Group Title: BMC Urology
Title: Utility of serial urinary cytology in the initial evaluation of the patient with microscopic hematuria
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Title: Utility of serial urinary cytology in the initial evaluation of the patient with microscopic hematuria
Physical Description: Book
Language: English
Creator: Nakamura, Kogenta
Kasraeian, Ali
Iczkowski, Kenneth
Chang, Myron
Pendleton, John
Anai, Satoshi
Rosser, Charles
Publisher: BMC Urology
Publication Date: 2009
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Abstract: BACKGROUND:We determine the utility of serial urinary cytologies in patients presenting with microscopic hematuria who were evaluated with upper and lower urinary tract studies to rule out a malignancy.METHODS:Two hundred and thirty-seven patients with the diagnosis of microscopic hematuria were evaluated at an inner-city tertiary care hospital. Of these 239 patients, 182 patients had 405 cytologies obtained as part of their evaluation for hematuria. In addition, all patients had their lower urinary tract and upper tract thoroughly evaluated.RESULTS:Two hundred and seventy four cytology samples were read as normal, 104 (26%) as atypia, 7 (2%) as suspicious/malignant, and 20 (5%) as unsatisfactory. Seventeen patients (9.3%) had biopsy confirmed bladder cancer. Of these 17 patients, 2 had normal cytology, 11 had atypia, and 5 had suspicious/malignant. No patient had a positive cytology and a negative biopsy. Overall the number of hematuric patients harboring bladder cancer was small (7%). Cytology #1 detected 4 cases of cancer, cytology #2 detected an additional case and cytology #3 did not detect any additional cancers.CONCLUSION:Because of this low prevalence of bladder cancer in patients presenting with microscopic hematuria and the low sensitivity of detecting bladder cancers, the utility of urinary cytology in the initial evaluation of patients with hematuria may be minimal. The exact role of urinary cytology in the evaluation of hematuria is unknown.
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BMC Urology BioMed Central



Research article

Utility of serial urinary cytology in the initial evaluation of the
patient with microscopic hematuria
Kogenta Nakamura', Ali Kasraeian4, Kenneth A Iczkowski2, Myron Chang3,
John Pendleton', Satoshi Anail and Charles J Rosser* I


Address: 'Division of Urology, The University of Florida, Jacksonville, Florida, USA, 2Department of Pathology, The University of Florida,
Gainesville, Florida, USA, 3Department of Epidemiology and Health Policy Research, The University of Florida, Gainesville, Florida, USA and
4Department of Urology, The University of Florida, Gainesville, Florida, USA
Email: Kogenta Nakamura kogenta.nakamura@jax.ufl.edu; Ali Kasraeian ali.kasraeian@urology.ufl.edu;
Kenneth A Iczkowski kenneth.Iczkowski@ufl.edu; Myron Chang m.chang@ufl.edu; John Pendleton john.pendleton@jax.ufl.edu;
Satoshi Anai satoshi.anai@jax.ufl.edu; Charles J Rosser* charles.rosser@urology.ufl.edu
* Corresponding author



Published: 10 September 2009 Received: 2 July 2008
BMC Urology 2009, 9:12 doi: 10. 186/1471-2490-9-12 Accepted: 10 September 2009
This article is available from: http://www.biomedcentral.com/1471-2490/9/12
2009 Nakamura et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.



Abstract
Background: We determine the utility of serial urinary cytologies in patients presenting with
microscopic hematuria who were evaluated with upper and lower urinary tract studies to rule out
a malignancy.
Methods: Two hundred and thirty-seven patients with the diagnosis of microscopic hematuria
were evaluated at an inner-city tertiary care hospital. Of these 239 patients, 182 patients had 405
cytologies obtained as part of their evaluation for hematuria. In addition, all patients had their lower
urinary tract and upper tract thoroughly evaluated.
Results: Two hundred and seventy four cytology samples were read as normal, 104 (26%) as
atypia, 7 (2%) as suspicious/malignant, and 20 (5%) as unsatisfactory. Seventeen patients (9.3%) had
biopsy confirmed bladder cancer. Of these 17 patients, 2 had normal cytology, I I had atypia, and
5 had suspicious/malignant. No patient had a positive cytology and a negative biopsy. Overall the
number of hematuric patients harboring bladder cancer was small (7%). Cytology #1 detected 4
cases of cancer, cytology #2 detected an additional case and cytology #3 did not detect any
additional cancers.
Conclusion: Because of this low prevalence of bladder cancer in patients presenting with
microscopic hematuria and the low sensitivity of detecting bladder cancers, the utility of urinary
cytology in the initial evaluation of patients with hematuria may be minimal. The exact role of
urinary cytology in the evaluation of hematuria is unknown.



