Dermatofibroma Clinical Presentation

  • Author: Joseph C Pierson, MD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: May 15, 2012
 

History

Dermatofibromas typically arise slowly and most often occur as a solitary nodule on an extremity, particularly the lower leg, but any cutaneous site is possible. Dermatofibromas are usually asymptomatic, but itching and pain often are noted. They are the most common of all painful skin tumors.[1] Women who shave their legs may be bothered by the razor traumatizing the lesion in that region, causing pain, bleeding, erosive changes, and ulceration. Although cases of unusually rapid growth exist, most dermatofibromas remain static for decades or persist indefinitely. Patients may describe a hard mole or unusual scar and are often concerned about the possibility of skin cancer.

Several lesions may be present, but rarely are numerous (ie, 15 or more) tumors found. A multiple eruptive variant occurs in only 0.3% of patients, many of whom have an alteration in their immune status, classically, HIV infection and systemic lupus erythematosus.[12, 13] However, dermatomyositis,[14] Graves disease,[15] Hashimoto thyroiditis,[16] myasthenia gravis,[16] Down syndrome,[17] leukemia,[18] myelodysplastic syndrome,[19] cutaneous T-cell lymphoma,[20] multiple myeloma,[20] and atopic dermatitis[21] have all been reported in association with the phenomenon. In addition, antiretroviral agents[22] and the biologic agent efalizumab[23] have been linked to their appearance.

Both congenital[24] and acquired[25] cases of multiple clustered dermatofibromas have been reported.

A case of halo asteatotic eczema developing around a dermatofibroma on an edematous lower extremity has been described.[26]

Spontaneous regression has been reported[27] and this may yield postinflammatory hypopigmentation.

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Physical

Typically, the clinical appearance of dermatofibroma is a solitary, 0.5- to 1-cm nodule. A sizable minority of patients may have several lesions, but rarely (0.3% of cases) are more than 15 lesions present. (See History) The overlying skin can range from flesh to gray, yellow, orange, pink, red, purple, blue, brown, or black, or a combination of hues (see the image below). On palpation, the hard nodule may feel like a small pebble fixed to the skin surface and is freely movable over the subcutis. Tenderness may be elicited with manipulation of the lesion.

Erythematous, slightly hyperpigmented nodule on thErythematous, slightly hyperpigmented nodule on the leg. Courtesy of David Barnette, MD.

The characteristic tethering of the overlying epidermis to the underlying lesion with lateral compression (pinching), called the dimple sign, may be a useful clinical sign for diagnosis.[28] However, presence of the dimple sign does not always assure the lesion is dermatofibroma,[29] and dermatoscopy may be useful in supporting the clinical impression.[30]

The extremities are the most common sites of involvement, particularly the lower legs. Although any cutaneous site can be seen, palm, sole, digital, oral, and genital involvement is relatively rare. Giant (>5 cm in diameter),[31] atrophic,[32] polypoid,[33] and dermatofibroma with spreading satellitosis[34] variants have been reported.

Multiple clustered dermatofibromas[25] are rare but can mimic dermatofibrosarcoma protuberans.

A halo of asteatotic eczema surrounding a dermatofibroma occurred in one patient.[26]

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Causes

Historically attributed to be a reactive process to some traumatic insult to the skin (eg, arthropod bite),[35] the cause of dermatofibroma is unknown. Clonal analysis suggest it may represent a true neoplasm.[2]

Altered immunity likely plays a role in many cases of multiple eruptive dermatofibromas (see History).

A study of eruptive dermatofibromas in a kindred suggests that a genetic component may exist.[36]

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Contributor Information and Disclosures
Author

Joseph C Pierson, MD  Consulting Staff, Department of Dermatology, Guthrie Army Clinic, Ft Drum, NY

Joseph C Pierson, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Coauthor(s)

Christine C Tam, MD  Staff Physician, Dermatology Office of David A Spott, MD

Christine C Tam, MD is a member of the following medical societies: American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Terry L Barrett, MD  Clinical Professor of Dermatology and Pathology, University of Texas Southwestern School of Medicine; Director, ProPath Dermatopathology, Dallas, Texas

Terry L Barrett, MD is a member of the following medical societies: American Academy of Dermatology, American Dermatological Association, American Medical Association, American Society of Dermatopathology, College of American Pathologists, and United States and Canadian Academy of Pathology

Disclosure: Nothing to disclose.

