f7750b8d00f59984283bb7398857be57 pmc_9221256.pdf 3467efe7e7aa0ff78dafee4afce128fc068239f6 pmc_9221256.pdf bc8f2949c77a3c2dacfeedaf2f9d05106b503b436c06598b6340cc42ec4f36f3 pmc_9221256.pdf Title: A Fibrosis Biomarker Early Predicts Cardiotoxicity Due to Anthracycline-Based Breast Cancer Chemotherapy Subject: Anthracycline-based cancer chemotherapy (ACC) causes myocardial fibrosis, a lesion contributing to left ventricular dysfunction (LVD). We investigated whether the procollagen-derived type-I C-terminal-propeptide (PICP): (1) associates with subclinical LVD (sLVD) at 3-months after ACC (3m-post-ACC); (2) predicts cardiotoxicity 1-year after ACC (12m-post-ACC) in breast cancer patients (BC-patients); and (3) associates with LVD in ACC-induced heart failure patients (ACC-HF-patients). Echocardiography, serum PICP and biomarkers of cardiomyocyte damage were assessed in two independent cohorts of BC-patients: CUN (n = 87) at baseline, post-ACC, and 3m and 12m (n = 65)-post-ACC; and HULAFE (n = 70) at baseline, 3m and 12m-post-ACC. Thirty-seven ACC-HF-patients were also studied. Global longitudinal strain (GLS)-based sLVD (3m-post-ACC) and LV ejection fraction (LVEF)-based cardiotoxicity (12m-post-ACC) were defined according to guidelines. BC-patients: all biomarkers increased at 3m-post-ACC versus baseline. PICP was particularly increased in patients with sLVD (interaction-p < 0.001) and was associated with GLS (p < 0.001). PICP increase at 3m-post-ACC predicted cardiotoxicity at 12m-post-ACC (odds-ratio 2.95 per doubling PICP, p 0.025) in both BC-cohorts, adding prognostic value to the early assessment of GLS and LVEF. ACC-HF-patients: PICP was inversely associated with LVEF (p = 0.004). In ACC-treated BC-patients, an early increase in PICP is associated with early sLVD and predicts cardiotoxicity 1 year after ACC. PICP is also associated with LVD in ACC-HF-patients. Keywords: anthracycline-based chemotherapy; myocardial fibrosis; biomarkers; global longitudinal strain; cardiotoxicity Author: Ana de la Fuente, Marta Santisteban, Josep Lupón, José Manuel Aramendía, Agnes Díaz, Ana Santaballa, Amparo Hernándiz, Pilar Sepúlveda, Germán Cediel, Begoña López, José María López Picazo, Manuel M. Mazo, Gregorio Rábago, Juan José Gavira, Ignacio García-Bolao, Javier Díez, Arantxa González, Antoni Bayés-Genís and Susana Ravassa Creator: LaTeX with hyperref Producer: pdfTeX-1.40.21 CreationDate: Wed Jun 15 10:52:40 2022 CEST ModDate: Wed Jun 15 10:59:03 2022 CEST Tagged: no UserProperties: no Suspects: no Form: none JavaScript: no Pages: 21 Encrypted: no Page size: 595.276 x 841.89 pts (A4) Page rot: 0 File size: 1655105 bytes Optimized: no PDF version: 1.7 name type encoding emb sub uni object ID ------------------------------------ ----------------- ---------------- --- --- --- --------- DGBDNV+VnURWPalladioL-Bold Type 1 Custom yes yes no 10 0 MWHIBA+VnURWPalladioL Type 1 Custom yes yes no 15 0 KWRUWF+URWPalladioL-Bold Type 1 Custom yes yes no 19 0 PIQDDC+URWPalladioL-Roma Type 1 Custom yes yes no 24 0 IEATLQ+URWPalladioL-Ital Type 1 Custom yes yes no 28 0 LCJEVJ+TimesNewRomanPS-BoldItalicMT Type 1C WinAnsi yes yes no 47 0 LFLYLN+CMSY10 Type 1 Builtin yes yes no 69 0 FPQCSC+PalatinoLinotype,Italic CID TrueType Identity-H yes yes yes 81 0 FPQCSC+PalatinoLinotype,Bold CID TrueType