Background tion, trauma, tuberculosis, and tumor [1]. Some of these
Gross or microscopic hematuria [>3 red blood cells (RBC) factors (e.g., tumor) may be life threatening. Thus prompt,
per high power field (hpf)] may be caused by numerous thorough evaluation and treatment are needed. Currently,
factors urinary calculi, hematologic abnormalities, infec- evaluation for the hematuric patient consists of inspecting


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the lower urinary tract by cystourethroscopy, inspecting
the upper urinary tract with computed tomography scan
of the abdomen and pelvis with and without intravenous
contrast, ultrasonography or intravenous pyelogram
(IVP), and obtaining a urine sample for cytologic evalua-
tion [2,31.

Urine for cytology can detect cancerous cells shed from
any part of the entire urothelium (i.e., collecting system to
urethra) in a voided urine specimen. Higher grade tumors
or larger tumors (> 3 cm) are more likely to shed cells into
the urine and thus the sample is more likely to be positive
for cancer. Urinary cytology has a notoriously low sensi-
tivity, but an extremely high specificity, thus making it a
useful tool in following patients with high grade cancers
[4,5]. Furthermore, interpretation of urinary cytology may
be difficult, especially in the face of such conditions as uri-
nary tract infection. With these notable limitations, the
question arises as to how effective is urinary cytology in
diagnosing bladder cancer in a patient presenting with
microscopic hematuria? Herein, we report the utility of
urinary cytology of patients presenting to a urology clinic
for evaluation of microscopic hematuria.

Methods
Study population
Institutional review board approval was obtained to query
medical records for pertinent clinical information in 239
consecutive patients evaluated between January 2003 and
August 2005 for microscopic hematuria at a urology out-
patient clinic in a tertiary-care inner-city hospital. Micro-
scopic hematuria was characterized as microscopic
hematuria [> 3 red blood cells (RBC) per high power field
(hpf)] [6]. Initial evaluations included medical history;
physical examination, urinalysis, and voided urinary
cytology. Urine cultures were obtained in patients if there
was high suspicion of a urinary tract infection as the cause
of the hematuria. Clinic and hospital records were
reviewed for several key factors including tobacco usage,
voiding symptoms (American Urologic Association, AUA,
symptom score), urinalysis, urinary cytology, cystoscopic/
radiologic evaluation, and pathologic outcomes. Median
follow-up was 40 months (range 1-66 months).

Based on AUA guideline criteria on the use of urinary
cytology, voided urinary cytologies were collected over a
seven day period prior to radiologic and cystoscopic eval-
uation. Of the 239 patients, 182 patients had one cytology
available for review whereas 125 and 96 patients had two
and three cytologies, respectively, available for evaluation.
Thus a total of 403 urinary cytologies were reviewed by
our cytopathologists. In accordance with accepted
nomenclature, final cytologic testing results were classi-
fied by the cytopathologists into I of 4 categories: normal,
atypical/indeterminate, suspicious, or malignant [7].


Cystoscopic evaluation of the lower urinary tract and
bladder biopsy
Hematuria evaluation included cystourethroscopy per-
formed by an attending urologist with a 30- and 70-degree
endoscope in a 17-F sheath in women in the outpatient
setting, an 18-F flexible cystoscopy in men in the outpa-
tient setting, or with a 30-and 70-degree endoscope with
a 21-F sheath in the operating room. Any abnormal blad-
der lesions were biopsied and frank tumors were rejected.
Pathologic specimens were sent for evaluation in 10% for-
malin. In patients with atypia, suspicious, or carcinoma
on cytology and no obviously bladder tumor, random
bladder and prostatic biopsies were obtained at the discre-
tion of the treating surgeon.

