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<Provider Id="sundheddkcms"> <Item Id="{A2618E4C-E629-4753-99F3-FF886440D76F}" Name="prostata-specifikt-antigen-psa" Type="LHContentPage" ParentProviderId="sundheddkcms" ParentItemId="{488A3120-72F2-48D6-A3D5-6D54B0EC0D2E}" SortOrder="1300" PublishDate="2011-03-03T14:11:00" DeleteDate="2999-12-31T00:00:00" PotItemType=""> <Content> <HtmlField Name="PageContent"><![CDATA[<h2>Basisoplysninger</h2> <h3>Definition</h3> <h2>Resumé</h2> <ul> <li>Prostate-specific antigen (PSA) er et organ- og ikke et tumorspecifikt glycoprotein, der tilhører kallikrein peptidase familien</li> <li>PSA secerneres fra epitelcellerne i prostata i høj koncentration i prostatasekret</li> <li>PSA spalter proteiner i sædvæsken og nedsætter dermed viskositeten</li> <li>PSA er bundet til antikymotrypsin, α2-makroglobulin, antitrypsin og andre proteaseinhibitorer. Derfor kan måles både total-PSA og frit-PSA</li> <li>Koncentrationen af PSA i plasma målt i µg/L er 1/1.000.000 i forhold til prostatavæv</li> <li>PSA-koncentrationen i blodet stiger i takt med den aldersrelaterede øgning af prostatavolumen (<a href="~/link.aspx?_id=3452EB9CC5FD415D9E38A1BE08FB318B&_z=z">benign prostatahyperplasi</a>), eller særligt i forbindelse med vævsskade, som ved f.eks. prostatitis, <a href="~/link.aspx?_id=509F510E8A5E471C9C66BFB7F1B6BB02&_z=z">cystitis</a>, <a href="~/link.aspx?_id=1FB63E52817D4AEEA315EC48CA99E233&_z=z">urinretention</a>, instrumentering/bioptering eller <a href="~/link.aspx?_id=3A046BC097F0409886A99BB24469190A&_z=z">prostatakræft</a></li> <li>De benigne tilstande bør derfor udelukkes i forbindelse med et isoleret tilfælde af lettere PSA-forhøjelse, ligesom man bør undgå at teste PSA i forbindelse med akut cystit eller urinretention</li> <li>PSA er en uspecifik markør til screening for prostatacancer, da både benigne og maligne tilstande giver udslag</li> <li>I forbindelse med prostatakræft indgår PSA-niveauet, sammen med det kliniske tumorstadie og den histologiske gradering af biopsierne, i risikostratificering og dermed behandlingsvalg, samt ligeledes vigtigt i monitorering af behandlingseffekt af prostatakræft<a title="Polascik TJ, Oesterling JE, Partin AW, Prostate specific antigen: a decade of discovery--what we have learned and where we are going. J Urol 1999;162: 293-306" href="/%20" data-type="journal-reference" data-value="Polascik TJ, Oesterling JE, Partin AW, Prostate specific antigen: a decade of discovery--what we have learned and where we are going. J Urol 1999;162: 293-306" data-value-piped="Polascik TJ, Oesterling JE, Partin AW|Prostate specific antigen: a decade of discovery--what we have learned and where we are going.|J Urol|1999|162|293-306|10411025" data-url="reference-link" data-pubmedid="10411025"><sup>1</sup></a></li> <li> Den positive prædiktive værdi af serum PSA niveauer (ng/ml) for samtidig prostatakræft målt hos asymptomatiske mænd<a title="Hugosson J. European ranodomized study for prostate cancer: results of PSA-related screening in Göteborg. Parthenon Publishing Group, 1997: 179-184" href="%20" data-type="other-reference" data-value="Hugosson J. European ranodomized study for prostate cancer: results of PSA-related screening in Göteborg. Parthenon Publishing Group, 1997: 179-184" data-url="reference-link"><sup>2</sup></a> (Figur 1):</li> </ul> <p style="text-align: left;"><img alt="Den positive prædiktive værdi af serum PSA niveauer (ng/ml) for samtidig prostatakræft målt hos asymptomatiske svenske mænd" src="A1C87539B2BA44EFA7227889B666438A-350-164" style="height: 164px; width: 350px;" title="Den positive prædiktive værdi af serum PSA niveauer (ng/ml) for samtidig prostatakræft målt hos asymptomatiske svenske mænd" height="164" width="350"> </p> <ul> <li style="text-align: left;">Anbefaling af den nedenstående aldersdifferentierede øvre PSA grænseværdi er begrundet i ønsket om, at <ul> <li style="text-align: left;">Øge PSA testens sensitivitet og derved opnå tidligere diagnostik af klinisk signifikant sygdom hos yngre mænd</li> <li style="text-align: left;">Øge PSA testens specificitet og derved nedsætte risikoen for overdiagnostik og deraf følgende risiko for