the vertebral artery is sacrificed if involved or if the adjacent subclavian artery is involved. In many cases, the tumor can be dissected away from the subclavian artery in the subadventitial plane (Fig. 68-10A). If the media of the artery has been invaded by tumor, steps should be taken for resection (see Fig. 68-10B). Systemic heparinization should be performed, usually with 5000 units of IV heparin. Then the artery can be clamped proximally and distally to permit en bloc resection of the involved portion with the tumor. Reconstruction should be delayed until the rest of the tumor resection is performed. In some cases, it may be helpful to generously wedge the tumor-bearing portion of the upper lobe to be removed with attached ribs and vascular structures so that the vascular reconstruction can be completed immediately, and the heparin then can be reversed. In this way, the completion lobectomy can be performed off heparin. Another option is to give heparin, clamp the artery, complete all the resection en bloc, and then perform the vascular reconstruction, but the vessels will be clamped for a longer period of time.

Figure 68-10.


A. Tumor can be dissected away from the subclavian artery in the subadventitial plane. B. If the media of the artery is invaded, the affected portion is reconstructed.

Reconstruction often can be end to end because the distance to traverse is diminished after first rib resection. Otherwise, the material of choice for vascular reconstruction is ringed polytetrafluoroethylene (6 or 8 mm) with end-to-end anastomoses, followed by reversal of heparin with protamine. In the series reported by Fadel and colleagues, the graft length was 1.5–4 cm.7 Shunts were not used. There is no need to place a tissue flap between the vascular graft and the lung. Artery ligation is not an option; if all collaterals are divided during tumor resection and mobilization of the artery, limb ischemia will occur.


Postoperative care is similar to that of any lung resection. With extensive chest wall resection, atelectasis is more common.15 Good postoperative analgesia, adequate pleural drainage, and aggressive pulmonary toilet cannot be overemphasized. Routine mechanical ventilatory support is not necessary. Special attention must be paid to the involved extremity when vascular resection is required, with hourly vascular checks initially. Some surgeons recommend IV heparinization within 4–6 hours postoperatively and then aspirin once the patient is ambulatory and continued for 6 months postoperatively.15 When concomitant venous ligation is necessary, it can be challenging to assess the perfusion of the extremity, and frequent Doppler checks may be reassuring. Arm elevation and lymphatic massage may help to alleviate edema. Wound healing can be more of a problem when extensive collaterals are ligated along the subclavian artery; diligence for this is encouraged, with aggressive debridement if wound necrosis occurs. When the clavicle has been divided and rewired, an arm sling for stabilization for 4–6 weeks postoperatively is recommended.

After arterial resection, follow-up duplex studies should be carried out at 3 and 6 months and annually thereafter. In addition, the blood pressure should be measured in both upper extremities at each follow-up visit. If symptoms of arterial insufficiency occur or duplex study suggests significant stenosis (>80%), angiography is recommended.7 In case of graft occlusion (most often from radiation fibrosis), it may not require intervention in the absence of symptoms. Reported 5-year patency rates are 85%.7


Aside from the usual array of postoperative events that may follow pulmonary resection, the vascular issues mentioned earlier are unique to this subset of patients. Acute graft thrombosis is a possibility but occurs rarely. Unusual neurologic sequelae deserve mention. Because of resection or dissection near nerve roots, several unusual problems may occur in the postoperative period, including meningitis, cerebrospinal fluid leaks, and even tension pneumocephalus.18 This is usually related to nerve root division or dissection near the dural sac in cases of vertebral body invasion. Often the cerebrospinal fluid leak is visible in the operating room; careful closure of the leak with fine monofilament suture, buttressed with a soft tissue flap such as intercostal muscle, is usually effective. If the leak is detected postoperatively, a lumbar drain will be required, which confines the patient to bed in the supine position. This is less than ideal in a patient needing vigorous pulmonary toilet.19 Subarachnoid-pleural fistula has been reported acutely or subacutely when a pulmonary parenchymal air leak communicates with the subarachnoid space.18,19 Patients may present with altered mental status, seizures, or hyponatremia, and this may mimic the clinical presentation of cerebral metastases. In one patient, reoperation with tissue flap coverage of the leaks was required; in another, expectant management was satisfactory.

