To determine if your symptoms are caused by lymphoma, your healthcare provider might ask you the following questions: Its a good idea to write down your symptoms, any questions you have, and all the medicines you take before seeing your doctor. Horesh N, et al. Cutaneous T-cell lymphoma. Like you I feel uncertain frightened and looking for answers. Learn about its symptoms, causes, treatments, and outlook. It can affect various parts of the body that contain lymph tissue, such as the: The first visible sign of possible lymphoma is often an enlarged lymph node. These rashes often occur in skin folds and can be easily confused with other conditions like eczema. Rashes can occur for many, noncancerous reasons. Your doctor may also use the following tests to get an internal view of your chest, abdomen, or pelvis. The following illnesses cause rashes that require immediate attention from a medical professional. my condolences on the loss of your mum in such a terrible way. Have you or your family members ever been exposed to toxins? So, rashes and other skin disorders can be a sign of something else going on inside of you especially when you have cancer. Thats why its wise to pay attention when you notice one, and get it checked out if it doesnt go away on its own. Rashes and skin conditions that resemble rashes can be a symptom of some types of cancer. In fact, many of the symptoms listed here are more likely to be caused by other conditions, such as an infection. Some symptoms are easy to identify as potentially serious health problems. It broke my heart seeing her on an oxygen machine and trying to get the fluid off her lungs. It can be life-threatening and must be treated right away. Eventually the Chemotherapy Caelyx stopped working, and the cancer had outsmarted it, becoming resistant to any Chemo treatment, her second line chemo also failed. While MF is the most common type of cutaneous T cell lymphoma, there are many other types, some of which are very rare. Please find a haemo-oncologist or dermatologist who knows about the disease, and try and get yourself staged. Multiple locations: lumps that appear in multiple locations. The medical term for this combination is psoralen and ultraviolet A, or PUVA, therapy. Webcutaneous B cell lymphoma (CBCL) starts in the B cells of the skin. (7). My Mum died sequelate of this disease at the end of May this year 2018. Sometimes, having a family member or close friend accompany you to your appointment is also helpful. Follicular lymphoma is a form of non-Hodgkin lymphoma. You may wake up drenched in sweat. You have come to the right place and here you will find others to talk to and will hopefully feel less alone after joining this forum. Cancer.org is provided courtesy of the Leo and Gloria Rosen family. I figure that you have have been through some TOUGH times. Early diagnosis and treatment are vital, and the combination of approaches will depend on the type of lymphoma a person has. Other factors also affect the outlook, such as the persons age, general health, and how well the cancer responds to treatment. This novel blood clot treatment doesn't increase bleeding risk, Why young women have more adverse outcomes after a heart attack than young men, Gut microbiome appears to fluctuate throughout the day and across seasons, One-hour endoscopic procedure could eliminate the need for insulin for type 2 diabetes, New clues to slow aging? My child is thought to have this condition. Lymphoma can occur in anyone, though some people have a higher risk. When Should You See a Doctor for Your Symptoms? NHLs that start in your skin can cause itchy, red or purple bumps to form. Our team is made up of doctors andoncology certified nurses with deep knowledge of cancer care as well as journalists, editors, and translators with extensive experience in medical writing. Itching can also be a reaction to certain cancer treatments, Primary bone lymphoma is a rare subtype of lymphoma that affects the bone marrow and skeletal system. The reason I stressed that most patients don't progress,is to not alarm the majority of newly diagnosed sufferers. For reprint requests, please see our Content Usage Policy. Cancer Information, Answers, and Hope. CTCL Mycosis Fungoides is a strange beast. Swelling there may put pressure on the nerves of the spinal cord. This is called SVC syndrome. Surgery: Surgical removal of the skin lymphoma may be possible, especially if there arent many areas of rash and if its possible for them to be completely removed. If you have enlarged lymph nodes, theyre also likely to take a tissue sample or biopsy from the lymph node to look for cancer cells. Other symptoms can be fever, unintentional weight loss, night sweats. Lymphoma skin rashes may be itchy and appear as red or purple with dry scales, especially along the skin folds. Various types of rash can occur, such as petechiae and purpura, which Does lymphoma differ between men and