CT与MRI对良、恶性胸膜病变的鉴别诊断
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摘要
目的：探讨CT与MRI对良、恶性胸膜病变的鉴别诊断价值。
材料与方法：对56例胸膜病变患者进行了CT检查，其中29例同时行MRI检查，20例加做HR-MRI检查。比较分析CT与MRI、常规MRI与HR-MRI对良恶性胸膜病变的鉴别诊断价值。
结果：1、CT检查显示，环绕形胸膜增厚在MPM、MPD的发生率分别为56％、18％，两者之间有显著性差异(P＜0.05)。胸膜病变侵犯纵隔结构、膈肌、胸壁仅见于MPM与MPD。结节状胸膜增厚在MPM、MPD、BPD中的发生率无显著性差异(P＞0.05)。2、MRI检查显示，纵隔胸膜受累、环绕形或不规则胸膜增厚、弥漫性胸膜增厚及胸壁、膈肌受侵等征象在良、恶性胸膜病变的出现率有显著性差异(P＜0.05)；虽然HR-MRI对胸壁的解剖结构(尤其是早期胸壁浸润)的显示比常规MRI优越，但二者对本组良、恶性胸膜病变的鉴别诊断作用无显著性差异(P＞0.05)。3、结合病变形态学与信号特点，MRI对良恶性胸膜病变的鉴别诊断价值优于CT(P＜0.05)。
结论：1、环绕形胸膜增厚有助于鉴别MPM与MPD。胸膜病变侵犯纵隔结构、膈肌、胸壁有助于诊断恶性胸膜病变。2、将MRI形态学与信号特征相结合有助于良、恶性胸膜病变的鉴别诊断。3、与常规MRI相比，HR-MRI对胸壁解剖结构(尤其是早期胸壁浸润)的显示更优越。
Objective: To explore the role of CT and MRI in the differential diagnosis of benign and malignant pleural disease.
Material and Methods: Fifty-six cases of pleural disease were examined with CT, 29 cases of them were also examined with MRI and 20 cases were examined with high resolution MRI (HR-MRI) at the same time. In this thesis, the diagnostic value between CT and MRI, ordinary MRI and HR-MRI in the benign and malignant pleural disease were comparatively evaluated.
Results: 1 .Examined with CT, the incidence rate of circumferential pleural thickening in the MPM and MPD was56% and 18%, respectively. It revealed significant difference between MPM and MPD (P<0.05). Mediastinal structures involvement, infiltration of the chest wall and/or diaphragm were only observed in the MPM and MPD. The difference of incidence rate of nodular pleural thickening in MPM, MPD and BPD was not significant (P>0.05). 2.Examined with MRI, mediastinal pleural involvement, circumferential pleural thickening, irregularity of pleural contour, diffuse pleural thickening and infiltration of the chest wall and /or diaphragm were significant different between malignant and benign pleural disease (P<0.05). Compared with ordinary MRI, although the HR-MRI had the advantage on displaying the anatomic structure of the chest wall, especially the infiltration of the chest wall in the early stage, the diagnostic values of them on benign and malignant pleural disease were not of statistic significant differenc
e (P>0.05). 3.Using morphologic features in combination with signal intensity features, MR was more superior to CT in differentiation of malignant from benign pleural disease (P<0.05). Conclusion: 1.Examined with CT, circumferential pleural thickening was the most useful feature in distinguishing MPM from MPD. Mediastinal structures involvement, infiltration of the chest wall and/or diaphragm directly suggested malignancy. 2. Combining the morphologic features and signal features, MRI was more helpful for
differentiation of malignant from benign pleural disease. 3.Compared with ordinary MRI, HR-MRI had advantage on displaying the anatomic structure of chest wall, especially in the detection of malignant chest wall infiltration in the early stage.
