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Bone Tumor & Tumor-like lesions Sun Yat-sen Memorial Hospital SYSU
Bone Tumor & Tumor like lesions <ul><li>Aims of Imaging modalities </li></ul><ul><li>Classification of Bone Tumor </li></u...
When presented with a lesion in a bone, three important questions require to be answered: <ul><li>Is the lesion neoplastic...
1.  Aims of Imaging modalities <ul><ul><li>Diagnosis  </li></ul></ul><ul><ul><li>Localization   </li></ul></ul><ul><ul><li...
2. Classification of Bone Tumor Tumor-like lesion  Bone cyst,  Fibrous dysplasia Primary Bone  Tumor Tumor from  Bone Tiss...
WHO  Classification of  Bone Tumor & Tumor like lesions ( 2002 )  1 . Cartilaginous tumor 2 . Osteogenic tumor 3 . Fibroge...
3,  Steps of Diagnostic Analysis---clinical data <ul><li>Disease incidence </li></ul><ul><li>Age of onset </li></ul><ul><l...
<ul><li>Disease incidence : </li></ul><ul><ul><li>Benign:  </li></ul></ul><ul><ul><ul><li>osteochondroma </li></ul></ul></...
<ul><li>Age: the distribution of lesion has a relative regularity  </li></ul><ul><ul><li>Malignant: </li></ul></ul><ul><ul...
3,  Steps of Diagnostic Analysis---clinical data
<ul><li>Symptoms & Physical sign </li></ul><ul><ul><li>Benign: painful, tenderness is not obvious, general state is good <...
<ul><li>Laboratory Examination </li></ul><ul><ul><li>Benign: blood, urine, marrow are NORMAL </li></ul></ul><ul><ul><li>Ma...
<ul><li>Imaging analysis:  </li></ul><ul><li>benign or malignant ->  histology </li></ul><ul><li>Location of the lesion </...
<ul><li>Location of the lesion  </li></ul><ul><ul><li>Giant cell tumor: ending of long bone </li></ul></ul><ul><ul><li>Ost...
<ul><ul><li>B  Number of lesion </li></ul></ul><ul><ul><ul><li>Primary tumor: single frequent </li></ul></ul></ul><ul><ul>...
<ul><ul><li>C.  Bony destruction </li></ul></ul><ul><ul><ul><li>Benign: expanding, pressure destruction, neighbouring cort...
<ul><ul><li>D.  Hyperostosis  and  Osteosclerosis  </li></ul></ul><ul><ul><ul><li>Tumor bone: ground-glass, spindle like, ...
Differential diagnosis between Benign and Malignant Bone Tumor items Benign Malignant growth Slow, compressing neightbouri...
Principles in diagnosing Bone Tumors <ul><li>Jaffe 3-combined Principles  (clinic, radiology, pathology ) </li></ul><ul><u...
Osteosarcoma <ul><li>Most frequent, primary, malignant bone tumor </li></ul><ul><li>Origin from primitive osteogenic tissu...
Radiological A ppearance <ul><li>Osteolytic  destruction </li></ul><ul><li>Tumor bone formation  </li></ul><ul><li>Periost...
Osteosclerotic  Osteosarcoma <ul><li>Mainly with tumor bone formation </li></ul><ul><li>Intact cortex in early stage, cort...
Osteosarcoma in superior part of tibia ( Osteosclerotic  type, ivory tumor bone), obvious tumor bone formation which invad...
<ul><li>Spiculate tumor bone </li></ul>Osteosclerotic Osteosarcoma in Fibula
Cotton like tumor bone, Codman’ triangle Osteosclerotic Osteosarcoma in Fibula
Osteosclerotic o steosarcoma in  inferior femur, obvious tumor bone formation (  ) and big mass in soft tissue (M) , corte...
Osteolytic  Osteosarcoma <ul><li>Osteolytic destruction </li></ul><ul><li>Tumor bone is rare </li></ul><ul><li>Periosteal ...
Osteolytic  o steosarcoma in  distal metaphysis of the femur, apparent  Osteolytic  destruction is seen, associated with s...
