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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 12  |  Issue : 1  |  Page : 1-9

Dosimetric comparison of two type's applicator geometry in the three-dimensional computed tomography image-based intracavitary brachytherapy treatment planning of carcinoma uterine cervix


1 Department of Radiation Oncology, Gandhi Medical College, Bhopal, Madhya Pradesh, India
2 Department of Ratiotherapy, Gajra Raja Medical College, Gwalior, Madhya Pradesh, India
3 Department of Radiotherapy, Indraprastha Apollo Hospitals, New Delhi, India
4 Department of Ratiotherapy, Chirayu Medical College, Bhopal, Madhya Pradesh, India
5 Department of Physics, Government Degree College, Karera, Shivpuri, Madhya Pradesh, India

Date of Submission17-Dec-2020
Date of Acceptance12-Jan-2021
Date of Web Publication12-Feb-2021

Correspondence Address:
Dr. Suresh Yadav
Department of Radiation Oncology, Gandhi Medical College, Bhopal, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jrcr.jrcr_71_20

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  Abstract 


Background: The swift dose fall-off traits with distance from the applicators are the dominant advantage of brachytherapy. The differences in applicator designs will produce different dose distributions in intracavitary brachytherapy (ICBT) applications. Aim: The present study was aimed to find out the dosimetric differences for two type's applicators geometry in ICBT applications for carcinoma uterine cervix (Ca-Cx) performing three-dimensional computed tomography (3D-CT) image-based planning as per recent guidelines from the International Commission on Radiation Units and Measurements report-89. Materials and Methods: Retrospectively, 15 patients of Ca-Cx who have received ICBT treatment based on the 3D-CT image during 1st and 2nd fractions using fixed-geometry and flexible-geometry applicators respectively were selected for this study. For comparison of two type's applicators geometry the dose-volume parameters D100% and D90% of high-risk clinical target volume (HR-CTV), V400%, V200%, V150%, V100%, V50% (volume enclosing 400%, 200%, 150%, 100%, and 50% isodoseline of prescribed dose around target, respectively), and average point “A” dose were evaluated for target. While for organs at risk (bladder, rectum, and sigmoid colon) the dose-volume parameters D2cc, D1cc, and D0.1cc were recorded and evaluated. Results: Fixed-geometry applicator produces significantly lesser HR-CTV volume (P = 0.016 <0.05) but delivered significantly 10.88% higher D90 mean doses (P = 0.031 <0.05) in comparison to flexible-geometry applicator. The flexible-geometry applicator created significantly higher central dose-volume structures around the target at the cost of significantly 15.89%, 17.04%, and 18.88% higher mean doses for rectum D2cc, D1cc, and D0.1cc, respectively, insignificant higher bladder dose, but lower sigmoid colon doses. Conclusion: The results of this study will be helpful to clinicians to select appropriate/suitable geometry applicator according to the patient's anatomical structure in brachytherapy treatment of Ca-Cx for better clinical outcome.

Keywords: Carcinoma uterine cervix, computed tomography, dosimetric comparison, fletcher-style applicator, intracavitary brachytherapy


How to cite this article:
Yogi V, Chandel SS, Yadav S, Singh OP, Goswami B, Ghosh G, Choudhary S. Dosimetric comparison of two type's applicator geometry in the three-dimensional computed tomography image-based intracavitary brachytherapy treatment planning of carcinoma uterine cervix. J Radiat Cancer Res 2021;12:1-9

How to cite this URL:
Yogi V, Chandel SS, Yadav S, Singh OP, Goswami B, Ghosh G, Choudhary S. Dosimetric comparison of two type's applicator geometry in the three-dimensional computed tomography image-based intracavitary brachytherapy treatment planning of carcinoma uterine cervix. J Radiat Cancer Res [serial online] 2021 [cited 2021 Jun 25];12:1-9. Available from: https://www.journalrcr.org/text.asp?2021/12/1/1/309344




  Introduction Top


Carcinoma cervix is the second most prevalent malignancy of the female genital organ, comprising nearly 17% of the incidence of cancer globally and 8.4% of the total incidence of cancer in India.[1] In many low- and middle-income countries (LMICs), mostly carcinoma of the uterine cervix (Ca-Cx) is diagnosed in an advanced stage, where resources are limited or unavailable for diagnosis, prevention, and treatment.[2] High-dose-rate (HDR) intracavitary brachytherapy (ICBT) either solo or along with external beam radiotherapy (EBRT) has become an establish and definitive treatment for Ca-Cx. The considerable benefit of HDR ICBT is that it gives a high localized dose to the tumor with a swift dose fall-off outside the tumor boundaries to spare the neighboring organs at risk (OARs) to large extent.