材料与方法：对56例胸膜病变患者进行了CT检查，其中29例同时行MRI检查，20例加做HR-MRI检查。比较分析CT与MRI、常规MRI与HR-MRI对良恶性胸膜病变的鉴别诊断价值。
结果：1、CT检查显示，环绕形胸膜增厚在MPM、MPD的发生率分别为56％、18％，两者之间有显著性差异(P＜0.05)。胸膜病变侵犯纵隔结构、膈肌、胸壁仅见于MPM与MPD。结节状胸膜增厚在MPM、MPD、BPD中的发生率无显著性差异(P＞0.05)。2、MRI检查显示，纵隔胸膜受累、环绕形或不规则胸膜增厚、弥漫性胸膜增厚及胸壁、膈肌受侵等征象在良、恶性胸膜病变的出现率有显著性差异(P＜0.05)；虽然HR-MRI对胸壁的解剖结构(尤其是早期胸壁浸润)的显示比常规MRI优越，但二者对本组良、恶性胸膜病变的鉴别诊断作用无显著性差异(P＞0.05)。3、结合病变形态学与信号特点，MRI对良恶性胸膜病变的鉴别诊断价值优于CT(P＜0.05)。
结论：1、环绕形胸膜增厚有助于鉴别MPM与MPD。胸膜病变侵犯纵隔结构、膈肌、胸壁有助于诊断恶性胸膜病变。2、将MRI形态学与信号特征相结合有助于良、恶性胸膜病变的鉴别诊断。3、与常规MRI相比，HR-MRI对胸壁解剖结构(尤其是早期胸壁浸润)的显示更优越。
Objective: To explore the role of CT and MRI in the differential diagnosis of benign and malignant pleural disease.
Material and Methods: Fifty-six cases of pleural disease were examined with CT, 29 cases of them were also examined with MRI and 20 cases were examined with high resolution MRI (HR-MRI) at the same time. In this thesis, the diagnostic value between CT and MRI, ordinary MRI and HR-MRI in the benign and malignant pleural disease were comparatively evaluated.
Results: 1 .Examined with CT, the incidence rate of circumferential pleural thickening in the MPM and MPD was56% and 18%, respectively. It revealed significant difference between MPM and MPD (P<0.05). Mediastinal structures involvement, infiltration of the chest wall and/or diaphragm were only observed in the MPM and MPD. The difference of incidence rate of nodular pleural thickening in MPM, MPD and BPD was not significant (P>0.05). 2.Examined with MRI, mediastinal pleural involvement, circumferential pleural thickening, irregularity of pleural contour, diffuse pleural thickening and infiltration of the chest wall and /or diaphragm were significant different between malignant and benign pleural disease (P<0.05). Compared with ordinary MRI, although the HR-MRI had the advantage on displaying the anatomic structure of the chest wall, especially the infiltration of the chest wall in the early stage, the diagnostic values of them on benign and malignant pleural disease were not of statistic significant differenc
e (P>0.05). 3.Using morphologic features in combination with signal intensity features, MR was more superior to CT in differentiation of malignant from benign pleural disease (P<0.05). Conclusion: 1.Examined with CT, circumferential pleural thickening was the most useful feature in distinguishing MPM from MPD. Mediastinal structures involvement, infiltration of the chest wall and/or diaphragm directly suggested malignancy. 2. Combining the morphologic features and signal features, MRI was more helpful for
differentiation of malignant from benign pleural disease. 3.Compared with ordinary MRI, HR-MRI had advantage on displaying the anatomic structure of chest wall, especially in the detection of malignant chest wall infiltration in the early stage.
引文
1. Mattison LE, Coppage L, Alderman DF. Pleural effusion in the medical ICU: prevalence, causes, and clinical implication. Chest, 1997, 111(3): 1018-1023
2. Mueller NL. Imaging of the pleura. Radiology, 1993, 186: 297-309.
3. Mcloud TC, Flower R. Imaging the pleura: Sonography, CT, and MR Imaging. AJR, 1991, 156(6): 1145-1153
4. Mcloud TC. CT and MR in pleural disease. Clinics in chest medicine, 1998, 19(2): 261-276
5. Murray JF, Nadel JA. Textbook of respiratory medicine. 2nd ed. Philadelphia: Saundes, 1994. 2145-2163
6. Miserocchi G. Physiology and pathophysiology of pleural fluid turnover. Eur Respir J, 1997, 10(1): 219-225
7. Hamm H, Ligt RW. The pleura: the outer space of pulmonary medicine. Eur Respir J, 1997, 10(1): 2-3
8. Corrin B, Addis BJ. Histopathology of the pleura. Respiration, 1990, 57(3): 160-175
9．俞森洋．胸膜和胸膜腔的解剖和生理功能的研究．中华结核和呼吸杂志，2001，24(1)：13-15
10. Hammerman AM, Susman N, Stuzembosz A, Kaiser LR. The Extrapleural fat sign: CT Characteristics. J Comput Assist Tomogr, 1990, 14(3): 345-347.