Radiologic evaluation of the upper urinary tract
The majority of patients (175, 74%) had their upper tracts
evaluated by computed tomography urography scan of
the abdomen and pelvis consisting of non-contrasted and
contrasted images [8]. Intravenous pyelogram (IVP) was
used to evaluate the upper tracts of 6 (3%) patients. In
patients with an intravenous contrast allergy or another
contraindication for CT scan or IVP, magnetic resonance
imaging (n = 15, 6%) or renal ultrasound and retrograde
pyelogram (n = 69, 29%) was used to evaluate the upper
urinary tracts.

Outcome Assessment
Biopsy specimens were graded histologically according to
established grading systems [9,10]. The 2002 Tumor-
Node-Metastasis (TNM) staging system was used for clin-
ical staging [11].

Statistical Analysis
Differences in distribution of demographic and clinical
variables were evaluated using the Chi-square test or the
Kruskal-Wallis test. P-values were obtained from the
Fisher's exact test for testing the null hypothesis that there
is no association between a "risk" factor (e.g., tobacco,
voiding symptoms, cystoscopic or radiologic abnormality
associated with bladder cancer) and abnormal urinary
cytology vs. the one-sided alternative hypothesis that
there is positive association between a "risk" factor and
abnormal urinary cytology. P < 0.05 is significant. Statisti-
cal analysis was performed using SAS software (SAS Insti-
tute, Cary, North Carolina).

Results
Of the 239 patients presenting for evaluation of micro-
scopic hematuria, 182 patients obtained urinary cytology
in the initial evaluation. Table 1 depicts the demographic
and clinical characteristics of all 239 patients presenting
for evaluation of microscopic hematuria.

A total of 403 cytologic specimens were reviewed. Eight-
een samples were unsatisfactory for interpretation due to

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Table 1: Demographics and clinical features of 239 patients presenting for microscopic hematuria evaluation


No cytology available

N = 57


Range

Median


63/37


Cytology available

N = 182


20-89


92/90


Race


Caucasian


African American

Other


Tobacco use


* difference between patients with cytology available compared to patients without cytology, p < 0.05


scant number of cells or severe degradation. Thus 385
specimens were reported. Two hundred and seventy four
urinary cytology samples were classified as negative
(72%) and 104 (27%) as atypia. The remaining 7 urinary
cytologies from 5 patients were categorized as suspicious
or malignant, which accounted for 1% of all of the urinary
cytology evaluated. Cytology #1 detected 4 cancers and
cytology #2 detected an additional cancer case (confirmed
2 cytologies from #1) whereas cytology #3 did not detect
any additional cancers.

Of the 182 patients with available cytologic data, 38
(21%) demonstrated an abnormality on cystoscopic
examination worrisome for malignancy, 9 (5%) an abnor-
mality on radiologic evaluation worrisome for malig-
nancy, or 10 (5%) an abnormality on both worrisome for
malignancy. Table 2 illustrates both cytologic and cysto-
scopic findings of the 182 patients. None of the non-sus-
picious bladder tumors proved to be cancer and 17 (45%)
of the suspicious bladder tumors were found to be malig-
nancy (Table 3). Biopsy proven bladder cancer was evi-
dent in 2% of patients with normal cytology, 15% of
patients with atypia, and 100% of patients with suspi-
cious or malignant cytology (Table 4). None of the
patients with biopsy proven bladder cancer was found to
have carcinoma in situ. Combining the above two groups
(atypia and suspicious/malignant cytology), we deter-
mined the unadjusted odds ratio (ORs) with 95% CIs for
patient characteristics that are associated with atypical or
suspicious/malignant cytology (Table 5).


