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Y4 Cancer Care > Oncology 1 > Flashcards

Oncology 1 Flashcards

Oncology and Cancer in PASSMED High Yield Textbook, Oncology in Geeky Medics, Oncological Emergencies

1
Q

What are the most common causes of cancer in the UK?

A
  1. Breast
  2. Lung
  3. Colorectal
  4. Prostate
  5. Bladder
  6. Non-Hodgkin’s lymphoma
  7. Melanoma
  8. Stomach
  9. Oesophagus
  10. Pancreas
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2
Q

What are the most common causes of death from cancer in the UK?

A
  1. Lung
  2. Colorectal
  3. Breast
  4. Prostate
  5. Pancreas
  6. Oesophagus
  7. Stomach
  8. Bladder
  9. Non-Hodgkin’s lymphoma
  10. Ovarian
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3
Q

What is anal cancer?

A

a malignancy which lies exclusively in the anal canal, the borders of which are the anorectal junction and the anal margin (area of pigmented skin surrounding the anal orifice)

80% are Squamous Cell Carcinoma

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4
Q

How does anal cancer present?

A

subacute onset of:
Perianal pain, perianal bleeding
A palpable lesion
Faecal incontinence
A neglected tumour in a female may present with a rectovaginal fistula

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5
Q

What are the risk factors for anal cancer?

A

HPV infection (usually HPV16 or HPV18)
Anal intercourse and a high lifetime number of sexual partners
Men who have sex with men
Women with a history of cervical cancer or CIN
HIV
Immunosuppressive medication
Smoking

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6
Q

How should anal cancer be investigated?

A

T stage assessment: examination, including a digital rectal examination, anoscopic examination with biopsy, and palpation of the inguinal nodes

Imaging: CT, MRI, endo-anal ultrasound and PET

Testing for relevant infections, including HIV.

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7
Q

Give some risk factors for developing lung cancer

A

Air pollution (indoor and outdoor)
Family history of cancer, especially lung cancer
Male sex
Radon gas (typically affects miners)

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8
Q

Lung cancer is initially classified histologically as being either small cell lung cancer (SCLC) or non-small cell lung cancer (NSCLC).

SCLC accounts for around 15% of cases and generally carries a worse prognosis.

How can NSCLC be further classified?

A

adenocarcinoma
most common type of lung cancer
often seen in non-smokers

squamous
cavitating lesions are more common than other types of lung cancer

alveolar cell carcinoma
not related to smoking
++sputum

large cell

bronchial adenoma
mostly carcinoid

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9
Q

What accounts for the majority of lung cancer cases in non-smokers?

A

adenocarcinoma

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10
Q

What features may lung cancer present with?

A

persistent cough, dyspnoea
haemoptysis
chest pain
weight loss and anorexia
hoarseness (seen with Pancoast tumours pressing on the recurrent laryngeal nerve)
superior vena cava syndrome

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11
Q

What may be found on examination in patients with lung cancer?

A

a fixed, monophonic wheeze may be noted
supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
clubbing

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12
Q

Give some differentials for lung cancer

A

Metastasis to the lungs from other sites

Tuberculosis

Sarcoidosis

Granulomatosis with polyangiitis (Wegener’s disease)

Non-Hodgkin’s lymphoma

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13
Q

What features would suggest that a patient has mets to the lung as opposed to a primary lung cancer?

A

Symptoms relevant to the primary tumour (e.g. haematuria due to renal cell carcinoma)
CT head-abdomen-pelvis: shows primary tumour
PET: increased uptake at the primary tumour site

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14
Q

What features may suggest that a patient has TB as opposed to lung cancer?

A

Drenching night sweats
Positive sputum culture and microscopy
Chest X-ray: cavitating lesion/hilar lymphadenopathy

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15
Q

What features may suggest that a patient has sarcoidosis as opposed to lung cancer?

A

Enlarged parotids
Skin signs: erythema nodosum and lupus pernio
Tissue biopsy: non-caseating granulomas

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16
Q

What features may suggest that a patient has Granulomatosis with polyangiitis (Wegener’s disease) as opposed to lung cancer?

A

Saddle-nose deformity
Positive cANCA
Urinalysis: haematuria, proteinuria, red cell casts

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17
Q

What features may suggest a patient has non-Hodgkin’s lymphoma as opposed to lung cancer?

