Patent Application
20140005465
The present invention relates to a system, apparatus, method and computer program product for brachytherapy guidance, wherein a radiation source is to be placed or moved in relation to tissue, especially tumorous tissue, in order to provide a radiation dose to tissue, especially according to a radiation therapy plan, e.g. a therapy plan envisaging several therapy fractions.
Radiation source placement technology in brachytherapy usually is based on a system using ultrasound imaging or on a system using X-ray or computed tomography. Integrated into an applicator or a catheter, such a system for correct placement or localization is aimed to provide a correct radiation dose to tumorous tissue and to prevent excessive radiation of healthy tissue.
In treatments of e.g. prostate cancer, breast cavities, cervix cancer, tumors of the mouth and pharynx, lung cancer or liver cancer, there are two radiation therapy concepts commonly applied: the isotopic brachytherapy and the electronic brachytherapy. The main differences consist in the radiation energy which is considerably lower in electronic brachytherapy, providing radiation energy of e.g. max. 50 keV, (the radiation source can be turned off also) as well as in the treatment possibilities: in electronic brachytherapy, x-ray facilities as well as standard operation rooms might be used (short range and low mean energy of the radiation), which is not possible in isotopic brachytherapy, especially in so called high dose rate (HDR) brachytherapy. Generally, in isotopic brachytherapy, the radiation sources usually are millimeter-sized seeds of radioactive isotopes, like e.g. the iridium isotope Ir-192, providing radiation energy in the range of 350 keV.
For both radiation therapy concepts, the exact position of the applicator as well as the exact position of the seed or any other radiation source is vital. Usually, an applicator can be placed under real-time image guidance based on e.g. ultrasound (US) or x-ray, or it can be imaged after placement (based on e.g. computer tomographic CT techniques) or placed based on previously registered images, wherein the seed is pulled (where applicable robotically) through the applicator or through interstitially implanted catheters. Problems appear when it is required to displace the applicator, not least because one or several additionally required CT scans of the treatment area, or when the applicator moves between fractions, so that radiation exposure of the patient might be disadvantageously high. For example, in isotopic brachytherapy, imaging is done before each fraction, wherein during the course of therapy e.g. about ten CT scans can be required to check if the applicator did not move since the last fraction.
In particular, in HDR brachytherapy, basing the placement on pre-registered images or on real-time ultrasonic imaging severely limits the placement accuracy due to limited resolution or patient movement, organ movements (e.g. bowel, uterus), or tissue deformation (e.g. tissue compression by the applicator, swelling, etc). Further, when using x-ray or CT placement guidance, as suggested above, care must be taken to keep down the dose delivered through the imaging and CT time is often scarce. Also, x-ray imaging has limited soft tissue contrast, making it difficult to discern tumorous tissue, fat, or muscle. Other problems usually met in context with radiation therapy are missing information on local tissue characteristics, i.e. exact localization of various soft tissues or determination of the local tumor grade resp. the microvascular environment, the tissue pH, the tissue oxygenation or any extent of necrotic regions is not possible. Also, e.g. in treatment of lumpectomized breast cancer, the tumor cavity being filled by air or liquid might result in different dose distributions, complicating a therapy according to a specific dose plan.
Furthermore, identification of the target volume and critical organ margins relative to the implanted applicators and controlling and compensating for patient motion is often difficult. But adherence to the dose plan which might be created based on tumor stage, tumor size, imaging, biopsy, and potential surgical information is vital in any form of brachytherapy. Thus, all these items lead to large safety margins in order to ensure dose delivery to all areas of malignant and potentially malignant tissue at the expense of side-effects to the patient caused by radiation exposure of healthy tissue.
Recently designed devices for tissue monitoring in brachytherapy are based on e.g. optical observation systems facilitating the identification of the tissue region which is to be irradiated. In particular, such optical systems can be arranged within a catheter and rely on e.g. optical coherence tomography (OCT). More details about such optical analyzing applications can be found e.g. in the US 2008/0298548 A1 or US 2005/0187422 A1. It is however possible to use this visualization technology, not to achieve the function of an exact absolute position determination, but to analyze any data related to tissue characteristics, e.g. in combination with generation of a mark of the tissue region to be treated. Furthermore, magnetic navigation is a known technique for determining the position of a radiation source, which is disclosed in the WO 2007/083310 A2 or WO 2009/053897 A1. It is possible to use this technology to position the applicator in relation to tissue which is to be treated. In this way, a positioning of an x-ray source in relation to the tissue is possible.