women? You can learn more about how we ensure our content is accurate and current by reading our. All rights reserved. If your physician thinks your symptoms might be lymphoma, he or she will likely order additional tests and may get a biopsy of a lymph node. Is his tumor shrink totally? These may help control pain and itchiness or clear the rash and help slow the progress of the cancer. The subtypes of lymphoma fall into two main categories: Hodgkins lymphoma and non-Hodgkins lymphoma (NHL). American Cancer Society. Lymphoma can cause a rash that appears as one or more scaly patches, plaques, or nodules. (8). It causes flat red patches on the skin that look like eczema and can be itchy. Have you ever had any type of autoimmune disorder? Your lymphatic system, which includes your lymph glands, bone marrow, thymus gland, and spleen, is an essential part of your immune system. My Dad died in 2010 of an even worse condition, Bile Duct cancer which has a very poor prognosis. In addition, imaging tests can help doctors determine whether skin lymphoma has spread to other areas of the body. The dermopathologist had a hunch, and applied the correct staining solution to the samples, and I was diagnosed in a fortnight. On the other hand, symptoms of lymphoma typically persist. Chemotherapy drugs may also be prescribed. Lymphoma of the skin can be treated in multiple ways, such as topically with medications, through radiation or UV light therapy, or with infusions of chemotherapy or biologic therapy. (2016). Here are our most recommended organizations, articles, and websites that provide the information and support you may need. The American Cancer Society offers programs and services to help you during and after cancer treatment. I even thought it was Psorasis because, you trust your Doctor's decisions. Lymphoma affects a type of white blood cells called a lymphocyte. Lymph nodes may be tender or even painful to the touch. Hodgkin lymphoma may cause the following general symptoms: If a lymphoma affects lymph nodes in your chest, you might experience coughing, chest pain, or trouble breathing, especially when lying down. Round patches of skin that may be raised or scaly and might be itchy, Patches of skin that appear lighter in color than surrounding skin, Lumps that form on the skin and may break open, Thickening of the skin on the palms of the hands and soles of the feet, A rash-like skin redness over the entire body that is intensely itchy. https://www.nccn.org/professionals/physician_gls/default.aspx. WebLymph nodes commonly swell if we have an infection but they usually go back to normal over a short time. But sometimes they grow very quickly. Symptoms, Causes, Diagnosis, Treatment, and Prevention, Lymphoma Survival Rates, Long-Term Effects of Treatment, Small Lymphocytic Lymphoma (SLL): Treatment, Stages, Prognosis, Surviving Cancer: From Teenage Diagnosis to Elite Athlete and Coach, Spotlight On: The Leukemia and Lymphoma Society, New Drug Combination May Be Game-Changer for Non-Hodgkin Lymphoma Patients, Lymphoma Resources: Finding the Help You Need. People die of the disease no not directly of it, but of what it does to you and your immune system. The most common sign of MF is a rash consisting of one or more scaly, inflamed patches of skin. What causes lymphomas is not known for certain. For this reason, the doctor will usually take multiple biopsies. I just don't know. By Julie Scott, MSN, ANP-BC, AOCNP Read on to learn more about the causes, symptoms, treatments, and prognosis for lymphoma. Your doctor will ask about your symptoms, such as: Your doctor will do a physical examination to check for swollen lymph nodes and other signs. The typical early symptoms such as fatigue, night sweats, and enlarged lymph nodes are similar in both men and women. Did you have a high wbc? Vijayakumar S, et al. Also, males are almost twice as likely to develop MF as females. It took over a year to get a diagnosis and referal, her referal was delayed time after timewhich I will be suing the local surgery for. I have a really rare NH Lymphoma called Mycosis Fungoides, that typically manifests itself as itchy patches on the skin in the early stages. Is the ketogenic diet right for autoimmune conditions? Cutaneous T-cell lymphoma is one of several types of lymphoma collectively called non-Hodgkin's lymphoma. Depending on the individual, fatigue can be mild or severe. If your doctor suspects that lymphoma has spread or might be present in your bone marrow, they may order a bone marrow biopsy. Non-Hodgkin lymphoma (Adults). Just like with other cancers, diagnosing lymphoma in its early stages can lead to a better outcome. Both women and men may experience the following classic lymphoma symptoms. In: Niederhuber JE, Armitage JO, Doroshow JH, Kastan MB, Tepper JE, eds. They can spread as the lymphoma progresses. When lymphoma affects the skin, it may cause a rash that appears as one or more