Identity-H yes yes yes 87 0 FPTMGB+PalatinoLinotype CID TrueType Identity-H yes yes yes 93 0 OVNEXW+EURM10 Type 1 Builtin yes yes no 107 0 QLBIEB+URWPalladioL-BoldItal Type 1 Custom yes yes no 114 0 FPQCSC+PalatinoLinotype,Italic CID TrueType Identity-H yes yes yes 129 0 FPQCSC+PalatinoLinotype,Bold CID TrueType Identity-H yes yes yes 135 0 FPTMGB+PalatinoLinotype CID TrueType Identity-H yes yes yes 141 0 FPQCSC+PalatinoLinotype,Italic CID TrueType Identity-H yes yes yes 159 0 FPDJLF+PalatinoLinotype,BoldItalic CID TrueType Identity-H yes yes yes 165 0 FPQCSC+PalatinoLinotype,Bold CID TrueType Identity-H yes yes yes 171 0 FPTMGB+PalatinoLinotype CID TrueType Identity-H yes yes yes 177 0 FPQCSC+PalatinoLinotype,Italic CID TrueType Identity-H yes yes yes 196 0 FPQCSC+PalatinoLinotype,Bold CID TrueType Identity-H yes yes yes 202 0 FPTMGB+PalatinoLinotype CID TrueType Identity-H yes yes yes 208 0 LJPPLL+PalatinoLinotype,Bold TrueType WinAnsi yes yes no 222 0 LJPPLN+PalatinoLinotype TrueType WinAnsi yes yes no 225 0 LJPPLP+PalatinoLinotype,Italic TrueType WinAnsi yes yes no 228 0 LJPPLL+PalatinoLinotype,Bold TrueType WinAnsi yes yes no 238 0 LJPPLN+PalatinoLinotype TrueType WinAnsi yes yes no 241 0 LJPPLP+PalatinoLinotype,Italic TrueType WinAnsi yes yes no 244 0 MPUDFL+PazoMath Type 1 Builtin yes yes no 251 0 FPQCSC+PalatinoLinotype,Italic CID TrueType Identity-H yes yes yes 263 0 FPQCSC+PalatinoLinotype,Bold CID TrueType Identity-H yes yes yes 269 0 FPTMGB+PalatinoLinotype CID TrueType Identity-H yes yes yes 275 0 Jhove (Rel. 1.22.1, 2019-04-17) Date: 2023-09-28 02:34:45 CEST RepresentationInformation: pmc_9221256.pdf ReportingModule: PDF-hul, Rel. 1.12.1 (2019-04-17) LastModified: 2023-09-27 02:17:41 CEST Size: 1655105 Format: PDF Version: 1.7 Status: Well-Formed and valid SignatureMatches: PDF-hul MIMEtype: application/pdf PDFMetadata: Objects: 450 FreeObjects: 1 IncrementalUpdates: 0 DocumentCatalog: PageLayout: SinglePage PageMode: UseNone Outlines: Item: Title: Introduction Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@262b2c86 Item: Title: Materials and Methods Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@371a67ec Children: Item: Title: Patients with BC (CUN Cohort) Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@5ed828d Children: Item: Title: Study Protocol Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@50d0686 Item: Title: Study Endpoints Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@7a3d45bd Item: Title: Patients with BC (HULAFE Cohort) Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@1e7c7811 Children: Item: Title: Study Protocol Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@77ec78b9 Item: Title: Study Endpoints Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@1a3869f4 Item: Title: Patients with ACC-Induced HF Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@a38d7a3 Item: Title: Circulating Biomarkers Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@77f99a05 Item: Title: Statistical Analysis Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@63440df3 Item: Title: Results Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@3aeaafa6 Children: Item: Title: Serum Biomarkers and ACC-Induced Subclinical LVD at 3 Months-Post-ACC in BC Patients (CUN Cohort) Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@76a3e297 