At the beginning of brachytherapy, preloaded applicators such as Manchester style which consist of rubber tandems and two vaginal ovoids, independent of each other, were used for ICBT applications. Thereafter, manual afterloading was developed and subsequently, it was replaced by remote afterloading HDR applicators for ICBT applications. For ICBT of Ca-Cx and other interstitial applications, the afterloading applicators have described by Henschke et al. in the 1960s.[3],[4] The modifications in the applicator's design were carried out by the brachytherapy equipment manufacturer depending on the user's feedback based on clinical experiences. The swift dose fall-off traits with distance from applicators are the dominant advantage and dominant disadvantage of brachytherapy. The differences in applicator designs will produce different dose distributions in ICBT applications.

There have few dosimetric studies for comparison of two type's applicators geometry in HDR ICBT of Ca-Cx based on orthogonal image-based planning following International Commission on Radiation Units and Measurements report 38 (ICRU-38) recommendations.[5] They reported differences in point doses for target and OARs namely bladder and rectum. Yet, it has been reported by many studies that the point doses may not reflect the true doses received by the volumes of target and OARs.[6],[7],[8],[9],[10] Due to inaccurate knowledge of OARs doses, the treatment-related side effects/toxicities cannot be correlated with estimated point doses.[11] Currently available advanced guidelines the Groupe Europeen de Curietherapie-European Society for Therapeutic Radiology and Oncology (GEC-ESTRO)[12],[13] and ICRU-89[14] has firmly recommended individualized volumetric image-based brachytherapy treatment planning for each fraction. However, with advancements in imaging technology and computerized treatment planning systems (TPS) many radiotherapy centers especially in LMICs are still forced to adopt either traditional standard library planning or two-dimensional (2D) orthogonal image-based planning for brachytherapy treatment. Yadav et al. study reported that the target and OARs (bladder and rectum) doses were increases in ICBT of Ca-Cx when using standard library plan approach in comparison to three-dimensional computed tomography (3D-CT) image-based planning.[15] It has been established by some studies that 3D-CT image may be the moderate option of imaging modalities for volumetric image-based ICBT of Ca-Cx for radiotherapy centers working with limited resources for better clinical outcomes.[16] It has been reported that radiotherapy centers practicing brachytherapy with limited resources may use the first fraction treatment plan based on the 3D-CT image dataset for treatment of successive fractions by careful applicator insertions, proper packing, and treatment planning using Fletcher-style tandem and ovoid (T and O) flexible-geometry applicator.[17]

The present study was aimed to find out the dosimetric differences for two type's applicators geometry in ICBT applications for Ca-Cx performing 3D-CT image-based planning as per recent ICRU-89 guidelines.


  Materials and Methods Top


Fifteen patients of Ca-Cx who have already received ICBT were selected for this retrospective dosimetric study. The patients' age distribution (mean ± standard deviation [SD]) was 48.40 ± 7.81, and their International Federation of Gynecology and Obstetrics disease stage range was IIB-IVA. The EBRT dose of 46–50 Gy (2 Gy/fraction for 23–25 fractions over 5 weeks) was received by all patients either on telecobalt or on 6/15 MV linear accelerator unit using either two parallel opposed anterior-posterior fields or four-field box technique before initiating ICBT. After completion of EBRT, all patients were planned for ICBT to deliver 21 Gy dose (7 Gy/fraction for 3 fractions over 3 weeks) using iridium-192 (Ir192) HDR radioactive source on Varian GammaMed Plus HDR brachytherapy unit (Varian Medical Systems, Inc. Palo Alto CA 9430 USA). The 1st and 2nd fractions of brachytherapy treatments were performed using Fletcher-style T and O applicator sets of defined (fixed-geometry) (Part no. GM11000810) and flexible-geometry (Part no. GM11000730) for each patient, respectively. For third fractions, either the first fraction plan (using fixed-geometry applicator) or second fraction plan (using flexible-geometry applicator) were used for brachytherapy treatment dose delivery. The applicator insertions were performed under general anesthesia taking care of all aseptic precautions. For immobilization and to prevent slippage of applicator geometry, adequate vaginal packing was done using Betadine soaked gauge pieces. Foley's catheter was inserted into the urinary bladder of all patients and the balloon was inflated with 7.0 cc of radio-opaque solution. Post insertion of applicators patients was shifted into simulator room for acquiring 3D axial images from umbilicus to mid-thigh with 2.5 mm slice thickness using CT simulator (WIPRO GE Discovery CT). The 3D axial images were imported into TPS Brachy Vision vs. 8.9 (Varian Medical Systems, Palo Alto, CA, USA) using DVD/CD.