It is an object of the present invention to provide a brachytherapy guidance system for acquiring exact position data of a radiation source within a body in order to reduce dosimetry deviations, e.g. due to the influence of applicator positioning and applicator attenuation. It is a further object of the present invention to provide an electronic brachytherapy guidance system with at least one position sensor for improving accuracy of position and movement information of a radiation source relative to the irradiated tissue. Also, it is an object of the present invention to provide a brachytherapy system for sparing healthy tissue of the patient as well as treatment personnel, and to facilitate radiation therapy, also in context with intra-fraction monitoring for a therapy plan envisaging several fractions or in context with adaptive re-planning. In other words, it is an aim of the present invention to improve source placement in vivo and thus achieve a higher precision in the administered dose and carry out a radiation therapy more effectively.
At least one of these objects is achieved by an apparatus as claimed in claim 1, an applicator device as claimed in claim 8, a system for integrated guidance for positioning a radiation source and/or its applicator within a body as claimed in claim 13, and a method for positioning a radiation source as claimed in claim 10. Thereby, the miniature radiation source can be provided e.g. in the form of a miniature x-ray tube or a radioactive source, e.g. Ir-192. Further, alternatively or in addition, means for local tissue sensing can also be incorporated in the system.
Accordingly, a brachytherapy guidance system, especially a low energy electronic brachytherapy guidance system, with one or more position sensors, especially tracking sensors, is provided for conducting a radiation therapy according to a dose plan, wherein an apparatus for guiding a radiation probe is provided which is arranged to provide an arrangement for combining several sensing techniques for acquiring position data as well as tissue data, especially with differing resolutions depending on a respective sensor. I.e., interventional guidance is provided by at least one position sensor adapted to a single of electromagnetic (EM) tracking and fiber Bragg grating (FBG) any fiber-optical shape sensing and localization technique e.g. based on Rayleigh scattering or other sensing techniques, especially optical sensing techniques, or a combination of these localization techniques, in order to improve source resp. tube placement as well as tissue treatment. By integrating guidance functions in a brachytherapy system, especially into an applicator and/or a catheter, the problems regarding lack of real-time imaging and imprecise radiation dose applied to tumorous tissue can be reduced or mitigated. Thereby, it has been found that in context with electronic brachytherapy providing much lower radiation energy, the radiation dose can be given with higher spatial resolution in the tissue, so that a surgeon can benefit of a more precise guiding in order to enhance the therapy plan and reduce tissue exposure. Also, a surgeon can benefit of more precise repeatable placement. In particular, it has been found that the exact positioning is more important for low-energy sources (e.g. mini-x-ray tubes) than for the traditional sources (e.g. Ir source, providing energies of more than 350 keV), especially because low energy allows for higher-resolution dose-painting. In non-implantable brachytherapy (meaning electronic and HDR isotopic), the radiation source is used with an applicator, which is placed first. It has been found that, in contrast thereto, a mini-x-ray-tube, especially directly on a probe, e.g. in the form of an endoscope, but thinner, can omit the use of an applicator, and thus call for accurate placement of the source directly instead of the applicator. Thereby, guiding means provided by an apparatus as claimed in claim 1 can be designed in the form of a probe, especially with the functionality of a thin endoscope, so that direct placement of the source can be realized, wherein only small incisions are required.
The brachytherapy guidance system can also be used in vessel applications, although the requirement of more precise guidance rather originates from brachytherapy since in vessel applications, guidance is given by the vessel itself in two dimensions and only the third dimension along the vessel has to be adjusted. Likewise, the requirement of more precise tissue monitoring rather originates from brachytherapy than from vessel applications, since a shorter radiation range in tissue is needed because the target tissue is closer.
Alternatively, or additionally, at least one tissue sensor resp. environment sensor for determining local tissue characteristics can be provided, e.g. based on spectroscopy measurements. By integrating tissue sensing functions in a brachytherapy system, the problems regarding low soft tissue contrast or missing information on the character of the irradiated tissue can be reduced or even mitigated.