11. Aquino AL, Chiles C, Oaks T. Displaced extrapleural fat as revealed by CT scanning: evidence of extrapleural hematoma. AJR, 1997, 169(3): 687-689.
12. Leung AN, Mueller NL, Miller RR. CT in differential diagnosis of diffuse pleural disease. AJR, 1990, 154(3): 487-492
13. Jimenez JA, Charterina SA, Paya JS, Latorre FF, Sanchez SG, Llorens ML. Evaluation of CT findings for diagnosis of pleural effusions. Eur Radiol. 2000, 10(4): 681-690
14. Aquino SL, Webb WR, Gushiken BJ. Pleural exudates and transudates: diagnosis with contrast-enhanced CT. Radiology, 1994, 192(3): 803-808
15．肖国文，李铁一．胸腔积液时胸膜增厚的CT鉴别诊断．中华放射学杂志，1996，30(12)：842-845
16. Scott EM, Marshall TJ, Flower DR, Stewart S. Diffuse Pleural Thickening: Percutaneous CT-Guided Cutting Needle Biopsy. Radiology, 1995, 194(3): 867-870
17．李一鸣，祁吉．胸膜和胸膜外脂肪的CT及MR成像进展．国外医学临床放射学分册，2002，25(2)：79-82
18. Bittner RC, Felix R. Magnetic Resonance (MR) imaging of the chest: State of the art. Eur Respir J, 1998, 11(6): 1392-1404
19. Davis SD, Henshcke CI, Yankelvitz DF, Cahill PT, Yi Y. MR imaging of pleural effusions. J Comput Assist Tomogr, 1990, 14(2): 192-198.
20．惠志强，姚安晋．胸膜疾病的影像学诊断．实用放射学杂志，1998，14(7)：428-430
21. Hierholzer J, Luo LP, Roland C, Bittner, Christian S, Ralf-Jurgen S, Nicolas S, Peter D, Robert L, Anne G. MRI and CT in the differential diagnosis of pleural disease. Chest, 2000, 118(3): 604-609
22. Falaschi F, Battdla L, Mascalchi M, Cioni R, Zampa V, Lencioni R, Antonelli A, Carlo B. Usefulness of MR signal intensity in distinguishing benign from malignant pleural disease. AJR, 1996(4), 166: 963-968
23．罗良平，陈金城，朱彬，夏建东．MRI在良、恶性胸膜肿瘤鉴别诊断中的价值中华放射学杂志，2001，35：659-662
24. Padovani B, Mouroux J, Seksik L, Chanalet S, Sedat J, Rotomondo C, Richelme H, Serres JJ. Chest wall invasion by bronchogenic carcinoma: evaluation with MR imaging. Radiology, 1993, 187(1): 33-38
25. Boraschi P, Neri S, Braccinig, Gigoni R, Leoncini B, Girseppe P. Magnetic resonance appearance of asbesto-related benign and malignant pleural disease. Scand J work Environ Health, 1999, 25(1): 18-23
26. Carlsen SE, Bergin CJ, Hoppe RT. MR imaging to detect chest wall and pleural involvement in patients with lymphoma: effect on radiation therapy planning. AJR, 1993, 160(6): 1191-1195
27．赵伟峰，潘纪戌，刘甫庚．胸膜外脂肪增厚在诊断中的意义．中华放射学杂志，1999，33(1)：51-53
28．高元桂，蔡幼铨，蔡祖龙主编．磁共振成像诊断学．人民军医出版社．2002第一版：49
29．韩艺东，李茂进，林怡蔼，郭玉鑫，章志霖．磁共振信号强度在胸膜疾病中的诊断意义．实用放射学杂志，2000，16(5)：285-288
30. Aberle DR. High resolution computed tomography of asbestos-related diseases. Seminars inn roentgenology, 1991, 26(4): 118-131
31. Patz EF, Shaffer K, Worms DR, Jochelson M, Sarin M, Sugarbaker DJ, Pugatch, RD. Malignant pleural mesothelioma: Value of CT and MR Imaging in predicting resectability. AJR, 1992, 159(5): 961-966