The OARs (bladder, rectum, and sigmoid colon) were contoured following the American Brachytherapy Society (ABS)[18],[19] and GEC-ESTRO[12],[13] guidelines. Viswanathan et al.[20] contouring guidelines were adopted for the contouring of target (high-risk clinical target volume [HR-CTV]) on 3D-CT axial images. To eliminate the inter-personal variations, all the brachytherapy treatment planning was done by a single medical physicist and all applicator insertions and contouring was done by a single radiation oncologist.

The ICBT treatment plans based on the 3D-CT image for fixed-geometry and flexible-geometry applicators were created as per the ABS[18],[19] and Indian brachytherapy Society[21] guidelines, and the dose of 7 Gy was prescribed to mean of point “A.” The plans were optimized for both the applicators in such a way that physical dose/fraction was kept ≤5.12 Gy for rectum and sigmoid colon and ≤7.12 for bladder so that combined EQD2 (equivalent dose in 2 Gy/fraction) doses from EBRT and ICBT was kept ≤75 Gy for rectum and sigmoid colon and ≤95 Gy for the bladder. The source loading patterns and source step size of 5 mm were kept similar in both types of applicator based planning.

For comparison of two applicators based ICBT plans, the different dose-volume parameters for target and OARs were evaluated using cumulative dose-volume histograms (cDVH) as per recent ICRU-89 guidelines. The dose-volume parameters D100% and D90% (minimum dose received to 100% and 90% volume of HR-CTV), V400%, V200%, V150%, V100%, V50% (volume enclosing 400%, 200%, 150%, 100%, and 50% isodoseline of prescribed dose around target, respectively), and average point “A” dose were recorded and evaluated for target (HR-CTV). The dose-volume parameters D2cc, D1cc, and D0.1cc (the maximum dose received by minimum volume of 2 cc, 1 cc, and 0.1 cc respectively) were recorded and evaluated for OARs (bladder, rectum, and sigmoid colon).

Statistical analysis

For statistical analysis, Statistical Software Package for Social Sciences (SPSS) versus 20 (IBM Corporation, New York, USA) was used. The descriptive analysis was carried out to determine the mean ± SD values for different dosimetric parameters of target and OARs. A paired two-tailed t-test was accomplished to appraise the statistical significance of dosimetric differences between two types of applicator based plans. For the level of statistical significance, the value of P < 0.05 was considered.


  Results Top


The organ volume of the target (HR-CTV) and OARs (bladder, rectum, and sigmoid colon) for ICBT treatment plans generated using fixed-geometry and flexible-geometry applicators are compiled in Table 1. The organ volumes were expressed as mean ± SD in a cubic centimeter (cc). For HR-CTV, the mean volume was 22.96% higher in flexible-geometry applicator-based plans than fixed-geometry applicator-based plans, and differences were found statically significant (P = 0.016 <0.05). For bladder, the mean volume was reported 1.07% higher in fixed-geometry applicator based plans in comparison to flexible-geometry applicator-based plans, and differences were found highly statistically insignificant (P = 0.938 >0.05). For rectum, the mean volume was reported 7.99% higher in flexible-geometry applicator based plans as compared to fixed-geometry applicator based plans, and differences were found statistically insignificant (P = 0.077 >0.05). For the sigmoid colon, the mean volume was 13.26% higher in flexible-geometry applicator-based plans than with fixed-geometry applicator-based plans but the differences were found statically insignificant (P = 0.125 > 0.05).

