Introduction
Endometrial carcinoma (EC) ranks as the sixth most
commonly occurring cancer in female patients, with 417,367 new
cases globally in 2020(1). Most EC
cases are diagnosed at an early stage, offering a favorable
prognosis; however, ~20% of patients present with high-grade EC,
characterized by extended disease and poor outcomes (2). Surgical staging, recommended by the
International Federation of Gynecology and Obstetrics (FIGO), is
typically the primary treatment approach for EC (3). This process involves abdominal
exploration, pelvic washings, hysterectomy, bilateral
salpingo-oophorectomy, omentectomy and systematic pelvic and
para-aortic lymphadenectomy.
The role of lymphadenectomy in the surgical
management of EC remains a topic of debate, particularly as many
patients are diagnosed at an early stage (4). Routine lymphadenectomy in all patients
may lead to unnecessary procedures, resulting in prolonged
operative time, extended hospital stay and risks such as vascular
injuries, hematomas, lymphocyst formation and ureteric and nerve
injury (5). However, although the
therapeutic benefits of lymphadenectomy are contested, it is key
for complete staging. Nodal stage of EC is a critical prognostic
factor and aids in tailoring adjuvant therapy (6).
Predicting lymph node invasion preoperatively and
intraoperatively could help avoid unnecessary lymphadenectomy
(7). In fact, Mariani et al
(7) proposed a selective lymph node
dissection criterion, suggesting lymphadenectomy can be omitted in
patients with preoperative endometrioid histology, grade 1 or 2
lesions, myometrial invasion ≤50% and a primary tumor diameter ≤2
cm. Conversely, patients with stage I and occult stage II disease
not meeting these criteria require comprehensive surgical staging,
including lymphadenectomy (7).
Therefore, tumor subtype and grade are key for risk stratification
before surgery. However, discordances in grading and histological
subtype between preoperative and final diagnoses may result in
either undertreatment, by underestimating the risk of lymph node
metastasis, or overtreatment, with unnecessary surgical procedures
and associated complications. Studies comparing endometrial biopsy
samples with surgical specimens have reported varying agreement
rates for FIGO grade and tumor subtype, generally ranging from 60
to 80% (8-11).
However, most of these studies are from Western countries, with a
lack of data from developing countries. Therefore, the present
study was designed to assess the concordance between preoperative
and postoperative pathology in a Bangladeshi referral center to
determine if preoperative endometrial curettage can reliably guide
the extent of surgery in EC in this patient population.
Materials and methods
Study design and participant
selection
The present single-center, cross-sectional
diagnostic-accuracy study was performed in a tertiary-care hospital
in a low-middle income country. All consecutive, eligible patients
who underwent hysterectomy for EC during the study period were
included. The study was conducted according to the guidelines of
the Declaration of Helsinki and approved by the Ethics Committee of
the National Institute of Cancer Research and Hospital (NICRH;
Dhaka, Bangladesh, approval no. NICRH/Ethics/2020/96). This
cross-sectional study assessed the agreement between
histopathological findings of preoperative endometrial curettage
and the final surgical specimen in EC. From July 2020 to June 2021,
48 outpatients (age: 29.5-79.2 years) with EC attending the
Department of Gynecological Oncology (NICRH) were included. Written
informed consent was obtained from all subjects. For illiterate
participants, written informed consent was obtained through a
thumbprint in the presence of an impartial witness, who confirmed
that the information was accurately conveyed and voluntarily agreed
to. The witness signed the consent form, in accordance with
international ethical guidelines for research involving human
subjects. Eligible participants were diagnosed by endometrial
curettage (dilatation and curettage) and underwent primary surgical
treatment. The index test consisted of the histological subtype and
FIGO grade as determined from the preoperative endometrial
curettage, which had been performed either at NICRH or at an
external facility. The reference standard was the final surgical
histopathology following hysterectomy. Inclusion criteria were as
follows: i) Preoperative endometrial curettage consistent with EC
and ii) subsequent hysterectomy with available final surgical
histopathology. Exclusion criteria were as follows: Neoadjuvant
therapy prior to surgery, non-EC histology on final pathology or
missing/indeterminate histological grade.