Thereby, the guidance function can be based on fiber Bragg grating (FBG). In particular, a FBG sensor is a distributed Bragg reflector inscribed in a segment of an optical fiber. By periodic modification of the refractive index of the fiber core, a dielectric mirror is achieved. The FBG sensor transmits all wavelengths except the reflected so-called Bragg wavelength and a certain bandwidth around it, wherein the Bragg wavelength of a certain FBG sensor changes with strain and temperature. Therefore, FBG sensors are often used as sensors of strain, temperature or other measures translated into these. A large number of FBG sensors can be multiplexed in (along) a same fiber using optical frequency domain reflectometry in order to obtain measurements along a whole catheter.
A guidance function of the brachytherapy system can also be based on electromagnetic (EM) position sensors resp. electromagnetic (EM) tracking sensors, solely or in addition to fiber Bragg grating (FBG). Generally, electromagnetic (EM) tracking can be carried out by placing a patient in a low-frequency electromagnetic field and locating spatial localization means on or within the patient's body. Localization data can be acquired by the position, where applicable the real-time position, of these spatial localization means, e.g. a coil or a multitude of small coils, which can be incorporated into the radiation source and/or its applicator, especially at a distal end of the applicator. EM guidance systems are available from e.g. Traxtal Inc and SuperDimension Inc. Prior art includes e.g. US 2002/0143317 and A. ERNST et al.: Electromagnetic guidance for transbronchial biopsy of peripheral lung lesions: navigational bronchoscopy, CTSNet. The coils can function as position sensors and provide feedback on position (x, y, z) and movement (yaw, pitch, roll). Relating to the brachytherapy application of the present invention, the position sensor can be such a coil for EM tracking, e.g. placed at the distal end or tip of a radiation source.
Thus, the position of the radiation source resp. the guidance of the radiation source, e.g. a miniature x-ray tube, can be provided by FBG sensors or EM tracking, as mentioned above, but alternatively also by optical spectroscopy, optical coherence tomography (interferometric imaging using near-IR), and/or GPS or dGPS. These methods have different spatial resolution and may be used single or in combination. In other words, only one of these systems may be used, or several or all of them in combination, e.g. FBG for accuracy better than 1 mm, EM tracking for accuracy in the region above 1 mm, and dGPS for cm accuracy. Other tracking technologies are possible. Further, position detection and/or tissue analyzing can be carried out with respect to a field of view which is different than the field of view of the radiation source, especially in case there are provided more than one tissue sensor resp. position sensor. Thus, the brachytherapy applicator can be arranged for both probing the tissue which is to be irradiated and probing the local microenvironment.
Thereby, the localization data provided by these localization techniques can be used to confirm the placement of the applicator and/or the source relative to the therapy plan or to improve placement accuracy. An on-probe localization system can also be used for intra-fraction monitoring for confirmation of source/applicator position or adaptive re-planning. The tracing data can be stored and used to refine future treatment plans and for future correlation with long-term treatment outcome. The data output from the guidance system can be analyzed and displayed as is or combined into real-time images or projected onto pre-registered images. That is to say, when using the above described techniques for radiation source guidance, the data collected can be used for different purposes. First, spectral, ultrasound, EM, and FBG data can be used to position the miniature x-ray source and/or its applicator, before treatment or during treatment for adaptive re-planning Second, after placement, data collected before, during, and after irradiation with the radiation source may be used to plan following fractions, and to assess e.g. amount of tissue necrosis or fast radiation toxicity effects and changes in tissue perfusion indicative of delivered dose and tissue response to irradiation, i.e. treatment monitoring.
According to a first aspect, first tissue sensing means for generating tissue data related to tissue characteristics can be provided and arranged for providing the tissue data to a position control device and/or the power control device of a brachytherapy system in order to analyze tissue, especially tissue to be treated. The first tissue sensing means can be composed of at least one sensor of the group comprising a pH sensor, an O2 sensor, an optical spectroscopy sensor and an optical coherence tomography sensor. Thereby, reflectance spectroscopy as well as fluorescence detection can be used to detect/image e.g. inherent tissue fluorescence or previously administered tumor staining, e.g. for intraoperative or lumpectomy use of the system. Thus, the brachytherapy applicator can be arranged for both position sensing and probing the local microenvironment. Further, the first position sensing means can be composed of at least one sensor of the group comprising a fiber BRAGG grating (FBG) sensor, an optical spectroscopy sensor, an optical coherence tomography sensor and a GPS sensor. The apparatus can further be arranged for providing the first position sensing means in conjunction with at least one sensor of the group comprising an FBG sensor, an optical spectroscopy sensor, an optical coherence tomography sensor, an electromagnetic (EM) sensor, a pH sensor, an O2 sensor, and a GPS sensor.