Item: Title: Serum Biomarkers and Prognosis of ACC-Induced Cardiotoxicity at 12 Months Post-ACC in BC Patients (CUN and HULAFE Cohorts) Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@4d3167f4 Item: Title: Serum Biomarkers and LVD in ACC-HF Patients Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@ed9d034 Item: Title: Discussion Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@6121c9d6 Item: Title: Conclusions Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@87f383f Item: Title: References Destination: edu.harvard.hul.ois.jhove.module.pdf.PdfSimpleObject@4eb7f003 Info: Title: A Fibrosis Biomarker Early Predicts Cardiotoxicity Due to Anthracycline-Based Breast Cancer Chemotherapy Author: Ana de la Fuente, Marta Santisteban, Josep Lupón, José Manuel Aramendía, Agnes Díaz, Ana Santaballa, Amparo Hernándiz, Pilar Sepúlveda, Germán Cediel, Begoña López, José María López Picazo, Manuel M. Mazo, Gregorio Rábago, Juan José Gavira, Ignacio García-Bolao, Javier Díez, Arantxa González, Antoni Bayés-Genís and Susana Ravassa Subject: Anthracycline-based cancer chemotherapy (ACC) causes myocardial fibrosis, a lesion contributing to left ventricular dysfunction (LVD). We investigated whether the procollagen-derived type-I C-terminal-propeptide (PICP): (1) associates with subclinical LVD (sLVD) at 3-months after ACC (3m-post-ACC); (2) predicts cardiotoxicity 1-year after ACC (12m-post-ACC) in breast cancer patients (BC-patients); and (3) associates with LVD in ACC-induced heart failure patients (ACC-HF-patients). Echocardiography, serum PICP and biomarkers of cardiomyocyte damage were assessed in two independent cohorts of BC-patients: CUN (n = 87) at baseline, post-ACC, and 3m and 12m (n = 65)-post-ACC; and HULAFE (n = 70) at baseline, 3m and 12m-post-ACC. Thirty-seven ACC-HF-patients were also studied. Global longitudinal strain (GLS)-based sLVD (3m-post-ACC) and LV ejection fraction (LVEF)-based cardiotoxicity (12m-post-ACC) were defined according to guidelines. BC-patients: all biomarkers increased at 3m-post-ACC versus baseline. PICP was particularly increased in patients with sLVD (interaction-p < 0.001) and was associated with GLS (p < 0.001). PICP increase at 3m-post-ACC predicted cardiotoxicity at 12m-post-ACC (odds-ratio 2.95 per doubling PICP, p 0.025) in both BC-cohorts, adding prognostic value to the early assessment of GLS and LVEF. ACC-HF-patients: PICP was inversely associated with LVEF (p = 0.004). In ACC-treated BC-patients, an early increase in PICP is associated with early sLVD and predicts cardiotoxicity 1 year after ACC. PICP is also associated with LVD in ACC-HF-patients. Keywords: anthracycline-based chemotherapy; myocardial fibrosis; biomarkers; global longitudinal strain; cardiotoxicity Creator: LaTeX with hyperref Producer: pdfTeX-1.40.21 CreationDate: Wed Jun 15 10:52:40 CEST 2022 ModDate: Wed Jun 15 10:59:03 CEST 2022 ID: 0xb8aecf3b5f71177232e291f6ff303864, 0xb8aecf3b5f71177232e291f6ff303864 Filters: FilterPipeline: FlateDecode Fonts: Type1: Font: BaseFont: QLBIEB+URWPalladioL-BoldItal FontSubset: true FirstChar: 110 LastChar: 112 FontDescriptor: FontName: QLBIEB+URWPalladioL-BoldItal Flags: Symbolic FontBBox: -170, -300, 1073, 935 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: KWRUWF+URWPalladioL-Bold FontSubset: true