A

Drenching night sweats
Hepatosplenomegaly
Positive lymph node biopsy (anti-CD20 stain)

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18
Q

Give some key features of Squamous Cell lung cancer

A

All the C’s - Central, Cavitating, Calcium, Clubbing

typically central
cavitating lesions are more common than other types

associated with parathyroid hormone-related protein (PTHrP) secretion → hypercalcaemia
strongly associated with finger clubbing
hypertrophic pulmonary osteoarthropathy (HPOA)

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19
Q

Give some paraneoplastic features of squamous cell lung cancer

A

parathyroid hormone-related protein (PTH-rp) secretion causing hypercalcaemia
clubbing
hypertrophic pulmonary osteoarthropathy (HPOA)
hyperthyroidism due to ectopic TSH

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20
Q

Give some key features of Adenocarcinoma lung cancer

A

typically peripheral
most common type of lung cancer in non-smokers, although the majority of patients who develop lung adenocarcinoma are smokers

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21
Q

Give some paraneoplastic features of Adenocarcinoma lung cancer

A

gynaecomastia
hypertrophic pulmonary osteoarthropathy (HPOA)

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22
Q

Give some key features of Large cell lung carcinoma

A

typically peripheral
anaplastic, poorly differentiated tumours with a poor prognosis
may secrete β-hCG

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23
Q

Give some key features of Small Cell Lung carcinoma

A

usually central, arise from APUD cells

associated with ectopic ADH and ACTH secretion
ADH → hyponatraemia
ACTH → Cushing’s syndrome
ACTH secretion can cause bilateral adrenal hyperplasia, the high levels of cortisol can lead to hypokalaemic alkalosis

Lambert-Eaton syndrome

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24
Q

Give some paraneoplastic features of SCLC

A

ADH
ACTH - not typical, hypertension, hyperglycaemia, hypokalaemia, alkalosis and muscle weakness are more common than buffalo hump etc
Lambert-Eaton syndrome

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25
Q

What is Lambert-Eaton syndrome?

A

antibodies to voltage gated calcium channels causing myasthenic like syndrome

leads to weakness, particularly in the proximal muscles - may present with difficulty walking and muscle tenderness

can affect the intraocular muscles, causing diplopia; levator muscles in the eyelid, causing ptosis; and pharyngeal muscles, causing slurred speech and dysphagia (difficulty swallowing)

patients may experience dry mouth, blurred vision, impotence and dizziness due to autonomic dysfunction

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26
Q

Superior vena cava obstruction is a complication of lung cancer, caused by direct tumour compression on the superior vena cava. How does it present?

A

facial swelling, difficulty breathing, and distended neck and upper chest veins. Pemberton’s sign is where raising the hands over the head causes facial congestion and cyanosis

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27
Q

What is Horner’s syndrome?

A

triad of partial ptosis, anhidrosis and miosis. It can be caused by a Pancoast tumour (tumour in the pulmonary apex) pressing on the sympathetic ganglion

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28
Q

What is Limbic encephalitis?

A

a paraneoplastic syndrome where small-cell lung cancer causes the immune system to make antibodies to tissues in the brain, specifically the limbic system, causing inflammation

causes symptoms such as short-term memory impairment, hallucinations, confusion and seizures

associated with anti-Hu antibodies.

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29
Q

How can lung cancer be investigated?

A

FBC: anaemia,raised platelets may be seen
LFTs: raised ALP and GGT may indicate hepatic metastases, raised ALP may indicate bone metastases
U&Es and serum calcium

CXR: often used first line
CT: investigation of choice

Bronchoscopy
this allows a biopsy to be taken to obtain a histological diagnosis sometimes aided by endobronchial ultrasound

PET scanning
is typically done in non-small cell lung cancer to establish eligibility for curative treatment

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30
Q

What findings on CXR may suggest lung cancer?

A

Hilar enlargement
Peripheral opacity (a visible lesion in the lung field)
Pleural effusion (usually unilateral in cancer)
Collapse

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31
Q

How can SCLC be managed?

A

usually metastatic disease by time of diagnosis

patients with very early stage disease (T1-2a, N0, M0) are now considered for surgery

however, most patients with limited disease receive a combination of chemotherapy and radiotherapy

patients with more extensive disease are offered palliative chemotherapy

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32
Q

How can NSCLC be managed?