overbehandling af latent sygdom hos ældre mænd</li> </ul> </li> <li> <table> <tbody> <tr> <td><strong>Alder</strong></td> <td><strong>Øvre grænseværdi</strong></td> </tr> <tr> <td>Under 60 år</td> <td>>3,0 ng/ml</td> </tr> <tr> <td>60-70 år</td> <td>>4,0 ng/ml </td> </tr> <tr> <td>Over 70 år</td> <td>>5,0 ng/ml</td> </tr> </tbody> </table> </li> </ul> <h2>Synonymer</h2> <ul> <li>Prostataspecifikt antigen (PSA), total; tPSA; PSA, total, frit PSA (fraktion), frit PSA (indeks), frit PSA (ratio)</li> </ul> <h2>Fortolkninger</h2> <h3>Generelt</h3> <ul> <li>Den intraindividuelle variation på PSA er omkring 30 %</li> <li>Hos omkring 50 % af patienterne, som får påvist en tilfældig lidt/moderat forhøjet PSA, vil PSA være normaliseret spontant i løbet af 1 – 4 år</li> </ul> <h2>Indikationer for PSA-måling</h2> <h3>Behandlingskontrol af prostatacancer og opsporing af recidiv efter:</h3> <ul> <li>Kirurgisk intervention <ul> <li>PSA umåleligt (<0,2 µg/L) – vellykket</li> <li>Opfølgning hver 3. måned det første år, derefter hver halve år det andet år og derefter årligt gennem flere år</li> <li>Lave stabile PSA tyder på helbredelse</li> </ul> </li> <li>Strålebehandling:</li> <li>PSA < 2,0 + nadir - vellykket</li> <li>Opfølgning hver 6-12 måned</li> <li>OBS - mange stråleregimer sker i kombination med 6-36 måneders endokrinterapi, hvorfor serum-testosteron samtidig bør følges </li> <li>Hormonbehandling <ul> <li>Kontrol hver 3. – 6. måned</li> <li>Stabile værdier tyder på manglende progression i sygdomsudviklingen</li> </ul> </li> </ul> <h3>PSA-testning/screening</h3> <ul> <li>I det tidlige klinisk lokaliserede tilfælde af prostatakræft vil en forhøjet PSA-værdi typisk være eneste abnorme fund</li> <li>Skønt systematisk PSA-screening i store studier har vist at reducere den sygdomsspecifikke mortalitet, har det været på bekostning af en uacceptabel overdiagnostik og overbehandling<a title="Schröder FH, Hugosson J, Roobol MJ, Tammela TL, Ciatto S, Nelen V, Kwiatkowski M, Lujan M, Lilja H, Zappa M, Denis LJ, Recker F, Berenguer A, Määttänen L, Bangma CH, Aus G, Villers A, Rebillard X, van der Kwast T, Blijenberg BG, Moss SM, de Koning HJ, Auvinen A, ERSPC Investigators., Screening and prostate-cancer mortality in a randomized European study. N Engl J Med 2009;360: 1320-8" href="/%20" data-type="journal-reference" data-value="Schröder FH, Hugosson J, Roobol MJ, Tammela TL, Ciatto S, Nelen V, Kwiatkowski M, Lujan M, Lilja H, Zappa M, Denis LJ, Recker F, Berenguer A, Määttänen L, Bangma CH, Aus G, Villers A, Rebillard X, van der Kwast T, Blijenberg BG, Moss SM, de Koning HJ, Auvinen A, ERSPC Investigators., Screening and prostate-cancer mortality in a randomized European study. N Engl J Med 2009;360: 1320-8" data-value-piped="Schröder FH, Hugosson J, Roobol MJ, Tammela TL, Ciatto S, Nelen V, Kwiatkowski M, Lujan M, Lilja H, Zappa M, Denis LJ, Recker F, Berenguer A, Määttänen L, Bangma CH, Aus G, Villers A, Rebillard X, van der Kwast T, Blijenberg BG, Moss SM, de Koning HJ, Auvinen A, ERSPC Investigators.|Screening and prostate-cancer mortality in a randomized European study.|N Engl J Med|2009|360|1320-8|19297566" data-url="reference-link" data-pubmedid="19297566"><sup>3</sup></a></li> <li>PSA bør generelt kun testes hos mænd, som er grundigt orienteret om mulige konsekvenser af en forhøjet værdi</li> <li>I henhold til de landsdækkende <a href="https://www.dmcg.dk/Kliniske-retningslinjer/kliniske-retningslinjer-opdelt-paa-dmcg/daproca/opsporing-og-diagnostisk-udredning-af-prostatacancer/">DAPROCA retningslinjer</a> anbefales derfor følgende: </li> </ul> <ol> <li>PSA-testen bør tilbydes mænd med palpatorisk malignitetssuspekt hård, uregelmæssig eller asymmetrisk prostata, samt hos mænd > 45 år med symptomer, der rejser mistanke om prostatakræft, eksempelvis: <ul> <li><strong>a)</strong> Perineale smerter</li> <li><strong>b)</strong> Lymfødem svarende til genitalier og/eller underekstremiteter</li> <li><strong>c)</strong> Knoglesmerter</li> <li><strong>d)</strong> Gentagne tilfælde af hæmospermi </li> </ul> </li> <li>PSA-test kan tilbydes den velinformerede, familiært disponerede* mand > 45 år med en forventet restlevetid >10-15 år <ul> <li><strong>* Familiær disposition</strong> gælder for mænd, hvis familie opfylder min. ét af følgende kriterier og som er 1. gradsslægtning** til en mand med prostatacancer <ul> <li><strong>a)</strong> To 1. - eller 2. gradsslægtninge*** fra samme gren af familien diagnosticerede med klinisk betydende prostatacancer < 60 år</li> <li><strong>b)</strong> Tre indbyrdes 1. gradsslægtninge fra samme gren af familien, heraf minimum én diagnosticeret med klinisk signifikant prostatacancer < 60 år</li> </ul> </li> <li><strong>**1. gradsslægtninge</strong> omfatter far, brødre og sønner</li> <li><strong>***2. gradsslægtninge</strong> omfatter farfar og farbrødre samt morfar og morbrødre</li> <li><strong>3)</strong> PSA-test kan tilbydes mænd > 40 år med en forventet restlevetid >10-15 år og påvist patogen BRCA2-variant. Opfølgende forløb forestås af urinvejskirurgisk afdeling </li> </ul> </li> </ol> <ul> <li>Mænd som opsøger læge for at få en generelt helbredskontrol eller undersøgelse for monosymptomatiske vandladningsgener (LUTS) med normal rektaleksploration (DRE), <strong>bør ikke</strong> automatisk have foretaget en PSA-test, og vil under alle omstændigheder først skulle informeres om den manglende evidens for værdi heraf, samt evt. konsekvenser herved inden en diagnostisk test og undersøgelse påbegyndes.<a href="/EditorPage.aspx?da=core&id=%7BA2618E4C-E629-4753-99F3-FF886440D76F%7D&ed=FIELD7539693175&vs&la=da&fld=%7B850D32D3-55A1-49E4-9CDF-F0C88D91563C%7D&so=%2Fsitecore%2Fsystem%2FSettings%2FHtml%20Editor%20Profiles%2FRich%20Text%20LHPH&di=0&hdl=H7539693234&us=sitecore%5Cmibo&mo&pe=0&fbd=1" data-type="journal-reference" data-value="Østerø Í Jákupsstovu J, Brodersen J, Do men with lower urinary tract symptoms have an increased risk of advanced prostate cancer?. BMJ 2018;361: k1202" data-value-piped="Østerø Í Jákupsstovu J, Brodersen J|Do men with lower urinary tract symptoms have an increased risk of advanced prostate cancer?|BMJ|2018|361|k1202|29724877" data-url="reference-link" data-pubmedid="29724877" title="Østerø Í Jákupsstovu J, Brodersen J, Do men with lower urinary tract symptoms have an increased risk of advanced prostate cancer?. BMJ 2018;361: k1202"><sup>4</sup></a> Se i øvrigt patientinformation om <a href="~/link.aspx?_id=D4F43474C7B8491CB8ED042F8A83D97C&_z=z">PSA - skal du lade dig teste</a> </li> <li>Et Cochrane review, <span>baseret på 339 artikler identificeret ved den systematiske gennemgang bekræfter, at der mangler dokumentation for at anbefale systematisk PSA screening, og at risikoen for skadelige effekter forbundet med screening er uacceptabelt store<a title="Ilic D, Neuberger MM, Djulbegovic M, Dahm P. Screening for prostate cancer. Cochrane Database of Systematic Reviews 2013, Issue 1" href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004720.pub3/full" data-type="other-reference" data-value="Ilic D, Neuberger MM, Djulbegovic M, Dahm P. Screening for prostate cancer. Cochrane Database of Systematic Reviews 2013, Issue 1" data-url="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004720.pub3/full"><sup>5</sup></a><sup>,</sup><a href="https://uroweb.org/guidelines/prostate-cancer" data-type="other-reference" data-value="European Association of Urology Guidelines on Prostate Cancer, N. Mottet (chair), P.J. Bastian, J. Bellmunt, R.C.N. van den Bergh, M. Bolla, N.J. van Casteren, P. Cornford, S. Joniau, M.D. Mason, V. Matveev, T.H. van der Kwast, H. van der Poel, O. Rouvière, T. Wiegel" data-url="https://uroweb.org/guidelines/prostate-cancer" title="European Association of Urology Guidelines on Prostate Cancer, N. Mottet (chair), P.J. Bastian, J. Bellmunt, R.C.N. van den Bergh, M. Bolla, N.J. van Casteren, P. Cornford, S. Joniau, M.D. Mason, V. Matveev, T.H. van der Kwast, H. van der Poel, O. Rouvière, T. Wiegel"><sup>6</sup></a></span></li> <li>De lavt differentierede meget aggressive kræfttyper mister evnen til at producere PSA, som derfor typisk testes lav. Ved undladt DRE er der dermed risiko for alvorlig fejlvurdering af tilstanden</li> <li>PSA-velocity refererer til hastigheden, hvormed PSA-værdien tiltager over tid. En PSA-fordoblingstid på under 10 måneder skønnes forbundet med betydelig øget risiko for aggressiv sygdom</li> </ul> <h3><a href="~/link.aspx?