FirstChar: 3 LastChar: 241 FontDescriptor: FontName: KWRUWF+URWPalladioL-Bold Flags: Symbolic FontBBox: -152, -301, 1000, 935 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: LFLYLN+CMSY10 FontSubset: true FirstChar: 0 LastChar: 21 FontDescriptor: FontName: LFLYLN+CMSY10 Flags: Symbolic FontBBox: -29, -960, 1116, 775 FontFile: true Font: BaseFont: PIQDDC+URWPalladioL-Roma FontSubset: true FirstChar: 1 LastChar: 252 FontDescriptor: FontName: PIQDDC+URWPalladioL-Roma Flags: Symbolic FontBBox: -166, -283, 1021, 943 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: DGBDNV+VnURWPalladioL-Bold FontSubset: true FirstChar: 161 LastChar: 243 FontDescriptor: FontName: DGBDNV+VnURWPalladioL-Bold Flags: Symbolic FontBBox: -152, -301, 1000, 935 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: OVNEXW+EURM10 FontSubset: true FirstChar: 22 LastChar: 22 FontDescriptor: FontName: OVNEXW+EURM10 Flags: Symbolic FontBBox: -32, -243, 1060, 720 FontFile: true Font: BaseFont: MPUDFL+PazoMath FontSubset: true FirstChar: 68 LastChar: 68 FontDescriptor: FontName: MPUDFL+PazoMath Flags: Symbolic FontBBox: -40, -283, 878, 946 FontFile: true Font: BaseFont: IEATLQ+URWPalladioL-Ital FontSubset: true FirstChar: 40 LastChar: 121 FontDescriptor: FontName: IEATLQ+URWPalladioL-Ital Flags: Symbolic FontBBox: -170, -305, 1010, 941 FontFile: true EncodingDictionary: Differences: true Font: BaseFont: MWHIBA+VnURWPalladioL FontSubset: true FirstChar: 161 LastChar: 226 FontDescriptor: FontName: MWHIBA+VnURWPalladioL Flags: Symbolic FontBBox: -166, -283, 1021, 943 FontFile: true EncodingDictionary: Differences: true Pages: Page: Sequence: 1 Annotations: Annotation: Subtype: Link Rect: 54, 323, 152, 332 Annotation: Subtype: Link Rect: 34, 313, 87, 320 Annotation: Subtype: Link Rect: 34, 164, 96, 186 Annotation: Subtype: Link Rect: 126, 90, 154, 99 Annotation: Subtype: Link Rect: 34, 78, 147, 87 Annotation: Subtype: Link Rect: 34, 756, 152, 792 Annotation: Subtype: Link Rect: 515, 756, 560, 792 Annotation: Subtype: Link Rect: 233, 660, 244, 674 Annotation: Subtype: Link Rect: 324, 660, 335, 674 Annotation: Subtype: Link Rect: 462, 660, 473, 674 Annotation: Subtype: Link Rect: 301, 648, 312, 661 Annotation: Subtype: Link Rect: 391, 648, 402, 661 Annotation: Subtype: Link Rect: 251, 635, 262, 649 Annotation: Subtype: Link Rect: 218, 623, 229, 636 Annotation: Subtype: Link Rect: 114, 17, 265, 28 Annotation: Subtype: Link Rect: 410, 17, 560, 28 Annotation: Subtype: Link Rect: 34, 432, 87, 451 Page: Sequence: 2 Annotations: Annotation: Subtype: Link Rect: 323, 555, 330, 564 ActionDest: 288 Annotation: Subtype: Link Rect: 422, 530, 429, 539 ActionDest: 288 Annotation: Subtype: Link Rect: 406, 492, 413, 501 ActionDest: 288 Annotation: Subtype: Link Rect: 413, 492, 420, 501 ActionDest: 288 Annotation: Subtype: Link Rect: 534, 442, 541, 451 ActionDest: 288 Annotation: Subtype: Link Rect: 541, 442, 548, 451 ActionDest: 288 Annotation: Subtype: Link Rect: 549, 442, 556, 451 ActionDest: 288 Annotation: Subtype: Link Rect: 262, 404, 269, 413 ActionDest: 288 Annotation: Subtype: Link Rect: 269, 404, 276, 413 ActionDest: 288 Annotation: Subtype: Link Rect: 318, 379, 325, 388 ActionDest: 288 Annotation: Subtype: Link Rect: 429, 316, 436, 325 ActionDest: 288 Annotation: Subtype: Link Rect: 436, 316, 448, 325 