A

only 20% suitable for surgery

mediastinoscopy performed prior to surgery as CT does not always show mediastinal lymph node involvement

curative or palliative radiotherapy
poor response to chemotherapy

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33
Q

Give some contraindications to surgery in NSCLC management

A

stage IIIb or IV (i.e. metastases present)
FEV1 < 1.5 litres is considered a general cut-off point
malignant pleural effusion
tumour near hilum
vocal cord paralysis
SVC obstruction

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34
Q

What are the options for surgical removal of a lung tumour?

A

Segmentectomy or wedge resection involves removing a segment or wedge of lung (a portion of one lobe)

Lobectomy involves removing the entire lung lobe containing the tumour (the most common method)

Pneumonectomy involves removing an entire lung

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35
Q

Give some risk factors for developing breast cancer

A

BRCA1, BRCA2 genes
1st degree premenopausal relative with breast cancer (e.g. mother)
past breast cancer
nulliparity, 1st pregnancy > 30 yrs
early menarche, late menopause
combined HRT, COCP
obesity
ionising radiation
p53 gene mutations

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36
Q

What is the breast triple assessment?

A

a hospital-based assessment clinic that allows for early and rapid detection of breast cancer

2 week wait referral

comprises of the history + examination, imaging, and histology

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37
Q

A 25yr old lady with a suspicious breast lump is referred to breast clinic for triple assessment. By what imaging modality would be best used as first line? Why?

A

USS

Ultrasound scanning is more useful in women <35 years and in men in identifying anomalies, due to the density of the breast tissue . This form of imaging is also routinely used during core biopsies.

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38
Q

How is mammography used to assess breast tissue?

A

Mammography involves compression views of the breast across two views (oblique and craniocaudal), allowing for the detection mass lesions or microcalcifications.

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39
Q

What is the difference between a core biopsy and FNA in assessing suspicious breast lumps?

A

A core biopsy provides full histology, allowing differentiation between invasive and in-situ carcinoma

FNA only provides cytology

Core biopsies can also generate important information about tumour grading and staging, and have a higher sensitivity and specificity than FNA for detecting breast cancer.

40
Q

Give some ddx for breast cancer

A

Benign breast tumours:
Fibroadenoma
Adenoma
Papilloma
Lipoma
Phyllodes Tumours

41
Q

What are fibroadenomas?
How do they present on examination?

A

most common benign breast growth that usually occurs in women of a reproductive age

proliferation of stromal and epithelial tissue of the duct lobules

highly mobile lesions - “breast mouse”
well-defined and rubbery on palpation
usually < 5cm diameter

42
Q

How should confirmed fibroadenomas be managed?

A

they have a very low malignant potential :
- can be left in situ with routine follow up appointments over a 2 year period
- 30% will get smaller

main indications for excision :
>3cm in diameter or patient preference.

43
Q

What is a ductal adenoma?

A

benign glandular tumour, typically occurring in the older female population

nodular lesions mimic malignancy - often escalated to triple assessment

44
Q

What is an intraductal papilloma?
Where are they found?
How do they present?

A

benign breast lesion that usually occurs in 40-50yr old women

typically in the subareolar region (usually less than 1cm away from the nipple)

often present with bloody or clear nipple discharge, if large can present as a mass

can appear similar to ductal carcinomas on imaging and therefore usually require biopsy
sometimes excised to ensure no atypical cells or neoplasia

45
Q

When is risk of breast cancer increased with intraductal papilloma? How is this managed?

A

Risk of breast cancer is only increased with multi-ductal papilloma

most are treated with microdochectomy

46
Q

What are Phyllodes tumours?

A

rare fibroepithelial tumours comprised of both epithelial and stromal tissue

occur in older age group

often larger and can grow rapidly

47
Q

How many Phyllodes tumours have malignant potential?
How many benign tumours will recur after excision? How does this affect the management?

A

1/3 have malignant potential

10% of benign tumours will recur after excision

most Phyllodes tumours should be widely excised (or mastectomy if large)

48
Q

Breast Carcinoma In Situ are neoplasms that are contained within the breast ducts and have not spread into the surrounding breast tissue.

What are the 2 types?

Which is more likely to progress to an invasive malignancy?