None of the 23 patients with atypia and negative evalua-
tion were noted to harbor symptoms or signs of bladder
cancer on subsequent follow-up. No patient with a nor-
mal cystoscopic evaluation and abnormal cytology was
noted to have bladder cancer on extensive evaluation. In
addition, no patient had a positive cytology and a nega-

Table 2: Cytologic and cystoscopic results of 182 patients
presenting with microscopic hematuria


Test result


N (%)


Cytology


Negative*


103 (57%)


Suspicious/Positive


5 (3%)


Atypia


74 (41%)


Cystoscopy


Normal


Non-suspicious Bladder Mass

Suspicious Bladder Mass


others**


115 (63%)


5 (3%)


38(21%)

24 (13%)


*: includes reactive changes, degenerative changes
** included stones, cystitis


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Characteristic


51/49*


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Table 3: Comparison of cystoscopic findings with biopsy pathology


Cystoscopy data


Biopsy results


Positive for cancer
(N = 17)

Negative for cancer
(N = 70)


Normal*
(N = 144)

0


* not all patients with normal cystopscopy underwent bladder biopsy.

tive biopsy. Median follow-up was 40 months with no
patient with a negative cytology and/or negative bladder
biopsy diagnosed with subsequent cancer.

Discussion
Our study indicates that the prevalence of bladder cancer
in patients presenting with microscopic hematuria is low
(7%). A key question is what is the proportion of subjects
in whom a positive cytology prompted a biopsy that was
positive for cancer, in whom a biopsy would not other-
wise have been performed? None of our patients had a
positive cytology and a negative cytsoscopic/radiologic
evaluation. This is consistent with our previous study that
demonstrated an extremely low yield of urinary cytology
in the evaluation of the patient with microscopic hematu-
ria [12]. To our knowledge, these are the first contempo-
rary report bringing the utility of urinary cytology in
patients with microscopic hematuria into question.

As for the application of serial urinary cytologies, previous
studies demonstrated a marginally improved by serial
examinations [4,13], which was confirmed in our study.
Because of this low prevalence and the low sensitivity, the
utility of urinary cytology in the initial evaluation of
patients with microscopic hematuria is minimal, espe-
cially since all high risk patients proceeded to cystoure-
throscopy and upper urinary tract radiologic evaluation.


Table 4: Comparison of cytologic findings with final pathology


Benign lesion (N = 5)


Tumors
(N = 38)


Current AUA guidelines recommend that patients pre-
senting with microscopic hematuria should undergo
upper tract evaluation along with cystoscopy. When the
CT scan is not feasible, MRI or renal ultrasound with bilat-
eral retrograde pyelograms can be substituted (2). This
evaluation is adequate in assessing the kidneys, collecting
system, ureters, bladder, and urethra as the cause of the
hematuria. Unfortunately, except in select patients our
current diagnostic modalities will not allow us to diag-
nose urothelial carcinomas without visualization of a
lesion followed by biopsy, which is the gold standard
[14]. With this said, the acquisition of urinary cytology
even as an adjunct to the above studies rarely changes the
evaluation or management and may lead to an exhaustive,
unfruitful, and costly evaluation. In the face of abnormal
cytology and normal cystoscopy confirmed by biopsy and
normal imaging of the upper tract, the question arises
whether to pursue the abnormal cytology as a possible
upper tract tumor. Evaluation may include retrograde
pyelogram, ureteroscopy, and selective cytology. The yield
of these maneuvers is reported to be extremely low and of
little benefit, except in highly select patients [15,16], espe-
cially in the face of normal radiologic studies and normal
cystoscopic evaluation. However, if an abnormality is
noted on radiologic or cystoscopic examination, urinary
cytology may prove to be useful as a confirmation of a
malignancy prior to formal biopsy.


Cytologic diagnosis#


Biopsy results


Negative *
(N = 103)


Positive for cancer
(N = 17)

Negative for cancer
(N = 70)


Atypical*
(N = 74)

II


23


Suspicious/Positive
(N = 5)

5


0


# most adverse cytologic result per patient
*not all patients underwent bladder biopsy.


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Table 5: Risk factors for abnormal (atypical, suspicious, or malignant) urinary cytologic testing


Risk of Abnormal Cytology (m/n)


Smoker


Non-Smoker


Dysuria


Radiology Study


48/109 (44%)

29/65 (45%)

12/31 (39%)

68/151 (68%)

30/77 (39%)