32. Sahin AA, Coplu L, Selcuk ZT, Eryilmaz M, Emri S, Akhan O, Bahs YL. Malignant pleural mesothelioma caused by environmental exposure to asbestos or erionite in rural turkey: CT findings in 84 patients. AJR, 1993, 161(3): 533-537
33. Moskal tl, urschel jd, anderson tm, antkowiak JG, Takita H. Malignant pleural mesothelioma: a problematic review. Surgical Oncology, 1999, 7: 5-12
34. Bonomo L, Feragallli B, Sacco R, Merlino B, Storto ML. Malignant pleural disease. AJR, 2000, 34(2): 98-118
35．肖国文，董世禄，李建文．恶性胸膜间皮瘤的CT诊断．中国医学影像技术，2000，16(5)：371-373
36. Knuuttila A, Kivisaari L, Kibisaari A, Palomaki A, Tervahartiala P, Mattson K. Evaluation of pleural disease using MR and CT. With special reference to malignant pleural mesothelioma. Acta Radiol, 2001, 42(5): 502-7
37. Muzaffer M, Irfan U, Osman E, Sinan E, Selma M, Mustafa K, Emel H, Fusun A, Gunnar H, Ragip O, Tamer K. Computed tomography features in malignant pleural mesothelioma and other commonly seen pleural diseases. EJR, 2002, 41(1): 1-9
38．甘新莲，肖永胜，周燕发．胸膜原发性肿瘤的影像学诊断(附26例分析)．放射学实践．2002，17(1)：5-7
39. Heelan RT, Rusch VW, Begg CB, Panicek DM, Caravelli JF, Eisen C. Staging of malignant pleural mesothelioma: Comparison of CT and MR imaging. AJR, 1999,
172(4): 1039-1047
40. Scott IR, Mueller NL, Miller RR. Resectable stage Ⅲ lung cancer: CT surgical, and pathologic correlation. Radiology, 1988, 166(1): 75-79
41. Zoe CT, Robert JO, Davies, Fergus VG. Thoracic computed tomography in patients with suspected Malignant Pleural Effusions. Clin Radiol, 2001, 56(3): 193-196
42. Gallardo X, Castaner E, Mata JM. Benign pleural disease. EJR, 2000, 34: 87-97
43. Ferretti GR, Chilles C, Choplin RG, Corlomb M. Localized benign fibrous tumors of the pleura. AJR, 1997, 169(3): 683-686
44. Staples CA. Computed tomography in the evaluation of benign asbestos-related disorders. Radiol Clin North Am, 1992, 30(6): 1191-1207
45. Lee KS, Gilm J, Choe KO, Kim CJ, Lee BH. CT findings in benign fibrous mesothelioma of the pleura: Pathologic correlation in nine patients. AJR, 1992, 158(5): 983-986
46. Sherakawa T, Fukuda K, Miyamoto Y, Tanabe H, Tada S. Parietal pleural invasion of lung mass: Evaluation with CT performed during deep inspiration and expiration. Radiology, 1994, 192(3): 809-811
47．夏兆云，施丁一，曹士兵．胸膜转移瘤CT分析(附87例报告)．中国医学影像技术，1999，15(12)：957-958
48. Muzaffer M, Necla O,Serap I. CT-Guided pleural needle biopsy in the diagnosis of malignant mesothelima. J Comput Assist Tomogr, 1995, 19(3): 370-374
49. Luo LP, Hierholzer J, Bittner RC, Chen JC, Huang L. Magnetic resonance imaging in distinguishing malignant from benign disease. Chinese Medical Journal, 2001, 114(6): 645-649.
