Gastric Lymphoma
MALT lymphoma

Video Endoscopic Sequence 1 of 12.

Endoscopic appearances of MALT lymphoma.

This is the case of a 44 year-old male who previo usly had two endoscopies practiced with another colleague, the first one due to epigastric pain, that endoscopy showed two ulcerated nodules at the antrum, biopsies displayed helicobacter pylori and a gastric lymphoma, after the eradication of H pylori the two nodules have been regressed. 3 months after the patient ask for second opinion, performing this endoscopy presented in this atlas.

 

Endoscopic appearances of MALT lymphoma

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Endoscopic appearances of MALT lymphoma.

Video Endoscopic Sequence 2 of 12.

This image shows multiple irregular and large ulcers.

EXTRANODAL MARGINAL ZONE B-CELL (MALT) LYMPHOMA — This tumor, previously called MALT-type lymphoma or MALT lymphoma is now called extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue in the WHO classification system.

Primary malignant lymphoma of the stomach are almost all non Hodgkin's type and of B-cell lineage. These lymphomas usually arise from MALT (mucosa associated lymphoid tissue)- also known as Marginal Zone B - cell lymphoma (Low and High grade). Diffuse large B-cell lymphoma include high grade lymphoma of MALT origin and non-MALT type and they are indistinguishable. Other types include mantle cell lymphoma (malignant lymphomatous polyposis) , follicular lymphoma, Burkitt's lymphoma and rare solitary plasmacytoma.

 

MALT lymphoma.

Video Endoscopic Sequence 3 of 12.

The vast majority of low-grade B-cell lymphomas of the stomach are derived from mucosa-associated lymphoid tissue, and are therefore of the MALT type. Approximately 40 to 50 percent present with indolent or low-grade histology, of which 70 to 80 percent are confined to the stomach (stage IE). An increasing body of evidence has shown that the development of MALT lymphomas (also called MALTomas) is due to the clonal expansion of B-cells that accompanies chronic gastritis in the presence of Helicobacter pylori. Molecular techniques have become so sensitive at detecting early emergence of B-cell clonal expansion of gastric lymphocytes, hat the distinction between chronic gastritis and low-grade MALT lymphomas has blurred.

The gastrointestinal (GI) tract, particularly the stomach, is the most common primary site of extranodal lymphoma. However, primary gastric lymphoma is uncommon and constitutes only 2%–5% of malignant gastric lesions. Most gastric lymphomas are of B-cell lineage. Among them, most primary low-grade B-cell lymphomas of the stomach have long been known as "pseudolymphomas" or "lymphoreticular hyperplasia" because of the presence of reactive follicles and mixed inflammatory cell infiltration at histopathologic examination and because of the favorable prognosis. However, recent immunohistochemical studies have shown that most pseudolymphomas are monoclonal B-cell proliferations and that the majority of these B cells are considered to originate from mucosa-associated lymphoid tissue (MALT). These B cells have the same cytologic and immunophenotypic characteristics as the B cells that are normally found around the mantle zones of Peyer patches Therefore, these low-grade B-cell lymphomas, which have the morphologic features of MALT with the high-grade lesions that may evolve from them, are known as MALT lymphoma.



MALT lymphoma.

Video Endoscopic Sequence 4 of 12.

Multiple irregular shallow ulcers.

The paradox of lymphomas arising in the stomach has been explained by the observation of MALT in the stomach in response to infections by H pylori and by the presence of this organism in more than 90% of gastric MALT lymphomas. In some cases, low-grade MALT lymphomashave regressed with eradication of H pylori.

Primary gastrointestinal non-Hodgkin lymphomas (NHLs) are a heterogeneous group of unique B- and T-cell lymphoid malignancies. Their pathology, clinical features, management, and prognosis may differ from lymphomas of lymph node origin. As an example, indolent lymphomas of lymph node origin are almost always disseminated at diagnosis, have frequent bone marrow involvement, generally respond to therapy, but continuously recur. Median survival can exceed 10 years, although cure is unusual.



MALT lymphoma.

Video Endoscopic Sequence 5 of 12.