David F Butler, MD  Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Edward F Chan, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine

Edward F Chan, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Catherine M Quirk, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Diane Pierson, DO, to the development and writing of this article.

References

  1. Naversen DN, Trask DM, Watson FH, Burket JM. Painful tumors of the skin: "LEND AN EGG". J Am Acad Dermatol. Feb 1993;28(2 Pt 2):298-300. [Medline].

  2. Chen TC, Kuo T, Chan HL. Dermatofibroma is a clonal proliferative disease. J Cutan Pathol. Jan 2000;27(1):36-9. [Medline].

  3. Kuroda K, Tajima S. Proliferation of HSP47-positive skin fibroblasts in dermatofibroma. J Cutan Pathol. Jan 2008;35(1):21-6. [Medline].

  4. Sellheyer K, Smoller BR. Dermatofibroma: upregulation of syndecan-1 expression in mesenchymal tissue. Am J Dermatopathol. Oct 2003;25(5):392-8. [Medline].

  5. Skroza N, Rotolo S, Ceccarelli S, et al. Modulation of the expression of the FGFR2-IIIb and FGFR2-IIIc molecules in dermatofibroma. J Dermatol Sci. Jul 2008;51(1):53-7. [Medline].

  6. Kubo M, Ihn H, Yamane K, Tamaki K. The expression levels and the differential expression of transforming growth factor-beta receptors in dermatofibroma and dermatofibrosarcoma protuberans. Br J Dermatol. May 2006;154(5):919-25. [Medline].

  7. Yamamoto T. Dermatofibroma: a possible model of local fibrosis with epithelial/mesenchymal cell interaction. J Eur Acad Dermatol Venereol. Apr 2009;23(4):371-5. [Medline].

  8. Kaddu S, McMenamin ME, Fletcher CD. Atypical fibrous histiocytoma of the skin: clinicopathologic analysis of 59 cases with evidence of infrequent metastasis. Am J Surg Pathol. Jan 2002;26(1):35-46. [Medline].

  9. Kimyai-Asadi A, Goldberg LH, Greenberg C, et al. Cellular, atypical, and indeterminate dermatofibromas: benign or malignant?. Dermatol Surg. Sep 2008;34(9):1264-71; discussion 1271-2. [Medline].

  10. Szumera-Cieckiewicz A, Ptaszynski K. Benign fibrous histiocytoma of the skin metastasizing to the inguinal lymph node. Pol J Pathol. Sep 2011;62(3):183-6. [Medline].

  11. Gleason BC, Fletcher CD. Deep "benign" fibrous histiocytoma: clinicopathologic analysis of 69 cases of a rare tumor indicating occasional metastatic potential. Am J Surg Pathol. Mar 2008;32(3):354-62. [Medline].

  12. Massone C, Parodi A, Virno G, Rebora A. Multiple eruptive dermatofibromas in patients with systemic lupus erythematosus treated with prednisone. Int J Dermatol. May 2002;41(5):279-81. [Medline].

  13. García-Millán C, Aldanondo I, Fernández-Lorente M, Carrillo R, Jaén P. [Multiple eruptive dermatofibromas in 2 patients infected with the human immunodeficiency virus]. Actas Dermosifiliogr. Dec 2007;98(10):702-6. [Medline].

  14. Huang PY, Chu CY, Hsiao CH. Multiple eruptive dermatofibromas in a patient with dermatomyositis taking prednisolone and methotrexate. J Am Acad Dermatol. Nov 2007;57(5 Suppl):S81-4. [Medline].