Study procedure
Patients with a preoperative diagnosis of EC by
endometrial curettage were enrolled. Preoperative endometrial
sampling (curettage) had been performed either at NICRH or at
external hospitals/clinics prior to referral. For patients sampled
outside NICRH, the original pathology report was obtained from the
referral records; centralized rereview of external slides/blocks
was not feasible because materials were not consistently available.
Final surgical histopathology following hysterectomy was performed
at NICRH. All consecutive eligible cases were included irrespective
of sampling location to reflect real-world practice. Preoperative
and postoperative histopathology reports and sociodemographic data
were collected from patients who underwent primary surgery outside
NICRH. Patients without prior treatment underwent surgery,
including laparotomy, peritoneal washing and total abdominal
hysterectomy with bilateral salpingo-oophorectomy. Pelvic and
para-aortic lymphadenectomy was performed according to the risk
stratification protocol (7). The
specimens were sent to NICRH Department of Pathology for
examination. Data were collected in detail and analyzed to assess
the agreement between preoperative and postoperative
histopathological findings.
Histopathology
Curettage and hysterectomy specimens were fixed in
10% neutral buffered formalin for ≥24 h at room temperature.
Paraffin embedding was performed, and blocks were sectioned at 4-5
µm. After deparaffinization and rehydration through graded
alcohols, sections were stained with Harris hematoxylin and eosin
following a standard protocol (3-5 min in hematoxylin and 1-2 min
in eosin) at room temperature, dehydrated and mounted with DPX.
Slides were examined by light microscopy. EC was classified as
endometrioid vs. non-endometrioid (including serous, clear cell,
undifferentiated carcinoma and carcinosarcoma). Tumor grade
followed standard FIGO architectural criteria (12): Grade 1 (≤5% solid non-squamous,
non-morular areas), grade 2 (6-50%) and grade 3 (>50%). Routine
digital slide imaging or image analysis was not performed.
Statistical analysis
Categorical data are presented as numbers and
percentages, while continuous data are presented as mean, standard
deviation and ranges. For binary classification of histological
subtype (endometrioid vs. non-endometrioid), diagnostic performance
was derived from the 2x2 contingency table. Sensitivity was
calculated as true positive (TP)/[TP + false negative (FN)];
specificity as true negatives (TN)/[TN + false positives (FP)];
positive predictive value as TP/(TP + FP); negative predictive
value as TN/(TN + FN); and diagnostic accuracy as (TP + TN)/n.
Two-sided 95% confidence intervals for these proportions were
computed by the exact (Clopper-Pearson) binomial method. For FIGO
grade, one vs. rest 2x2 tables were generated for each grade (grade
1 vs. all other grades; grade 2 vs. all other grades; grade 3 vs.
all other grades) to calculate the same metrics and confidence
intervals. Agreement between preoperative curettage and final
histopathology for subtype and grade was assessed using Cohen's κ
with 95% confidence intervals. Data were analyzed using SPSS for
Windows (version 25.0; IBM Corp.). P<0.05 was considered to
indicate a statistically significant difference.
Results
A total of 48 patients with EC were included.
Table I presents the
socio-demographic characteristics of the study participants. The
mean age was 53.8±13.0 years. The majority of patients had attained
primary education (23; 47.9%), and a notable proportion (13, 27.1%)
were illiterate. A total of 35 patients (73%) were postmenopausal
at presentation, and the remaining 13 subjects (27%) were
premenopausal. Most participants (35, 72.9%) were married, 11
(22.9%) were widowed, one (2.1%) was divorced and one (2.1%) was
never married.
 | Table IDemographic variables. |
Table I
Demographic variables.
| Characteristic | Value |
|---|
| Mean age, years | 53.8±13.0 |
| Level of education,
% | |
|
Illiterate | 13 (27.1) |
|
Primary | 23 (47.9) |
|
Secondary | 5 (10.4) |
|
Higher and
above | 7 (14.6) |
| Menopausal
status | |
|
Pre-menopausal | 13 (27.1) |
|
Post-menopausal | 35 (72.9) |
| Marital status | |
|
Single | 1 (2.1) |
|
Married | 35 (72.9) |
|
Divorced | 1 (2.1) |
|
Widowed | 11 (22.9) |
The histological subtype diagnostic characteristics
from the preoperative biopsy are detailed in Table II. Of the 43 patients
preoperatively diagnosed with endometrioid adenocarcinoma, 31
(72.1%) were confirmed. For endometrioid vs. non-endometrioid
classification, sensitivity was 93.9% (31/33; 95% CI: 79.8-99.3)
and specificity (Sp) was 20.0% (3/15; 95% CI: 4.3-48.1%). Of five
non-endometrioid lesions identified in preoperative curettage, two
(40.0%) were reclassified as endometrioid in the final pathology.