24/55 (44%)

10/16 (63%)


Positive

Negative

Positive


Unadjusted OR
(95% Cl)

0.98 (0.53-1.81)



0.77 (0.35-1.70)



0.82 (0.41-1.66)



2.29 (0.79-6.58)


Negative 70/



Recent studies have reported the limitations of urinary
cytology in the evaluation of patients with hematuria.
Paez and colleagues reported that no tumor could be diag-
nosed with cytology alone and that a negative cytology
could not exclude a malignancy [17]. Because of its limi-
tations, Nabi et al. recommended the judicial use of cytol-
ogy in the proper clinical context [18]. Similar to the
report by Deshpande et al., over 25% of patients with
atypical urinary cytology were found to have biopsy
proven cancer [19]. Because of this, atypia may require
biopsy to rule out malignancy, closer follow-up, or other
urinary based assays to improve sensitivity (e.g., fluores-
cent in situ hybridization, FISH).

Our study has several limitations. First, this is a small, ret-
rospective study from a single institution. Not only could
biases have been introduced in patient selection and eval-
uation, this group may not represent patients with micro-
scopic hematuria seen by urologists outside of a tertiary
care setting or those seen by primary care physicians. Sec-
ondly, a paucity of outside medical records were available
to review in order to determine how the patients initially
were found to have microscopic hematuria (i.e., were they
diagnosed based on history, urine dipstick, microscopic
analysis). Thirdly, other urine based assays (e.g., NMP-22,
BTA, etc) also have reduced sensitivity in this cohort.
Lastly, there was no standardized follow-up protocol in
place to monitor patients with a negative hematuria eval-
uation in order to determine possible long-term develop-
ments.

The interpretation of urinary cytology can be extremely
challenging and should be used only as an adjunct to eval-
uation of upper tract and bladder. Due to the complex
nature of evaluating cytologic specimens, it is of utmost


I 66 (42%)



importance to have an experienced cytopathologist inter-
preting these results. Current urine based assays (e.g.,
NMP-22, BTA) are not at the point of being able to exon-
erate the bladder of harboring bladder cancer, thus
patients suspected of a bladder cancer should be evaluated
with upper tract imaging and cystoscopy. The addition of
urinary cytology in patients with gross hematuria may be
justifiable, however, its addition to the evaluation of the
patient with microscopic hematuria has an extremely low
yield in detecting cancer and may lead to unnecessary,
invasive procedures with known side effects not to men-
tion high costs.

Conclusion
Current practice patterns for the evaluation of micro-
scopic hematuria include assessing the lower and upper
urinary tracts. Due to the low prevalence of bladder cancer
and the low sensitivity of cytology detecting bladder can-
cer, the exact role of urinary cytology in the evaluation of
the patient with microscopic hematuria may be minimal.

Competing interests
Dr. Charles J. Rosser, Xceed Inc research scholarship to
study bladder cancer. All other authors declare that they
do not have a competing interests.

Authors' contributions
KN, AK, JP, SA-Authors queried hospital records, formu-
lated database and wrote manuscript.

KAI-Staff pathologist who assisted in the interpretation of
results

MC-Participated in the design of the study and performed
the statistical analysis


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Characteristic


Tobacco


P-Value


0.59


0.097


BMC Urology 2009, 9:12








BMC Urology 2009, 9:12


http://www.biomedcentral.com/1471-2490/9/12


CJR-Conceived of the study, and participated in its design Pre-publication history
and coordination The pre-publication history for this paper can be accessed
here:
All authors read and approved the final manuscript
http://!!www.biomedcentral.com/1471-2490/9/12/prepub
Acknowledgements
Joanne Clarke for revising and critically analysis of the intellectual content.