Other neurologic sequelae include weakness of intrinsic muscles of the hand after T1 nerve root division, but the hand is usually still functional. When C8 or the lower trunk of brachial plexus must be divided, permanent paralysis of intrinsic muscles of the hand should be expected.


Understanding of the anatomy of the thoracic inlet has led to novel surgical approaches to superior sulcus tumors. Many technical challenges have been overcome, making R0 resection feasible in patients with tumors anterior and superior within the thoracic inlet that previously had been deemed unresectable. Several modifications to Dartevelle's technique have either facilitated exposure or improved functional or cosmetic results. The latest data on trimodality therapy in patients with Pancoast-Tobias tumors have further extended the likelihood of prolonged survival. Further refinement of surgical technique, it is hoped, will continue to improve longevity and minimize the morbidity associated with resection.


A 55-year-old white woman with a history of smoking and a cough presented with left-sided shoulder pain. The patient developed numbness, tingling, and discoloration of the left fourth and fifth digits. Chest x-ray was positive for a lesion along the anterior apical superior sulcus with a shadow between the first and second ribs. A CT scan was positive for a tumor that appeared to be invading the first, second, and third ribs and was questionably involving the subclavian artery and vein and the lower trunk of the brachial plexus. This was followed by MRI, which showed nerve root involvement at T1 with possible involvement of vertebral bodies C6–C8. The edge of the subclavian artery was clear, and the edge of the subclavian vein was not.

The patient underwent a percutaneous needle biopsy, which was positive for non-small cell lung cancer. A PET scan was positive for a tumor in the lung and the chest wall with questionable mediastinal lymph nodes. The patient underwent a transbronchial needle aspiration of the paratracheal lymph nodes on the left side, and these were positive for metastatic non-small cell lung cancer, and the patient was referred for neoadjuvant chemotherapy with Carboplatin and Taxol with radiation therapy concurrently at 61.2 Gy with a spinal cord dose at 45 Gy. Six weeks after treatment, the patient had repeat CT and PET scans. These both showed shrinkage of the tumor and no uptake in the mediastinum and decreased uptake in the tumor. An MRI of the brain at that time was negative, and the MRI of the chest still showed some questionable involvement of subclavian vessels and the lower trunk of the brachial plexus. The patient underwent a planned bronchoscopy and mediastinoscopy, which was negative for any evidence of persistent mediastinal nodal disease. The patient was explored starting with a left-sided anterior Dartevelle approach. Sparing the clavicle, the T1 nerve root was divided, and the first rib was cut anteriorly. The subclavian artery was mobilized successfully without any tumor involvement. However, division of the subclavian vein was necessary. After this was done and full mobilization was achieved, the patient was repositioned in the lateral decubitus position, and the standard posterior Shaw approach was used for resection of the tumor and en bloc chest wall resection of ribs 1, 2, and 3. The chest then was entered from the fourth intercostal space, and a left upper lobectomy with mediastinal lymph dissection was performed. All lymph nodes were negative. The patient had a complete pathologic response on final pathology. An intercostal muscle flap, harvested at the time of posterior chest entry, was placed at the bronchial stump. Postoperatively, the patient developed upper extremity edema, as expected with vein ligation, and this was treated with Jobst stockings and arm elevation.


The anterior approach is especially useful for patients with Pancoast tumors that involve the anterior chest wall and/or the anterior vessels. By using either a classic Dartevelle approach or a modified anterior "hemiclamshell," one can gain excellent access to the upper lobes, sternum, ribs, and vena cava as necessary. We have found that by modifying the location of the incision one can either perform a separate thoracotomy posteriorly or remove the lobe from the same anterior incision.



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