Take CE/CME Test
Take CE/CME Test
Epilepsy, Paediatric Neurology, Rare Diseases CE/CME ACCREDITED Watch Time: 34 mins

touchMDT Improving outcomes for patients with tuberous sclerosis complex-associated seizures: Integrating new treatment options into existing care pathways

MDT specialists and a caregiver of a patient with tuberous sclerosis complex (TSC) discuss current and emerging management strategies for TSC-associated seizures.

 Overview & Learning Objectives

Patient with TSC-associated seizures
Paediatric neurologist and epilepsy specialist, epilepsy specialist & caregiver
Watch Video
Management of TSC-associated seizures Prof. James Wheless, Prof. Katarzyna Kotulska, Ms Lisa Moss

Watch a paediatric neurologist and epilepsy specialist, another epilepsy specialist and a caregiver of a patient with TSC discuss the clinical burden of TSC-associated seizures and review existing treatment options and unmet needs.

Watch Video
Epilepsy specialist & paediatric neurologist and epilepsy specialist
Watch Video
Delaying seizures in patients with TSC Prof. Katarzyna Kotulska, Prof. James Wheless

Watch an epilepsy specialist, and a paediatric neurologist and epilepsy specialist, evaluate the potential for approved and emerging treatments with anti-seizure properties to prevent or delay the onset of seizures in patients with TSC.

Watch Video
Paediatric neurologist and epilepsy specialist, epilepsy specialist & caregiver
Watch Video
Emerging agents for patients with TSC Prof. James Wheless, Prof. Katarzyna Kotulska, Ms Lisa Moss

Watch a paediatric neurologist and epilepsy specialist, another epilepsy specialist and a caregiver of a patient with TSC review investigational agents for TSC-associated seizures and their potential impact on patient outcomes.

Watch Video
Paediatric neurologist and epilepsy specialist, epilepsy specialist & caregiver

Watch a paediatric neurologist and epilepsy specialist, another epilepsy specialist and a caregiver of a patient with TSC discuss the clinical burden of TSC-associated seizures and review existing treatment options and unmet needs.
Expert Spotlight
Prof. James Wheless
University of Tennessee Health Science Center, Memphis, TN, USA
Prof. Katarzyna Kotulska
The Children’s Memorial Health Institute, Warsaw, Poland
Ms Lisa Moss
TSC Alliance, Silver Spring, MD, USA

Prof. James Wheless, Prof. Katarzyna Kotulska and Ms Lisa Moss discuss the clinical burden of TSC-associated seizures, current treatment options and unmet needs for patients and caregivers.

Listen on the Go

 Learn more Back to MDT Hub Time: 13:20
 
Epilepsy specialist & paediatric neurologist and epilepsy specialist

Watch an epilepsy specialist, and a paediatric neurologist and epilepsy specialist, evaluate the potential for approved and emerging treatments with anti-seizure properties to prevent or delay the onset of seizures in patients with TSC.
Expert Spotlight
Prof. Katarzyna Kotulska
The Children’s Memorial Health Institute, Warsaw, Poland
Prof. James Wheless
University of Tennessee Health Science Center, Memphis, TN, USA

Prof. Katarzyna Kotulska and Prof. James Wheless review the potential for approved and emerging treatments to prevent or delay the onset of seizures in patients with TSC.

Listen on the Go

 Learn more Back to MDT Hub Time: 09:04
 
Paediatric neurologist and epilepsy specialist, epilepsy specialist & caregiver

Watch a paediatric neurologist and epilepsy specialist, another epilepsy specialist and a caregiver of a patient with TSC review investigational agents for TSC-associated seizures and their potential impact on patient outcomes.
Expert Spotlight
Prof. James Wheless
University of Tennessee Health Science Center, Memphis, TN, USA
Prof. Katarzyna Kotulska
The Children’s Memorial Health Institute, Warsaw, Poland
Ms Lisa Moss
TSC Alliance, Silver Spring, MD, USA

Prof. James Wheless, Prof. Katarzyna Kotulska and Ms Lisa Moss discuss emerging agents for the treatment of patients with TSC-associated seizures and the potential they hold for improving patient outcomes.