References
I. Grossfeld GD, Carroll PR: Evaluation of asymptomatic micro-
scopic hematuria. Urol Clin North Am 1998, 25:661-76.
2. Grossfeld GD, Litwin MS, Wolf JS Jr, Hricak H, Shuler CL, Agerter
DC, Carroll PR: Evaluation of asymptomatic microscopic
hematuria in adults: the American Urological Association
best practice policy--part II: patient evaluation, cytology,
voided markers, imaging, cystoscopy, nephrology evalua-
tion, and follow-up. Urology 2001, 57:604-10.
3. Mariani AJ: The evaluation of adult hematuria: a clinical
update. AUA Update Series 1998, 17:186-91.
4. Badalament RA, Hermansen DK, Kimmel M, Gay H, Herr HW, Fair
WR, Whitmore WF Jr, Melamed MR: The sensitivity of bladder
wash flow cytometry, bladder wash cytology, and voided
cytology in the detection of bladder carcinoma. Cancer 1987,
60:1423-7.
5. Novicki DE, Stern JA, Nemec R, Lidner TK: Cost-effective evalua-
tion of indeterminate urinary cytology. j Urol 1998, 160(3 Pt
I):734-6.
6. Grossfeld GD, Litwin MS, Wolf JS, Hricak H, Shuler CL, Agerter DC,
Carroll PR: Evaluation of asymptomatic microscopic hematu-
ria in adults: the American Urological Association best prac-
tice policy--part I: definition, detection, prevalence, and
etiology. Urology 2001, 57:599-603.
7. Murphy WM: Current status of urinary cytology in the evalua-
tion of bladder neoplasms. Hum Pathol 1990, 21:886-96.
8. Lang EK, Macchia RJ, Thomas R, Watson RA, Marberger M, Lechner
G, Gayle B, Richter F: Improved detection of renal pathologic
features on multiphasic helical CT compared with IVU in
patients presenting with microscopic hematuria. Urology
2003, 61:528-32.
9. Mostofi FK, Sorbin LH, Torloni H: Histological typing of urinary
bladder tumours. International classification of tumours 19.
Geneva: World Health Organization; 1973.
10. Murphy WM: ASCP survey on anatomic pathology examina-
tion of the urinary bladder. AmJ Clin Pathol 1994, 102:715-717.
I I. Greene FL, Page DL, Fleming ID: AJCC cancer staging manual.
6th edition. New York: Springer-Verlag; 2002.
12. Yeung L, Nakamura K, Kasraeian A, Pendleton J, Chang M, Anai S,
Rosser CJ: The Use of Three Serial Urinalyses to Detect
Hematuria. Is it Efficacious? American Urological Association Annual
Meeting. Anaheim, CA May 2007.
13. Hermansen DK, Badalament RA, Bretton PR, Kimmel M, Aswad CM,
Whitmore WF Jr, Melamed MR: Voided urine flow cytometry in
screening high-risk patients for the presence of bladder can-
cer. j Occup Med 1990, 32:894-7.
14. Planz B, Jochims E, Deix T, Caspers HP, Jakse G, Boecking A: The
role of urinary cytology for detection of bladder cancer. Eur
J Surg Oncol 2005, 3 1:304-8.
15. Dooley RE, Pietrow PK: Ureteroscopy for benign hematuria. Publish with BioMed Central and every
Urol Clin North Am 2004, 3 l(I):137-43. scientist can read your work free of charge
16. Yazaki T, Kamiyama Y, Tomomasa H, Shimizu H, Okano Y, liyama T,
lizumi T, Umeda T: Ureteropyeloscopy in the diagnosis of "BioMed Central will be the most significant development for
patients with upper tract hematuria: an initial clinical study, disseminating the results of biomedical research in our lifetime."
Int] Urol 1999, 6:219-25.
17. Paez A, CobaJM, Murillo N, Fernandez P, de la Cal MA, Lujin M, Ber- Sir Paul Nurse, Cancer Research UK
enguer A: Reliability of the routine cytological diagnosis in Your research papers will be:
bladder cancer. Eur Urol 1999, 35:228-32.
18. Nabi G, Greene DR, O'Donnell M: How important is urinary *available free of charge to the entire biomedicalcommunity
cytology in the diagnosis of urological malignancies? Eur Urol peer reviewed and published immediately upon acceptance
2003, 43:632-6.
19. Deshpande V, McKee GT: Analysis of atypical urine cytology in cited in PubMed and archived on PubMed Central
a tertiary care center. Cancer 2005, 105:468-75. yours you keep the copyright

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