A

Ductal Carcinoma In Situ (DCIS) (more common) and Lobular Carcinoma In Situ (LCIS)

LCIS

49
Q

What is DCIS?

5 major types?

How does it present?

Tx?

A

most common type of non-invasive breast malignancy (20% of breast cancer)
malignancy of the ductal tissue that is contained within the basement membrane

comedo, cribriform, micropapillary, papillary, and solid (most lesions are mixed)

Picked up on screening - microcalcifications seen on mammography

Tx is surgical excision

50
Q

What is LCIS?

How does it present?

Tx?

A

Lobular Carcinoma in Situ (LCIS) is a non-invasive lesion of the secretory lobules of the breast that is contained within the basement membrane

usually diagnosed before menopause

asymptomatic - incidental finding during biopsy of the breast

Management is dependent on extent of disease:
- Low grade LCIS - monitoring
- Bilateral prophylactic mastectomy can be potentially indicated if individuals possess the BRCA1 or BRCA2 genes

51
Q

Invasive carcinoma of the breast can be classified into:

A

Invasive ductal carcinoma (70-80%)
Invasive lobular carcinoma (5-10%)
Other subtypes, such as medullary carcinoma, invasive micropapillary carcinoma, or metaplastic carcinoma

52
Q

Invasive ductal carcinoma (IDC) is the most common type of breast carcinoma. How does it present on microscopy?

A

nests and cords of tumour cells with associated gland formation

53
Q

Invasive lobular carcinoma (ILC) is the second most common type of breast cancer and is more common in older women. What is it characterised by?

A

diffuse (stromal) pattern of spread - makes detection more difficult
by the time of diagnosis, tumours can often be large

54
Q

How may breast cancer present if symptomatic?

A

breast or axillary lump
asymmetry or swelling
abnormal nipple discharge / nipple retraction
skin changes (peau d’orange or Paget’s-like nipple changes)
mastalgia

55
Q

What clinicopathological staging system is widely used for primary breast cancer prognosis?

A

Nottingham Prognostic Index (NPI)

It is calculated by:

(Size x 0.2) + Nodal Status + Grade

56
Q

All breast malignancies are checked for their expression of which receptors?

A

Oestrogen Receptor (ER), Progesterone Receptor (PR), and Human Epidermal growth factor Receptor (HER2)

determines suitability of targeted adjuvant therapies (including endocrine and monoclonal antibody therapies)

tumours that are negative for all three receptors are associated with a poorer prognosis

57
Q

What is Paget’s disease of the nipple?
How can it be differentiated from eczema?

A

persistent roughening, scaling, ulcerating or eczematous change to the nipple

vast majority of Paget’s (85-88%) will also have an underlying neoplasm

Paget’s always affects the nipple and only involves the areola as a secondary event, whilst eczema nearly always only involves the areola and spares the nipple

58
Q

How can Paget’s disease of the nipple be investigated?
What is the first line management ?

A

Investigations:
punch biopsy, mammography and ultrasound of the breast

Mx:
operative, if possible - in all cases the nipple and areola will need to be removed

In cases associated with an underlying malignancy, radiotherapy may be necessary

59
Q

Breast conserving treatment is only suitable for individuals with localised operable disease and no evidence of metastatic disease.

What is the most common breast conserving tx?

A

A Wide Local Excision (WLE) - excision of the tumour, a 1cm margin of macroscopically normal tissue is taken along with the malignancy

only suitable for focal smaller cancers

60
Q

A mastectomy removes all the tissue of the affected breast. When would it be indicated?

A

multifocal disease
high tumour:breast tissue ratio
disease recurrence
patient choice

61
Q

Axillary surgery is most commonly performed alongside WLE and mastectomies, in order to assess nodal status and remove any nodal disease.

What is a sentinel node biopsy?

A

removing first lymph nodes into which the tumour drains

nodes are identified by injecting a blue dye with associated radioisotope into the peri-areolar skin

radioactivity detection and / or visual assessment (blue nodes) can identify the sentinel nodes, which can be removed and sent for histological analysis

62
Q

Axillary node clearance involves removing all nodes in the axilla. What are the complications of this procedure?

A

paraesthesia, seroma formation, and lymphoedema in the upper limb

63
Q

A risk-reducing mastectomy is an operation to remove healthy breast tissue in order to reduce the risk of developing breast cancer.

What patient factors confer high risk of developing breast cancer?