_id=3A046BC097F0409886A99BB24469190A&_z=z">Prostatacancer</a></h3> <ul> <li>Prostatacancer diagnosticeres sjældent før 50-årsalderen, hvorefter incidensen stiger stejlt</li> <li>Prostatakræft udvikler sig generelt langsomt og meget forskelligt</li> <li>Mens hver 6. mand (17 %) får stillet diagnosen prostatakræft, dør ”kun” 1 af 30 mænd (3 %) af prostatakræft<a title="Jemal A, Thomas A, Murray T, Thun M, Cancer statistics, 2002. CA Cancer J Clin 2002;52: 23-47" href="%20" data-type="journal-reference" data-value="Jemal A, Thomas A, Murray T, Thun M, Cancer statistics, 2002. CA Cancer J Clin 2002;52: 23-47" data-value-piped="Jemal A, Thomas A, Murray T, Thun M|Cancer statistics, 2002.|CA Cancer J Clin|2002|52|23-47|11814064" data-url="reference-link" data-pubmedid="11814064"><sup>7</sup></a></li> <li>Diagnosen kunne ved intensiv opsporing reelt stilles hos mange flere, dvs. hos op imod ca. hver anden 60-årige mand og hos tre ud af fire 75-årige</li> <li>Hos de fleste vil forandringerne aldrig udvikle sig til klinisk kræftsygdom<a title="Sakr WA, Grignon DJ, Crissman JD, Heilbrun LK, Cassin BJ, Pontes JJ, Haas GP, High grade prostatic intraepithelial neoplasia (HGPIN) and prostatic adenocarcinoma between the ages of 20-69: an autopsy study of 249 cases. In Vivo 1994;8: 439-43" href="%20" data-type="journal-reference" data-value="Sakr WA, Grignon DJ, Crissman JD, Heilbrun LK, Cassin BJ, Pontes JJ, Haas GP, High grade prostatic intraepithelial neoplasia (HGPIN) and prostatic adenocarcinoma between the ages of 20-69: an autopsy study of 249 cases. In Vivo 1994;8: 439-43" data-value-piped="Sakr WA, Grignon DJ, Crissman JD, Heilbrun LK, Cassin BJ, Pontes JJ, Haas GP|High grade prostatic intraepithelial neoplasia (HGPIN) and prostatic adenocarcinoma between the ages of 20-69: an autopsy study of 249 cases.|In Vivo|1994|8|439-43|7803731" data-url="reference-link" data-pubmedid="7803731"><sup>8</sup></a></li> <li>Det store flertal af mænd med (erkendt og ikke erkendt) prostatakræft dør fortsat <strong>med </strong>og ikke <strong>af </strong>sygdommen</li> </ul> <h2>Fejlkilder (og kilder til normal variation)</h2> <h3>Giver høje værdier</h3> <ul> <li>Prostatahypertrofi – se tidligere</li> <li>Prostatitis, prostatainfarkt</li> <li>Kateter a demeure, urinretention, cystitis</li> <li>Voldsom fysisk aktivitet kan medføre moderat stigning</li> <li>Prostata biopsi og transuretral resektion kan også give forhøjede værdier</li> <li>Ejakulation indenfor de seneste 24 timer medfører forhøjede værdier</li> <li>OBS: I dagligdagen tages ikke længere hensyn til den marginale påvirkning, en almindelig rektal eksploration af prostata med fingrene via endetarmen kan medføre, da den ændring i PSA, undersøgelsen kan medføre, ikke er større end måleusikkerheden</li> </ul> <h3>Giver for lave værdier</h3> <ul> <li>Behandling af prostatahypertrofi med finasterid giver lave PSA-værdier <ul> <li>Tommelfingerregel ved finasteridbehandling: Aktuel PSA = målt PSA x 2</li> </ul> </li> <li>Behandling med statin giver lavere PSA-værdier</li> </ul> <h2>Prøvetagning</h2> <h3>Forberedelse</h3> <ul> <li>Prostatapalpation ved rektal eksploration, kateterbehandling, fysisk aktivitet og ejakulation påvirker normalt kun PSA-koncentrationen lidt og anses ikke som kontraindikation </li> <li>Transrektal ultralydsskanning påvirker ikke PSA</li> <li>Prostatamassage, cystoskopi og biopsi giver en betydelig stigning i PSA (2 – 4 gange) <ul> <li>Blodprøvetagning min. 3 uger efter</li> </ul> </li> <li>Operation med resektion giver en betydelig stigning i PSA <ul> <li>Blodprøvetagning min. 1 måned efter</li> </ul> </li> <li>Blodprøven bør ikke tages ved pågående prostatit <ul> <li>Blodprøvetagning min. 6 – 8 uger efter</li> </ul> </li> <li>Blodprøven bør ikke tages ved pågående cystit <ul> <li>Blodprøvetagning min. 3 uger efter</li> </ul> </li> </ul> <h3>ICPC-2</h3> <p>[ICPC]</p> <h3>ICD-10/SKS-koder</h3> <p>[ICD10]</p> <h2>Prostatapalpation ved rektaleksploration (DRE)</h2> <ul> <li>Prostatakræft - hård, uregelmæssig, knudret, udvisket midtfure</li> <li>Benign prostatahyperplasi - fast, glat elastisk