  15. Lopez N, Fernandez A, Bosch RJ, Herrera E. Multiple eruptive dermatofibromas in a patient with Graves-Basedow disease. J Eur Acad Dermatol Venereol. Mar 2008;22(3):402-3. [Medline].

  16. Kimura Y, Kaneko T, Akasaka E, Nakajima K, Aizu T, Nakano H, et al. Multiple eruptive dermatofibromas associated with Hashimoto's thyroiditis and myasthenia gravis. Eur J Dermatol. Jul-Aug 2010;20(4):538-9. [Medline].

  17. Monteagudo B, Suarez-Amor O, Cabanillas M, et al. [Down syndrome: another cause of immunosuppression associated with multiple eruptive dermatofibromas?]. Dermatol Online J. Sep 15 2009;15(9):15. [Medline].

  18. Alexandrescu DT, Wiernik PH. Multiple eruptive dermatofibromas occurring in a patient with chronic myelogenous leukemia. Arch Dermatol. Mar 2005;141(3):397-8. [Medline].

  19. Bhattacharjee P, Umar SA, Fatteh SM. Multiple eruptive dermatofibromas occurring in a patient with myelodysplastic syndrome. Acta Derm Venereol. 2005;85(3):270-1. [Medline].

  20. Zaccaria E, Rebora A, Rongioletti F. Multiple eruptive dermatofibromas and immunosuppression: report of two cases and review of the literature. Int J Dermatol. Jul 2008;47(7):723-7. [Medline].

  21. Yazici AC, Baz K, Ikizoglu G, Koca A, Kokturk A, Apa DD. Familial eruptive dermatofibromas in atopic dermatitis. J Eur Acad Dermatol Venereol. Jan 2006;20(1):90-2. [Medline].

  22. Bachmeyer C, Cordier F, Blum L, Cazier A, Vérola O, Aractingi S. Multiple eruptive dermatofibromas after highly active antiretroviral therapy. Br J Dermatol. Dec 2000;143(6):1336-7. [Medline].

  23. Santos-Juanes J, Coto-Segura P, Mallo S, Galache C, Soto J. Multiple eruptive dermatofibromas in a patient receiving efalizumab. Dermatology. 2008;216(4):363. [Medline].

  24. Finch J, Berke A, McCusker M, Chang MW. Congenital Multiple Clustered Dermatofibroma in a 12-Year-Old Girl. Pediatr Dermatol. Dec 30 2011;[Medline].

  25. Gershtenson PC, Krunic AL, Chen HM. Multiple clustered dermatofibroma: case report and review of the literature. J Cutan Pathol. Sep 2010;37(9):e42-5. [Medline].

  26. Cox NH. Halo asteatotic eczema localized around a dermatofibroma in acute-onset leg oedema. Br J Dermatol. Aug 2008;159(2):496. [Medline].

  27. Niemi KM. The benign fibrohistiocytic tumours of the skin. Acta Derm Venereol Suppl (Stockh). 1970;50(63):Suppl 63:1-66. [Medline].

  28. Fitzpatrick TB, Gilchrest BA. Dimple sign to differentiate benign from malignant pigmented cutaneous lesions. N Engl J Med. Jun 30 1977;296(26):1518. [Medline].

  29. Lookingbill DP. A malignant dimple. N Engl J Med. Oct 13 1977;297(15):841-2. [Medline].

  30. Meffert JJ, Peake MF, Wilde JL. 'Dimpling' is not unique to dermatofibromas. Dermatology. 1997;195(4):384-6. [Medline].

  31. Requena L, Farina MC, Fuente C, et al. Giant dermatofibroma. A little-known clinical variant of dermatofibroma. J Am Acad Dermatol. May 1994;30(5 Pt 1):714-8. [Medline].

  32. Ohnishi T, Sasaki M, Nakai K, Watanabe S. Atrophic dermatofibroma. J Eur Acad Dermatol Venereol. Sep 2004;18(5):580-3. [Medline].