MALT lymphoma is an indolent (commonly called low grade) type of B-cell non-Hodgkin lymphoma, first recognised as a specific type of lymphoma in 1983. It occurs at sites that are outside lymph nodes or the spleen. The organisation of the lymphoma cells, when viewed under the microscope, resembles the lymphoid tissue normally found in the gut, which is called ‘mucosa-associated lymphoid tissue (MALT). MALT lymphoma most frequently arises within this type of lymphoid tissue after it has accumulated as part of a reaction to an infection or inflammation.



MALT lymphoma.

Video Endoscopic Sequence 6 of 12.

Chromoendoscopy with indigo carmine stain.

MALT lymphoma is an indolent (commonly called low grade) type of B-cell non-Hodgkin lymphoma, first recognised as a specific type of lymphoma in 1983. It occurs at sites that are outside lymph nodes or the spleen. The organisation of the lymphoma cells, when viewed under the microscope, resembles the lymphoid tissue normally found in the gut, which is called ‘mucosa-associated lymphoid tissue’ (MALT). MALT lymphoma most frequently arises within this type of lymphoid tissue after it has accumulated as part of a reaction to an infection or inflammation.




MALT lymphoma.

Video Endoscopic Sequence 7 of 12.

In the new World Health Organisation classification of lymphoid tumours, MALT lymphoma is more correctly called 'extra-nodal marginal zone B-cell lymphoma'. This is because there is now strong evidence to suggest that the type of cell from which the lymphoma develops is a specific B-cell which is founding a specific compartment of the lymphoid tissue called the marginal zone.

 



MALT lymphoma.

Video Endoscopic Sequence 8 of 12.

MALT lymphoma is the third most common type of non-Hodgkin lymphoma, although it only accounts for about 7-8% of these tumours. MALT lymphomas have been described at almost all extra-nodal sites (sites other than lymph nodes), but are most commonly found in the gastrointestinal tract - the gut - (50% of all MALT lymphomas) within which the stomach is the most frequently involved area (34% overall; 50-70% of gastrointestinal MALT lymphomas). It appears to be a contradiction that MALT lymphomas are found least frequently in sites in which MALT is normally present, like the terminal part of the small intestine, and seem only to develop when the lymphoid tissue arises in response to infection or other cause of inflammation.



MALT lymphoma.

Video Endoscopic Sequence 9 of 12.

Gastric MALT lymphomas account for up to 4% of all primary gastric tumours and 40-50% of all primary gastric lymphomas (the remaining being mostly the more aggressive (commonly called high grade) diffuse large B-cell lymphomas).

MALT lymphomas are approximately equally distributed between men and women. This lymphoma is most frequent in late middle aged/elderly people although it may be found in any age-group.


MALT lymphoma

Video Endoscopic Sequence 10 of 12.

MALT lymphomas arise at sites that have acquired some MALT-type lymphoid tissue due to some other disease/disorder or infection. For some MALT lymphomas this underlying condition remains a mystery, while for others more is known about predisposing factors. For example, in the thyroid and salivary glands, MALT lymphomas can develop due to autoimmune inflammatory conditions known respectively as Hashimoto’s thyroiditis and Sjogren’s syndrome.

However, most is known about gastric MALT lymphoma, as this is the commonest site at which these lymphomas develop. In the stomach, the majority of these lymphomas are associated with infection by a bacterium called Helicobacter pylori This causes inflammation of the lining of the stomach which includes the development of MALT-type lymphoid tissue. Once the MALT-type tissue is acquired, there is continuous stimulation of the lymphocytes to replicate and increase in number as a result of the constant presence of bacteria (a normal immune reaction). However, in a small minority of people, this results in a mistake within the genetic material of a lymphoid cell and continuation of this faulty cell line leads to the development of a lymphoma.




MALT lymphoma

Video Endoscopic Sequence 11 of 12.

Until the early 1990's surgery was probably the most commonly used treatment for gastric MALT lymphoma. However, with the recognition of the common association between gastric MALT lymphoma and Helicobacter infection and following some laboratory-based studies on cells derived from lymphomas, it was suggested that eradication of Helicobacter alone might have a therapeutic effect. Further studies some of which now have follow-up extending to over ten years, have shown that eradication of Helicobacter alone can induce tumour regression in 50-70% of cases. The cases that respond the best are those that have not extended very far through the gastric wall and have not spread to lymph nodes. An initial antibiotic-based regime for eradication is usually prescribed, followed by endoscopies to confirm eradication of the organism and to assess tumour response.