Osteosarcoma Osteolytic  destruction  in sup erior tebia, soft tissue mass formation, with Codman’  triangle (  )
Osteolytic  O steosarcoma in  Inferior Femur <ul><li>pathologic fracture </li></ul>
<ul><li>Combining the appearance of osteosclerotic type & osteolytic type </li></ul>Mixed osteosarcoma O steosarcoma in  d...
Osteosarcoma in superior tibia, obvious bone destruction and tumor bone formation,  periosteum proliferation. Codman’  tri...
Mixed Osteosarcoma
Osteosarcoma <ul><li>Pyogenic Osteomyelitis: </li></ul><ul><li>Acute onset, frequent in  metaphysis of tubular bone, tende...
Giant Cell Tumor <ul><li>Origin from the mesenchyma of connective tissue of bone,  it’s mainly composed of mononuclear str...
<ul><li>Radiological  appearances </li></ul><ul><ul><li>Site: bone  extremities, often reach to the subchondral region </l...
Giant cell tumor of fibular
Giant cell tumor of radius Expansive bone destruction in the distal end of L-radius, reach to the subchondral region of th...
Giant cell tumor   Expansive bone destruction in distal end of R-radius (  ), with in complete bone shell, soft tissue for...
Bone cyst <ul><li>Tumor-like lesion </li></ul><ul><li>Common in  adolescent </li></ul><ul><li>Frequent in long bone, espec...
Radiological  Appearances <ul><li>Expansive,  ovoid-shape bone destruction  develop along the longitudinal axis of bone sh...
(A)  Bone cyst of   R- Humerus ,  develop longitudinally, slight expansive: (B) Complicate with pathologic fracture; (C): ...
Bone cyst of femur Radiolucent,  develop longitudinally, well-defined margin, no sclerosis.  CT show uniform low density i...
Bone cyst of humerus   <ul><li>pathologic fracture </li></ul><ul><li>“ Falling Fragment Sign” </li></ul>
Bone  Metastases <ul><li>Most frequent malignant bone tumor, multiple. </li></ul><ul><li>Primary tumor:  breast cancer, lu...
Osteolytic Bone Metastases Nasopharyngeal Carcinoma  patient,  osteolytic bone destruction in R- humerus and clavicle, unc...
Osteolytic Bone Metastases  Round destruction area in  cranial bones, ill-defined margin, no sclerosis
Bone Metastases
Prostatic carcinoma. Increase density in pelvis, lumbosacral vertebrae and bilateral femur . Osteoblstic Bone Metastases
Uniform increased density of L 2 , L 4 , L 5  vertebra, sacral vertebrae and iliac bone. Osteoblstic Bone Metastases
Mixed Bone Metastases Small and large patchy bone destruction area as well as increased density area in pelvis, lumbosacra...
Questions <ul><li>How to differentiate benign or malignant bone tumor ? </li></ul><ul><li>How many  types of osteosarcoma ...
 
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Bone Tumor And Tumor Like Diseases

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Bone Tumor And Tumor Like Diseases

  1. 1. Bone Tumor & Tumor-like lesions Sun Yat-sen Memorial Hospital SYSU
  2. 2. Bone Tumor & Tumor like lesions <ul><li>Aims of Imaging modalities </li></ul><ul><li>Classification of Bone Tumor </li></ul><ul><li>Steps of Diagnostic Analysis </li></ul><ul><ul><li>Clinical data </li></ul></ul><ul><ul><li>Imaging data </li></ul></ul><ul><li>Common bone tumor & tumor like lesions </li></ul><ul><ul><li>Osteosarcoma </li></ul></ul><ul><ul><li>Giant cell tumor of bone </li></ul></ul><ul><ul><li>Bone cyst </li></ul></ul><ul><ul><li>Bone metastatic tumor </li></ul></ul>