Listen on the Go

 Learn more Back to MDT Hub Time: 11:38
 
Back To Top
Overview & Learning Objectives
Overview

In this activity, a paediatric neurologist and epilepsy specialist, along with another epilepsy specialist involved in managing patients with TSC, share their insights on the current management strategies for TSC-associated seizures and the potential for preventing or delaying seizures in patients with TSC, and review emerging treatment options. Plus, hear from a caregiver of a patient with TSC on her experience and how novel treatments may improve outcomes.

This activity is jointly provided by USF Health and touchIME. read more

Target Audience

This activity has been designed to meet the educational needs of neurologists, including paediatric neurologists, epilepsy specialists, neurology nurses, paediatricians and primary care physicians involved in the management of tuberous sclerosis complex.

Disclosures

USF Health adheres to the Standards for Integrity and Independence in Accredited Continuing Education. All individuals in a position to influence content have disclosed to USF Health any financial relationship with an ineligible organization. USF Health has reviewed and mitigated all relevant financial relationships related to the content of the activity. The relevant relationships are listed below. All individuals not listed have no relevant financial relationships.

Faculty

Prof. James Wheless discloses: Grants/research support from Aucta, AveXis, Envision, EpiWatch, Marinus Pharmaceuticals, Neurelis Inc., Neuro Event Labs, Neurocrine Biosciences, NeuroPace, SK Life Sciences, Stoke Therapeutics, UCB, Xenon Pharmaceuticals and Zogenix. Consulting fees from Azurity Pharmaceuticals, BioMarin Pharmaceutical Inc., Eisai, Jazz Pharmaceuticals, Marinus Pharmaceuticals, Neurelis Inc., Radius Health and Supernus. Speaker’s bureau fees from Aquestive Therapeutics, BioMarin Pharmaceutical Inc., Eisai, Jazz Pharmaceuticals, LivaNova, Neurelis Inc., SK Life Sciences, Supernus, UCB and Zogenix.

Prof. Katarzyna Kotulska discloses: Grants/research support from Novartis (relationship terminated). Advisory board or panel fees from Biogen, GW Pharmaceuticals, Novartis, Roche and UCB.

Ms Lisa Moss has no interests/relationships or affiliations to disclose in relation to this activity.

Content reviewer

Rebecca Margaret Gonzalez-Winegar, PharmD, BCOP has no relevant financial relationships to disclose.

Touch Medical Directors

Katrina Lester and Sola Neunie have no financial interests/relationships or affiliations in relation to this activity.

USF Health Office of Continuing Professional Development and touchIME staff have no financial interests/relationships or affiliations in relation to this activity.

Requirements for Successful Completion

In order to receive credit for this activity, participants must review the content and complete the post-test and evaluation form. Statements of credit are awarded upon successful completion of the post-test and evaluation form.

If you have questions regarding credit please contact cpdsupport@usf.edu.

Accreditations

Physicians

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through a joint providership of USF Health and touchIME. USF Health is accredited by the ACCME to provide continuing medical education for physicians.

USF Health designates this enduring material for a maximum of 0.75 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

The European Union of Medical Specialists (UEMS) – European Accreditation Council for Continuing Medical Education (EACCME) has an agreement of mutual recognition of continuing medical education (CME) credit with the American Medical Association (AMA). European physicians interested in converting AMA PRA Category 1 CreditTM into European CME credit (ECMEC) should contact the UEMS (www.uems.eu).

Advanced Practice Providers

Physician Assistants may claim a maximum of 0.75 Category 1 credits for completing this activity. NCCPA accepts AMA PRA Category 1 CreditTM from organizations accredited by ACCME or a recognized state medical society.

The AANPCP accepts certificates of participation for educational activities approved for AMA PRA Category 1 CreditTM by ACCME-accredited providers. APRNs who participate will receive a certificate of completion commensurate with the extent of their participation.

Date of original release: 8 December 2022. Date credits expire: 8 December 2024.

If you have any questions regarding credit please contact cpdsupport@usf.edu.