scaly, reddish-to-purple patches, plaques, or nodules. A lymphoma rash, such as mycosis fungoides (MF), can be easy to confuse with other skin conditions, such as psoriasis or eczema, which can cause similar symptoms. Whether you or someone you love has cancer, knowing what to expect can help you cope. Another person on here I spoke to a few weeks ago, his/her mum also passed away in same circumstances where the NHS let their Mum down as well with poor/late diagnosis which resulted in poor outcomes. One important distinction is that symptoms of a less serious problem usually wont last long. 1. If its not causing symptoms, it can often be monitored closely without needing to be treated right away. A skin biopsy can be done in multiple ways and is most often performed by a dermatologist (a physician specializing in diseases of the skin, hair, and nails): Determining the exact type of skin lymphoma can be difficult at times. Cutaneous T-cell lymphoma (CTCL):. When the cells in your lymphatic system become cancerous, these cancers are called lymphomas. Treatments are incredibly varied, depending on which blood cancer you have. So have those holidays anyway, did you go yet? The same doctor would see 1 case of tuberculosis every 5.6 years. Since it is Lymphoma is a kind of cancer that starts in the lymphatic system, which is part of your immune system. Has anyone in your family ever had cancer? Our website services, content, and products are for informational purposes only. What Is Follicular Lymphoma? What Is Hodgkins Lymphoma (Hodgkins Disease)? The skin that is affected is often very itchy, and some of the lesions may even open up and leak fluid. They can do a thorough skin examination, and get a biopsy of any of the rash areas. (7). In some instances, the UV light is able to treat lymphoma. They can spread as the lymphoma progresses. Healthline Media does not provide medical advice, diagnosis, or treatment. While you have a rash, I think it would be wrong for me to conclude that you absolutely have a CTCL Berd. The lymphocytes are treated with psoralen (which sensitizes them to UV light) and UV light. All Doctors did was to chuck lots and lots of different creams that worked, then stopped working then tried another one. Early detection, diagnosis, and staging. (2018). Targeted biologic therapy: These medications can be given to target specific proteins on the lymphoma cells, to help the immune system fight them off and destroy the cancer. Each type of lymphoma may exhibit unique symptoms and require specific treatments. Enlarged lymph nodes might feel or look like lumps under the skin, which typically dont cause discomfort. Any medical information published on this website is not intended as a substitute for informed medical advice and you should not take any action before consulting with a healthcare professional. This can lead to swelling (and sometimes a bluish-red color) in the head, arms, and upper chest. It can come back after treatment, but it seldom spreads inside the body and is rarely fatal. Cutaneous T-cell lymphoma is a blanket term for a group of blood cancers that target white blood cells and produce rashes on the skin. Multiple types of lymphoma can cause a rash. In my case suddenly things blew up this november with skin lumps and bumps, now a problembut in all the time before, i only needed uvb treatment on an off, and steroid creams for really dry bits, to keep the skin in reasonable condition.and moisturisers of course. You may experience heavy sweating during the daytime as well, but its not as common. They may appear as reddish or purple scaly areas. Being a dermatologist, he took some skin punch biopsies and sent them to a dermopathologist. Everybody's basket is different. This cancer is often slow-growing. Healthline has strict sourcing guidelines and relies on peer-reviewed studies, academic research institutions, and medical associations. Standard cancer therapies, such as the following, are common treatments for lymphoma: For skin lymphomas, such as MF, doctors may recommend prescription topical creams or ointments that contain corticosteroids, chemotherapy drugs, or retinoids. Accompanying symptoms: lumps accompanied by additional symptoms such as fevers, night sweats, and weight loss. In: Dermatology. No standard diagnostic criteria for MF exist, and a diagnosis largely relies on the findings of a skin biopsy. The fags I smoke and the red wine that I love. A lymphoma that affects the skin can cause a rash to develop. Just waiting for a diagnosis. Doru Paul, MD, is triple board-certified in medical oncology, hematology, and internal medicine. They are often diagnosed early, grow slowly and respond well to treatment. Having no symptoms of lymphoma can make getting an early diagnosis more challenging. We are in New York. It took my sister over a year to get diagnosed with a malignant brain tumor and she was highly symptomatic. I was diagnosed 6 years