The interval between Helicobacter eradication and regression of the tumour is highly variable between patients. A proportion of patients will not respond to eradication therapy alone and will go on to more conventional anti-lymphoma therapies such as chemotherapy or radiotherapy. There is, at present, no clear agreement between doctors as to when eradication therapy can be assessed as having failed in an individual, but while there are sequential improvements in biopsies taken during endoscopies, it may be worth delaying the use of other therapies. Some cases have been reported where there has been regression of the lymphoma many years after eradication and in the absence of other therapies.

 

MALT lymphoma

Video Endoscopic Sequence 12 of 12.

When Helicobacter eradication has been deemed to have failed, more conventional therapies can be used. While surgery has, in the past, been the mainstay of treatment for gastric lymphoma, this is no longer the case. Several studies have shown that, although the lymphoma is usually concentrated in one part of the stomach, there are small deposits all over the stomach lining.

Both radiotherapy and chemotherapy have been shown to be highly effective in the treatment of gastric MALT lymphoma. Single-agent chemotherapy with alkylating agents (substances which are used to treat some cancers by interfering with cell metabolism and growth) such as cyclophosphamide or chlorambucil or nucleoside analogues (other drugs used to check the growth of lymphoma cells) such as cladribine appear to have equal activity.



Video Endoscopic Sequence 1 of 7.

Malt Lymphoma showing multiple irregular shallow ulcers.

This is an 85-year old male that was referred to our endoscopy unit due to inappetence. An upper endoscopy was performed. Finding multiple and larger irregulars ulcers.

 

 

Malt Lymphoma


 

Endoscopy of Malt Lymphoma

Video Endoscopic Sequence 2 of 7.

Endoscopy of Malt Lymphoma

With the help of many clinical studies, the diagnosis and therapy of gastric MALT lymphoma have evolved. Major progress has been seen in this area, including improvement of biopsy diagnosis, better histologic classification, new information concerning pathogenesis, and, especially, the start of a revolution in the treatment of low-grade gastric MALT lymphomas by eradicating H. pylori. About 12 clinical studies with almost 400 patients and case reports have shown that cure of H. pylori infection is associated with complete remission in approximately 80% of patients with low-grade MALT lymphoma in an early clinical stage.

 

 

Endoscopy of Malt Lymphoma

Video Endoscopic Sequence 3 of 7.

Multiple irregular ulcers of the gastric fundus are displayed

To establish H. pylori eradication as the primary choice in low-grade gastric MALT lymphoma further, it is necessary to select patients before therapy who are most likely to benefit from this single treatment modality. An excellent histologic workup of obtained biopsy specimens and comprehensive clinical staging are necessary. Because of the supposition that H. pylori-related growth support may play a role only in the early stages of low-grade gastric MALT lymphoma, the importance of determining the depth of lymphoma infiltration in the gastric wall is evident.




Endoscopy of Malt Lymphoma

Video Endoscopic Sequence 4 of 7.

Large irregular ulcer at the angular incisure of stomach

Examinations by endosonographic ultrasonography have been shown to be the most reliable method to differentiate the layers of the gastric wall and to determine the infiltration depth of lymphomas. Eradication of H. pylori has to be considered as a first-line and single treatment modality in patients with low-grade gastric MALT lymphoma in clinical stage EI1. As a therapy with fewer side effects than radiation, surgery, or chemotherapy and as a stomach-conserving treatment, eradication of H. pylori in patients with low-grade gastric MALT lymphoma should be the treatment of the choice within clinical trials because there are no long-term results available thus far.



Endoscopy of Malt Lymphoma

Video Endoscopic Sequence 5 of 7.

An ulcerated MALT lymphoma with large confluent ulcers covered with exudate.

Larger irregular ulcer with yellowish fibrin at the greater curvature.

We have observed several cases of lymphoma diagnosed by endoscopy, were presented with yellow fibrin, they have not suffered from jaundice

Besides pretreatment patient selection, careful follow-up with endoscopy, biopsies, and clinical staging including endoscopic ultrasonography is necessary. A 5- to 10-year follow-up is necessary before the definitive value of H. pylori eradication can be established, but long-term results are excellent thus far.

 

 

Endoscopy of Malt Lymphoma

Video Endoscopic Sequence 6 of 7.