Learning Objectives

After watching this activity, participants should be better able to:

  • Discuss the burden of TSC for patients and caregivers, and explore how TSC-associated seizures are currently managed
  • Assess existing and emerging treatment options for TSC-associated seizures including their impact on seizure prevention and delay in onset
  • Evaluate to what extent current treatment challenges and knowledge gaps in TSC-associated seizures impact clinical practice
Faculty & Disclosures
Prof. James Wheless

University of Tennessee Health Science Center, Memphis, TN, USA

Prof. James Wheless is professor and chief of paediatric neurology and the Le Bonheur chair in paediatric neurology at the University of Tennessee Health Science Center (UTHSC) in Memphis, USA. He also serves as director of the Neuroscience Institute and the Le Bonheur Comprehensive Epilepsy Program for the Le Bonheur Children’s Hospital (LCH), and is an adjunct clinical faculty member in the Department of Pediatric Medicine at St. Jude Children’s Research Hospital. read more

Prof. Wheless is an experienced neurologist and researcher whose research is focused on paediatric anti-epileptic drug development, the ketogenic diet, epilepsy surgery and non-invasive brain mapping (transcranial magnetic stimulation, magnetoencephalography). He is a diplomat of the American Board of Pediatrics and the American Board of Psychiatry and Neurology, with special qualifications in child neurology, clinical neurophysiology and epilepsy. Prof. Wheless is a fellow of the American Academy of Pediatrics, the American Academy of Neurology and the American Epilepsy Society. He is a member of the editorial board of the Journal of Child Neurology, and serves as a reviewer for a number of journals including Neurology, Epilepsia, Pediatrics and Epilepsy & Behavior. Prof. Wheless has authored more than 830 chapters, articles and abstracts on childhood convulsive disorders, and is the editor of four textbooks on epilepsy. He lectures widely on paediatric epilepsy and oversees an interdisciplinary team of paediatric specialists that treat patients with epilepsy.

Prof. James Wheless discloses: Grants/research support from Aucta, AveXis, Envision, EpiWatch, Marinus Pharmaceuticals, Neurelis Inc., Neuro Event Labs, Neurocrine Biosciences, NeuroPace, SK Life Sciences, Stoke Therapeutics, UCB, Xenon Pharmaceuticals and Zogenix. Consulting fees from Azurity Pharmaceuticals, BioMarin Pharmaceutical Inc., Eisai, Jazz Pharmaceuticals, Marinus Pharmaceuticals, Neurelis Inc., Radius Health and Supernus. Speaker’s bureau fees from Aquestive Therapeutics, BioMarin Pharmaceutical Inc., Eisai, Jazz Pharmaceuticals, LivaNova, Neurelis Inc., SK Life Sciences, Supernus, UCB and Zogenix.
Prof. Katarzyna Kotulska

The Children’s Memorial Health Institute, Warsaw, Poland

Prof. Katarzyna Kotulska is the professor and head of the Department of Neurology and Epileptology at The Children’s Memorial Health Institute, Warsaw, Poland. read more

Prof. Kotulska is a representative of Poland in the Board of Member States for European Reference Networks. Her clinical and basic research focuses mainly on rare diseases of the developing nervous system and epileptology. In 2009, Prof. Kotulska received the L’Oréal-UNESCO For Women in Science Award (Poland). She is a coordinator of two large non-commercial ongoing clinical trials that are investigating the safety and efficacy of rapamycin in preventive treatment in infants with TSC (ViRap study), and drug-resistant epilepsy associated with TSC (RaRE-TS study). Prof. Kotulska has authored over 160 scientific papers published in peer-reviewed journals and several book chapters.

Prof. Katarzyna Kotulska discloses: Grants/research support from Novartis (relationship terminated). Advisory board or panel fees from Biogen, GW Pharmaceuticals, Novartis, Roche and UCB.
Ms Lisa Moss

TSC Alliance, Silver Spring, MD, USA

Ms Lisa Moss is the mother of a patient with TSC and the vice president of Donor Relations at TSC Alliance, a charity dedicated to finding a cure for TSC while improving the lives of those affected. read more

Lisa oversees fundraising at TSC Alliance; her development team focuses on building relationships with private, corporate and industry donors while raising valuable resources through corporate sponsorships, grants, appeals and individual gifts. Since 2019, Lisa has been involved in cultivating and securing leadership gifts to underwrite the TSC Alliance’s research platform to provide increased funding to accelerate the development of new treatments.

Lisa was first introduced to the TSC Alliance in 2006 when her son, Evan, was diagnosed with TSC. The following year she began volunteering. From 2008 to 2012, Lisa served as co-chair of the TSC Alliance of Metropolitan DC. In 2012, Lisa established Art for a Cure and the first Step Forward to Cure TSC® National Walk in DC, which eventually led to her joining the TSC Alliance staff full time. In 2007, Lisa and her husband, Rob, co-founded SeizureTracker.com, a database-driven website that acts as a comprehensive seizure diary system and free resource for patients and families. Lisa is incredibly grateful for the guidance and support of TSC families and individuals. Her hope is for a better future for the TSC community and that she can repay that gratitude through her work at TSC Alliance.