Of five non-endometrioid lesions identified in preoperative
curettage, two (40.0%) were reclassified as endometrioid in the
final pathology. Therefore, subtype agreement was slight (κ=0.17),
consistent with sparse non-endometrioid counts (Table III).
| Table IIDiagnostic characteristics of
preoperative endometrial curettage for diagnosing histological
subtypes. |
Table II
Diagnostic characteristics of
preoperative endometrial curettage for diagnosing histological
subtypes.
| | Postoperative
histological type | Diagnostic
characteristic |
|---|
| Preoperative
histological subtype | Endometrioid | Non-Endometrioid | Sn | Sp | PPV | NPV | DA |
|---|
| Endometrioid | 31 | 12 | 93.9 | 20.0 | 72.1 | 60.0 | 70.8 |
| Non-Endometrioid | 2 | 3 | (95%CI:
79.8-99.3) | (95%CI:
4.3-48.1) | (95%CI:
56.3-84.7) | (95%CI:
14.7-94.7) | (95%CI:
55.9-83.0) |
| Table IIIAgreement between the histological
subtype of preoperative endometrial curettage report and final
histopathology report. |
Table III
Agreement between the histological
subtype of preoperative endometrial curettage report and final
histopathology report.
| | Tumor cell type on
final histopathological report | |
|---|
| Tumor cell type on
preoperative biopsy report | Endometrioid (%) | Non-endometrioid
(%) | κ coefficient | P-value |
|---|
| Endometrioid | 31 (93.9) | 12 (80.0) | 0.170 | 0.143 |
| Non-endometrioid | 2 (6.1) | 3 (20.0) | (95% CI:
0.09-0.43) | |
Table IV outlines
the diagnostic properties of preoperative endometrial curettage for
FIGO tumor grading. The biopsy showed 57.1% Sn, 80.5% Sp, 33.3%
positive predictive value (PPV), 91.7% negative predictive value
(NPV) and 77.1% diagnostic accuracy (DA) for diagnosing FIGO grade
1. As shown in Table IV,
diagnostic performance varied by FIGO grade. Accuracy was highest
for grade 3 (93.8%), followed by grade 2 (79.2%) and grade 1
(77.1%; Table IV). Sensitivity was
lowest for grade 1 and highest for grade 2, whereas specificity
exceeded 95% for grade 3.
| Table IVDiagnostic characteristics of
preoperative endometrial curettage for diagnosing tumor grade. |
Table IV
Diagnostic characteristics of
preoperative endometrial curettage for diagnosing tumor grade.
| | Postoperative
grade | Diagnostic
characteristics |
|---|
| | v | |
|---|
| Preoperative
grade | 1 | Other | Sn | Sp | PPV | NPV | DA |
|---|
| 1 | 4 | 8 | 57.1 | 80.5 | 33.3 | 91.7 | 77.1 |
| Other grades | 3 | 33 | (95%CI:
18.4-90.1) | (95%CI:
65.1-91.2) | (95%CI:
9.9-65.1) | (95%CI:
77.5-98.2) | (95%CI:
62.7-88.0) |
| | 2 | Other | | | | | |
| Grade 2 | 29 | 3 | 80.6 | 75.0 | 90.6 | 56.3 | 79.2 |
| Other grades | 7 | 9 | (95%CI:
64.0-91.8) | (95%CI:
42.8-94.5) | (95%CI:
75.0-98.0) | (95%CI:
29.9-80.2) | (95%CI:
65.0-89.5) |
| | 3 | Other | | | | | |
| 3 | 3 | 1 | 60.0 | 97.7 | 75.0 | 95.5 | 93.8 |
| Other | 2 | 42 | (95%CI:
14.7-94.7) | (95%CI:
87.7-99.9) | (95%CI:
19.4-99.4) | (95%CI:
84.5-99.4) | (95%CI:
82.8-98.7) |
The overall agreement between preoperative and
postoperative tumor grading was moderate, as indicated by κ
statistic of 0.45 (Table V). Given
the limited sample, the present study did not perform stratified
accuracy analyses by sampling location (NICRH vs. external).