Larger ulcerations at the gastric fundus

There are many questions to be addressed: What are the exact mechanisms that lead to the malignant transformation of a reactive infiltrate? Why do approximately 20% of low-grade MALT lymphomas not regress after H. pylori eradication? Is there a molecular-genetic or immunologic point of no return? What is the biologic significance of the immunoglobulin rearrangement detected with PCR? What will be the 5- and 10-year relapse-free survival rates of patients suffering from low-grade MALT lymphoma treated with H. pylori eradication alone as first and only treatment? The wave of new data each year about the role of H. pylori in gastric MALT lymphoma may help many of these questions to be answered.

 

Endoscopic appearances of MALT lymphoma.

Video Endoscopic Sequence 7 of 7.

Endoscopic appearances of MALT lymphoma.

This lesion proved to be a MALT lymphoma. (C) Ulcerated type.

 

 

 

 



Primary gastric lymphoma following renal transplantation

Video Endoscopic Sequence 1 of 3.

Primary gastric lymphoma following renal transplantation.

This 40 year-old woman who had a renal transplantation a gastric lymphoma was detected during the 14th year post transplantation she was under immune suppression drugs using azathioprine, cyclosporine and prednisone.

Endoscopic views showing deep, large irregular ulcers on lesser curvature of stomach

Multiple biopsy specimens revealed diffuse large B-cell lymphoma, which was positive for CD20 and negative for Epstein-Barr virus.

Chronic immune suppression is a risk for the development of post-transplantation lymphoproliferative disorders, which are frequently caused by a B-cell dyscrasia.

Patients who have undergone renal transplantation, along with recipients of other types of solid-organ transplantations, undergoing long-term immunosuppression are at high risk for the development of lymphomas. Approximately 1% of renal transplant recipients have post -transplantation lymphoproliferative disorders (PTLD) develop. The emergence of PTLD has been observed soon after transplantation followed by immunosuppression, especially with cyclosporine. In this setting, the association between Epstein-Barr virus infection and PTLD is well recognized. The pathogenesis of the Epstein Barr virus-negative, late-occurring PTLD has not been extensively investigated.

 

Primary gastric lymphoma following renal transplantation



Primary gastric lymphoma following renal transplantation

Video Endoscopic Sequence 2 of 3.

An increased incidence of non-Hodgkin's lymphoma is seen in patients with immunodeficiency from any cause. The majority of these are high grade B-cell lymphoma and most are associated with the Epstein-Barr virus (EBV). In post-transplant lymphoma/lymphoproliferative disorders the tumour may regress following reduction of immunosuppression but in AIDS the lymphomas show a characteristic aggressive course and poor prognosis.

Although it is now accepted that the development of gastricmucosa associated lymphoid tissue (MALT) lymphoma ispreceded by H pylori infection, there is no clear evidenceindicating that immunosuppression increases the incidence of Hpylori infection, or that H pylori is implicated in the pathogenesisof PTLD. Because of the truly lymphomatous phenotype ofEBV-negative late-developing PTLD, H pylori infection mayrepresent a pathogenic factor especially in MALT lymphomatype. However, clinical and morphologic data suggest that atleast some high-grade lymphomas of the stomach may develop from low-grade mucosa-associated lymphoid tissue (MALT)lymphomas. In MALT lymphoma, advanced tumor stages (EII),or tumors with transition to high-grade malignancy did notrespond to eradication of the H pylori infection.. The possibility for complete remission in high-grade lymphomas needs to beinvestigated in prospective studies. Therapy to eradicateH pylori should not replace conventional treatment; bacterialeradication should be considered as a component of therapy forgastric large-cell lymphoma.

 

Primary gastric lymphoma following renal transplantation

Video Endoscopic Sequence 3 of 3.

Multiple and irregular ulcers are displayed.

Patients who have undergone solid-organ transplantation have a 20- to 120-fold higher incidence of non-Hodgkin's lymphoma (NHL), depending on the degree and duration of immunosuppression.


Gastric lymphoma with metastases to the duodenum

Endoscopic Sequence 1 of 15.

Gastric lymphoma with metastases to the duodenum

This 74 year-old male with weigh loss of 20 pounds and vomiting.

The image and the video clip shows a large mass in the duodenal bulb.