In other words, in addition to a guidance function, a tissue monitoring function, especially a kind of photonic needle function can be integrated in an electronic brachytherapy system, wherein radiation resp. light is provided to the tissue area and reflected back to the applicator resp. to any analyzing apparatus ex vivo, i.e. outside the applicator resp. catheter, the light being supplied to the tissue area e.g. by means of optical fibers. Likewise, a light source can be arranged outside the applicator resp. catheter. Thereby, acquiring tissue data can simply be achieved by providing guiding means which are arranged for housing optical sensors as well as pH sensors and/or O2 sensors, wherein an ex vivo arrangement can ensure an applicator to be provided with small dimensions resp. diameter.
Various optical techniques are of interest for in vivo characterization in conjunction with brachytherapy. These include optical spectroscopy, optical coherence tomography, fluorescence and luminescence. Prior art includes e.g. WO 2009/050667 and WO 2009/109879. Accordingly, it has been recognized that by integrating a photonic needle function into the brachytherapy system, soft tissue contrast and high resolution real-time information or even imaging can be provided, allowing for improved sparing of organs at risk as well as possibilities to irradiate certain tumor volumes with a higher dose. Thereby, the photonic needle function can denote reflectance spectroscopy using visible to IR wavelengths and potentially fluorescence spectroscopy using UV. The excitation light can be provided via an optical fiber from a white light source ex vivo. The reflected light, which is also transmitted through the irradiated tissue, can be collected via an optical fiber and the analysis can be done with a grating spectrometer ex vivo. Excitation and reflected radiation may be transmitted through the same or through different optical fibers. The excitation radiation can be pulsed or continuous. Thereby, the detected spectrum varies as a function of tissue type, e.g. varies with fat content, tissue perfusion, and is different for tumorous and non-tumorous tissue. In a simplified version, it is possible to excite only at selected wavelengths using e.g. light emitting diodes (LEDs) and detecting only certain relevant wavelength intervals without using a spectrometer. The fiber(s) for the reflectance spectroscopy can be integrated in or at the radiation source or in or at an applicator. The detected spectra can be analyzed or displayed as is, e.g. using pattern recognition techniques, or in combination with or mapped onto real-time or pre-registered images. Detected spectra collected during photonic needle movement/stepping may even be used for spectra imaging.
According to a second aspect which can be combined with the above first aspect, the first position sensing means including its optical fiber can be arranged within guiding means, at least partially adjacent to the radiation source. Thereby, the expression at least partially adjacent implies that the sensing means can be arranged both next to the radiation source or (partially) within the radiation source. The first position sensing means can further be arranged at or at least proximate to the distal end of the guiding means. The apparatus can further comprise second position sensing means in the form at least one electromagnetic (EM) tracking sensor arranged within the guiding means. The second position sensing means can be arranged to provide the position data to the position control device and/or power control device of the brachytherapy system in order to position the radiation source within the body. The first and second position sensing means can further be arranged in such a way that both position data of the radiation source and the position data of the distal end can be provided. Thereby, the first and second position sensing means can provide different spatial resolution, e.g. in the range of cm, mm, or sub-mm accuracy. This provides the advantage of generating position data with respect to specific purposes.
According to a third aspect which can be combined with any one of the above first and second aspects, the first tissue sensing means can be arranged within the guiding means, at least partially adjacent to the radiation source, especially at or at least proximate to the distal end of the guiding means. The apparatus can further comprise second tissue sensing means in the form of at least one ultrasonic (US) probe which can be arranged within the guiding means. The second tissue sensing means can be arranged to provide the tissue data to the position control device and/or power control device of the brachytherapy system in order to analyze tissue, especially tissue to be treated. Thereby, the first tissue sensing means can be arranged to probe the tissue which is to be irradiated, and the second tissue sensing means can be arranged to probe local environment, or vice versa. That is to say, the first and second tissue sensing means have different fields of view, in order to provide a capacious resp. extensive impression of the treatment area to the surgeon. Further, the first and second tissue sensing means can be arranged in such a way that both tissue data of tissue to be irradiated by the radiation source and tissue data of tissue encompassing the tissue to be irradiated can be provided, especially with different resolution. Thereby, a surgeon can get an overview of the area in which the therapy is to be conducted, also during treatment, in order to ensure that sensitive tissue is not radiated excessively.