| Table VAgreement between grading of
preoperative endometrial curettage report and final histopathology
report. |
Table V
Agreement between grading of
preoperative endometrial curettage report and final histopathology
report.
| | Grading on final
histopathological report | |
|---|
| Grading on
preoperative biopsy report | Grade I (%) | Grade II (%) | Grade III (%) | κ coefficient | P-value |
|---|
| Grade I | 4 (57.1) | 7 (19.4) | 1 (20.0) | 0.450 (95% CI:
0.21-0.70) | <0.001 |
| Grade II | 2 (28.6) | 29 (80.6) | 1 (20.0) | | |
| Grade III | 1 (14.3) | 0 (0.0) | 3 (60.0) | | |
Discussion
The present study examined the reliability of
preoperative endometrial curettage for predicting final
histopathology in a low-resource setting. Compared with cohorts
(8-11)
from higher-income countries, where patients tend to be older and
have higher levels of educational attainment, our population
reflects a younger and more socio-economically disadvantaged group.
Such contextual differences may influence patterns of presentation,
access to imaging, and the feasibility of comprehensive staging.
Previous studies from well-resourced settings have reported
variable but generally moderate agreement between preoperative and
final histopathology, particularly for high-grade or
non-endometrioid tumors (8-11).
Our findings align with this in showing better concordance for
endometrioid cancers and more limited accuracy for non-endometrioid
subtypes and low-grade lesions. These observations highlight the
challenges of relying solely on curettage-based assessment in
environments where advanced diagnostic techniques or centralized
pathology review may not be available. Moreover, the slight
concordance in subtype (κ=0.17) mirrors findings from high-income
settings 8-11), where non-endometrioid tumors likewise demonstrate
low biopsy-to-hysterectomy agreement, reflecting the heterogeneity
and sampling limitations inherent to these histologies.
The present findings align with multiple
investigations in higher-income contexts (8-11),
which consistently document imperfect agreement between
preoperative biopsy and final surgical pathology (Table VI). For example, Batista et
al (13) found a fair overall
concordance for grading (κ=0.22) and noted that 15% of initially
designated grade 1 tumors were upgraded. Similarly, in a large
Turkish cohort, Göksedef et al (14) observed that nearly one-third of
tumors diagnosed as grade 1 were upgraded postoperatively,
illustrating how baseline curettage can underestimate tumor
aggressiveness.
| Table VIComparison of preoperative biopsy vs.
final pathology in EC. |
Table VI
Comparison of preoperative biopsy vs.
final pathology in EC.
| Study (Year) | Country
(Income) | No. of
Patients | Biopsy
Method(s) | Subtype
Concordance | Grade
Concordance | Upgrade /
Downgrade | Key
Observations | (Refs.) |
|---|
| Batista et
al, (2016) | Brazil (UMI) | 79 | Mix (~40%
hysteroscopy, ~38% D&C, ~12% other) | Some mismatch
(e.g., adenosquamous reclassified) | Overall: 60.8%
(κ=0.22, ‘fair’) G1: 67%, G2: 44%, G3: 40% Accuracy for final G1:
~67% | 15.2% of preop G1 →
G2/G3 | Authors consider
preop biopsy only a ‘modest’ predictor of final grade, stressing
need to include other pre/intraoperative parameters (imaging, tumor
markers). | (13) |
| Goksedef et
al, (2012) | Turkey (UMI) | 335 (endometrioid
only) | D&C | Not specifically
detailed | Accuracy: G1=
75.5%, G2= 66.2%, G3=88.3 | G1→G2: 32.9%,
G1→G3: 3.6%, G2→G3: 11.4% | Nearly 1/3 of
initially G1 tumors were upgraded, emphasizing underestimation of
high-grade disease with preop sampling. | (14) |
| Su et al,
(2015) | Taiwan (HI) | 203 | D&C vs. TCR
(transcervical resectoscopy) | Not reported | Not reported | TCR upgraded: 2.6%
D&C upgraded: 12.6% | Direct