A

A strong family history of breast or ovarian cancer

Testing positive for genetic mutations, such as BRCA1 or BRCA2, PTEN, or TP53 mutations

Previous history of breast cancer

can refer patients to a genetic counsellor to discuss options

64
Q

Hormone treatments provide the biggest contributor in medical management to improved survival in breast cancer.

What options are available?
(explain how they work, suitable patients and ADRs)

A

Tamoxifen:
blockade of oestrogen receptors
pre-menopausal patients
increases risk of VTE operatively
increases risk of endometrial cancer

Aromatase inhibitors:
Examples: Anastrozole, Letrozole, or Exemestane
inhibit the action of aromatase, which normally converts androgens into oestrogens
post-menopausal patients as adjuvant therapy
increases risk of osteoporosis - DEXA scan before starting

Immunotherapy:
may be used in patients whose cancers express specific growth factor receptors
Herceptin for HER-2 +ve malignancies
Risk of cardiotoxicity

65
Q

What surgical reconstructive techniques are available in the oncoplastic treatment of breast malignancy?

A

therapeutic mammoplasty:
WLE combined with a breast reduction technique
nipple and areola preserved

flap formation

66
Q

How does the presence/absence of axillary lymphadenopathy determine surgical management of breast cancer?

A

women with no palpable axillary lymphadenopathy at presentation:
pre-operative axillary USS before primary surgery
if +ve then they should have a sentinel node biopsy to assess the nodal burden

in patients with clinically palpable lymphadenopathy:
axillary node clearance is indicated at primary surgery
this may lead to arm lymphoedema and functional arm impairment

67
Q

What factors favour Mastectomy V Wide Local Excision of breast cancer?

A

Mastectomy V Wide Local Excision

Multifocal tumour V Solitary lesion

Central tumour V Peripheral tumour

Large lesion in small breast V Small lesion in large breast

DCIS > 4cm V DCIS < 4cm

68
Q

What radiotherapy is offered after wide local excision?
After mastectomy?

A

WLE = always whole breast radiotherapy as this may reduce the risk of recurrence by around two-thirds

Mastectomy = radiotherapy is offered for T3-T4 tumours and for those with 4+ positive axillary nodes

69
Q

Who can Trastuzumab (Herceptin) not be used in?

A

Patients with heart disorders

70
Q

When are FEC-D and FEC chemotherapy used?

A

FECD: when node +ve
FEC: node -ve but requires chemotherapy

71
Q

What is the chance of siblings and children of BRCA1 carrier to also have the gene?

A

50/50

72
Q

The presence of positive axillary lymph nodes and residual tumour at resection margins post-mastectomy are both indications for what tx?

A

adjuvant ipsilateral chest wall and regional lymph node radiotherapy

73
Q

progressive erythema and oedema of the breast in the absence signs of infection such as fever, discharge or elevated WCC and CRP suggests what?

A

inflammatory breast cancer (IBC)- rare but rapidly progressive breast cancer caused by obstruction of lymph drainage

managed with neo-adjuvant chemotherapy first-line, followed by total mastectomy +/- radiotherapy.

74
Q

Colorectal cancer is the third most common type of cancer in the UK and the second most cause of cancer deaths. How may it present?

A

Change in bowel habit (usually to more loose and frequent stools)
Rectal bleeding
Unexplained weight loss
Unexplained abdominal pain
Iron deficiency anaemia (microcytic anaemia with low ferritin)
Abdominal or rectal mass on examination
Bowel Obstruction

75
Q

Give some risk factors for developing colorectal cancer

A

Family history of bowel cancer
Familial adenomatous polyposis (FAP)
Hereditary nonpolyposis colorectal cancer (HNPCC), also known as Lynch syndrome
Inflammatory bowel disease (Crohn’s or ulcerative colitis)
Increased age
Diet (high in red and processed meat and low in fibre)
Obesity and sedentary lifestyle
Smoking and Alcohol

76
Q

It is currently thought there are three types of colon cancer: what are they?

A

sporadic (95%)
hereditary non-polyposis colorectal carcinoma (HNPCC, 5%)
familial adenomatous polyposis (FAP, <1%)

77
Q

HNPCC (Lynch syndrome), an autosomal dominant condition, is the most common form of inherited colon cancer.

What genes is it associated with?