Ms Lisa Moss has no interests/relationships or affiliations to disclose in relation to this activity.
Downloads

View and download resources from this activity to support your learning and share with colleagues.

Download Slides
Download Slides
Download Slides
Download Slides
Download Slides
Download Slides
Download Slides
Download Slides
REGISTER NOW FOR FREE ACCESS TO
  • 1000+ topical and insightful peer-reviewed journal articles
  • 100+ hours of bite-sized congress highlights
  • 8 major therapy areas packed with the latest scientific advances
  • 150+ specialties offering learn-on-the-go medical education
  • + Concise email updates and newsletters so you never miss out
Register For Free Now
This Activity Is Funded By:

An independent medical education grant from Jazz Pharmaceuticals.
This activity is jointly provided by USF Health and touchIME.

The information provided by this CME activity is for continuing education purposes only and is not meant to substitute for the independent medical/clinical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient’s medical condition.

USF is an Equal Opportunity / Affirmative Action / Equal Access Institution.

USF Health is accredited by the Accreditation Council for Continuing Medical Education, the American Nurses Credentialing Center and the Accreditation Council for Pharmacy Education to provide continuing education to healthcare professionals. As an accredited provider, USF Health is required to disclose personal information to relevant accredited bodies that certify CME to process credits/contact hours, comply with reporting requirements, and for internal recordkeeping and regulatory purposes. USF Health does not share or sell any individual’s contact information or unique identifiers to any commercial supporter, advertiser, or third party without the specific permission of the individual.

Unapproved products or unapproved uses of approved products may be discussed by the faculty; these situations may reflect the approval status in one or more jurisdictions. The presenting faculty have been advised by touchIME and USF Health to ensure that they disclose any such references made to unlabelled or unapproved use. No endorsement by touchIME or USF Health of any unapproved products or unapproved uses is either made or implied by mention of these products or uses in touchIME or USF Health activities. touchIME and USF Health accept no responsibility for errors or omissions.

This content is intended for healthcare professionals.

Date of original release: 8 December 2022. Date credits expire: 8 December 2024.

This content is intended for healthcare professionals only. Please confirm that you are a healthcare professional.

Accept Decline
CE/CME Test (0.75 Points) Close
CE/CME Test

To obtain the CME credit(s), please complete this post-test. Please complete and click to see your results and continue.
Question 1/4
Your 13-year-old patient has TSC-associated SEGA that requires therapeutic intervention, but cannot be curatively resected. You propose initiating treatment with everolimus. What information would you give to your patient and their caregiver about the potential challenges associated with everolimus treatment?

SEGA, subependymal giant cell astrocytoma; TSC, tuberous sclerosis complex.
 Correct

Neuropsychiatric manifestations, grouped under the umbrella term ‘TAND’ (TSC-associated neuropsychiatric disorders), are common in patients with TSC,1 and are associated with significant morbidity and burden of care.2 Two randomized controlled trials compared the efficacy of everolimus versus placebo for improving neurocognition and behaviour in children with TSC.2,3 No significant differences between the two treatment groups were found in either study for any of the neurocognitive and behavioural assessments2,3 except for executive function, which favoured placebo (p=0.025), and social cognition, which favoured everolimus (p=0.011).2

Everolimus is not a contraindication to receiving the inactivated flu vaccine, but live vaccines should be avoided.4,5 During everolimus treatment, the immune response to vaccination may be reduced,4,5 meaning vaccination may be less effective.5

Abbreviation

TSC, tuberous sclerosis complex.

References

  1. Northrup H, et al. Pediatr Neurol. 2021;123:50–66.
  2. Krueger DA, et al. Ann Clin Transl Neurol. 2017;4:877–87.
  3. Overwater IE, et al. Neurology. 2019;93:e200–9.
  4. FDA. Everolimus PI. Available at: https://bit.ly/3UOm1Sp (accessed 20 October 2022).
  5. EMA. Everolimus SmPC. Available at: https://bit.ly/3G8pYNs (accessed 20 October 2022).
Question 2/4
Your patient is a 1.5-month-old baby with TSC. He has epileptiform activity on EEG, cardiac irregularities and skin manifestations characteristic of TSC, and has experienced infantile spasms. Based on current data and recommendations, what course of action or therapy do you propose for this infant?