visualization (TCR) greatly reduced underestimation compared to
D&C, suggesting more accurate surgical planning. | (26) |
| Lago et al,
(2018) | Spain (HI) | 332 | D&C (13%),
Pipelle (31%), Hysteroscopy (56%) | Not the main
focus | Accuracy: G1=
74.7%, G2= 73.2%, G3=89.8% | 14.2% upgraded,
11.7% downgraded; Hysteroscopy best (κ=0.55) | Large tumors (>3
cm) correlate with higher mismatch. Conclude hysteroscopy yields
better sampling vs. ‘blind’ methods (D&C or Pipelle). | (27) |
| Garcia et
al, (2017) | Brazil (UMI) | 166 | Mixed (D&C,
officea,
hysteroscopy) | Endometrioid:
93.2%, Non-endometrioid: 68.9% (κ=0.73) | G1: 61.5%, G2:
56.0%, G3: 78.9% (overall κ=0.46) | 1.9% G1→G3, 16%
G2→G3 | ‘Suboptimal’
accuracy: authors warn against fully trusting biopsy for surgical
decision-making. | (28) |
| Kisielewski et
al, (2016) | Poland (HI) | 204 total (160 EC,
44 atypical hyperplasia) | Fractional
curettage (D&C) | ~83.75% (overall),
~85.8% (endometrioid specifically) | ~69.31% | 34% of
‘hyperplasia’ were invasive | Emphasizes a
significant fraction of ‘atypical hyperplasia’ harbor true
carcinoma, underlining importance of definitive surgical
pathology. | (29) |
| Liberis et
al, (2021) | Greece (HI) | 203 | D&C | 94.1% (κ=0.73) | 89.1% (κ=0.76) | ~10.9% grade
mismatch, ~5.9% subtype mismatch | Despite
‘substantial’ agreement, caution remains for under-or overtreatment
due to remaining discordance. | (30) |
| Present Study | Bangladesh
(LMI) | 48 | D&C | Endometrioid:
93.9%, Non-endometrioid: 20% (κ=0.17) | G1: 77.1%, G2:
79.2%, G3: 93.8% (overall κ=0.45) | ~41.7% of G1
upgraded | Subtype accuracy
especially low for non-endometrioid. Additional diagnostic
strategies recommended given limited resources in LMIC
setting. | |
In the present study, subtype concordance between
preoperative curettage and final histopathology was slight
(κ=0.17), reflecting sparse non-endometrioid counts (five
preoperative; three confirmed). For endometrioid vs.
non-endometrioid classification, Sn was 93.9% (31/33) and Sp 20.0%
(3/15), with a PPV of 72.1% and NPV of 60.0%. Grading concordance
was higher than subtype concordance, although still limited,
particularly for low-grade tumors (κ=0.45): Grade-specific
diagnostic accuracy was 77.1 for grade 1, 79.2 for grade 2 and
93.8% for grade 3. These data suggest that relying solely on
preoperative curettage to determine the extent of surgery risks
under-treatment for certain patients and over-treatment for others,
particularly because access to intraoperative frozen section and
advanced imaging markedly improve the accuracy of preoperative
assessment of tumor grade and myometrial invasion, as demonstrated
in prior studies (15-25).
Beyond curettage, more targeted sampling is performed. Su et
al (26), for example, compared
dilation and curettage (D&C) with transcervical resectoscopy
(TCR) and reported an upgrade rate of 2.6% in the TCR group,
compared with 12.6% with D&C, suggesting that direct
visualization boosts diagnostic accuracy. Lago et al
(27) similarly demonstrated that
hysteroscopic biopsy yielded the highest κ-value (0.55), whereas
D&C showed the lowest (0.39) and noted 14.2% of tumors were
upgraded and 11.7% downgraded at final pathology.
Garcia et al (28) found 16% of grade 2 tumors being
upgraded to grade 3 and 1.9% of grade 1 lesions upgraded to grade
3, highlighting how higher grade disease can initially be
misclassified. Kisielewski et al (29) demonstrated 34% of patients
preoperatively labeled with atypical hyperplasia turned out to have
invasive carcinoma upon final assessment. Liberis et al
(30) reported that concordance for
subtype and grade both exceeded 80% but observed ~10% discordance,
underscoring the persistent risk of under- or overtreatment.