A

MSH2/MLH1 genes

78
Q

Patients with HNPCC are at a higher risk of cancer, primarily colorectal and endometrial cancer.

The Amsterdam criteria are sometimes used to aid diagnosis. What is this?

A

at least 3 family members with colon cancer
the cases span at least two generations
at least one case diagnosed before the age of 50 years

79
Q

FAP is a rare autosomal dominant condition which leads to the formation of hundreds of polyps by the age of 30-40 years. Patients inevitably develop carcinoma.

What causes this? How can it be investigated and managed?

A

due to a mutation in a tumour suppressor gene called adenomatous polyposis coli gene (APC), located on chromosome 5

Ix: genetic testing can be done by analysing DNA from a patient’s white blood cells

Mx: patients generally have a total proctocolectomy with ileal pouch anal anastomosis (IPAA) formation in their twenties.

80
Q

Where is colorectal cancer commonly found?

A

rectal: 40%
sigmoid: 30%
ascending colon and caecum: 15%
transverse colon: 10%
descending colon: 5%

81
Q

All patients with newly diagnosed colorectal cancer should have the following for staging:

A

carcinoembryonic antigen (CEA)

staging CT of the chest, abdomen and pelvis

their entire colon should have been evaluated with colonoscopy or CT colonography

patients whose tumours lie below the peritoneal reflection should have their mesorectum evaluated with MRI

82
Q

What is CT colonography?

A

a CT scan with bowel prep and contrast to visualise the colon in more detail. This may be considered in patients less fit for a colonoscopy but it is less detailed and does not allow for a biopsy.

83
Q

What is sigmoidoscopy?

A

involves an endoscopy of the rectum and sigmoid colon only. This may be used in cases where the only feature is rectal bleeding. There is the obvious risk of missing cancers in other parts of the colon.

84
Q

What is Duke’s classification for bowel cancer? (now largely replaced with TNM staging)

A

Dukes A – confined to mucosa and part of the muscle of the bowel wall
Dukes B – extending through the muscle of the bowel wall
Dukes C – lymph node involvement
Dukes D – metastatic disease

85
Q

What are the options for management of bowel cancer?

A

Surgical resection
Chemotherapy
Radiotherapy
Palliative care

86
Q

What does surgery for bowel cancer involve?

A

Removing the section of bowel containing the tumour,
Creating an end-to-end anastomosis (sewing the remaining ends back together)
Alternatively creating a stoma (bringing the open section of bowel onto the skin)

87
Q

Right hemicolectomy involves removal of :

A

the caecum, ascending and proximal transverse colon

88
Q

Left hemicolectomy involves removal of:

A

the distal transverse and descending colon

89
Q

High anterior resection involves removing:

A

the sigmoid colon (may be called a sigmoid colectomy)

90
Q

Low anterior resection involves removing:

A

the sigmoid colon and upper rectum but sparing the lower rectum and anus.

91
Q

Abdomino-perineal resection (APR) involves removing:

A

the rectum and anus (plus or minus the sigmoid colon) and suturing over the anus.

It leaves the patient with a permanent colostomy

92
Q

What is Hartmann’s procedure?

A

an emergency procedure that involves the removal of the rectosigmoid colon and creation of an colostomy. The rectal stump is sutured closed.

93
Q

What chemotherapy is commonly used in the mx of colon cancer?

A

Common regimens include FOLFOX and FOLFIRI

94
Q

What targeted therapies can be used for colorectal cancer?

A

Bevacizumab (anti-VEGF) and Cetuximab (anti-EGFR)

95
Q

Give some potential complications of surgery for bowel cancer:

A

Bleeding, infection and pain
Damage to nerves, bladder, ureter or bowel
Post-operative ileus
Anaesthetic risks
Laparoscopic surgery converted during the operation to open surgery (laparotomy)
Leakage or failure of the anastomosis
Requirement for a stoma
Failure to remove the tumour
Change in bowel habit
Venous thromboembolism (DVT and PE)
Incisional hernias
Intra-abdominal adhesions

96
Q

Low anterior resection syndrome may occur after resection of a portion of bowel from the rectum, with anastomosis between the colon and rectum. It can result in a number of symptoms, including:

A

Urgency and frequency of bowel movements
Faecal incontinence
Difficulty controlling flatulence

Y4 Cancer Care (13 decks)

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