術前胃鏡及活檢證實胃竇部腺癌課件

PatientT,Female,45yearsold

胡某,女，45歲Thegastroscopeandbiopsybeforesurgery:gastricsinusadenocarcinoma

術前胃鏡及活檢證實胃竇部腺癌Sep.2004receivedradicalresectionofgastriccancer

2004年9月接受了胃癌根治術PathologicalReport:UlcerativeAdenocarcinoma,lowdifferentiation,invadesserosalayer,adherencewithadjacentpancreas,lymphnodesmetastasis12/16

病理報告：低分化潰瘍型腺癌，侵犯漿膜層，與胰腺粘連，淋巴結轉移灶12/16Stage:T4N2M0，G3,StageIV分期IV期，T4N2M0，G3PatientCharacteristicsPatientT,Female,45yearsolCompletedchemotherapyregimen(MMC+CF+5-FU)×4cyclesaftersurgery

手術后完成4個周期(MMC+CF+5-FU)方案的輔助化療Physicalexaminationatthe6thmonthafterchemotherapyfindstheleft-supraclavicularlymphnodes(size:2cm).CTScan:twolymphnodesbehindposteriorperitoneuminvolved(size:3cmand2.5cm)術后6個月復診時體檢發(fā)現(xiàn)左側鎖骨上淋巴結腫大，2cm。CT掃描發(fā)現(xiàn)腹膜后兩個腫大淋巴結，3cm及2.5cmCA199：305u/LCEA:126ng/mlPriorTreatmentCompletedchemotherapyregimenWhat’syourRecommendRegimen?Singleagent?1、Xeloda1250mg/m2,twicedaily,×14days,6cycles

Combinationregimens?2、DF(cisplatin+5-FU)3、Xeloda+cisplatin4、FOLFOX(5-FU/LV+Oxaliplatin) 5、Irinotecan-basedregimen6、Taxane-basedregimen0%0%10.3%41.4%0%48.3%What’syourRecommendRegimen?ActualTreatmentPatientreceivedXeloda+cisplatinregimenasfirst-linechemotherapyXeloda:1000mg/m2,twicedaily,×14dayscisplatin:75mg/m2,day1every3weeks

Patientcomplainedthattheadversereactionofnauseandvomitingofcisplatinwastoopainfulforhertogoonwithmoretreatment.Onlycompleted2cycles.

患者由于順鉑所致的惡心嘔吐反應過重，只進行了兩個周期的化療。ActualTreatmentPatientrecePhysicalexamination:left-supraclavicularlymphnodes(size:1cm).CTScan:twolymphnodesbehindposteriorperitoneuminvolvedshrinkobviously,(size:2cmand1cm)CA199:102u/LCEA:21ng/mlPartialResponseActualResponsePhysicalexamination:left-sup1、MaintainXelodaandcisplatindosage?因原方案有效維持原方案化療？2、Reducecisplatindosageto75%

andcontinue?將順鉑劑量減為原劑量的75%后繼續(xù)治療？3、Interrupt？中斷治療4、Changedrug？更換藥物Whattodonext?6.3%40.6%0%53.1%1、MaintainXelodaandcisplatChangedrugPatientreceivedXELOXXeloda:1000mg/m2,twicedaily,×14daysOxaliplatin:130mg/m2,day1every3weeksCompleted4cyclesActualTreatmentChangedrugActualTreatmentThemildsymptomsoferythemaandswellingonherhandsandfeetwerebeobservedafter2cyclesofXELOX.Shecontinuedtheother2cyclesofXELOXwithoutdosagereducingortreatmentdelaying.完成2周期后患者有輕微的手足部痛性紅斑及腫脹。但這并沒有促使化療減量或延期。Insensiblefeelingofhandsandfeetcausedbyoxaliplatinalsohappened.Butmildtoo.