EEG, electroencephalography; TSC, tuberous sclerosis complex.
 Correct

The International Tuberous Sclerosis Complex Consensus Group recommends vigabatrin as the first-line treatment for infants with infantile spasms.1 Although vigabatrin is indicated for the treatment of infantile spasms in patients aged ≥1 month,2,3 the EPISTOP trial assessed vigabatrin for preventing, or delaying, onset of clinical seizures in patients with TSC aged ≤4 months (mean age 34–43 days).4 Results demonstrated that initiating vigabatrin at first detection of epileptiform activity on an EEG, compared with at seizure onset, increased median time to first clinical seizure.4 A similar study in patients aged ≤2 months found that initiating vigabatrin at first detection of epileptiform activity on EEG resulted in better controlled TSC-associated epilepsy that required fewer AEDs, and reduced the frequency of drug-resistant epilepsy.5

Abbreviations

AEDs, anti-epileptic drugs; EEG, electroencephalography; TSC, tuberous sclerosis complex.

References

  1. Northrup H, et al. Pediatr Neurol. 2021;123:50–66.
  2. FDA. Vigabatrin PI. Available at: http://bit.ly/3UqomTA (accessed 11 November 2022).
  3. EMA. Vigabatrin SmPC. Available at: http://bit.ly/3Eod3pm (accessed 20 October 2022).
  4. Kotulska K, et al. Ann Neurol. 2021;89:304–14.
  5. Jóźwiak S, et al. Eur J Paediatr Neurol. 2011;15:424–31.
Question 3/4
The ongoing phase II/III ViRap trial is investigating the efficacy, tolerability and safety of vigabatrin versus rapamycin in babies with TSC aged:

TSC, tuberous sclerosis complex.
 Correct

ViRap (NCT04987463) is an ongoing two-arm, randomized, double-blind and double-dummy, placebo-controlled study to evaluate the efficacy, tolerability and safety of vigabatrin versus rapamycin as a preventive treatment in infants with TSC. The co-primary endpoints are occurrence of clinical seizures and volume of TSC-associated tumours ≥125% of initial value, both assessed over 730 days. Eligible patients must be aged 4–16 weeks with a diagnosis of TSC. Estimated study completion is March 2026.

Abbreviation

TSC, tuberous sclerosis complex.

Reference

ClinicalTrials.gov. NCT04987463. Available at: https://bit.ly/3gEvQnt (accessed 21 October 2022).

Question 4/4
Your 2-year-old patient with TSC has been receiving vigabatrin since 2 months of age. Recently, their seizures have become more frequent and retinal toxicity associated with vigabatrin remains a risk. An MRI scan shows no indication of SEGA. Assuming availability in your region, what therapeutic option would you choose to treat your patient’s seizures?

MRI, magnetic resonance imaging; SEGA, subependymal giant cell astrocytoma; TSC, tuberous sclerosis complex.
 Correct

Based on the 2021 recommendations from the International Tuberous Sclerosis Complex Consensus Group, patients with TSC-associated seizures should receive the same treatment as patients with other epilepsies.1 Alternative AEDs approved for children aged 2 years include levetiracetam2,3 and lacosamide.4,5 Alternative AEDs, such as these, should be tried prior to surgery or vagus nerve stimulation.1

Abbreviations

AEDs, anti-epileptic drugs; TSC, tuberous sclerosis complex.

References

  1. Northrup H, et al. Pediatr Neurol. 2021;123:50–66.
  2. FDA. Levetiracetam PI. Available at: http://bit.ly/3U1X3hl (accessed 23 November 2022).
  3. EMA. Levetiracetam SmPC. Available at: http://bit.ly/3XqGtL6 (accessed 23 November 2022).
  4. FDA. Lacosamide PI. Available at: http://bit.ly/3OuNYMS (accessed 23 November 2022).
  5. EMA. Lacosamide SmPC. Available at: http://bit.ly/3Osil6R (accessed 23 November 2022).
Post Test Feedback Close
Step 1: Post CE/CME Test Feedback

Please note this feedback form is compulsory to complete your CE/CME evaluation

* = Mandatory Field

Please complete this short online feedback form.
Please indicate how well each statement met your expectations.
Accreditation Close
Accreditation

Please provide your details so that we can send you your certificate, which will be emailed to the address provided. All fields are required.