In other words, alternatively or in addition, for sensing of the tissue characteristics, a miniature ultrasound transducer (US probe) can be integrated in the brachytherapy system to provide soft tissue contrast (e.g. intra vascular ultrasound type). Thereby, regions of necrotic tissue and certain tumorous tissue types can be detected or imaged, as well as certain organ margins and gas. The output signals can be used or interpreted as is or integrated with real-time or pre-registered images from external imaging. Further, sensing of the tissue characteristics can be provided by use of optical spectroscopy, optical coherence tomography, pH meters, and/or O2 meters. The output from these tissue sensors can be used for feedback to adapt the dose plan or even to monitor the treatment in real-time. For example, the US probe can provide information on organ margins, gas, necrotic tissue, and spectroscopy/tomography can potentially detect bleedings or characterize tumor tissue. Data on pH and O2 level can give information on tissue/tumor radiosensitivity and can therefore be used for dose adaption.
Thus, the at least one tissue sensor can be a miniature US probes, an optical spectroscopy sensor, a sensor for optical coherence tomography, a pH meter, and/or an O2 meter. Other sensing technologies are possible. Further versions of sensors can include several chips for ultrasound mounted around the radiation source, around its applicator, around high voltage cabling or optical fibers. The same reasoning can be applied to the optical spectroscopy part, with several fibers or several output/input points positioned e.g. around the x-ray source or its applicator. The individual components may be arranged in various ways including all or some of the functions suggested by the present invention.
According to a fourth aspect which can be combined with any one of the above first, second and third aspects, the radiation source can be arranged within a radiation source guiding means, and the first position sensing means can be arranged within a position sensor guiding means which is provided adjacent to the radiation source guiding means. The first tissue sensing means can be being arranged within a tissue sensor guiding means which can be provided adjacent to the radiation source guiding means, so that the guiding means can provide a channel-like arrangement with each channel-like guiding means being arranged adjacent to at least one other of the channel-like guiding means. Thereby, the expression adjacent to implies that the guiding means can be arranged next to each other respectively in such a way that they directly contact each other, but also in such a way that there is a gap there between or any compensating material. Thereby, an arrangement can be provided which is flexible in view of providing different sensors with different sensor techniques or resolution. Also, one or several guiding means can be provided in such a way that the applicator possesses e.g. a specific stiffness resp. rigidity, or a specific elasticity.
According to a fifth aspect which can be combined with any one of the above aspects, the first tissue sensing means can be at least composed of an optical spectroscopy sensor using visible to infrared (IR) wavelength, and excitation light can be provided from a light source ex vivo via first optical fiber means. Reflected light can be provided via the first or via second optical fiber means. The apparatus can be connected to a grating spectrometer ex vivo for analyzing reflected light. Thereby, analyzing tissue data can be done effectively and by techniques which can be handled quite easily.
According to a sixth aspect which can be combined with any one of the above aspects, the second tissue sensing means can be provided in the form of at least one optical fiber which can be integrated, at least partially, in the radiation source within the radiation source guiding means, or which can be integrated at the radiation source within at least one of the guiding means. Alternatively, or in addition, the second tissue sensing means can be provided in the form of at least two chips for ultrasonic (US) detection, and the chips can be mounted around the radiation source and/or around the optical fiber and/or along the guiding means. Thereby, not only the characteristics of tissue encompassing the distal end of an applicator, but also tissue along the longitudinal extension of the applicator can be analyzed.
The above described techniques for radiation source guidance provide data that can be used for different purposes. Firstly, spectral, ultrasound, EM, and FBG data can be used to position the radiation source and/or its applicator, before treatment or during treatment for adaptive re-planning. Secondly, after placement, data collected before, during, and after irradiation with the radiation source may be used to plan following fractions and to monitor treatment. The output from these position or tissue sensors can be used to for accurate source placement relative to the target tissue, to monitor the treatment in real-time or for feedback to adapt the dose plan of current or future fractions.