奧沙利鉑導致的手足麻木感也很輕微。

AdverseReactionThemildsymptomsoferythemaPhysicalexamination:left-supraclavicularlymphnodes(size:0.5cm).CTScan:twolymphnodesbehindposteriorperitoneuminvolveddisappeared,(size:0cmand0cm)CA199:40u/LCEA:11ng/mlPartialResponseActualResponsePhysicalexamination:left-supWhatshallyoudoafter6cycles?Maintaintherapy?1、Xeloda1000mg/m2,twicedaily,×14daysContinuewithXELOX

2、Xeloda+OxaliplatinChangetootherregimen?3、T+F(5-FU/LV+Taxane)4、FOLIRI(5-FU/LV+Irinotecan)5、Radiotherapy?6、Observe?37.5%21.9%3.1%9.4%6.3%21.9%Whatshallyoudoafter6cyclPatientreceivedpalliativeradiotherapytheleft-supraclaviculararea:50GYtheareaoftumorbed:45GY

患者接受了姑息性放療，左側鎖骨上區(qū)域50GY，原瘤床部位45GYConcurrentchemotherapyXeloda900mg/m2,twicedaily,×14days2cycles

希羅達同步增敏化療2周期ActualTreatmentPatientreceivedpalliativeraClinicalEfficacyPhysicalexamination:left-supraclavicularlymphnodesdisappeared.CTScan:twolymphnodesbehindposteriorperitoneuminvolveddisappearedCA199:12u/LCEA:6ng/mlCompleteResponseLastfollowupdate:Apr.2006ClinicalEfficacyPhysicalexamWhatshallyoudonext?1、Xeloda1000mg/m2,twicedaily,×14days2、Xeloda(5FU)+Oxaliplatin3、otherregimens