  3. 3. When presented with a lesion in a bone, three important questions require to be answered: <ul><li>Is the lesion neoplastic or infective ? </li></ul><ul><li>Is it benign or malignant ? </li></ul><ul><li>Is it a primary or secondary neoplasm ? </li></ul><ul><li>-- Donald Resnick, MD </li></ul>yes
  4. 4. 1. Aims of Imaging modalities <ul><ul><li>Diagnosis </li></ul></ul><ul><ul><li>Localization </li></ul></ul><ul><ul><li>Qualification </li></ul></ul><ul><ul><ul><li>Benign or Malignant? </li></ul></ul></ul><ul><ul><ul><li>Histological type? </li></ul></ul></ul><ul><ul><li>Quantitation </li></ul></ul><ul><ul><ul><li>Invasion extant </li></ul></ul></ul><ul><ul><ul><li>Number of lesion </li></ul></ul></ul><ul><li>normal variant ? d eformation ? </li></ul><ul><li>trauma ? </li></ul><ul><li>inflammation? </li></ul><ul><li>tumor ? </li></ul>Imaging Anatomy X-ray Signs Clinical Data
  5. 5. 2. Classification of Bone Tumor Tumor-like lesion Bone cyst, Fibrous dysplasia Primary Bone Tumor Tumor from Bone Tissue benign Osteochondroma, Giant cell tumor, Osteoma, Chondroma, Chondroblastoma malignant Osteosarcoma, Chondrosarcoma, Fibrosarcoma Tumor from Bone Affiliated Tissue benign Osteoangioma, Odontogenic tumor (exp. Adamantinoma) malignant Ewing's sarcoma, Reticulum cell sarcoma of bone, Notochordoma, Myeloma Metastatic Tumor Carcinoma, Sarcoma, Neuroblastoma Carcinoma, Sarcoma, Neuroblastoma
  6. 6. WHO Classification of Bone Tumor & Tumor like lesions ( 2002 ) 1 . Cartilaginous tumor 2 . Osteogenic tumor 3 . Fibrogenic tumor 4 . Fibrohistiocytic tumor 5 . Ewing sarcoma/Primitive neuroectodermal tumor 6 . Blood-cell forming tissue tumor 7 . Giant cell tumor 8 . Notochord tumor 9 . Vascular tumors 10 . Myogenic tumor 11 . Lipogenic tumor 12 . Neural tumor 13 . Confounding tumor 14 . Other tumor 15 . Arthropathy synovial chondromatosis 16 . Bone and soft tissue tumor related c ongenital or hereditary syndrome
  7. 7. 3, Steps of Diagnostic Analysis---clinical data <ul><li>Disease incidence </li></ul><ul><li>Age of onset </li></ul><ul><li>Site </li></ul><ul><ul><li>Skeleton all over the body </li></ul></ul><ul><ul><li>Single bone </li></ul></ul><ul><li>Symptoms & Physical sign </li></ul>
  8. 8. <ul><li>Disease incidence : </li></ul><ul><ul><li>Benign: </li></ul></ul><ul><ul><ul><li>osteochondroma </li></ul></ul></ul><ul><ul><li>Malignant: </li></ul></ul><ul><ul><ul><li>Metastatic tumor </li></ul></ul></ul><ul><ul><ul><li>(frequent) </li></ul></ul></ul><ul><ul><ul><li>Primary: osteosarcoma </li></ul></ul></ul><ul><ul><ul><li>(most frequent) </li></ul></ul></ul>exogenous osteochondroma 3, Steps of Diagnostic Analysis---clinical data
  9. 9. <ul><li>Age: the distribution of lesion has a relative regularity </li></ul><ul><ul><li>Malignant: </li></ul></ul><ul><ul><ul><li>Infant: neuroblastoma metastasis </li></ul></ul></ul><ul><ul><ul><li>Childhood, adolescent: Ewing's sarcoma </li></ul></ul></ul><ul><ul><ul><li>Teenagers : osteosarcoma </li></ul></ul></ul>3, Steps of Diagnostic Analysis---clinical data
  10. 10. 3, Steps of Diagnostic Analysis---clinical data
  11. 11. <ul><li>Symptoms & Physical sign </li></ul><ul><ul><li>Benign: painful, tenderness is not obvious, general state is good </li></ul></ul><ul><ul><li>Malignant: painful, obvious tenderness, quick development, short course </li></ul></ul>3, Steps of Diagnostic Analysis---clinical data