The dosimetric parameters D90, D100, average point “A” dose, V400%, V200%, V150%, V100%, and V50% of HR-CTV for treatment plans generated with fixed-geometry and flexible-geometry applicators are compiled in Table 2. The dose to HR-CTV for D90 and D100 parameters was expressed as mean ± SD in percentage (%) and the dose to average point “A” was expressed as mean ± SD in Gy. The values for V400%, V200%, V150%, V100%, and V50% parameters were expressed as mean ± SD in cc. For HR-CTV D90, the mean dose was reported significantly higher (10.88%) in fixed-geometry applicator based plans than with flexible-geometry applicator based plans, and differences were found statistically significant (P = 0.031 < 0.05). For HR-CTV D100, the mean dose was reported 11.93% higher in fixed-geometry applicator based plans than with flexible-geometry applicator-based plans but the differences were found statistically insignificant (P = 0.062 > 0.05). For average point “A,” the mean dose was found lower (0.74%) in fixed-geometry applicator-based plans than flexible-geometry applicator-based plans, and the differences were statistically insignificant (P = 0.517 > 0.05).

For V400%, the mean volume was found 11.21% higher in flexible-geometry applicator-based plans in comparison to fixed-geometry applicator-based plans, and differences were found statistically significant (P = 0.000 < 0.05). For V200%, the mean volume was reported 8.35% higher in flexible-geometry applicator based plans than fixed-geometry applicator-based plans, and differences were found statistically significant (P = 0.001 < 0.05). For V150%, the mean volume was reported 8.10% higher in flexible-geometry applicator based plans in comparison to fixed-geometry applicator based plans, and differences were found statistically significant (P = 0.000 < 0.05). For V100%, the mean volume was found higher (7.65%) in flexible-geometry applicator based plans in comparison to fixed-geometry applicator-based plans, and differences were found statistically significant (P = 0.001 < 0.05). For V50%, the mean volume was reported 7.14% higher in flexible-geometry applicator-based plans than fixed-geometry applicator-based plans, and differences were also found statistically significant (P = 0.002 < 0.05).

The dose-volume parameters D2cc, D1cc, and D0.1cc of OARs (bladder, rectum, and sigmoid colon) for treatment plans generated with fixed-geometry and flexible-geometry applicators are compiled in Table 3. The doses to OARs for these parameters were expressed as mean ± SD in Gy. The mean dose value for bladder D2cc was found 4.41 ± 1.17 Gy and 4.71 ± 1.04 Gy in fixed-geometry and flexible-geometry applicator-based plans, respectively. The mean dose value for bladder D1cc was found 4.90 ± 1.37 Gy and 5.24 ± 1.16 Gy in fixed-geometry and flexible-geometry applicator based plans, respectively. The mean dose value for bladder D0.1cc was found 6.03 ± 1.94 Gy and 6.57 ± 1.61 Gy in fixed-geometry and flexible-geometry applicator based plans, respectively. The mean differences for none of the bladder dose-volume parameters (D2cc, D1cc, and D0.1cc) were found statistically significant [Table 3].

For rectum, the D2cc mean dose was found 15.89% higher in flexible-geometry applicator-based plans than with fixed-geometry applicator-based plans, and differences were found statically significant (P = 0.013 < 0.05). For rectum, the D1cc mean dose was found 17.04% higher in flexible-geometry applicator based plans than with fixed-geometry applicator-based plans, and differences were found statically significant (P = 0.015 < 0.05). For rectum, the D0.1cc mean dose was found 18.88% higher in flexible-geometry applicator based plans than with fixed-geometry applicator based plans, and differences were found statically significant (P = 0.017 < 0.05).

For sigmoid colon, the D2cc mean dose was found 4.41% higher in fixed-geometry applicator based plans than flexible-geometry applicator based plans but the differences were found statistically insignificant (P = 0.102 > 0.05). For sigmoid colon D1cc, the mean dose was found 6.39% higher in fixed-geometry applicator-based plans than flexible-geometry applicator based plans, and the differences were found statistically significant (P = 0.027 < 0.05). For sigmoid colon D0.1cc, the mean dose was found 10.68% higher in fixed-geometry applicator-based plans than flexible-geometry applicator-based plans but the differences were found statistically insignificant (P = 0.051 > 0.05).