ActionDest: 288 Annotation: Subtype: Link Rect: 417, 266, 429, 275 ActionDest: 291 Page: Sequence: 3 Annotations: Annotation: Subtype: Link Rect: 305, 365, 312, 377 ActionDest: 73 Page: Sequence: 4 Annotations: Annotation: Subtype: Link Rect: 461, 610, 473, 619 ActionDest: 291 Annotation: Subtype: Link Rect: 257, 522, 269, 531 ActionDest: 291 Annotation: Subtype: Link Rect: 238, 497, 250, 506 ActionDest: 291 Annotation: Subtype: Link Rect: 246, 242, 252, 254 ActionDest: 73 Page: Sequence: 5 Annotations: Annotation: Subtype: Link Rect: 486, 720, 498, 729 ActionDest: 291 Annotation: Subtype: Link Rect: 273, 381, 285, 390 ActionDest: 291 Page: Sequence: 6 Annotations: Annotation: Subtype: Link Rect: 424, 685, 436, 694 ActionDest: 291 Annotation: Subtype: Link Rect: 436, 685, 448, 694 ActionDest: 291 Annotation: Subtype: Link Rect: 324, 282, 331, 294 ActionDest: 118 Page: Sequence: 7 Page: Sequence: 8 Annotations: Annotation: Subtype: Link Rect: 302, 657, 309, 669 ActionDest: 118 Annotation: Subtype: Link Rect: 292, 607, 299, 619 ActionDest: 121 Annotation: Subtype: Link Rect: 389, 139, 396, 151 ActionDest: 148 Annotation: Subtype: Link Rect: 457, 102, 464, 114 ActionDest: 148 Annotation: Subtype: Link Rect: 498, 102, 505, 114 ActionDest: 121 Page: Sequence: 9 Annotations: Annotation: Subtype: Link Rect: 255, 336, 261, 344 ActionDest: 118 Annotation: Subtype: Link Rect: 505, 146, 512, 158 ActionDest: 151 Annotation: Subtype: Link Rect: 551, 121, 557, 133 ActionDest: 151 Page: Sequence: 10 Annotations: Annotation: Subtype: Link Rect: 194, 342, 201, 354 ActionDest: 184 Annotation: Subtype: Link Rect: 493, 329, 500, 341 ActionDest: 184 Page: Sequence: 11 Annotations: Annotation: Subtype: Link Rect: 553, 298, 559, 308 ActionDest: 118 Annotation: Subtype: Link Rect: 300, 227, 307, 239 ActionDest: 188 Annotation: Subtype: Link Rect: 353, 227, 360, 239 ActionDest: 216 Annotation: Subtype: Link Rect: 254, 214, 261, 226 ActionDest: 188 Annotation: Subtype: Link Rect: 307, 214, 314, 226 ActionDest: 216 Annotation: Subtype: Link Rect: 412, 176, 419, 188 ActionDest: 232 Annotation: Subtype: Link Rect: 195, 164, 202, 176 ActionDest: 232 Annotation: Subtype: Link Rect: 199, 151, 206, 163 ActionDest: 232 Annotation: Subtype: Link Rect: 251, 151, 258, 163 ActionDest: 232 Page: Sequence: 12 Page: Sequence: 13 Annotations: Annotation: Subtype: Link Rect: 256, 421, 262, 431 ActionDest: 118 Page: Sequence: 14 Annotations: Annotation: Subtype: Link Rect: 553, 238, 559, 248 ActionDest: 118 Annotation: Subtype: Link Rect: 519, 149, 526, 161 ActionDest: 248 Page: Sequence: 15 Annotations: Annotation: Subtype: Link Rect: 418, 336, 424, 346 ActionDest: 118 Annotation: Subtype: Link Rect: 500, 173, 507, 185 ActionDest: 255 Annotation: Subtype: Link Rect: 199, 111, 206, 123 ActionDest: 255 Page: Sequence: 16 Page: Sequence: 17 Annotations: Annotation: Subtype: Link Rect: 200, 502, 207, 511 ActionDest: 288 Annotation: Subtype: Link Rect: 208, 502, 220, 511 ActionDest: 291 Annotation: Subtype: Link Rect: 220, 502, 232, 511 ActionDest: 291 Annotation: Subtype: Link Rect: 235, 502, 247, 511 ActionDest: 291 Annotation: Subtype: Link Rect: 309, 427, 316, 436 ActionDest: 288 Annotation: Subtype: Link Rect: 317, 427, 329, 436 ActionDest: 288 Annotation: Subtype: Link Rect: 486, 402, 498, 411 ActionDest: 