konsistens</li> <li>Prostatitis - smertefuld palpation</li> </ul> <h2>Supplerende undersøgelser</h2> <h3>I almen praksis</h3> <ul> <li>Anamnese vedr. familiær disposition (se definition ovenfor)</li> <li>Urinundersøgelse</li> <li>Blodprøver</li> <li>Prostatapalpation ved rektaleksploration (hård, uøm og uregelmæssig knude). De fleste tilfælde af tidlig lokaliseret prostatakræft kan ikke erkendes ved palpation eller transrektal ultralydsskanning</li> <li>MR-skanning har øget muligheden for at identificere og lokalisere klinisk betydende kræftforandringer i prostata</li> <li>Bemærk, at omkring halvdelen af alle unormale PSA resultater normaliseres ved 1-4 års opfølgning, uden medicinsk eller kirurgisk intervention<a title="Eastham JA, Riedel E, Scardino PT, Shike M, Fleisher M, Schatzkin A, Lanza E, Latkany L, Begg CB, Polyp Prevention Trial Study Group., Variation of serum prostate-specific antigen levels: an evaluation of year-to-year fluctuations. JAMA 2003;289: 2695-700" href="%20" data-type="journal-reference" data-value="Eastham JA, Riedel E, Scardino PT, Shike M, Fleisher M, Schatzkin A, Lanza E, Latkany L, Begg CB, Polyp Prevention Trial Study Group., Variation of serum prostate-specific antigen levels: an evaluation of year-to-year fluctuations. JAMA 2003;289: 2695-700" data-value-piped="Eastham JA, Riedel E, Scardino PT, Shike M, Fleisher M, Schatzkin A, Lanza E, Latkany L, Begg CB, Polyp Prevention Trial Study Group.|Variation of serum prostate-specific antigen levels: an evaluation of year-to-year fluctuations.|JAMA|2003|289|2695-700|12771116" data-url="reference-link" data-pubmedid="12771116"><sup>9</sup></a></li> </ul> <h4>Vurdering af prøvesvar</h4> <p>Se figur 1</p> <ul> <li>Værdier 3-5 - Normal øvre aldersdifferentierede grænseværdier, men udelukker ikke kræft. Specielt anaplastiske højmaligne Gleason score 10-tumorer har mistet evnen til at producere PSA</li> <li>Værdier 4-10 - Gråzone, hvor hver tredje patient vil kunne diagnosticeres med prostatacancer </li> <li>Værdier 10-30 - Risikoen for cancer stiger med PSA niveauet. Ved cancer vil sygdommen typisk være lokal/lokal avanceret med mulighed for helbredelse</li> <li>Værdier >30 - den prædiktive værdi nærmer sig 50 %. Risikoen for lokalavanceret og ikke helbredelig sygdom stiger</li> <li>Værdier over 100 - typisk ensbetydende med dissemineret uhelbredelig prostatacancer. Svær cystit kan i sjældne tilfælde resultere i trecifret PSA værdi </li> </ul> <h4>Hurtigt stigende PSA</h4> <ul> <li>Er forbundet med klart dårligere prognose, end hvor stigningen sker langsomt <a href=" " data-type="journal-reference" data-value="D'Amico AV, Chen MH, Roehl KA, Catalona WJ, Preoperative PSA velocity and the risk of death from prostate cancer after radical prostatectomy.. N Engl J Med 2004;351: 125-35" data-value-piped="D'Amico AV, Chen MH, Roehl KA, Catalona WJ|Preoperative PSA velocity and the risk of death from prostate cancer after radical prostatectomy.|N Engl J Med|2004|351|125-35|15247353" data-url="reference-link" data-pubmedid="15247353" title="D'Amico AV, Chen MH, Roehl KA, Catalona WJ, Preoperative PSA velocity and the risk of death from prostate cancer after radical prostatectomy.. N Engl J Med 2004;351: 125-35"><sup>10</sup></a> </li> </ul> <h4>Kontrol af prostatakræft</h4> <ul> <li>Ved behandlingskontrol anvendes PSA til at sikre effekt, recidiv og evt. progression af sygdommen - herunder udvikling af kastrationsresistens og metastaser</li> </ul> <h3>Andre undersøgelser</h3> <ul> <li>Multiparametrisk MR-skanning vil i dag typisk udgøre 1. billeddiagnostiske undersøgelse og være udslagsgivende i forhold til evt. diagnostiske biopsier</li> <li>Transrektal ultralydsskanning (TRUS)+/- transperineale biopsier, CT-skanning af thorax og abdomen, knoglescintigrafi samt PSMA-PET-CT</li> </ul> <h2>Tiltag og råd</h2> <h3>Henvisninger</h3> <ul> <li>Henvis til urolog ved 2 forhøjeede PSA-tests, symptomer eller suspekt rektal eksploration</li> </ul> <h3>Råd</h3> <ul> <li>Hurtigt stigende PSA er forbundet med dårligere prognose, end hvor øgningen sker langsomt<a href=" " data-type="journal-reference" data-value="D'Amico AV, Chen MH, Roehl KA, Catalona WJ, Preoperative PSA velocity and the risk of death from prostate cancer after radical prostatectomy.. N Engl J Med 2004;351: 125-35" data-value-piped="D'Amico AV, Chen MH, Roehl KA, Catalona WJ|Preoperative PSA velocity and the risk of death from prostate cancer after radical prostatectomy.