  Discussion Top


It is well known that brachytherapy follows the inverse square rule in dose distribution and it is the utmost preeminent physical effect. Hence, the different applicators geometry will deposit radiation dose differently in ICBT applications for Ca-Cx. In this study, two types of applicator geometry namely fixed and flexible of the GammaMed Fletcher-style applicator set was used and both these applicators geometry depend on the dosimetry of conventional Fletcher-style applicator. Figure 1 illustrates the applications of fixed-geometry and flexible-geometry applicators in HDR ICBT treatments of a reference patient during 1st and 2nd fractions respectively. Nonetheless, the analogous positions of tandem with respect to ovoids are distinct in both fixed-geometry and flexible-geometry applicators as shown in Figure 1. The applicators orientation concerning the target (HR-CTV), OARs (bladder, rectum, and sigmoid colon), and 100% isodoseline are shown in Figure 2a and b for fixed-geometry and flexible-geometry applicators, respectively. The results of our study demonstrated that the flexible-geometry applicator produces significantly higher structure volume for the target (HR-CTV) as compared to the fixed-geometry applicator [Table 1]. We observed that the HR-CTV D90 mean dose was significantly higher in fixed-geometry applicator based plan in comparison to flexible-geometry applicator based plan and in 13 patients out of 15 patients, it was higher as shown in Figure 3a. While, the HR-CTV D100 was also higher in fixed-geometry applicator based plans as compared to flexible-geometry applicator-based plan but differences were statically insignificant and in 12 patients out of 15 patients it was higher as shown in Figure 3b. Dimopoulos et al.'s[22] study examined the value of DVH parameters for forecasting the local control in image-guided brachytherapy treatment (IGBT) of cervical cancer patients and they reported that the dose-volume parameters D90 and D100 conveyed the increase in local control with dose delivered to HR-CTV.

Regarding volumetric dose parameters V400%, V200%, V150%, V100%, and V50% our study also demonstrated that flexible-geometry applicator produces significantly higher dose volume structure around the target in comparison to fixed-geometry applicator [Table 2]. Figure 4 illustrates the variations in volumetric dose parameters V400%, V200%, V150%, V100%, and V50% of individualized patents for two type's applicators geometry. Hence, the higher dose-volume structures produced by flexible-geometry applicator around target may be helpful to deliver sufficient higher dose to parametrium for those patients which have large parametrial involvement.

In our study, a flexible-geometry applicator produces a lesser mean volume for the bladder in comparison to a fixed-geometry applicator [Table 1]. It was noticed that lesser mean volume structure of the bladder receiving higher dose in flexible-geometry applicator based plans. For all the dose-volume parameters D2cc, D1cc, and D0.1cc of bladder mean dose were found higher when flexible-geometry applicator was used compared to fixed-geometry applicator but the differences were statistically not significant [Table 3]. While our study demonstrated that a flexible-geometry applicator produces a higher mean volume for rectum in comparison to a fixed-geometry applicator [Table 1]. For rectum mean dose, all dose-volume parameters D2cc, D1cc, and D0.1cc was reported significantly higher in flexible-geometry applicator based plans than with fixed-geometry applicator based plans [Table 3]. Figure 5 illustrates the percentage dose difference between two type's applicators based plans of individualized patients for all DVH parameters of the rectum. For rectum, it was realized that the flexible-geometry applicator produces a higher mean volume structure in comparison to the fixed-geometry applicator which receiving a higher mean dose. The colpostats are positioned less posteriorly in the fixed-geometry type applicator as compared to the flexible-geometry type applicator. Hence, higher rectum and bladder dose in flexible-geometry applicator-based plans may be due to applicators geometry and relative positions of rectum/bladder from tandem/ovoids. The OARs (bladder and rectum) are the anterior and posterior organs to the target regions in Ca-Cx patients. Hence, the higher volumetric structures produced around the target by flexible-geometry applicator may be the reason for the increase in the OARs (rectum and bladder) doses as compared to fixed-geometry applicators.