* = Mandatory Field
Your Accreditation Close
Your Accreditation

Thank you for your submission. Your certificate has been emailed to you.

Copied to clipboard!
accredited arrow-down-editablearrow-downarrow_leftarrow-right-bluearrow-right-dark-bluearrow-right-greenarrow-right-greyarrow-right-orangearrow-right-whitearrow-right-bluearrow-up-orangeavatarcalendarchevron-down consultant-pathologist-nurseconsultant-pathologistcrosscrossdownloademailexclaimationfeedbackfiltergraph-arrowinterviewslinkmdt_iconmenumore_dots nurse-consultantpadlock patient-advocate-pathologistpatient-consultantpatientperson pharmacist-nurseplay_buttonplay-colour-tmcplay-colourAsset 1podcastprinter scenerysearch share single-doctor social_facebooksocial_googleplussocial_instagramsocial_linkedin_altsocial_linkedin_altsocial_pinterestlogo-twitter-glyph-32social_youtubeshape-star (1)tick-bluetick-orangetick-red tick-whiteticktimetranscriptup-arrowwebinar Sponsored Department Location NEW TMM Corporate Services Icons-07NEW TMM Corporate Services Icons-08NEW TMM Corporate Services Icons-09NEW TMM Corporate Services Icons-10NEW TMM Corporate Services Icons-11NEW TMM Corporate Services Icons-12Salary £ TMM-Corp-Site-Icons-01TMM-Corp-Site-Icons-02TMM-Corp-Site-Icons-03TMM-Corp-Site-Icons-04TMM-Corp-Site-Icons-05TMM-Corp-Site-Icons-06TMM-Corp-Site-Icons-07TMM-Corp-Site-Icons-08TMM-Corp-Site-Icons-09TMM-Corp-Site-Icons-10TMM-Corp-Site-Icons-11TMM-Corp-Site-Icons-12TMM-Corp-Site-Icons-13TMM-Corp-Site-Icons-14TMM-Corp-Site-Icons-15TMM-Corp-Site-Icons-16TMM-Corp-Site-Icons-17TMM-Corp-Site-Icons-18TMM-Corp-Site-Icons-19TMM-Corp-Site-Icons-20TMM-Corp-Site-Icons-21TMM-Corp-Site-Icons-22TMM-Corp-Site-Icons-23TMM-Corp-Site-Icons-24TMM-Corp-Site-Icons-25TMM-Corp-Site-Icons-26TMM-Corp-Site-Icons-27TMM-Corp-Site-Icons-28TMM-Corp-Site-Icons-29TMM-Corp-Site-Icons-30TMM-Corp-Site-Icons-31TMM-Corp-Site-Icons-32TMM-Corp-Site-Icons-33TMM-Corp-Site-Icons-34TMM-Corp-Site-Icons-35TMM-Corp-Site-Icons-36TMM-Corp-Site-Icons-37TMM-Corp-Site-Icons-38TMM-Corp-Site-Icons-39TMM-Corp-Site-Icons-40TMM-Corp-Site-Icons-41TMM-Corp-Site-Icons-42TMM-Corp-Site-Icons-43TMM-Corp-Site-Icons-44TMM-Corp-Site-Icons-45TMM-Corp-Site-Icons-46TMM-Corp-Site-Icons-47TMM-Corp-Site-Icons-48TMM-Corp-Site-Icons-49TMM-Corp-Site-Icons-50TMM-Corp-Site-Icons-51TMM-Corp-Site-Icons-52TMM-Corp-Site-Icons-53TMM-Corp-Site-Icons-54TMM-Corp-Site-Icons-55TMM-Corp-Site-Icons-56TMM-Corp-Site-Icons-57TMM-Corp-Site-Icons-58TMM-Corp-Site-Icons-59TMM-Corp-Site-Icons-60TMM-Corp-Site-Icons-61TMM-Corp-Site-Icons-62TMM-Corp-Site-Icons-63TMM-Corp-Site-Icons-64TMM-Corp-Site-Icons-65TMM-Corp-Site-Icons-66TMM-Corp-Site-Icons-67TMM-Corp-Site-Icons-68TMM-Corp-Site-Icons-69TMM-Corp-Site-Icons-70TMM-Corp-Site-Icons-71TMM-Corp-Site-Icons-72