 

Gastric lymphoma with metastases to the duodenum

Endoscopic Sequence 2 of 15.

Post Bulbar Metastases.

Nearly all cases of primary gastric lymphoma are of the non-Hodgkin's variety. Diagnoses in such cases are difficult due to considerable histological similarities between the 2 disease entities.

 


Gastric lymphoma with metastases to the duodenum

Endoscopic Sequence 3 of 15.

Another view of the mass in the duodenal bulb.


Gastric lymphoma with metastases to the duodenum

Endoscopic Sequence 4 of 15.

Retroflexed view in the duodenum showing the large mass in the bulb in the limit of the second part of the duodenum.


Retroflexed view in the duodenum showing the large mass

Endoscopic Sequence 5 of 15.

Retroflexed view.

 

Endoscopic Sequence 6 of 15.

The Pre-pyloric antrum is showed with infiltration with the neoplasia.

 

 

Endoscopic Sequence 7 of 15.

The antrum with extensive malign infiltration.

 

 

Endoscopic Sequence 8 of 15.

The gastric angle is infiltrated.

 

 

Endoscopic Sequence 9 of 15.

Some rest of food is observed.

 

 

Endoscopic Sequence 10 of 15.

In this image shows the freshness of the banana in the middle of neoplasia is evident.


Endoscopic Sequence 11 of 15.

Again, post bulbar metastases.

 

Endoscopic Sequence 12 of 15.

 

 

Endoscopic Sequence 13 of 15.


Endoscopic Sequence 14 of 15.


Endoscopic Sequence 12 of 15.

 

 

Gastric Lymphoma.

B-Cell Lymphoma.

Non-Hodgkin's Lymphomas caused by malignant
(cancerous) B-Cell lymphocytes represent a largesubset
(about 85% in the US) of the known types of lymphoma
(the other 2 subsets being T-Cell lymphomas and
lymphomas where the cell type is unknown). B-Cells
undergo many changes in their life cycle dependent on
complex signaling processes between cells and interaction
with foreign substances in the body. Apparently various
types of lymphoma or leukemia can occur in the B-Cell life
cycle.

 

Malt Lymphoma.

Small cell lymphomas may resemble reactive lymphoid
hyperplasia.
Lymphomatous involvement of the stomach may have
a variety of manifestations, including large infiltrated
rouge, eroded nodules and exophytic and ulcerated
masses, erosions and ulcers.


 Systemic Lymphoma.

 There are several lesions in the stomach that histologically
 and proved to be systemic lymphoma.



Video Endoscopic Sequence 1 of 7.

Non-Hodking Lymphoma B Cells. MALT
(mucosa associated lymphoid tissue).




Video Endoscopic Sequence 2 of 7.

Non-Hodking Lymphoma MALT
(mucosa associated lymphoid tissue).

 

 

 


Video Endoscopic Sequence 3 of 7.

Lymphoid Neoplasia that substitutes the gastric mucosa.



Video Endoscopic Sequence 4 of 7.

Cytokeratine negative by Inmunohistochemistry.

 

Video Endoscopic Sequence 5 of 7.

LCA positive.

 

 

Video Endoscopic Sequence 6 of 7.

CD20: Positive in cells tumor.

 

Video Endoscopic Sequence 7 of 7.

CD3: Negative.

Non-Hodking Lymphoma B Cells.



Video Endoscopic Sequence 1 of 3.

Non-Hodking Lymphoma


Video Endoscopic Sequence 2 of 3.

Non-Hodking Lymphoma

 

 

Video Endoscopic Sequence 3 of 3.

Non-Hodking Lymphoma

 

 

Paciente femenino de 69 ańos quien se nos refiere a nuestra unidad endoscópica para valoración de pérdida de peso y vómitos.

Video Endoscopic Sequence 1 of 10.

 

This 69 year-old woman, was referred to our unit for
endoscopic evaluation of previous diagnostic of a gastric
lymphoma.

A large and ulcerated mass was found at on the greater
curvature of the body and fundus.

GastricLymphoxc2


Video Endoscopic Sequence 2 of 10.

Fungating, ulcerated mass extending from the distal foundus to the body.

Fondo y Cuerpo Gástrico

Video Endoscopic Sequence 3 of 10.