ago and the itchy patches come and go, but for me the disease is largely indolent - which means it's not aggressive. In this article, learn more about lymphoma rashes. That is exceptional. Most lymphoma-related fevers are relatively low-grade. Several parts of the body can be affected. There are quite a few weird variants of the disease. This rash is mildly itchy, but it does not itch like poison ivy. Symptoms of spreading or progression can include: These symptoms can result from many types of lymphoma, including those that originate in areas other than the skin, known as systemic lymphomas. The lymphoma might show up as more than one type of lesion and on different parts of the skin (often in areas not exposed to the sun). Any skin problems they cause come and go and only need treatment some of the time. The pathologist evaluating the specimen may need to run specialized tests to determine the type of cancer. Lymphomas that start or grow in the abdomen (belly) can cause swelling or pain in the abdomen. Mycosis fungoides and Sezary syndrome (adult). All rights reserved. It can be flat, raised, or in lumps. Available Every Minute of Every Day. Theyre often accompanied by chills. On very rare occasions, a rash can be a symptom of cancer. Knowing the difference can help a person seek the necessary help or avoid anxiety about a noncancerous rash. Changes in the skin can occur due to a cancerous cause or a precancerous cause. The American Cancer Society note that nearly half of all skin lymphomas are MF. Having one or more symptoms doesnt mean you definitely have lymphoma. They are often itchy as well. Bone marrow is taken from within the bone by a hollow needle. Many newly diagnosed CTCL MF patients use Dr Google, and see pictures of tumours like your mother had, and freak out. Types of lymphoma include Hodgkin lymphoma and More and more people are surviving Hodgkin disease and non-Hodgkin lymphoma. Lymphomas in the stomach or intestines can cause abdominal pain, nausea, or vomiting. These are usually not painful. The doctor will likely also check for signs of enlarged lymph nodes, and if these are present, they may request a biopsy of an enlarged node. 2023 Dotdash Media, Inc. All rights reserved, Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. The most common type is mycosis fungoides. Philadelphia, Pa: Lippincott Williams & Wilkins; 2015. Become a volunteer, make a tax-deductible donation, or participate in a fundraising event to help us save lives. Be sure to see your doctor if you have any symptoms of lymphoma that persist or get worse, such as swollen lymph nodes. Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press. We avoid using tertiary references. The Truth Behind 10 Common Skin Cancer Myths, FDA Approves New Extended-Release Injectable for Schizophrenia and Bipolar Disorder. Affected skin may be itchy, and the lesions may However, there are many more likely causes of lower back pain than lymphoma. Chapter 106: Non-Hodgkin Lymphoma. Doctors don't know why the cells attack the skin. Rashes are most commonly seen in lymphomas of the skin. If youre concerned that a rash thats been on your body is getting worse or may not be a simple rash, see your healthcare provider, specifically a dermatologist. Narrow-band ultraviolet B treatment is a very common phototherapy for MF. The skin rash, or lesions, can be described in multiple ways, such as: These skin lesions are often red or purple in color, can be scaly, and can often be itchy. 1996-2023 Everyday Health, Inc., a Ziff Davis company. I'm sorry to hear about your pain and anger over the tragic loss of your mum. I hope someone with the same type of lymphoma will see your post and reply soon, as well as some of our other members who may have felt like you after being diagnosed with a rare cancer. Ellison LF. (2018). I was diagnosed 6 years ago and the itchy patches Differences in cancer survival in Canada by sex. When this happens, the rash is called stage two and can occur up to six months after the bite. What are the symptoms of lymphoma in women? Some are deep, while others are fairly close to the surface. The affected skin may get thick and hard, and form raised plaques. Other types of lymphoma can spread to the area around the brain and spinal cord. Privately we would of, but there isn't an oncology center for about 100 miles from here. NHS has let my Mum down, I just want to speak to her again but I can't. The two main types of lymphoma, non-Hodgkin lymphoma (NHL) and Hodgkin lymphoma, can both cause swollen or enlarged lymph nodes. Lymphoma is more common in people with immune system diseases or in people who take drugs that suppress their immune system. Scientists use genetic rewiring to increase lifespan of cells, What to know about cancer and lymph nodes in the neck. In: DeVita VT, Lawrence TS, Rosenberg SA, eds. Roberts ME, et al. If your son's diagnosis is confirmed, you will need to be strong on