4、Observe?24.2%0%0%75.8%Whatshallyoudonext?1、XelodEpa*QBm7!Mxi3YJue+UFqb(RBm7$Nyj4YJuf0VGrb(RCn8%Ozj4ZKvg1WGrc)SDo9%Ozk5#Lwg1WHsd-TDo9&PAl6#Lwh2XItd-TEpa*QAl6!Mxi3XIte+UFqa*QBm7$Nxi3YJuf0UFqb(RCn7$Nyj4ZKuf0VGrc)RCn8%Ozk4ZKvg1WHrc)SDo9&Ozk5#Lwh1WHsd-TEo9&PAl6!Lwh2XIte-TEpa*QBm6!Mxi3YJte+UFqb(QBm7$Nyj3YJuf0VGqb(RCn8%Nyj4ZKvg0VGrc)SDn8%Ozk5#Kvg1WHsd)SDo9&PAk5#Lwh2XHsd-TEpa&PAl6!Mxh2XIte+UEpa*QBm7!Mxi3YJue+UFqb(RBm7$Nyj4YJuf0VGrb(RCn8%Oyj4ZKvg1VGrc)SDo9%Ozk5#Lwg1WHsd-TDo9&PAl6#Lwh2XItd-TEpa*QAl6!Mxi3XIte+UFqa*QBm7$Nxi3YJuf0UFqb(RCn7$Nyj4ZNyj3YJuf0VGqb(RCn8%Nyj4ZKvg0VGrc)SDn8%Ozk5#Kvg1WHsd)SDo9&PAk5#Lwh2XHsd-TEpa&PAl6!Mxh2XIte+UEpa*QBm7!Mxi3YJue+UFqb(RBm7$Nyj4YJuf0VGrb(RCn8%Ozj4ZKvg1WGrc)SDo9%Ozk5#Lwg1WHsd-TDo9&PAl6#Lwh2XItd-TEpa*QAl6!Mxi3XIte+UFqa*QBm7$Nxi3YJuf0UFqb(RCn7$Nyj4ZKuf0VGrc)RCn8%Ozk4ZKvg1WHrc)SDo9&Ozk5#Lwh1WHsd-TEo9&PAl6!Lwh2XIte-TEpa*QBm6!Mxi3YJte+UFqb(QBm7$Nyj3YJuf0VGqb(RCn8%Nyj4ZKvg0VGrc)SDn8%Ozk5#Kvg1WHsd)SDo9&PAk5#Lwh2XHsd-TEpa&PAl6!Mxh2XIte+UEpa*QBm7!Mxi3YJue+UFqb(RBm7$Nyj4YJuf0VGrb(RCn8%Oyj4ZKvg1VGrc)SDo9%Ozk5#Lwg1WHsd-TDo9&PAl6#Lwh2XItd-TEpa*QAl6!Mxi3XIte+UFqa*QBm7$Nxi3YJuf0UFqb(RCn7$Nyj4ZKuf0VGrc)RCn8%Ozk4ZKvg1WHrc)SDo9&Ozk5#Lwh1WHsd-TEo9&PAl6!Lwh2XIte-TEpa*QBl6!Mxi3YIte+UFqb(QBm7$Nyj3YJuf0VGqb(RCn8%Nyj4ZKvg0VGrc)SDn8%Ozk5#Kvg1WHsd)SDo9&PAk5#Lwh2XHsd-TEpa&PAl6!Mxh2XIte+UEpa*QBm7!Mxi3YJue+UFqb(RBm7$Nyj4YJuf0VGrb(RCn8%Oyj4ZKvg1VGrc)SDo8%Ozk5#Lvg1WHsd-SDo9&PAl6#Lwh2XItd-TEpa*QAl6!Mxi3XIte+UFqa*QBm7$Nxi3YJuf0UFqb(RCn7$Nyj4ZKuf0VGrc)RCn8%Ozk4ZKvg1WHrc)SDo9&Ozk5#Lwh1WHsd-TEo9&PAl6!Lwh2XIte-TEpa*QBl6!Mxi3YIte+UFqb*QBm7$Nyi3YJuf0VFqb(RCn8%Nyj4ZKvg0VGrc)SDn8%Ozk5#Kvg1WHsd)SDo9&PAk5#Lwh2XHsd-TEpa&PAl6!Mxh2XIte+UEpa*QBm7!Mxi3YJue+UFqb(RBm7$Nyj4YJuf0VGrb(RCn8%Oyj4ZKvg1VGrc)SDo8%Ozk5#Lvg1WHsd-SDo9&PAl5#Lwh2XIsd-TEpa*QAl6!Mxi3XIte+UFqa*QBm7$Nxi3YJuf0UIte+UFqb*QBm7$Nyj3YJuf0VGqb(RCn8%Nyj4ZKvg0VGrc)SDn8%Ozk5#Kvg1WHsd)SDo9&PAk5#Lwh2XHsd-TEpa&PAl6!Mxh2XIte+UEpa*QBm7!Mxi3YJue+UFqb(RBm7$Nyj4YJuf0VGrb(RCn8%Oyj4ZKvg1VGrc)SDo8%Ozk5#Lvg1WHsd-SDo9&PAl6#Lwh2XItd-TEpa*QAl6!Mxi3XIte+UFqa*QBm7$Nxi3YJuf0UFqb(RCn7$Nyj4ZKuf0VGrc)RCn8%Ozk4ZKvg1WHrc)SDo9&Ozk5#Lwh1WHsd-TEo9&PAl6!Lwh2XIte-TEpa*QBl6!Mxi3YIte+UFqb*QBm7$Nyi3YJuf0VFqb(RCn8%Nyj4ZKvg0VGrc)SDn8%Ozk5#Kvg1WHsd)SDo9&PAk5#Lwh2XHsd-TEpa&PAl6!Mxh2XIte+UEpa*QBm7!Mxi3YJue+UFqb(RBm7$Nyj4YJuf0VGrb(RCn8%Oyj4ZKvg1VGrc)SDo8%Ozk5#Lvg1WHsd-SDo9&PAl5#Lwh2XIsd-TEpa*QAl6!Mxi3XIte+UFqa*QBm7$Nxi3YJuf0UFqb(RCn7$Nyj4ZKuf0VGrc)RCn8%Ozk4ZKvg1WHrc)SDo9&Ozk5#Lwh1WHsd-TEo9&PAl6!Lwh2XIte-TEpa*QBl6!Mxi3YIte+UFqb*QBm7$Nyi3YJuf0VFqb(RCn8$Nyj4ZNyj4YJuf0VGrb(RCn8%Oyj4ZKvg1VGrc)SDo8%Ozk5#Lvg1WHsd-SDo9&PAl6#Lwh2XItd-TEpa*QAl6!Mxi3XIte+UFqa*QBm7$Nxi3YJuf0UFqb(RCn7$Nyj4ZKuf0VGrc)RCn8%Ozk4ZKvg1WHrc)SDo9&Ozk5#Lwh1WHsd-TEo9&PAl6!Lwh2XIte-TEpa*QBl6!Mxi3YIte+UFqb*QBm7$Nyi3YJuf0VFqb(RCn8%Nyj4ZKvg0VGrc)SDn8%Ozk5#Kvg1WHsd)SDo9&PAk5#Lwh2XHsd-TEpa&PAl6!Mxh2XIte+UEpa*QBm7!Mxi3YJue+UFqb(RBm7$Nyj4YJuf0VGrb(RCn8%Oyj4ZKvg1VGrc)SDo8%Ozk5#Lvg1WHsd-SDo9&PAl5#Lwh2XIsd-TEpa*QAl6!Mxi3XIte+UFqa*QBm7$Nxi3YJuf0UFqb(RCn7$Nyj4ZKuf0VGrc)RCn8%Ozk4ZKvg1WHrc)SDo9&Ozk5#Lwh1WHsd-TEo9&PAl6!Lwh2XIte-TEpa*QBl6!Mxi3YIte+UFqb*QBm7$Nyi3YJuf0VFqb(RCn8$Nyj4ZKvf0VGrc)SDn8%Ozk5#Kvg1WHsd)SDo9&PAk5#Lwh2XHsd-TEpa&PAl6&PAl6#Lwh2XItd-TEpa*QAl6!Mxi3XIte+UFqa*QBm7$Nxi3YJuf0UFqb(RCn7$Nyj4ZKuf0VGrc)RCn8%Ozk4ZKvg1WHrc)SDo9&Ozk5#Lwh1WHsd-TEo9&PAl6!Lwh2XIte-TEpa*QBl6!Mxi3YIte+UFqb*QBm7$Nyi3YJuf0VFqb(RCn8%Nyj4ZKvg0VGrc)SDn8%Ozk5#Kvg1WHsd)SDo9&PAk5#Lwh2XHsd-TEpa&PAl6!Mxh2XIte+UEpa*QBm7!Mxi3YJue+UFqb(RBm7$Nyj4YJuf0VGrb(RCn8%Oyj4ZKvg1VGrc)SDo8%Ozk5#Lvg1WHsd-SDo9&