Taken together, the aforementioned studies suggest
preoperative sampling methods frequently underestimate tumor grade
and aggressiveness, particularly in lesions that appear
well-differentiated and direct visualization approaches
(hysteroscopy or TCR) generally outperform blind sampling. These
patterns point to the potential value of a multimodal approach
(imaging, pathology expertise, selected immunohistochemical
markers) where resources permit; however, these modalities were not
assessed in the present study, and no inferences about their
diagnostic performance can be drawn. The limitations in
preoperative biopsy are universal, although the gap in specialized
resources may be especially impactful in under-resourced
settings.
The present study focused on an LMIC referral
center, filling a gap in the literature where data are lacking, and
provided a direct comparison of preoperative and final
histopathology in a patient cohort that mirrors real-world clinical
circumstances in under-resourced settings. However, the present
study has limitations: The small, single-center sample limits
precision and generalizability, blinding of pathologists to
preoperative results was not feasible in this real-world setting
and some subgroup estimates are underpowered. These constraints,
which are common in LMIC tertiary-care settings, underscore the
need for larger multicenter validations and standardized
preoperative sampling protocols. Second, preoperative biopsies were
obtained both at NICRH and external facilities; because centralized
rereview of external slides was not systematically feasible,
variability in sampling technique and interpretive expertise may
have introduced misclassification. While this reflects real-world
care pathways in resource-constrained systems, it limits internal
validity; future multicenter work with standardized sampling and
central pathology review is needed. Moreover, estimates for
non-endometrioid disease are based on small numbers (five
preoperative; three confirmed), yielding wide confidence intervals
and an unstable κ for subtype (0.17), and should not be
over-interpreted. Furthermore, because the sample size was limited,
the present study did not have sufficient power for subgroup
analyses. Lastly, the present study did not assess whether more
advanced sampling methods (hysteroscopic or pipelle) would have
improved accuracy.
From a clinical standpoint, the present findings
suggest the importance of confirming risk stratification beyond
preoperative curettage, where feasible, while acknowledging the
preliminary, single-center nature of these estimates. Relying
exclusively on curettage in suspected low-grade cases risks
undertreatment if the tumor is actually higher grade or
non-endometrioid. Conversely, overtreatment may occur if the
preoperative biopsy suggests a more aggressive lesion than is
confirmed on final histopathology. This is particularly crucial in
resource-limited settings, where patient comorbidities may make
extensive surgical staging risky and cost-effective decision-making
is paramount. Where available, adjunct approaches such as
immunohistochemical biomarkers and imaging may refine preoperative
risk stratification; however, these modalities were not evaluated
in the present study.
Larger multicenter studies are warranted to validate
the present results and explore how emerging technologies, such as
office-based hysteroscopic biopsy or low-cost molecular markers,
may improve diagnostic accuracy. Additionally, research examining
how these findings translate into treatment outcomes, including
rates of overtreatment or undertreatment, is key. In LMICs,
collaborative efforts to standardize pathology review, train
specialized gynecological pathologists and optimize imaging
resources could help mitigate the diagnostic pitfalls.
In the present preliminary single-center study from
a LMIC, preoperative endometrial curettage showed moderate
agreement with final histopathology for subtype and grade. These
results should be interpreted cautiously given the small sample and
single-center design and should inform, rather than determine,
preoperative risk stratification and surgical planning. Larger
multicenter studies using standardized sampling and pathology
protocols are needed to refine estimates and identify
context-appropriate pathways.
Despite being conducted in a resource-limited
setting, the present findings are in line with those from
high-income countries (8-11),
indicating similar challenges in the preoperative assessment of EC
across healthcare settings.
Acknowledgements
Not applicable.
Funding
Funding: No funding was received.
Availability of data and materials
The data generated in the present study may be
requested from the corresponding author.
Authors' contributions
RK conceived and designed the study, performed the
literature review and analyzed data. SP, TN, EG, RA, AAZ and AGM
analyzed and interpreted data and revised the manuscript. RA and
MKB performed the literature review. All authors have read and
approved the final manuscript. RK and SP confirm the authenticity
of all the raw data.
Ethics approval and consent to
participate
The study was conducted according to the guidelines
of the Declaration of Helsinki and approved by the Ethics Committee
of the National Institute of Cancer Research and Hospital (Dhaka,
Bangladesh, approval no. NICRH/Ethics/2020/96). Written informed
consent was obtained from all subjects.
Patient consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing
interests.
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