Helicobacter pylori infection is a risk factor for gastric lymphoma

Some MALT lymphomas have been reported in
immunocompromised patients (in AIDS and following
organ transplantation). High grade lymphoma following
organ transplantation may be related to Epstein-Barr virus.

 

 

GastricLymphoxc4


Video Endoscopic Sequence 4 of 10.

An endoscopic view from the cardias and fundus.


GastricLymphoxc5

Video Endoscopic Sequence 5 of 10.

A close up showing multiple irregular ulcers


Citoqueratina evidenciando las diferencias de la parte epitelial y linfoide.

Video Endoscopic Sequence 6 of 10.

Cytokeratin negative on lymphoid infiltrate

 

 





GastricLymphoxc7

 

Video Endoscopic Sequence 7 of 10.

Giemsa stain shows severe lymphoid infiltration.

GastricLymphoxc8

Video Endoscopic Sequence 8 of 10.

There are lymphocytic infiltration with lymphoepithelial lesion.


Infiltrado linfocitario sustituyendo la lamina propria.

Video Endoscopic Sequence 9 of 10.

Lymphocyte infiltrating the lamina propria

 

GastricLymphoxc10

Video Endoscopic Sequence 10 of 10.

Leucocyte common antigen positive

Abstracts:

Critical evaluation of Bcl-6 protein expression in diffuse large Bcell lymphoma of the stomach and small intestine. Am J of SurgPathol. 2003 ; 27 (6): 790-8.

Regression of high grade mucosa associated lymphoid tissue
(MALT) lymphoma after Helicobacter pylori eradication. Gut
2001 ; 49 ( 4) : 584-7. (full text)

Clinicopathological features of gastric-mucosa associated
lymphoid tissue lymphoma : a comparison with diffuse largeB-cell lymphoma without a mucosa associated lymphoid tissuelymphoma component . J Gastroenterol Hepatol. 2001; 16 (7):734-9.

Histological grading with clinical relevance in gastricmucosa-associated lymphoid tissue (MALT) lymphoma. RecentResults Cancer Res. 2000 : 156: 27-32.

Clinicopathological features of gastric mucosa associatedlymphoid tissue (MALT) lymphomas: high grade transformationand comparison with diffuse large B cell lymphomas withoutMALT lymphoma features. J Clin Pathol 2000; 53: 187-190.

Gastrointestinal lymphoma. Hum Pathol. 1994; 25; 1020-29.
Relationship between high-grade lymphoma and B-cellmucosa-associated lymphoid tissue lymphoma (MALToma) ofthe stomach. Am J Pathol. 1990; 136;1153-1164

Gastrointestinal lymphomas: an overview with emphasis on newfindings and diagnostic problems.Seminars in DiagnosticPathology 1996; 13 260-96

The significance of B -cell clonality in gastric lymphoid infiltrates.J Pathol 1996;180-26-32.

 

 

 

Maltomaxza1

Video Endoscopic Sequence 1 of 8.

Endoscopic appearances of MALT lymphoma.

Low-grade gastric MALT-lymphoma is a neoplasia with a
very indolent course and an excellent prognosis. Even if
the most common endoscopic findings have described
non-specific aspects, often suggestive for benign
conditions, the endoscopy reveals a wide range of gastric
mucosal changes both at diagnosis and at relapse.

 

 

Maltomaxza2

Video Endoscopic Sequence 2 of 8.

Endoscopic appearances of MALT lymphoma.

Findings have demonstrated the close association between
primary gastric B-cell lymphomas originating from
mucosa-associated lymphoid tissue (MALT) and
Helicobacter pylori (HP) infection, with their regression
after an HP eradication therapy in up to 70% of the cases.
Endoscopic-biopsy diagnosis and endoscopic ultrasound
are of major importance as decisive prognostic factors and
therapeutic determinants.

 

 

Maltomaxz3

Video Endoscopic Sequence 3 of 8.

Endoscopy of MALT Lymphoma

 

Maltomaxz4

Video Endoscopic Sequence 4 of 8.

 

Maltomaxz5

Video Endoscopic Sequence 5 of 8.

 

Maltomaxz6

Video Endoscopic Sequence 6 of 8.

 

Maltomaxz7

Video Endoscopic Sequence 7 of 8.

 

Maltomaxz8

Video Endoscopic Sequence 8 of 8.

 

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