  33. Kai H, Fujita H, Yamamoto M, Asahina A. Letter: Polypoid dermatofibroma with a slim pedicle: A case report. Dermatol Online J. Mar 15 2012;18(3):16. [Medline].

  34. Curco N, Jucgla A, Bordas X, Moreno A. Dermatofibroma with spreading satellitosis. J Am Acad Dermatol. Dec 1992;27(6 Pt 1):1017-9. [Medline].

  35. Evans J, Clarke T, Mattacks CA, Pond CM. Dermatofibromas and arthropod bites: is there any evidence to link the two?. Lancet. Jul 1 1989;2(8653):36-7. [Medline].

  36. Samlaska C, Bennion S. Eruptive dermatofibromas in a kindred. Cutis. Mar 2002;69(3):187-8, 190. [Medline].

  37. Wortsman X, Wortsman J. Clinical usefulness of variable-frequency ultrasound in localized lesions of the skin. J Am Acad Dermatol. Feb 2010;62(2):247-56. [Medline].

  38. Demir MK, Ozdemir H, Genchallaç H, Altaner S, Kartal O. Dermatofibroma mimicking malignancy on integrated F-18 fluorodeoxyglucose PET-CT. Diagn Interv Radiol. Mar 2009;15(1):61-3. [Medline].

  39. Zaballos P, Puig S, Llambrich A, Malvehy J. Dermoscopy of dermatofibromas: a prospective morphological study of 412 cases. Arch Dermatol. Jan 2008;144(1):75-83. [Medline].

  40. Cavicchini S, Tourlaki A, Tanzi C, Alessi E. Dermoscopy of solitary yellow lesions in adults. Arch Dermatol. Oct 2008;144(10):1412. [Medline].

  41. Pereira Guedes RV, Noronha de Menezes NM, Leite IB, Baptista MA. Benign fibrous histiocytoma: Particular aspects on confocal laser scanning microscopy. Eur J Dermatol. Mar-Apr 2012;22(2):288-9. [Medline].

  42. Kideryova L, Lacina L, Dvorankova B, et al. Phenotypic characterization of human keratinocytes in coculture reveals differential effects of fibroblasts from benign fibrous histiocytoma (dermatofibroma) as compared to cells from its malignant form and to normal fibroblasts. J Dermatol Sci. Jul 2009;55(1):18-26. [Medline].

  43. Nair V, Weinreb I, MacNeil N, Szollosi Z, Chetty R, Ghazarian D. A unique biphasic variant of cutaneous fibrous histiocytoma with a storiform pattern and intralesional pigmented melanocytes: "storiform melano-fibrous histiocytoma". Eur J Dermatol. May-Jun 2008;18(3):332-6. [Medline].

  44. Wick MR, Ritter JH, Lind AC, Swanson PE. The pathological distinction between "deep penetrating" dermatofibroma and dermatofibrosarcoma protuberans. Semin Cutan Med Surg. Mar 1999;18(1):91-8. [Medline].

  45. Goldblum JR, Tuthill RJ. CD34 and factor-XIIIa immunoreactivity in dermatofibrosarcoma protuberans and dermatofibroma. Am J Dermatopathol. Apr 1997;19(2):147-53. [Medline].

  46. Kim HJ, Lee JY, Kim SH, et al. Stromelysin-3 expression in the differential diagnosis of dermatofibroma and dermatofibrosarcoma protuberans: comparison with factor XIIIa and CD34. Br J Dermatol. Aug 2007;157(2):319-24. [Medline].

  47. Maekawa T, Jinnin M, Ihn H. The expression levels of thrombospondin-1 in dermatofibroma and dermatofibrosarcoma protuberans. Eur J Dermatol. Jul-Aug 2011;21(4):534-8. [Medline].

  48. Li J, Yu Y, Yang Y, Wang L, Cao J, Liang X, et al. IGFBP7, a novel immunohistochemical marker in differentiating dermatofibroma from dermatofibrosarcoma protuberans. J Eur Acad Dermatol Venereol. Mar 2012;26(3):382-5. [Medline].