his behalf, talk to specialists, and establish what stage of the disease he has. Lymphomas are cancers that originate in the lymphatic system. (2019). The doctors haven't communicated clearly - perhaps because it israre. Some low-grade lymphomas do not become obvious until they are more advanced and the disease has spread to the lymph nodes, blood or internal The type of cutaneous T-cell lymphoma you have helps determine which treatments are best for you. I was seeing a dermatologist about some skin issues, and happened to mention the strange red patches on my lower legs. If so, what type? Most people with MF may also benefit from phototherapy, which uses ultraviolet light. Everyday Health is among the federally registered trademarks of Everyday Health, Inc. and may not be used by third parties without explicit permission. The plaques may darken and possibly bleed. Lymphoma can sometimes cause an itchy rash . What to do if you have symptoms of lymphoma, cancer.org/cancer/cancer-basics/lymph-nodes-and-cancer.html, sciencedirect.com/science/article/pii/S2352578918301036?via%3Dihub, ccij-online.org/article.asp?issn=2278-0513;year=2016;volume=5;issue=3;spage=287;epage=290;aulast=Srivastava, dirjournal.org/en/primary-lymphomas-of-the-female-genital-tract-imaging-findings-13981, sciencedirect.com/science/article/pii/S2352578916300649?via%3Dihub, spandidos-publications.com/10.3892/ol.2018.7805, ncbi.nlm.nih.gov/pmc/articles/PMC6789275/, Understanding Triple-Hit Lymphoma, a Rare Type of Non-Hodgkins Lymphoma, its stage, meaning how far its progressed in your body. American Cancer Society. In my case it was discovered by accident. Surgery is not a common treatment for cutaneous T cell lymphoma unless a person has only an isolated plaque, which can occur with certain types of this lymphoma. Its not uncommon for someone to develop a rash on their skin at some point in their lives. You can help reduce your risk of cancer by making healthy choices like eating right, staying active and not smoking. The earlier lymphoma can be diagnosed and treated, the better the outlook. WebThe most common symptom of Hodgkin lymphoma is a painless swelling in a lymph node. The most common type of cutaneous T cell lymphoma, MF occurs when cancerous T cells are present in the skin with a characteristic presentation of patches, plaques, and sometimes tumor-like lesions. Hopefully you can support each other since you both have this rare condition. Over time, the rash may become more severe and spread to other areas. Lymphoma of the female genital tract: a clinicopathological analysis of 25 cases. Although it is extremely rare, with NHL, tumors may grow in the reproductive organs, most commonly in the cervix or ovaries, per a rare case report published in 2016. DOI: The American Cancer Society medical and editorial team. Differences in epidemiology, clinical behavior, and therapy. If any rash does not resolve on its own after two weeks, you should see your doctor for further evaluation. what treatment does he have currently? Cutaneous T-cell lymphoma (CTCL) is a rare type of cancer that begins in white blood cells called T cells (T lymphocytes). It passes near the thymus and lymph nodes inside the chest. The big question for me is whether I should make a decision to throw the job in, and enjoy travel while I am still able. As a result, tiny bruises may start to form in areas where blood What are your symptoms? In that article, the author estimated that the average doctor would have around 2,000 patients, and would for example see 6.2 casesof cardiovascular mortality per year. (2018). Treatment, Prognosis, Symptoms, Causes, and More, What Is Lymphoma? Lymphoma rashes and skin changes can appear differently on the body and may not all look the same. Leukemia is a type of blood cancer that affects many parts of the body, including the skin. Plymouth Meeting, Pa.: National Comprehensive Cancer Network. NHL is much more common and makes up 4 percent of all cancers in the United States. No treatment recommended at this time and the tumor sponstaneiusly regressed. A 33-year study looked at the medical records of patients diagnosed with NHL of the female genital tract. Irritation may sometimes occur with or without (3). Its usually slow-growing and responds well to treatment but is difficult to cure. At stage IIB, the skin involvement morphsfrom patches and plaques totumours. Several types of cutaneous T-cell lymphoma exist. Swellings in more superficial locations can be more noticeable. We avoid using tertiary references. Connect with others like you for support and answers to your questions in the Blood Cancers & Disorders support group on Mayo Clinic Connect, a patient community. The point I was trying to make is that disease progression is not automatic. (2018). Groups of these small structures are located in your armpits (axillary), neck (cervical), chest, abdomen, and groin (inguinal). In cutaneous T-cell