  12. 12. <ul><li>Laboratory Examination </li></ul><ul><ul><li>Benign: blood, urine, marrow are NORMAL </li></ul></ul><ul><ul><li>Malignant: </li></ul></ul><ul><ul><ul><li>Osteosarcoma: Alkali Phosphatase (ALP) </li></ul></ul></ul><ul><ul><ul><li>Ewing's sarcoma: WBC </li></ul></ul></ul><ul><ul><ul><li>metastatic tumor & myeloma: secondary anemia and blood calcium </li></ul></ul></ul><ul><ul><ul><li>Myeloma : Bence-Jones protein in urine </li></ul></ul></ul>3, Steps of Diagnostic Analysis---clinical data
  13. 13. <ul><li>Imaging analysis: </li></ul><ul><li>benign or malignant -> histology </li></ul><ul><li>Location of the lesion </li></ul><ul><li>Number of the lesion </li></ul><ul><li>Bony destruction </li></ul><ul><li>Hyperostosis </li></ul><ul><li>Periosteal reaction </li></ul><ul><li>Surrounding soft tissue </li></ul><ul><li>changes </li></ul>3, Steps of Diagnostic Analysis---imaging data chondroblastoma
  14. 14. <ul><li>Location of the lesion </li></ul><ul><ul><li>Giant cell tumor: ending of long bone </li></ul></ul><ul><ul><li>Osteosarcoma: metaphysis of long bone </li></ul></ul><ul><ul><li>Ewing sarcoma: diaphysis </li></ul></ul><ul><ul><li>Myeloma, metastasis tumor: flat bone, irregular bone </li></ul></ul>3, Steps of Diagnostic Analysis---imaging data
  15. 15. <ul><ul><li>B Number of lesion </li></ul></ul><ul><ul><ul><li>Primary tumor: single frequent </li></ul></ul></ul><ul><ul><ul><li>Metastasis: multiple </li></ul></ul></ul><ul><ul><ul><li>Myeloma: multiple </li></ul></ul></ul>Multiple Myeloma Osteogenic metastasis Giant cell tumor 3, Steps of Diagnostic Analysis---imaging data
  16. 16. <ul><ul><li>C. Bony destruction </li></ul></ul><ul><ul><ul><li>Benign: expanding, pressure destruction, neighbouring cortex is continuous and integrated </li></ul></ul></ul><ul><ul><ul><li>Malignant: invasive bone destruction, ill-defined margin, moth-eaten, spot like bone destruction, mass invading to the soft tissue, periosteal reactive hyperplasia and Codman’ triangle </li></ul></ul></ul>3, Steps of Diagnostic Analysis---imaging data benign malignant
  17. 17. <ul><ul><li>D. Hyperostosis and Osteosclerosis </li></ul></ul><ul><ul><ul><li>Tumor bone: ground-glass, spindle like, patchy </li></ul></ul></ul><ul><ul><ul><li>Tumor cartilage: spot, c urve, ring shape </li></ul></ul></ul><ul><ul><ul><li>Osteogenesis reaction in Neighbouring bone tissue---benign or low grade malignant tumor </li></ul></ul></ul>Normal periosteal ossification Tumor cell ossification 3, Steps of Diagnostic Analysis---imaging data
  18. 18. Differential diagnosis between Benign and Malignant Bone Tumor items Benign Malignant growth Slow, compressing neightbouring tissue, no metastasis Quick, neightbouring tissue invading, metastasis Signs of the Lesion Expansive, well-defined, thin but continue tissue Invading, ill-defined, irregular destruction of cortex, tumor bone formation Periosteal reaction most of time (-), can be shown after pathological fracture, but no bony destruction Different forms of periosteal reaction, can be destructed by the tumor Surrounding soft tissue No mass, well-defined if there is Mass formation, indistinct demarcation with surrounding tissue
  19. 19. Principles in diagnosing Bone Tumors <ul><li>Jaffe 3-combined Principles (clinic, radiology, pathology ) </li></ul><ul><ul><li>Clinical manifestation (history, symptoms, physical signs), laboratory tests (routine test, biochemistry ) </li></ul></ul><ul><ul><li>Imaging examination (X-ray, CT, MRI, ultra-sound, nuclear ) </li></ul></ul><ul><ul><li>Pathology test and other special test (immunology, infrared ray, flourescence) </li></ul></ul>