  49. Mori T, Misago N, Yamamoto O, Toda S, Narisawa Y. Expression of nestin in dermatofibrosarcoma protuberans in comparison to dermatofibroma. J Dermatol. Jul 2008;35(7):419-25. [Medline].

  50. Wang L, Xiang YN, Zhang YH, Tu YT, Chen HX. Collagen triple helix repeat containing-1 in the differential diagnosis of dermatofibrosarcoma protuberans and dermatofibroma. Br J Dermatol. Jan 2011;164(1):135-40. [Medline].

  51. Bandarchi B, Ma L, Marginean C, Hafezi S, Zubovits J, Rasty G. D2-40, a novel immunohistochemical marker in differentiating dermatofibroma from dermatofibrosarcoma protuberans. Mod Pathol. Mar 2010;23(3):434-8. [Medline].

  52. Yan X, Takahara M, Xie L, Tu Y, Furue M. Cathepsin K expression: a useful marker for the differential diagnosis of dermatofibroma and dermatofibrosarcoma protuberans. Histopathology. Sep 2010;57(3):486-8. [Medline].

  53. Toyozawa S, Yamamoto Y, Ishida Y, Kondo T, Nakamura Y, Furukawa F. Immunohistochemical analysis of CXCR4 expression in fibrohistiocytic tumors. Acta Histochem Cytochem. May 1 2010;43(2):45-50. [Medline]. [Full Text].

  54. Horenstein MG, Prieto VG, Nuckols JD, Burchette JL, Shea CR. Indeterminate fibrohistiocytic lesions of the skin: is there a spectrum between dermatofibroma and dermatofibrosarcoma protuberans?. Am J Surg Pathol. Jul 2000;24(7):996-1003. [Medline].

  55. Wang WL, Patel KU, Coleman NM, et al. COL1A1:PDGFB chimeric transcripts are not present in indeterminate fibrohistiocytic lesions of the skin. Am J Dermatopathol. Apr 2010;32(2):149-53. [Medline].

  56. Zelger BG, Zelger B. [Dermatofibroma. A clinico-pathologic classification scheme]. Pathologe. Nov 1998;19(6):412-9. [Medline].

  57. Zelger BG, Sidoroff A, Zelger B. Combined dermatofibroma: co-existence of two or more variant patterns in a single lesion. Histopathology. Jun 2000;36(6):529-39. [Medline].

  58. Gonzalez-Vela MC, Val-Bernal JF, Martino M, Gonzalez-Lopez MA, Garcia-Alberdi E, Hermana S. Sclerotic fibroma-like dermatofibroma: an uncommon distinctive variant of dermatofibroma. Histol Histopathol. Jul 2005;20(3):801-6. [Medline].

  59. de Feraudy S, Mar N, McCalmont TH. Evaluation of CD10 and procollagen 1 expression in atypical fibroxanthoma and dermatofibroma. Am J Surg Pathol. Aug 2008;32(8):1111-22. [Medline].

  60. Sanchez Yus E, Soria L, de Eusebio E, Requena L. Lichenoid, erosive and ulcerated dermatofibromas. Three additional clinico-pathologic variants. J Cutan Pathol. Mar 2000;27(3):112-7. [Medline].

  61. Aiba S, Terui T, Tagami H. Dermatofibroma with diffuse eosinophilic infiltrate. Am J Dermatopathol. Jun 2000;22(3):281-4. [Medline].

  62. Aydin E, Vardareli OS, Bilezikci B, Ozgirgin ON. [Dermatofibroma accompanied by perforating dermatosis in the auricle: a case report]. Kulak Burun Bogaz Ihtis Derg. 2005;15(3-4):83-6. [Medline].

  63. Fuciarelli K, Cohen PR. Sebaceous hyperplasia: a clue to the diagnosis of dermatofibroma. J Am Acad Dermatol. Jan 2001;44(1):94-5. [Medline].

  64. Spaun E, Zelger B. Dermatofibroma with intracytoplasmic eosinophilic globules: an unusual phenomenon. J Cutan Pathol. Jul 2009;36(7):796-8. [Medline].