50. Lorigan JG, Libshitz HI. MR imaging of malignant pleural mesothelioma. J Comput Assist Tomogr, 1989, 13(4): 617-619
51．杭俊德，陈培青，陈丽英，陈炽贤．恶性胸膜间皮瘤的MRI评价．临床放射学杂志．1995，14(3)：148-150
52．罗良平，陈金城，陈棣华．MR信号强度在良、恶性胸膜病变鉴别诊断中的作用．中国医学影像技术，2001，17(6)：539-541
53. Mouroux PI, Raffaelli C, Chanalet HS, Michiels JF, Brunner P, Bruneton JN.
Benign fibrous mesothelioma of the pleura: MR study and pathologic correlation. Eur Radiol, 1996, 6(4): 425: 428
54. Ferretti GR, Chiles C, Cox JE, Choplin RH, Coulomb M. Localized Benign Fibrous Tumors of the Pleura: MR Appearance. J Comput Assist Tomogr, 1997, 21(1): 115-120
55. Harris GN, Rozenshtein A, Schiff MJ. Benign fibrous mesothelioma of the pleural: MR imaging findings. AJR, 1995, 165(5): 1143-1144
56. Askai SJ, Murayama S, Murakami J, Hashiguchi N, Masuda K. Bronchogenic Carcinoma Invasion of the Chest Wall: Evaluation with Dynamic Cine MRI During Breathing. J Comput Assist Tomogr, 1997, 21(4): 595-600
57．高元桂，蔡幼铨，蔡祖龙主编．磁共振成像诊断学．人民军医出版社．2002第一版：403
2. Mueller NL. Imaging of the pleura. Radiology, 1993, 186: 297-309.
3. Mcloud TC, Flower R. Imaging the pleura: Sonography, CT, and MR Imaging. AJR, 1991, 156(6): 1145-1153
4. Mcloud TC. CT and MR in pleural disease. Clinics in chest medicine, 1998, 19(2): 261-276
5. Murray JF, Nadel JA. Textbook of respiratory medicine. 2nd ed. Philadelphia: Saundes, 1994. 2145-2163
6. Miserocchi G. Physiology and pathophysiology of pleural fluid turnover. Eur Respir J, 1997, 10(1): 219-225
7. Hamm H, Ligt RW. The pleura: the outer space of pulmonary medicine. Eur Respir J, 1997, 10(1): 2-3
8. Corrin B, Addis BJ. Histopathology of the pleura. Respiration, 1990, 57(3): 160-175
9．俞森洋．胸膜和胸膜腔的解剖和生理功能的研究．中华结核和呼吸杂志，2001，24(1)：13-15
10. Hammerman AM, Susman N, Stuzembosz A, Kaiser LR. The Extrapleural fat sign: CT Characteristics. J Comput Assist Tomogr, 1990, 14(3): 345-347.
11. Aquino AL, Chiles C, Oaks T. Displaced extrapleural fat as revealed by CT scanning: evidence of extrapleural hematoma. AJR, 1997, 169(3): 687-689.
12. Leung AN, Mueller NL, Miller RR. CT in differential diagnosis of diffuse pleural disease. AJR, 1990, 154(3): 487-492
13. Jimenez JA, Charterina SA, Paya JS, Latorre FF, Sanchez SG, Llorens ML. Evaluation of CT findings for diagnosis of pleural effusions. Eur Radiol. 2000, 10(4): 681-690
14. Aquino SL, Webb WR, Gushiken BJ. Pleural exudates and transudates: diagnosis with contrast-enhanced CT. Radiology, 1994, 192(3): 803-808
15．肖国文，李铁一．胸腔积液时胸膜增厚的CT鉴别诊断．中华放射学杂志，1996，30(12)：842-845
16. Scott EM, Marshall TJ, Flower DR, Stewart S. Diffuse Pleural Thickening: Percutaneous CT-Guided Cutting Needle Biopsy. Radiology, 1995, 194(3): 867-870
17．李一鸣，祁吉．胸膜和胸膜外脂肪的CT及MR成像进展．国外医学临床放射学分册，2002，25(2)：79-82
18. Bittner RC, Felix R. Magnetic Resonance (MR) imaging of the chest: State of the art. Eur Respir J, 1998, 11(6): 1392-1404
19. Davis SD, Henshcke CI, Yankelvitz DF, Cahill PT, Yi Y. MR imaging of pleural effusions. J Comput Assist Tomogr, 1990, 14(2): 192-198.