PAl5#Lwh2XIsd-TEpa*QAl6!Mxi3XIte+UFqa*QBm7$Nxi3YJuf0UFqb(RCn7$Nyj4ZKuf0VGrc)RCn8%Ozk4ZKvg1WHrc)SDo9&Ozk5#Lwh1WHsd-TEo9&PAl6!Lwh2XIte-TEpa*QBl6!Mxi3YIte+UFqb*QBm7$Nyi3YJuf0VFqb(RCn8$Nyj4ZKvf0VGrc)SDn8%Ozk5#Kvg1WHsd)SDo9&PAk5#Lwh2XHsd-TEpa&PAl6!Mxh2#Lwh2XItd-TEpa*QAl6!Mxi3XIte+UFqa*QBm7$Nxi3YJuf0UFqb(RCn7$Nyj4ZKuf0VGrc)RCn8%Ozk4ZKvg1WHrc)SDo9&Ozk5#Lwh1WHsd-TEo9&PAl6!Lwh2XIte-TEpa*QBl6!Mxi3YIte+UFqb*QBm7$Nyi3YJuf0VFqb(RCn8%Nyj4ZKvg0VGrc)SDn8%Ozk5#Kvg1WHsd)SDo9&PAk5#Lwh2XHsd-TEpa&PAl6!Mxh2XIte+UEpa*QBm7!Mxi3YJue+UFqb(RBm7$Nyj4YJuf0VGrb(RCn8%Oyj4ZKvg1VGrc)SDo8%Ozk5#Lvg1WHsd-SDo9&PAl5#Lwh2XIsd-TEpa*QAl6!Mxi3XIte+UFqa*QBm7$Nxi3YJuf0UFqb(RCn7$Nyj4ZKuf0VGrc)RCn8%Ozk4ZKvg1WHrc)SDo9&Ozk5#Lwh1WHsd-TEo9&PAl6!Lwh2XIte-TEpa*QBl6!Mxi3YIte+UFqb*QBm7$Nyi3YJuf0VFqb(RCn8$Nyj4ZKvf0VGrc)SDn8%RCn8%Oyj4ZKvg1VGrc)SDo8%Ozk5#Lvg1WHsd-SDo9&PAl6#Lwh2XItd-TEpa*QAl6!Mxi3XIte+UFqa*QBm7$Nxi3YJuf0UFqb(RCn7$Nyj4ZKuf0VGrc)RCn8%Ozk4ZKvg1WHrc)SDo9&Ozk5#Lwh1WHsd-TEo9&PAl6!Lwh2XIte-TEpa*QBl6!Mxi3YIte+UFqb*QBm7$Nyi3YJuf0VFqb(RCn8%Nyj4ZKvg0VGrc)SDn8%Ozk5#Kvg1WHsd)SDo9&PAk5#Lwh2XHsd-TEpa&PAl6!Mxh2XIte+UEpa*QBm7!Mxi3YJue+UFqb(RBm7$Nyj4YJuf0VGrb(RCn8%Oyj4ZKvg1VGrc)SDo8%Ozk5#Lvg1WHsd-SDo9&PAl5#Lwh2XIsd-TEpa*PAl6!Mxi3XIte+UFqa*QBm7$Nxi3YJuf0UFqb(RCn7$QBm7$Nyj3YJuf0VGqb(RCn8%Nyj4ZKvg0VGrc)SDn8%Ozk5#Kvg1WHsd)SDo9&PAk5#Lwh2XHsd-TEpa&PAl6!Mxh2XIte+UEpa*QBm7!Mxi3YJue+UFqb(RBm7$Nyj4YJuf0VGrb(RCn8%Oyj4ZKvg1VGrc)SDo8%Ozk5#Lvg1WHsd-SDo9&PAl5#Lwh2XItd-TEpa*QAl6!Mxi3XIte+UFqa*QBm7$Nxi3YJuf0UFqb(RCn7$Nyj4ZKuf0VGrc)RCn8%Ozk4ZKvg1WHrc)SDo9&Ozk5#Lwh1WHsd-TEo9&PAl6!Lwh2XIte-TEpa*QBl6!Mxi3YIte+UFqb*QBm7$Nyi3YJuf0VEpa*QBm7!Mxi3YJue+UFqb(RBm7$Ny*apET-dtIX2hwL#6lAP&9oDT-dsHW1gvL#5kzO%8oDS)crGV1gvKZ4jyO%8nCR(brGV0fuJY4jyN$7mBR(bqFU+euJY3ixM!7mBQ*apEU+etIX2hxM!6lAP&apET-dsHX