291 Annotation: Subtype: Link Rect: 335, 276, 342, 285 ActionDest: 288 Annotation: Subtype: Link Rect: 199, 176, 206, 185 ActionDest: 288 Annotation: Subtype: Link Rect: 543, 163, 555, 172 ActionDest: 291 Annotation: Subtype: Link Rect: 386, 151, 398, 160 ActionDest: 291 Annotation: Subtype: Link Rect: 401, 151, 413, 160 ActionDest: 291 Annotation: Subtype: Link Rect: 286, 113, 298, 122 ActionDest: 291 Page: Sequence: 18 Annotations: Annotation: Subtype: Link Rect: 343, 698, 349, 707 ActionDest: 288 Annotation: Subtype: Link Rect: 220, 673, 232, 682 ActionDest: 291 Annotation: Subtype: Link Rect: 357, 673, 369, 682 ActionDest: 294 Annotation: Subtype: Link Rect: 369, 673, 381, 682 ActionDest: 294 Annotation: Subtype: Link Rect: 525, 182, 560, 193 Annotation: Subtype: Link Rect: 165, 170, 375, 181 Page: Sequence: 19 Annotations: Annotation: Subtype: Link Rect: 135, 331, 173, 342 Annotation: Subtype: Link Rect: 179, 331, 215, 342 Annotation: Subtype: Link Rect: 312, 297, 350, 307 Annotation: Subtype: Link Rect: 356, 297, 392, 307 Annotation: Subtype: Link Rect: 519, 273, 557, 284 Annotation: Subtype: Link Rect: 59, 262, 95, 273 Annotation: Subtype: Link Rect: 104, 239, 142, 249 Annotation: Subtype: Link Rect: 148, 239, 184, 249 Annotation: Subtype: Link Rect: 340, 215, 378, 226 Annotation: Subtype: Link Rect: 384, 215, 420, 226 Annotation: Subtype: Link Rect: 509, 204, 547, 215 Annotation: Subtype: Link Rect: 319, 181, 357, 192 Annotation: Subtype: Link Rect: 356, 158, 393, 169 Annotation: Subtype: Link Rect: 109, 124, 146, 134 Annotation: Subtype: Link Rect: 59, 67, 96, 77 Page: Sequence: 20 Annotations: Annotation: Subtype: Link Rect: 240, 711, 277, 721 Annotation: Subtype: Link Rect: 283, 711, 319, 721 Annotation: Subtype: Link Rect: 436, 676, 474, 687 Annotation: Subtype: Link Rect: 480, 676, 516, 687 Annotation: Subtype: Link Rect: 59, 619, 96, 629 Annotation: Subtype: Link Rect: 102, 619, 138, 629 Annotation: Subtype: Link Rect: 59, 584, 96, 594 Annotation: Subtype: Link Rect: 503, 572, 541, 583 Annotation: Subtype: Link Rect: 198, 549, 235, 560 Annotation: Subtype: Link Rect: 130, 527, 168, 537 Annotation: Subtype: Link Rect: 262, 503, 300, 514 Annotation: Subtype: Link Rect: 126, 458, 164, 468 Annotation: Subtype: Link Rect: 95, 412, 132, 422 Annotation: Subtype: Link Rect: 236, 377, 273, 387 Annotation: Subtype: Link Rect: 279, 377, 315, 387 Annotation: Subtype: Link Rect: 519, 353, 557, 364 Annotation: Subtype: Link Rect: 59, 343, 95, 353 Annotation: Subtype: Link Rect: 394, 319, 431, 330 Annotation: Subtype: Link Rect: 437, 319, 473, 330 Annotation: Subtype: Link Rect: 99, 285, 137, 295 Annotation: Subtype: Link Rect: 208, 250, 246, 261 Annotation: Subtype: Link Rect: 164, 215, 201, 226 Annotation: Subtype: Link Rect: 380, 181, 417, 192 Annotation: Subtype: Link Rect: 95, 147, 133, 157 Annotation: Subtype: Link Rect: 59, 113, 96, 123 Annotation: Subtype: Link Rect: 108, 67, 146, 77 Page: Sequence: 21 Annotations: Annotation: Subtype: Link Rect: 253, 710, 290, 721 Annotation: Subtype: Link Rect: 297, 710, 333, 721 Annotation: Subtype: Link Rect: 122, 665, 159, 675 Annotation: Subtype: Link Rect: 165, 665, 201, 675 Checksum: c48ef0ea Type: CRC32 Checksum: f7750b8d00f59984283bb7398857be57 Type: MD5 Checksum: 3467efe7e7aa0ff78dafee4afce128fc068239f6 Type: SHA-1