  65. Garrido-Ruiz MC, Carrillo R, Enguita AB, Peralto JL. Signet-ring cell dermatofibroma. Am J Dermatopathol. Feb 2009;31(1):84-7. [Medline].

  66. Quigley BC, Ricciuti J, Morgan MB. Amyloid Light Chain Deposition Associated with Dermatofibroma: Serendipity or Association?. Am J Dermatopathol. Jan 23 2010;[Medline].

  67. Yamamoto T. Incidental acantholysis of the overlying epidermis of dermatofibroma. J Eur Acad Dermatol Venereol. Jun 2009;23(6):735-6. [Medline].

  68. Gonzalez S. Regarding the case report of Dr Phillip W. Allen on apocrine gland cyst with hemosiderotic dermatofibroma. Adv Anat Pathol. Nov 2008;15(6):376; author reply 376. [Medline].

  69. Shuweiter M, Boer A. Spectrum of follicular and sebaceous differentiation induced by dermatofibroma. Am J Dermatopathol. Dec 2009;31(8):778-85. [Medline].

  70. King R, Googe PB, Page RN, Mihm MC Jr. Melanocytic lesions associated with dermatofibromas: a spectrum of lesions ranging from junctional nevus to malignant melanoma in situ. Mod Pathol. Aug 2005;18(8):1043-7. [Medline].

  71. Kovach BT, Boyd AS. Melanoma associated with a dermatofibroma. J Cutan Pathol. May 2007;34(5):420-2. [Medline].

  72. Orrock JM, Abbott JJ, Gibson LE, Folpe AL. INI1 and GLUT-1 expression in epithelioid sarcoma and its cutaneous neoplastic and nonneoplastic mimics. Am J Dermatopathol. Apr 2009;31(2):152-6. [Medline].

  73. Weber PJ, Moody BR, Foster JA. Inverted pyramidal biopsy. Dermatol Surg. Jul 2001;27(7):681-4. [Medline].

  74. Krupa Shankar DS, Kushalappa AA, Suma KS, Pai SA. Multiple dermatofibromas on face treated with carbon dioxide laser. Indian J Dermatol Venereol Leprol. May-Jun 2007;73(3):194-5. [Medline].

  75. Alonso-Castro L, Boixeda P, Segura-Palacios JM, de Daniel-Rodríguez C, Jiménez-Gómez N, Ballester-Martínez A. Dermatofibromas treated with pulsed dye laser: Clinical and dermoscopic outcomes. J Cosmet Laser Ther. Apr 2012;14(2):98-101. [Medline].

  76. Fernandez-Flores A, Manjon JA. Mitosis in dermatofibroma: a worrisome histopathologic sign that does not necessarily equal recurrence. J Cutan Pathol. Sep 2008;35(9):839-42. [Medline].

  77. Troxel DB. An insurer's perspective on error and loss in pathology. Arch Pathol Lab Med. Oct 2005;129(10):1234-6. [Medline].

  78. Heenan PJ. Tumors of the fibrous tissue involving the skin. In: Elder D, ed. Lever's Histopathology of the Skin. 8th ed. Philadelphia, Pa: Lippincott-Raven; 1997:847-53.

  79. Sanchez RL. The elusive dermatofibromas. Arch Dermatol. Apr 1990;126(4):522-3. [Medline].

  80. Zelger B, Zelger BG, Burgdorf WH. Dermatofibroma-a critical evaluation. Int J Surg Pathol. Oct 2004;12(4):333-44. [Medline].

 
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Erythematous, slightly hyperpigmented nodule on the leg. Courtesy of David Barnette, MD.
Acanthotic epithelium with basilar hyperpigmentation (dirty feet) over a dermal spindle cell proliferation (X10). Courtesy of David Barnette, MD.
Collagen trapping by the dermal fibrohistiocytic infiltrate (X40). Courtesy of David Barnette, MD.
 
 
 
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