2hwL#5kAP&9oDS)dsHW1gvK#5kzO%8nDS)crGV0gvKZ4jyN%8nCR(bqGV0fuJY3jyN$7mBQ(bqFU+etIY3ixM!6lBQ*apET-etIX2hwL!6lAP&9oET-dsHW1hwL#5kzO&9oDS)crHW1gvKZ4kzO%8nCR)crGV0fuKZ4jyN$7nCR(bqFU0fuJY3ixN$7mBQ*aqFU+etIX3ixM!6lAQ*apET-dtIX2hwL#6lAP&9oDT-dsHW1gwL#5kzO%9oDS)crGV1gvKZ4jyO%8nCR(brGV0fuJY4jyN$7mBR(bqFU+euJY3ixM!7mBQ*apEU+etIX2hxM!6lAP&apET-dsHX2hwL#5kAP&9oDS)dsHW1gvK#5kzO%8nDS)crGV0gvKZ4jyN%8nCR(bqGV0fuJY3jyN$7mBQ(bqFU+etJY3ixM!6mBQ*apET-etIX2hwL!6lAP&9oET-dsHW1hwL#5kzO&9oDS)crHW1gvKZ4kzO%8nCR)crGV0fuKZ4jyN$7nCR(bqFU0fuJY3ixN$7mBQ*aqFU+etIX3ixM!6lAQ*apET-dtIX2hwL#6lAP&9oDT-dsHW1gwL#5kzO%9oDS)crGW1gvKZ4jzO%8nCO%8nDS)crGV0gvKZ4jyN%8nCR(bqGV0fuJY3jyN$7mBQ(bqFU+etIY3ixM!6lBQ*apET-etIX2hwL!6lAP&9oET-dsHW1hwL#5kzO&9oDS)crHW1gvKZ4kzO%8nCR)crGV0fuKZ4jyN$7nCR(bqFU0fuJY3ixN$7mBQ*aqFU+etIX3ixM!6lAQ*apET-dtIX2hwL#6lAP&9oDT-dsHW1gwL#5kzO%9oDS)crGV1gvKZ4jyO%8nCR(brGV0fuJY4jyN$7mBR(bqFU+euJY3ixM!7mBQ*apEU+etIX2hxM!6lAP&apET-dsHX2hwL#5kAP&9oDS)dsHW1gvK#5kzO%8nDS)crGV0gvKZ4jyN%8nCR(bqGV0fuJY3jyN$7mBQ(bqFU+etJY3ixM!6mBQ*apET-etIX2hwL!6lAP&9oET-dsHW1hwL#5kzO&9oDS)crHW1gvKZ4kzO%8nCR)crGV0fuKZ4jyN$7nCR(bqFU0fuJY3ixN$7mBQ*aqFU+etIX3ixM!6lAQ*apET-dtIX2hwL#6lAP&9oDT-dsHW1gwL#5kzO%9oDS)crGW1gvKZ4jzO%8nCR(brGV0fuJY4jyN$7mBR(bqFU+euJY3ixM!7mBQ*apEU+etIX2hxM!6lAP&apET-dsHX2hwL#5kAP&9oDS)dsHW1gvK#5kzO%8nDS)crGV0gvKZ4jyN%8nCR(bqGV0fuJY3jyN$7mBQ(bqFU+etJY3ixM!6mBQ*apET+etIX2hwM!6lAP&9oET-dsHW1hwL#5kzO&9oDS)crHW1gvKZ4kzO%8nCR)crGV0fuKZ4jyN$7nCR(bqFU0fuJY3ixN$7mBQ*aqFU+etIX3ixM!6lAQ*apET-dtIX2hwL#6lAP&9oDT-dsHW1gwL#5kzO%9oDS)crGW1gvKZ4jzO%8nCR(crGV0fuJZ4jyN$7mBR(bqFU+euJY3ixM!7mBQ*apEU+etIX2hxM!6lAP&apET-dsHX2hwL#5kAP&9oDS)dsHW1gvK#5kzO%8nDS)crGV0gvKZ4jyN%8nCR(bqGV0fuJY3jyN$7mBQ(bqFU+etJY3ixM!6mBQ*apET+etIX2hwM!6lAP&9pET-dsHW2hwL#5kzO&9oDS)crHW1gvKZ4kzO%8nCR)crGV0fuKZ4jyN$7nCR(bqFU0fuJY3ixN$7mBQ*aqFU+etIX3ixM!6lAQ*apET-dtIX2hwL#6lAP&9oDT-dsHW1gwL#5kzO%9oDS)crGW1gvKZ4jzO%8nCR(crGV0fuJZ4jyN$7mCR(bqFU+fuJY3ixM!7mBQ*apEU+etIX2hxM!6lAP&apET-dsHX2hwL#5kAP&9oDS)dsHW1gvK#5kzO%8nDS)crGV0gvKZ4jyN%8nCR(bqGV0fuJY3jyN$7mBQ(bqFU+etJY3ixM!6mBQ*apET+etIX2hwM!6lAP&9pET-dsHW2hwL#5kzP&9oDS)csHW1gvKZ5kzO%8nCR)crGV0fuKZ4jyN$7nCR(bqFU0fuJY3ixN$7mBQ*aqFU+etIX3ixM!6lAQ*apET*apEU+etIX2hxM!6lAP&apET-dsHX2hwL#5kAP&9oDS)dsHW1gvK#5kzO%8nDS)crGV0gvKZ4jyN%8nCR(bqGV0fuJY3jyN$7mBQ(bqFU+etJY3ixM!6mBQ*apET+etIX2hwM!6lAP&9pET-dsHW2hwL#5kzP&9oDS)crHW1gvKZ4kzO%8nCR)crGV0fuKZ4jyN$7nCR(bqFU0fuJY3ixN$7mBQ*aqFU+etIX3ixM!6lAQ*apET-dtIX2hwL#6lAP&9oDT-dsHW1gwL#5kzO%9oDS)crGW1gvKZ4jzO%8nCR(crGV0fuJZ4jyN$7mCR(bqFU+fuJY3ixM$7mBQ*apEU+etIX2hxM!6lAP&apET-dsHX2hwL#5kAP&9oDS)dsHW1gvK#5kzO%8nDS)crGV0gvKZ4jyN%8nCR(bqGV0fuJY3jyN$7mBQ(bqFU+etJY3ixM!6mBQ*apET+etIX2hwM!6lAP&9pET-dsHW2hwL#5kzP&9oDS)csHW1gvKZ5kzO%8nCR)crGV0fuKZ4jyN$7nCR(bqFU0fuJY3ixN$7mBQ*aqFU+etIX3ixM!6lAQ*apET-dtIX2hwL#6lAP&9oDT-dsHW1gwL#5kzO%9oDS)crGW1gvKZ4jzO%8nCR(crGV0fuJZ4jyN$7mCR(bqFU+fuJY3ixM$7mBQ*apFU+etIX2ixM!6lAP&apET-dsHX2hwL#5kAP&9oDS)dsHW1gvK#5kzO%8nDS)crGV0gvKZ4jyN%8nCR(bqGV0fuJY3jyN$7mBQ(bqFU+etJY3ixM!6mBQ*apET+etIX2hwM!6lAP&9pET-dsHW2hwL#5kzP&9oDS)csHW1gvKZ5kzO%8nCS)crGV0fvKZ4jyN$7nCR(bqFU0fuJY3ixN$7mBQ*aqFU+etIX3ixM!6lAQ*apET-dtIX2hwL#6lAP&9oDT-dsHW1gwL#5kzO%9oDS)crGW1gvKZ4jzO%8nCR(crGV0fuJZ4jyN$7mCR(bqFU+fuJY3ixM$7mBQ*apFU+etIX2ixM!6lAP*apET-dsIX2hwL#5kAP&9oDS)dsHW1gvK#5kzO%8nDS)crGV0gvKZ4jyN%8nCR(bqGV0fuJY3jyN$7mBQ(bqFU+etJY3ixM!6mBQ*apET+etIX2hwM!6lAP&9pET-dsHW2hwL#5kzP&9oDS)csHW1gvKZ5kwL#5kzO%9oDS)crGW1gvKZ4jzO%8nCR(crGV0fuJZ4jyN$7mCR(bqFU+fuJY3ixM$7mBQ*apFU+etIX2ixM!6lAP&apET-dsHX2hwL#5kAP&9oDS)dsHW1gvK#5kzO%8nDS)crGV0g