  20. 20. Osteosarcoma <ul><li>Most frequent, primary, malignant bone tumor </li></ul><ul><li>Origin from primitive osteogenic tissue, to form tumor bone and bone like tissue . </li></ul><ul><li>3 types according to the X-ray: Osteosclerotic, Osteolytic, Mixed type </li></ul><ul><li>Age: frequent in teenagers (10-20y), M ≥F </li></ul><ul><li>Favourite Site: metaphysis, surrounding the knee joint (50%), especially the superior part of humerus </li></ul><ul><li>Clinic: progressive pain, functional disturbance, venous engorgement </li></ul><ul><li>Laboratory: Alkali Phosphatase (ALP) ↑ </li></ul><ul><li>Develop fast, pulmonary metastasis is common </li></ul>
  21. 21. Radiological A ppearance <ul><li>Osteolytic destruction </li></ul><ul><li>Tumor bone formation </li></ul><ul><li>Periosteal proliferation and periosteal new bone destruction--- Codman’ triangle </li></ul><ul><li>Soft tissue mass and bone tumor inside ( ivory/marble, cotton, spiculate, radial, sunburst ) </li></ul>Geographic bone destruction Moth-eaten bone destruction Permeative bone destruction
  22. 22. Osteosclerotic Osteosarcoma <ul><li>Mainly with tumor bone formation </li></ul><ul><li>Intact cortex in early stage, cortex destruction in advance stage. </li></ul><ul><li>Obvious periosteal reaction </li></ul><ul><li>Tumor bone in soft tissue </li></ul>
  23. 23. Osteosarcoma in superior part of tibia ( Osteosclerotic type, ivory tumor bone), obvious tumor bone formation which invading into soft tissue Osteosclerotic Osteosarcoma
  24. 24. <ul><li>Spiculate tumor bone </li></ul>Osteosclerotic Osteosarcoma in Fibula
  25. 25. Cotton like tumor bone, Codman’ triangle Osteosclerotic Osteosarcoma in Fibula
  26. 26. Osteosclerotic o steosarcoma in inferior femur, obvious tumor bone formation ( ) and big mass in soft tissue (M) , cortex destruction and become thinner ( ) Osteosclerotic Osteosarcoma M M
  27. 27. Osteolytic Osteosarcoma <ul><li>Osteolytic destruction </li></ul><ul><li>Tumor bone is rare </li></ul><ul><li>Periosteal proliferation Codman’ triangle ( ) </li></ul><ul><li>Tumor bone is not common in soft tissue </li></ul><ul><li>Extensive bone destruction with pathologic fracture </li></ul>
  28. 28. Osteolytic o steosarcoma in distal metaphysis of the femur, apparent Osteolytic destruction is seen, associated with soft tissue mass and Codman’ triangle ( ) Osteolytic Osteosarcoma
  29. 29. Osteosarcoma Osteolytic destruction in sup erior tebia, soft tissue mass formation, with Codman’ triangle ( )
  30. 30. Osteolytic O steosarcoma in Inferior Femur <ul><li>pathologic fracture </li></ul>
  31. 31. <ul><li>Combining the appearance of osteosclerotic type & osteolytic type </li></ul>Mixed osteosarcoma O steosarcoma in diaphysis of femur, bone cortex destruction, thickness decrease and defect of the cortex, mass formation in soft tissue, flocculent tumor bone inside the mass
  32. 32. Osteosarcoma in superior tibia, obvious bone destruction and tumor bone formation, periosteum proliferation. Codman’ triangle ( ) Mixed Osteosarcoma
  33. 33. Mixed Osteosarcoma
  34. 34. Osteosarcoma <ul><li>Pyogenic Osteomyelitis: </li></ul><ul><li>Acute onset, frequent in metaphysis of tubular bone, tendency of extensive spreading. Osteoporosis and small quantity of bone destruction in acute stage, reactive hyperostosis surround the lesion, periosteal proliferation and sometimes soft tissue mass . </li></ul>D.D.