lymphoma, the T cells develop abnormalities that make them attack the skin. Combination therapies can be very effective in some cases. You should contact your doctor about any persistent pain anywhere on your body. To make matters more difficult, eczema and similar conditions can look like MF on a biopsy. The DNA mutations tell the cells to grow and multiply rapidly, creating many abnormal cells. Triple-hit lymphoma (THL) is an aggressive type of lymphoma. We can also help you find other free or low-cost resources available. This content does not have an Arabic version. In some cases, the doctor may prescribe a particular medication that aids treatment with ultraviolet A rays. Its characterized by swelling and distortion of facial bones. A bone marrow transplant may be performed to help strengthen your immune system. Wang F, et al. Common sites for enlarged lymph nodes include: While enlarged lymph nodes are a symptom of lymphoma, theyre more commonly caused by infection. Its also important to see your doctor if youre experiencing pelvic pain or abnormal vaginal bleeding, since most women with non-Hodgkins lymphoma in their reproductive organs dont experience classic NHL symptoms. Julie is an Adult Nurse Practitioner with oncology certification and a healthcare freelance writer with an interest in educating patients and the healthcare community. The next step in diagnosing lymphoma is a biopsy. If you have suddenly lost weight without trying to, it could be a symptom of lymphoma as well as other health conditions. How have you been since you last posted? CBCL is a more unusual type. Lymphoma can be challenging to diagnose in its early stages. Now, shes that role model. They often start in the T cells and can have names such as cutaneous T-cell lymphoma, mycosis fungoides, or Sezary syndrome. While both women and men may experience the same classic symptoms of lymphoma, a type of cancer that affects your lymphatic system, women may have different symptoms if the lymphoma has developed in a reproductive organ. These include: However, children may have other symptoms, too. Many symptoms of lymphoma are also present in other, less serious illnesses, such as an infection like the flu or a common cold. NHLs that start in your skin can cause itchy, red or purple bumps to form. If the symptoms are not managed properly, the I am in so much regret right now of what I could of/should of done to save her life. I just wanted to let you know that someone posted tonight who also has mycosis fungoides. Cookies collect information about your preferences and your devices and are used to make the site work as you expect it to, to understand how you interact with the site, and to show advertisements that are targeted to your interests. You really need a diagnosis, so that you can better appreciate what you are facing. Seek expert advice please. Symptoms of lymphoma often depend on the type you have, what organs are involved, and how advanced your disease is. Freedman AS, Jacobson CA, Mauch P, Aster JC. Please try notblame yourself that it should have been identified earlier, becauseCTCL MF is such a rare cancer. Patients with skin lymphoma might experience a variety of vague or unusual symptoms, including: Peeled skin Rash, which sometimes can itch Mushroom-like skin B. Cauthen MD that was published in 1994. Still, if you have any of these symptoms, have them checked by a doctor so that the cause can be found and treated, if needed. Some skin lymphomas Philadelphia, Pa: Elsevier; 2014. Many medications can help treat heart attacks after they occur or help prevent them. Skin-directed treatments for skin lymphomas. Swollen lymph nodes are more likely to be caused by infection than cancer. Excessive sweating can sometimes occur during the day as well. I let her down, she would still be here like yourself if she was refered quicker to someone who knew what they were doing. (1) There are about 600 lymph nodes in your body. I was outcasted by "fake" friends years ago, it hurt my confidence and she was the only one that understood me and comforted me. A pelvic mass can cause sex to be painful or uncomfortable. According to some studies, about 80% of MF patients don't progress above the lower stages. People under 60 years old typically have better survival rates, for example. Common symptoms children with lymphoma have include: If your child is experiencing frequent infections or any of these symptoms, see your doctor for an examination. These details can be reviewed with the oncologist treating you. Night sweats may occur if you have a fever while asleep. Chemotherapy, immunotherapy, and radiation are commonly used to treat many types of lymphoma. They may refer you to a dermatologist who can perform a biopsy of the rash and determine what is going on. Leukemia can impair the bodys ability to generate platelets, which makes repairing itself harder.
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