Of course other guiding and tracking options can be used. For example, arrangement of the radiation source could be specifically adapted to the tissue area or to the shape of the applicator, and any position and/or tissue sensors could be arranged for optimal data acquisition.
It shall be understood that the apparatus of claim 1, the applicator device of claim 8, the method of claim 10, the system of claim 13 and the computer program of claim 15 have similar and/or identical preferred embodiments, in particular, as defined in the dependent claims.
It shall be understood that a preferred embodiment of the invention can also be any combination of the dependent claims with the respective independent claim.
These and other aspects of the invention will be apparent from and elucidated with reference to the embodiments described hereinafter.
In the following drawings:
In the following embodiments, an enhanced brachytherapy apparatus and system for exact radiation dose delivery is proposed where at least position data is generated by means of at least one position sensor and wherein additionally, tissue data is generated by means of at least one tissue sensor. The sensors can be based on e.g. optical sensing techniques.
According to the embodiments, a flexible brachytherapy system for generating position and/or tissue data before, during and/or after irradiation is provided, wherein the data can be used e.g. to plan following fractions of a therapy plan scheduling several fractions. Hence, the system is adapted to re-planning of brachytherapy. I.e., at least two different sensors are provided so that position data and/or tissue data can be provided by an applicator device in order to monitor treatment progress or to plan treatment according to a dose plan.
In the following, three embodiments using different sensors resp. a different combination of sensing techniques are described.
Generally, the first and/or second tissue sensing means 51, 52 as well as the first and/or second position sensing means 61, 62 can be arranged within the guiding means 32, 33, 34, at least partially adjacent to the radiation source 31, especially at or at least proximate to the distal end 30a of the guiding means 32, 33, 34. The guiding means 32, 33, 34 can be provided in the form of a channel-like structure, especially a solid multi-channel arrangement, so that generally, for each sensor, a specific channel-like or tube-like guiding device can be provided. Alternatively, several or all sensors can be provided within one specific channel of the guiding means. This means that each sensor can be provided in a specific channel, but at least two or even all sensor can be provided in one specific channel also, when appropriate. The channel-like arrangement provides a catheter or an applicator in the form of a needle, tubing or balloon design. In other words, basically, the brachytherapy probe can include several sensing means independently of its specific design, and independently of the number of channels, i.e., a single channel may be sufficient.
In summary, in brachytherapy where position information relating to a radiation source is to be generated, a guidance system is adapted to acquire and process position data or position and tissue data, so that high-precision interventional radiotherapy can be carried out, especially according to a dose plan and for intra-fraction monitoring for a therapy plan and/or adaptive re-planning. The data can be stored and used to refine future treatment plans and for future correlation with long-term treatment outcome, especially in context with low energy brachytherapy.
Other variations to the disclosed embodiments can be understood and effected by those skilled in the art in practicing the claimed invention, from a study of the drawings, the disclosure, and the appended claims.
In the claims, the word “comprising” does not exclude other elements or steps, and the indefinite article “a” or “an” does not exclude a plurality.
A single processor, sensing unit or other unit may fulfill the functions of several items recited in the claims. The mere fact that certain measures are recited in mutually different dependent claims does not indicate that a combination of these measures cannot be used to advantage.
It is noted that the proposed solution according to the above embodiments can be implemented at least partially in software modules at the relevant functional blocks of
A computer program may be stored/distributed on a suitable medium, such as an optical storage medium or a solid-state medium supplied together with or as part of other hardware, but may also be distributed in other forms, such as via the Internet or other wired or wireless telecommunication systems.
Any reference signs in the claims should not be construed as limiting the scope thereof.
In brachytherapy where position information relating to a radiation source is to be generated, a guidance system is adapted to acquire and process position data or position and tissue data, so that high-precision interventional radiotherapy can be carried out, especially according to a dose plan and for intra-fraction monitoring for a therapy plan or adaptive re-planning. The data can be stored and used to refine future treatment plans and for future correlation with long-term treatment outcome, especially in context with low energy brachytherapy.
| Number | Date | Country | Kind |
|---|---|---|---|
| 11159620.1 | Mar 2011 | EP | regional |
| Filing Document | Filing Date | Country | Kind | 371c Date |
|---|---|---|---|---|
| PCT/IB2012/051418 | 3/26/2012 | WO | 00 | 9/13/2013 |