|N Engl J Med|2004|351|125-35|15247353" data-url="reference-link" data-pubmedid="15247353" title="D'Amico AV, Chen MH, Roehl KA, Catalona WJ, Preoperative PSA velocity and the risk of death from prostate cancer after radical prostatectomy.. N Engl J Med 2004;351: 125-35"><sup>10</sup></a> </li> <li>Ved kontrol efter eller under behandling bruges PSA for at opspore recidiv, følge sygdomsaktivitet samt opdage udvikling af metastaser og kastrationsresistens</li> <li><a href="http://pro.medicin.dk/Laegemiddelgrupper/Grupper/291069">Antiandrogen behandling</a> virker antineoplastisk og reducerer ligesom finastrid PSA-niveauet </li> </ul> <h2>Patientinformation</h2> <h3>Hvad findes af patientinformation</h3> <ul> <li><a href="~/link.aspx?_id=D4F43474C7B8491CB8ED042F8A83D97C&_z=z">PSA - skal du lade dig teste?</a></li> <li>Informationsmateriale fra Region Midtjylland: <a rel="noopener noreferrer" href="https://www.psa-test.dk/" target="_blank">PSA-test</a></li> </ul> <h3>Animationer og video</h3> <ul> <li><a href="~/link.aspx?_id=EB2969F475724939B898F458CE61EA07&_z=z">Prostata nålebiopsi</a></li> <li><a href="~/link.aspx?_id=FB4DB004289F4BA18111E42A0A759F4C&_z=z">Godartet forstørret prostata</a></li> <li><a rel="noopener noreferrer" href="https://www.cancer.dk/prostatakraeft/undersogelser-prostatakraeft/hvem-boer-fa-malt-psa-p3/" target="_blank">Hvem bør få målt PSA i blodet?</a> Information fra Kræftens Bekæmpelse</li> <li><a href="https://www.sundhed.dk/sundhedsfaglig/information-til-praksis/midtjylland/almen-praksis/regionalt/cancer-i-praksis/arbejdsredskaber-til-praksis/dialogguide/">Dialogpakke om prostatacancer, Cancer i Praksis, Information til praksis, Midtjylland</a></li> </ul> <h2>Vejledninger</h2> <ul> <li><a href="https://vaelgklogt.dk/anbefalinger/blodproever">Blodprøver | Vælg Klogt (vaelgklogt.dk)</a></li> </ul>]]></HtmlField> <LinkListField Name="Spot2"> <LinkField linktype="internal">{99A85AFD-2F7A-4B5D-A1C9-C2701D5E7D30}</LinkField> </LinkListField> <TextField Name="DoctorsHandbookID">34023</TextField> <TextField Name="PageTitle">Prostata specifikt antigen (PSA)</TextField> <TextField Name="NavigationTitle">Prostata specifikt antigen (PSA)</TextField> <CheckBoxField 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f9XXR/+4fc/wDZZirvqf5lf9XXR/8AuH3P/ZZirvqf5lf9XXR/+4fc/wDZZirvqf5lf9XXR/8AuH3P/ZZirvqf5lf9XXR/+4fc/wDZZirvqf5lf9XXR/8AuH3P/ZZirvqf5lf9XXR/+4fc/wDZZirRs/zJof8AcrpH/cPuf+yzFU18scv8OaXy3P1SCpGwr6a/PFUzxV//1/VJ6Yq8886+VPO3mCDVNDMllNoupyRtbahLyS6sIwE9RYo1TjM4dPUhlaWNkd/i58MVQ17+X/maUal5fie2PlfV9WXVri7Zn+txq08dzPbrFxKP6s0Z4zeovBJP7tuOKsq8w6Bd6vqumo3BNJtWa7uv9+S3EVPqqEU/u43JuD8X97DD/lYqkf5X+S9b8t/Wf0iIIhJbWVsyW8jSCe4tRKJ76QsqcZrv1E5r8f8AdLykfFWdyQxSU9RA1OlRXFXg3lVVW5sAoAAvF2H/ADEHFXvgxV2KuxV2KuxV2KuxV2KuxV2KuxV2KuxV2KuxV2KuxV2KuxVhf5vf8oTJ/wAx+l/91G3zJ0n95H3olyeFfmX/AMc2w/5iX/6g7jOl1vIe/wD3rTF9QaX/AMc21/4wx/8AERnIt6JxV2KuxVjX5ef8o9P/ANtXWf8AurXWKslxV2KuxV2KuxV2KuJoMVSC58++T7aeW3n1a2SaBikqc68WXqppXcdxkhCR6ItM9J1fTdX0+PUNNuY7uxm5ejcQtyRuDFGoR4MrLkUqPlr/AJR3S/8AmEg/5NriqZYq/wD/0PVOKuxV2KuxV2KuxV4J5X/3qsP+Yxf+og4q97GKuxV2KuxV2KuxV2KuxV2KuxV2KuxV2KuxV2KqN1e2dpH6l1PHbx1A5yuqLU9BViMVUrTV9KvJDHaXsFxIo5FIpUdgtaVopO2KovFXYqwv83v+UJk/5j9L/wC6jb5k6T+8j70S5PCvzL/45th/zEv/ANQdxnS63kPf/vWmL6g0v/jm2v8Axhj/AOIjORb0TirsVdirGvy8/wCUen/7aus/91a6xVkuKuxV2KuxV2KuxVLfMsjx+XdUkRirpZzsrDYgiJiCMRzV8v6/5W0C38mT3MFlHHcLbI4kFa8m41PXvXOqngjHHsGgHd7v+SKqv5ZaWqgKolvgANgAL6fOazipkN4ZT5a/5R3S/wDmEg/5NrlSplir/9H1TirCfMP5iX+jTajctoc0mgaO8cepam0gib94qsz28LL/AKRHEJF5t6ifFySPmyYqtu/zNMGoXTrpbP5dsNQj0m+1n1VBjupGSMlYONXhimljill5rxbl8DcMVXx/mZbDX7mxu7UW2lwSXsK6k0oJ9TTokluC8XH93GEduEnNuXD7PxLirJdA1K51PR7W/ubVrKW6T1RauauiNugfYUfhx5r+w3w4qmBxV866Nqgt72wt7aI3d+boOlqhC0H1g0aRztGh8T9r9hWxV7INc86U/wCUaj/6T0/6pYq3+nfOn/UtR/8ASen/AFSxV36d86f9S1H/ANJ6f9UsVd+nfOn/AFLUf/Sen/VLFXfp3zp/1LUf/Sen/VLFXfp3zp/1LUf/AEnp/wBUsVd+nfOn/UtR/wDSen/VLFXfp3zp/wBS1H/0np/1SxV36d86f9S1H/0np/1SxV36d86f9S1H/wBJ6f8AVLFXfp3zp/1LUf8A0np/1SxV36d86f8AUtR/9J6f9UsVd+nfOn/UtR/9J6f9UsVd+nfOn/UtR/8ASen/AFSxV36c86f9S1H/ANJ6f9UsVeS+fbK88w+crj9OxT2LWNrbi1sobt2jT1TKXccBGvJ+IDfD+xm67LwRkCTzDCZpJ/ymjvdL/NLVP0VZnUZoraeARzXBRlhH1R/7xxJWjsfh/wAvKNfARv3rEvcv0750/wCpaj/6T0/6pZrGbv0750/6lqP/AKT0/wCqWKsV/MvVfM1x5W9K+0RLO1a/03ncC7WUrTUICPgEa15H4ftZk6T+8j70S5PJfzK/45un/wDMS/8A1B3GdLreQ9/+9aYve9O1zzmNPtgPLcbL6SUP15RUcR29LORb0T+nfOn/AFLUf/Sen/VLFXfp3zp/1LUf/Sen/VLFXHXfOn/UtR/9J6f9UsVY95F1nzdHoUyw+Xo5U/SerEt9dVaM2p3JZaekfssStf2sVZD+nfOn/UtR/wDSen/VLFXfp3zp/wBS1H/0np/1SxV36d86f9S1H/0np/1SxV36d86f9S1H/wBJ6f8AVLFXfp3zp/1LUf8A0np/1SxV36d86f8AUtR/9J6f9UsVS3zJrfnFvLuqCTy5GiG0nDsL5CQPSapp6QriOavGfM//ACgdz/zCR/8AGudfl/unH6vRvyk1bzTb+QLGKy0NLu2Sa99K4N2sRYG9mJ+AxtSh+H7WctqP7wt4eieWCT5c0uoofqkFR1/3WuUpTPFX/9L1SemKvLPNEnmjVvNklvqnlzUbvyrpksT2NrZm29O9nSj+tcmSZHMUUn91Bx4syerJy+FFVQ+o+WvMz6frfk6PS5ng1rXP0jHrKtGLaO0nu47ybnVvVE0XGWJEWP4/3fxYqyLzR5Os9R1+2jtdLijN7yuNb1TgAZIrcoY7Vm6n6zKsPq/zW8EiP+xiql+WC+cR9Z/T63YT6tZ+p9dYMx1Gkv14wcSaWv8AcekB8H2+C4qzW90+C7C+q0g4Vp6cjx9fHiRXFXg/k6ztra5s/RQKZL4PI3VmY3B+JmO7H54q+gRirsVdirsVdirsVdirsVdirsVdirsVdirsVdirxvz1/wCTA1L/AJgrL9c+dB2P9EmrIkX5N/8Ak39a/wCYe5/VY5i9pdf6yYPoEZqWx2KsL/N7/lCZP+Y/S/8Auo2+ZOk/vI+9EuTwr8y/+ObYf8xL/wDUHcZ0ut5D3/71pi+oNL/45tr/AMYY/wDiIzkW9E4q7FXYqxr8vP8AlHp/+2rrP/dWusVZLirsVdirsVdirsVSvzT/AMozq/8AzBXH/JpsRzV87eZ/+UDuf+YSP9S51+X+6+Tjjm9k/JP/AMlppn/GW+/6jp85bUf3hbwyfy1/yjul/wDMJB/ybXKUplir/9P1TirsVdirsVdirsVeCeV/96rD/mMX/qIOKvexirsVdirsVdirsVdirsVdirsVdirsVdirsVdirxvz1/5MDUv+YKy/XPnQdj/RJqyJF+Tf/k39a/5h7n9VjmL2l1/rJg+gRmpbHYqwv83v+UJk/wCY/S/+6jb5k6T+8j70S5PCvzL/AOObYf8AMS//AFB3GdLreQ9/+9aYvqDS/wDjm2v/ABhj/wCIjORb0TirsVdirGvy8/5R6f8A7aus/wDdWusVZLirsVdirsVdirsVSvzT/wAozq//ADBXH/JpsRzV87eZ/wDlA7n/AJhI/wBS51+X+6+Tjjm9k/JP/wAlppn/ABlvv+o6fOW1H94W8Mn8tf8AKO6X/wAwkH/JtcpSmWKv/9T1TiqS6n5w0DTtd0zQbm7Qatq7ulnaL8Uh4RvKzsB9lOMbfE37WKoO4/MPy7BrTaU7Tco7iOymvRE5tY7qYAxwPMBwWR+af7J0X7TYqqW3nrRLjXptFQyLPE00YuXTjbvLbKrzxpIerwrIpf8A2X8j4qmui6va6xpdvqdoHFrdL6kBkHEtGT8L0/ldfjX/ACWxVG4q+e9F1G0sZNPkuXIregIiqzu5FxWiIoLMafyjFXsg87aR/vi//wCkG6/6p4q3/jfSP98X/wD0g3X/AFTxV3+N9I/3xf8A/SDdf9U8Vd/jfSP98X//AEg3X/VPFXf430j/AHxf/wDSDdf9U8Vd/jfSP98X/wD0g3X/AFTxV3+N9I/3xf8A/SDdf9U8Vd/jfSP98X//AEg3X/VPFXf430j/AHxf/wDSDdf9U8Vd/jfSP98X/wD0g3X/AFTxV3+N9I/3xf8A/SDdf9U8Vd/jfSP98X//AEg3X/VPFXf430j/AHxf/wDSDdf9U8Vd/jfSP98X/wD0g3X/AFTxVr/G2kf74v8A/pBuv+qeKvMPNGpW+o+d9TuIFlRPqlmtJopIWqPW/ZkCtT3zoOx/ok1ZEh/K/VLbTfzY1iedJXRobhAIIpJmqVsj9mNWam3XMXtLr/WTB7b/AI20j/fF/wD9IN1/1TzUtjf+N9I/3xf/APSDdf8AVPFWJ/mf5o06+8qfVYYrtZJL/TeJltLiJPh1CBjV3RVGw8cydJ/eR96JcnkP5l/8c2w/5iX/AOoO4zpdbyHv/wB60xfQOm+ddJXTrUGC+qIk6WN0f2R/xXnIt6J/xvpH++L/AP6Qbr/qnirv8b6R/vi//wCkG6/6p4q1/jbSP98X/wD0g3X/AFTxVj3kTzfpUGhTI0N6SdT1d6rZXLCj6pcsNxH1ofiH7OKsi/xvpH++L/8A6Qbr/qnirv8AG+kf74v/APpBuv8Aqnirv8b6R/vi/wD+kG6/6p4q7/G+kf74v/8ApBuv+qeKu/xvpH++L/8A6Qbr/qnirv8AG+kf74v/APpBuv8AqniqW+ZfOekyeXdUQQ3wLWc6gmyugN4mG5MeI5q8T8z/APKB3P8AzCR/8a51+X+6cfq9M/KLzTp1j+X+n2ssV20kc17yaK0uJU3vZjs6Iynr2OctqP7wt4Z/5YNfLmln/l0g9v8Ada5SlMsVf//V9U4qwTztpEC+b/JV/bWim4fWmN5colX4JpV8ieo4FeILBV5Yqw7VvVXRfMnkwwzf4h1TzJ9ZsYxE5D29xfw3SXIkA4enBCDzbl8DQ8P5cVT/AM3eTNMl16C0sRcG81lrme8jEjejBasqLfyxr+xNeBYrWtf93ySJ/uzFUd+VvmrWdcjnjvki9GG0sZx6MTQrb3Fwsnr2BBJq9p6cdf2v3vxYqzTULO6uQgt72SzK15GNY25fP1Ff8MVeCeTdNgg1KzumZp7p7wAzyULBfrNeKUACL7Lir6GGKuxV2KuxV2KuxV1cVdXBauwq7FXE0FcVYrefmj5Ds7iW3uNXiEkBKy8FkkUFeo5IrLt33yYxyPRFp5omt6XrmmQappVwt3YXIJguErxYKxU0rToykZBKOxV2KvG/PX/kwNS/5grL9c+dB2P9EmrIkX5N/wDk39a/5h7n9VjmL2l1/rJg+gRmpbHYqwv83v8AlCZP+Y/S/wDuo2+ZOk/vI+9EuTwr8y/+ObYf8xL/APUHcZ0ut5D3/wC9aYvqDS/+Oba/8YY/+IjORb0TirsVdirGvy8/5R6f/tq6z/3VrrFWS4q7FXYq7FXYq7FUr80/8o1q/wDzBXH/ACabEc1fO3mf/lA7n/mEj/41zr8v918nH6vZPyT/APJaaZ/xlvv+o6fOW1H94W8Mn8tf8o7pf/MJB/ybXKUplir/AP/W9U4q6mKtcRy5dxiriiluX7XSvtirlRVrxAFTU08TireKvBPK/wDvVYf8xi/9RBxV72MVdirsVdirsVdirz383PMPmfTo9N07y/PFaXOo+s813KpZkjt/TqsdNgzmX7RH2cytHp/FnSJGnmOiecPzGg/MLQ9K1DXGmtJp7ZriJPiEqTTNFwbmuwHEn4cytXpBAFAlb6QGatk7FUu8yMyeXtUZSVZbScqw2IIjbfEK+YNc8seXofJctzDp8Ec62qOJFQBuR4kmvvXOrnijHFy6NF7vevyXAH5b6WBsPUvKD/o9mzmc4qZDeGbZUrsVeN+ev/Jgal/zBWX6586Dsf6JNWRIvyb/APJv61/zD3P6rHMXtLr/AFkwfQIzUtjsVYX+b3/KEyf8x+l/91G3zJ0n95H3olyeFfmX/wAc2w/5iX/6g7jOl1vIe/8A3rTF9QaX/wAc21/4wx/8RGci3onFXYq7FWNfl5/yj0//AG1dZ/7