  35. 35. Giant Cell Tumor <ul><li>Origin from the mesenchyma of connective tissue of bone, it’s mainly composed of mononuclear stromal cell and multinucleated giant cell </li></ul><ul><li>Anaplastic tumor, can divided into benign, active growing and malignant one. </li></ul><ul><li>Common in 20 ~ 40y ( 80 % >20y), knee joint bone and distal end of radius are favorite sites. </li></ul><ul><li>Clinical symptoms: local pain, varicose veins of skin </li></ul><ul><li>Frequent in bone extremities </li></ul>
  36. 36. <ul><li>Radiological appearances </li></ul><ul><ul><li>Site: bone extremities, often reach to the subchondral region </li></ul></ul><ul><ul><li>Eccentric, osteolytic, expansive bone destruction, well-defined , with fine bone ridge inside, no calcification or ossification </li></ul></ul><ul><ul><li>No reactive hyperostosis nearby, no periosteal reaction if there is no fracture happened </li></ul></ul><ul><ul><li>No soft tissue mass generally, spot or moth-eaten bone destruction in the distal edge of tumor </li></ul></ul>Giant Cell Tumor
  37. 37. Giant cell tumor of fibular
  38. 38. Giant cell tumor of radius Expansive bone destruction in the distal end of L-radius, reach to the subchondral region of the joint but the bone surface is still intact, multilocular, well-defined, no sclerosis, no calcification or ossification inside
  39. 39. Giant cell tumor Expansive bone destruction in distal end of R-radius ( ), with in complete bone shell, soft tissue formation extend outside the bone shell.
  40. 40. Bone cyst <ul><li>Tumor-like lesion </li></ul><ul><li>Common in adolescent </li></ul><ul><li>Frequent in long bone, especially femur and upper humerus </li></ul><ul><li>Originate from metaphysis, but “stay” in the diaphysis with growing, develop along the longitudinal axis of bone shaft </li></ul><ul><li>Asymptomatic, discover by pathologic fracture </li></ul>
  41. 41. Radiological Appearances <ul><li>Expansive, ovoid-shape bone destruction develop along the longitudinal axis of bone shaft, sometimes multi-capsular, symmetrical thinner of the cortex, no periosteal reaction </li></ul><ul><li>After pathologic fracture, the fracture fragment fall into the capsular space ( Falling Fragment Sign). Then the bone cyst can be heal, the cyst reduced or self-limited </li></ul>
  42. 42. (A) Bone cyst of R- Humerus , develop longitudinally, slight expansive: (B) Complicate with pathologic fracture; (C): Recheck after fracture, density increase inside the cyst. A B C
  43. 43. Bone cyst of femur Radiolucent, develop longitudinally, well-defined margin, no sclerosis. CT show uniform low density inside the cyst.
  44. 44. Bone cyst of humerus <ul><li>pathologic fracture </li></ul><ul><li>“ Falling Fragment Sign” </li></ul>
  45. 45. Bone Metastases <ul><li>Most frequent malignant bone tumor, multiple. </li></ul><ul><li>Primary tumor: breast cancer, lung cancer, thyroid cancer, prostatic carcinoma, renal carcinoma, nasopharyngeal carcinoma (NPC). </li></ul><ul><li>Route of metastasis: hematogenous </li></ul><ul><li>Frequent site: spongy bone with red marrow </li></ul><ul><ul><li>vertebral body, rib, superior femur, iliac bone, cranial bones, humerus </li></ul></ul><ul><li>Seldom involve the distal part of knee and elbow joint. </li></ul>
  46. 46. Osteolytic Bone Metastases Nasopharyngeal Carcinoma patient, osteolytic bone destruction in R- humerus and clavicle, unclear margin, no ossification or calcification. Clavicle mass formation ( M ) M
  47. 47. Osteolytic Bone Metastases Round destruction area in cranial bones, ill-defined margin, no sclerosis
  48. 48. Bone Metastases
  49. 49. Prostatic carcinoma. Increase density in pelvis, lumbosacral vertebrae and bilateral femur . Osteoblstic Bone Metastases
  50. 50. Uniform increased density of L 2 , L 4 , L 5 vertebra, sacral vertebrae and iliac bone. Osteoblstic Bone Metastases
  51. 51. Mixed Bone Metastases Small and large patchy bone destruction area as well as increased density area in pelvis, lumbosacral vertebrae and bilateral femur.
  52. 52. Questions <ul><li>How to differentiate benign or malignant bone tumor ? </li></ul><ul><li>How many types of osteosarcoma there are by X-ray signs? What are they? What is the radiological appearances of them? </li></ul><ul><li>What is the radiological appearance of Giant cell tumor? </li></ul><ul><li>What is the radiological appearances of bone cyst? </li></ul>

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