20．惠志强，姚安晋．胸膜疾病的影像学诊断．实用放射学杂志，1998，14(7)：428-430
21. Hierholzer J, Luo LP, Roland C, Bittner, Christian S, Ralf-Jurgen S, Nicolas S, Peter D, Robert L, Anne G. MRI and CT in the differential diagnosis of pleural disease. Chest, 2000, 118(3): 604-609
22. Falaschi F, Battdla L, Mascalchi M, Cioni R, Zampa V, Lencioni R, Antonelli A, Carlo B. Usefulness of MR signal intensity in distinguishing benign from malignant pleural disease. AJR, 1996(4), 166: 963-968
23．罗良平，陈金城，朱彬，夏建东．MRI在良、恶性胸膜肿瘤鉴别诊断中的价值中华放射学杂志，2001，35：659-662
24. Padovani B, Mouroux J, Seksik L, Chanalet S, Sedat J, Rotomondo C, Richelme H, Serres JJ. Chest wall invasion by bronchogenic carcinoma: evaluation with MR imaging. Radiology, 1993, 187(1): 33-38
25. Boraschi P, Neri S, Braccinig, Gigoni R, Leoncini B, Girseppe P. Magnetic resonance appearance of asbesto-related benign and malignant pleural disease. Scand J work Environ Health, 1999, 25(1): 18-23
26. Carlsen SE, Bergin CJ, Hoppe RT. MR imaging to detect chest wall and pleural involvement in patients with lymphoma: effect on radiation therapy planning. AJR, 1993, 160(6): 1191-1195
27．赵伟峰，潘纪戌，刘甫庚．胸膜外脂肪增厚在诊断中的意义．中华放射学杂志，1999，33(1)：51-53
28．高元桂，蔡幼铨，蔡祖龙主编．磁共振成像诊断学．人民军医出版社．2002第一版：49
29．韩艺东，李茂进，林怡蔼，郭玉鑫，章志霖．磁共振信号强度在胸膜疾病中的诊断意义．实用放射学杂志，2000，16(5)：285-288
30. Aberle DR. High resolution computed tomography of asbestos-related diseases. Seminars inn roentgenology, 1991, 26(4): 118-131
31. Patz EF, Shaffer K, Worms DR, Jochelson M, Sarin M, Sugarbaker DJ, Pugatch, RD. Malignant pleural mesothelioma: Value of CT and MR Imaging in predicting resectability. AJR, 1992, 159(5): 961-966
32. Sahin AA, Coplu L, Selcuk ZT, Eryilmaz M, Emri S, Akhan O, Bahs YL. Malignant pleural mesothelioma caused by environmental exposure to asbestos or erionite in rural turkey: CT findings in 84 patients. AJR, 1993, 161(3): 533-537
33. Moskal tl, urschel jd, anderson tm, antkowiak JG, Takita H. Malignant pleural mesothelioma: a problematic review. Surgical Oncology, 1999, 7: 5-12
34. Bonomo L, Feragallli B, Sacco R, Merlino B, Storto ML. Malignant pleural disease. AJR, 2000, 34(2): 98-118
35．肖国文，董世禄，李建文．恶性胸膜间皮瘤的CT诊断．中国医学影像技术，2000，16(5)：371-373
36. Knuuttila A, Kivisaari L, Kibisaari A, Palomaki A, Tervahartiala P, Mattson K. Evaluation of pleural disease using MR and CT. With special reference to malignant pleural mesothelioma. Acta Radiol, 2001, 42(5): 502-7
37. Muzaffer M, Irfan U, Osman E, Sinan E, Selma M, Mustafa K, Emel H, Fusun A, Gunnar H, Ragip O, Tamer K. Computed tomography features in malignant pleural mesothelioma and other commonly seen pleural diseases. EJR, 2002, 41(1): 1-9
38．甘新莲，肖永胜，周燕发．胸膜原发性肿瘤的影像学诊断(附26例分析)．放射学实践．2002，17(1)：5-7
39. Heelan RT, Rusch VW, Begg CB, Panicek DM, Caravelli JF, Eisen C. Staging of malignant pleural mesothelioma: Comparison of CT and MR imaging. AJR, 1999,
172(4): 1039-1047
40. Scott IR, Mueller NL, Miller RR. Resectable stage Ⅲ lung cancer: CT surgical, and pathologic correlation. Radiology, 1988, 166(1): 75-79
41. Zoe CT, Robert JO, Davies, Fergus VG. Thoracic computed tomography in patients with suspected Malignant Pleural Effusions. Clin Radiol, 2001, 56(3): 193-196
42. Gallardo X, Castaner E, Mata JM. Benign pleural disease. EJR, 2000, 34: 87-97
43. Ferretti GR, Chilles C, Choplin RG, Corlomb M. Localized benign fibrous tumors of the pleura. AJR, 1997, 169(3): 683-686
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