q11irJcVdirRIG52GBWhLGTQMpPhUYVXYq7FUr80/8ozq/wDzBXH/ACabEc1fO3mf/lA7n/mEj/Uudfl/uvk445vZPyT/APJaaZ/xlvv+o6fOW1H94W8Mn8tf8o7pf/MJB/ybXKUplir/AP/X9U4q7FUsn8z+X4NVj0ibUbaPVJaGOyeVRK3LdaITX4qfDirdt5j0S61O40u3vYZdRtRyuLVXBkQClar/AJPJeX8vJcVRdhf2l/aR3lnKs9tMOUUyGqsOlQe4xVXxV4F5adEnsXdgqLeAszGgA+sHqTir3EaxpP8Ay2wf8jU/rirjrOkgf72wf8jU/rirB9e/PbyJo+qzaY873c9seNw1t6ZRH7pyd05MP2uP2cux6eUhaCU08l/mn5W8221zcWEj28dtII2+tcI+fJeQaOjMHT/KyucDE0U2yT9M6T/y2wf8jU/rkVd+mdJ/5bYP+Rqf1xV5z+al9Z3Ot+XxbzxzFYr4sI3VqVNv4HNp2Qf3p9zDJyeaGSOP81tBkkYIitYFmYgAD65J1JzM7THP3MYPpH9M6T/y2wf8jU/rnPBtd+mdJ/5bYP8Akan9cKpb5l1fSj5d1QC8gJNnOABIn++m98CvAPMX/KBzf8wkf6lzsMu+L4Bo6vXfyd1TTovy702OW6hjkWS85I8iqR/ps3UE5y2o/vC3Bmn6Z0n/AJbYP+Rqf1ylLv0zpP8Ay2wf8jU/riryPzncQXHn3U5IJFlT6nZDkjBhWs/cZv8Asf6ZNWQpD+Ud1b2/5uay88qRIYLkBnYKK0sdqnMbtLr/AFkwe9fpnSf+W2D/AJGp/XNS2O/TOk/8tsH/ACNT+uKsO/NjUtPm8nNHDdQySNf6ZxRJFYmmowE7A5k6T+9j70S5PE/zL/45th/zEv8A9QdxnSa07D3/AO9aYh9KaZrGkjTrUG9gB9GOo9VP5R75yTeif0zpP/LbB/yNT+uKu/TOk/8ALbB/yNT+uKu/TOk/8tsH/I1P64qxv8v9V0xPL8yvdwKf0rrBoZEGx1W6IPXuMVZJ+mdJ/wCW2D/kan9cVd+mdJ/5bYP+Rqf1xV5r+cd4NUfSNHtdTeK0uRczXi2kicnMBiEauaN8H71jx/a+HM7s/CMmSixkaDyeysV0r8y/LsZvZmgjubKeszqqq0l2I2J4BARwFPizM12njAbMYSt9RfpnSf8Altg/5Gp/XNIGx36Z0n/ltg/5Gp/XCqWeZ9X0pvLerAXkBJs7gACRP99N74hXgPmf/lA7n/mEj/41zr8p/dfANHV61+TOp6dB+XGnRzXUMTpLfckeRVYf6dOdwTnLaj6y3BmHldlfy3pTIQytaQFWBqCDGvTKUpnir//Q9U4q49MVeHa61sPK3n6OVkHmU+Y0Nkp4/WPVMlqdOMf7f936fp0/y/8ALxVNfNHlSXS9WCWuoOZNUfU5LeGKMCa2tr547nVLhpAxL+msfpWvwrwmuIeXPFWV/l15qXV7L6kNOTTVs7SxuLaCGX1oxa3kJe3XkFTjIixlXT/V+JuWKsnvn1JeH1KOGQ7+p6zslPCnFHrirxO2/Kv8xpoVaRNOCB3aKGSeZSvJyw5AQn4sVV/+VU/mF/Jpf/SRN/1QxVTh/K78xJGlBh01BG/AM1xNRhxVuS/uenxcf9jiqjaflD+ZtpG8NvPpaxPLLMFaSRiDPK0rCvofzOaZm49dOEeEUxMbQuifkr550hRYW8OnsqxqWuZLmY8uPwBf7jbiB9mmYs8hkbKQE1/5VR+YX8ml/wDSRN/1QyCVKX8r/wAxI5IUEOmuJXKsy3E1EHBm5N+56VXj/rNiqyX8ofzHN3BdwyaZDNAkkakTysCspQtUGD/itcv0+olilYQRaBv/AMmfzDk1BNVu/qF5PCscccKTyqvwyFlYqIByKF2brk8+rnk5oEaTX/lVP5hH9jS/+kib/qhmKyd/yqn8wv5NL/6SJv8AqhiqHX8qfzCvdOpJDp0P1mKjxtcTB09Rd1P7g/EtcVUrv8nPzOu9LbTJrrTfqzxiJuMsgfitOh9A77ZsJdpZJR4WAiv078pPPsET2sMGmxxW7lUZ7mc8+QEjOCYTWru3I/z8swCbJLNF/wDKqPzC/k0v/pIm/wCqGBVJfyv/ADE+svCYdNCoiOJfrE3Fi5YFR+56rwq3+uuKrE/KP8y4Lue5tptMiNwsYkUzSsP3fLiRWD/KzL0+sniBEerExtBQfkx5/tdUe+ddPubu/kIkl+sShYgYxX4RAKK3oov7TcuOVZtRLIbKQKTX/lVH5hfyaX/0kTf9UMqJSpXP5X/mJBA0iwabKVpSNLiYk1NNqwjAqy7/ACg/MG5iVAdMjZJYpkcXExo0MiyLsYP5kyeOfDISHMIIQ+q/kt+Y+rLBHqE+nSQQSeqI0mlj5Eo0dCwgrx4u3TMvN2hknzYiCKtPyt/MOW2ikMGmQlkUmJriYMlR9kj0Oq9MwWat/wAqo/ML+XS/+kif/qhiqlB+V/5iS+pyg02Pg5Qc7ib4gP2h+5+ycVVf+VUfmF/Jpf8A0kTf9UMVQtp+Uvn62eS0ig01YgWn9Q3E5VnuJZJHAPo9m3/2a4qiv+VUfmF/Jpf/AEkTf9UMVUpvyv8AzEjkhQQaa4lcozLcTUQcGbk37npVeP8ArNiqyX8ofzHN3BdwPpkM8CSRqRPKwKylC1QYP+K1y/T6iWKVhBFoG/8AyX/MKbUodUvP0feTxelDHCs8qoB6tRIwEG/pluf+xyefVzyc0CNJsfyp/MI/saX/ANJE/wD1QzFZNf8AKqfzC/l0v/pIm/6oYqhx+VH5hX2nUlh06H61DSSNriYOnqJup/cH4lriqje/k3+Z15pT6ZPdab9VkjWJuMsgbitOh9DrtmfPtHJKPCWAinfkr8mJklkj8zCP6hZScYNPt2d47ksqytLNI4R5E5yMvpceLOr8+S/DmDI2bZvX4YY4YlijUJGgCoigAAAUAAHQYFX4q//R9U4q7FUvm8u6FPqkWrTafbyanAKRXrxIZlA6cZCOQp23xVEPp9m94L0wobsRGAT8RzERbkUDdeJYVpiqhpOgaNo8UkWlWUNjFK/qSpBGsYZ6UqQtOwxVH4q7FXYqgtZfVU025bSY4pdRCE2sdwzJEX7ByoLUxVjOojzlLoWiTRSSw6kuo2Z1WBIowz25u0WdTxaVUiSEs1VdmaNftfaxVmeKuxVx6HFWHaZN5zs9Q19Jrd9VhOoE6c0rpbKtsbKBwsfwtyQXBli5fa58nxVZ5OuPME3mnzCb/wCvR2CSIlnDex0jLBpC8lu6qqejRkiReTs3petJ/e4qzTFXYqwvzrceYY/Mvl6PShfeiZWe8aCPlZ8FZSUuGCMQ8391GzMkcStJM3xpGrKqHma+85zTaK1rYXdlOL6D1ktZI54Hg9SEzi4agMY9Jp+DfY+Bv92PDirOx0xV2KsR/M2TX08tsdBF4dTLj6ubFUY8wjlBMH/3S7hUZh9hmR5P3Pq4qpebJ/Otx5b1dNLtX0+/ht5HsLiB0uJZZEY8Y1jKjiZFAPL9nl/P8WKrfJ7+bj5r18av6/6ODkWnrBRD/vRN6P1cgVZfqf1cy/8AF3+VyxVmuKuPQ4qx/T5fNT65qUVzHGmigUsLhwBP6u2wRGZXhG9Hf0pP2eDfbxVhmlf8rMj17RIryS7ntlurtbmZo0WKSFb66HO4AHwA2gtGtOOKvU8VdirsVdirsVdirj0xVjsVx5qPmC/juoFXSEhJ057fizSNRa+qzsGSWvLgoj9Lj9qXFVD8uH11tCm/TH1syC7m+qNfqqXJtzQp6ir0ZCWj/wAvh6ifu3TFWU4q7FUi80y+Z41tD5ehjnujKBPHcUEHpUPIyPyEiU/ZMSSty/3XxxVLbuTzD/ysawW3F5+hvqsgvgyp9SqQTG6N9r1lkXg6H4mWRHT4EfFWX4q7FXYq/wD/0vVOKuxV2KuxV2KuxV2KuxV2KuxV2KuxV2KuxV2KuxV2KuxV2KuxV2KuxV2KuxV2KuxV2KuxV2KuxV2KuxV2KuxV2KuxV2KuxV2KuxV2KuxV2KuxV//T9U4q7FXYq7FXYq7FXYq7FXYq7FXYq7FXYq7FXYq7FXYq7FXYq7FXYq7FXYq7FXYq7FXYq7FXYq7FXYq7FX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