Whereas, the D2cc, D1cc, and D0.1cc parameters of sigmoid colon was reported higher in fixed-geometry applicator-based plans in comparison to flexible-geometry applicator-based plans and differences was reported statistically significant only for D1cc parameter [Table 3]. Figure 6 illustrates the percentage dose difference between two type's applicators based plans of individualized patients for all DVH parameters of sigmoid colon.

As it is well known that an increment in doses received by the small volume of OARs can give a hike to complications such as fistula and toxicity. Georg et al. performed a study to assess the forecasting value of the DVH parameters for late side effects of the rectum, bladder, and sigmoid colon in IGBT of Ca-Cx.[23] They demonstrated that for rectal toxicity D2cc and D1cc have good forecasting values, the DVH parameters were forecasting only for severe toxicity for bladder, and while for sigmoid colon, no forecasting was reported due to limited data. The popular Ir192 HDR radioisotope was used for the comparison of two type's applicators geometry in our study. Yadav et al.'s[24] study emphasized that Ir192 radioisotopes should be preferred for ICBT due to their ideal gamma energy and miniaturize physical size for better clinical benefit.

In contrast to our study, similar results were reported by S. Singh et al.[5] in their similar study in which they performed a dosimetric comparison between fixed-geometry and flexible-geometry of Fletcher-style applicator based on 2D orthogonal image-based planning. They reported 8.8% and 16% higher bladder and rectum ICRU reference point doses when using the flexible-geometry applicator as compared to fixed-geometry applicators although the differences were statistically insignificant. They also expressed that flexible-geometry applicator produces larger thickness of pear-shaped isodose volume and which revealing higher doses to OARs in comparison to the fixed-geometry applicator. Although S Singh et al. study also suggested determining the differences between two types of geometry applicator in terms of clinically more significant dose-volume parameters for the target (CTV) and OARs in 3D image-based planning.[5]

Thirion et al.'s[25] study performed a randomized comparison of two different applicators namely Henschke shielded (HS) and Fletcher-Suit-Declos (FSD) applicators for low-dose-rate brachytherapy practices using Cesium-137 (Cs137) radioactive sources based on 2D planning as per ICRU-38 recommendations. In HS applicators, tungsten alloy shielding was done on anterior and posterior aspects of ovoids to reduce the bladder and rectum point doses, respectively, although the FSD applicator was not shielded. An in-house correction, depend on comprehensive transmission measurement, for correction of attenuation of shielding material for HS applicators. They reported a significant reduction in ICRU reference point doses for bladder and rectum for HS applicator due to impact of ovoids shielding than with FSD applicator. A significant reduction in treated volume (considered as predictive of ICRU-38 60 Gy volume) was reported in the use of HS applicators than with FSD applicators.

A clinical investigation was carried out by Basu et al. to compare the dose distribution arises from the use of Manchester-style and Fletcher-style applicators in ICBT treatments of cervical cancer.[26] The two applicators were used for alternate insertions of each patient. They reported wider target coverage (the 100% isodose volume and its maximum width) in Manchester-style applicator based plans in comparison to Fletcher-style applicator based plan at the cost of increased bladder dose. Although their dosimetric comparison was based on CT image-based planning and they reported reference point doses and dose-volume parameters for bladder and rectum while for target only about 100% isodose line.


  Conclusion Top


The results of our study manifested that the use of flexible-geometry applicators produces significantly larger HR-CTV volumes in comparison to fixed-geometry applicators but lesser D90 and D100 dose values to HR-CTV. The geometry of flexible applicator created significantly higher central dose-volume structures around the target at the cost of significantly increased dose to the rectum, higher dose to the bladder but increased doe was statistically insignificant, whereas lower sigmoid colon dose as compared to the fixed-geometry applicator. This dosimetric study based on 3D-CT image-based treatment planning following advanced ICRU-89 guidelines will be helpful to clinicians to select appropriate/suitable geometry applicator for better clinical outcome in brachytherapy treatment of Ca-Cx patients. The clinical pertinence of the properties of both type's applicators geometry can only be confirmed by a clinical study on fairly large datasets.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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