Breast Cancer Attire

michelle snow: sorry for the delay everybody.welcome to the patient education lunch and learn. my name is michelle snow and i’mpatient education librarian here at the princess margaret cancer centre and i will be introducingour speaker today. dr. toni zhong is an academic plastic surgeon at the university health networkand her role at princess margaret is the clinical and research director of the uhn breast reconstructionprogram. she was recently awarded the canadian institute of health research, cihr, new investigatoraward for five years from 2015 to 2020. as well she was one of the first new investigatorsto hold a cihr foundation’s scheme program grant for the next five years for the programtitled “development of a national quality improvement program in post mastectomy breastreconstruction to optimise patient centered

experience”. doctor zhong was appointedthe provincial clinical lead for the development of breast reconstruction guidelines for cco,cancer care ontario, and through both her clinical practice and research dr. zhongs’goal is to optimize shared decision making and surgical methods of post mastectomy breastreconstruction for breast cancer survivors. so please join me in welcoming dr. zhong dr. zhong: thank you everyone for attendingthis lunch and learn opportunity. so these are just my funding disclosures as michellehas already mentioned. these are the funding i get from different research grants and alsobecause this is a talk about breast reconstruction there will be photos on breasts. so firstof all i’d like to begin my talk by giving

you some background on breast reconstruction.breast reconstruction until recently has been an underemphasized area of breast cancer care.unlike mastectomy or chemotherapy or radiation which most people know to be associated withthe treatment of breast cancer, until recently knowledge on breast reconstruction in thepublic domain has been relatively scaled but just like other areas of breast cancer care,breast reconstruction has really evolved in the last decade. today we have far betterknowledge of breast cancer biology, we now have a wider and safer selection of breastimplants that we use for reconstruction, there have been many innovations in the technologythat have made breast reconstruction more personalized for patients. we now have improvedsurgical techniques, such as using the patient’s

own tissue to recreate a breast mound thatis both esthetic and natural. and lastly the area that i really spend a lot of my timedevoted to is on generating better research that can hopefully transform clinical practice. so this is photo of what is called a radicalmastectomy. this is a patient of mine who received this type of mastectomy which wasquite popular about 20 years ago and even in many other parts of the world this is thetypical result after a radical mastectomy. but now our improved understanding of breastcancer biology has shifted our surgical treatment from surgeries like this, which i think theword radical well describes. it’s a radical form of treatment. we now know we no longerneed to perform this type of radical surgery

and we’ve shifted towards more skin sparingor in some cases even nipple sparing mastectomy that combined with the same time as immediatereconstruction can give you a much better outcome. so this is something we don’t dounless it’s a patient with very, very advanced and very aggressive breast cancer now. nowi’m going to show you a couple of clinical photos. this is a 42 year old patient of minewho was diagnosed recently with left breast dcis. dcis is in situ breast cancer and youcan see she has a small biopsy result on her left breast. so this is her before surgeryand this is her on her oblique side before surgery and you can see that she has verynice, useful, aesthetic breasts. so this is her after surgery, after undergoing left nipplesparing mastectomy with immediate reconstruction

and we had to use silicone implants in hercase. oh sorry she had skin sparing mastectomy and we reconstructed her nipple with justtattooing and using a little flap in the middle. this is her after surgery. again this is thesame patient after surgery on her oblique views. and now i’ll share with you anotherpatient. this is a young brca gene positive patientand most of you probably know that patients that carry this brca gene have upwards of80% risk of developing breast cancer in their lifetime as well as other ovarian cancer andother gynecological cancers. this young patient came to see me because she was interestedin undergoing bilateral prophylactic mastectomy. and she was also interested in preservingher own nipples. so this is her after surgery.

and we did bilateral nipple sparing mastectomyso we preserved her own nipple and we did immediate reconstruction using silicone implantright away. this is again her after surgery after undergoing bilateral nipple sparingmastectomy with immediate reconstruction. and you can see that her scars are still there,however over time those scars will fade a great deal and really what is left behindis a peace of her mind that she has undergone the prophylactic mastectomy which has basicallyeliminated about 95% of her own breast tissue. so the second major advancement in breastreconstruction is in the field of breast implants. some of you may know that back in 1992 thefda imposed this moratorium on silicone implants. so since 1992 silicone implants actually probablybecame one of the most well studied medical

devices in the last 20 years. so today siliconeimplants are not only approved for breast reconstruction in the united states as wellas canada but they are very well made and very well tolerated. as you can see they comein a wide array of different shapes and sizes. so instead of the older generation, roundsilicone or saline implants that had this extremely unnatural and amorphous shape thattended to cause a great deal of capsular contracture which is basically scarring around a foreignbody. we now use a newer generation of what we call form stable and they are anatomicallyshaped implants. so these implants actually come in a shape that resemble more of a maturebreast form and because of this they produce a much more natural shape and have greaterdurability.

along with the improvements with how implantsare made, we now have innovations in the technology that helps us surgeons with selecting implantsto make breast reconstruction more personalized to the patients’ own individual anatomyand just like no two women are identical neither are two sets of breasts. so in order to obtainvery precise measurements of the patients’ own breast dimensions we now have what’scalled this vectra 3-dimensional ultra-high resolution photography imaging system wherethe patient can stand in front of this 3d photo system and we can obtain very precisemeasurements and photos of the patients before surgery. so this is the typical picture thatis generated after a patient uses vectra. so you can see this gives you very specificmeasurements of rights side versus left side,

it gives you the patients’ individual anatomyup to millimetres and also what is really nice is it helps us surgeons point out tothe patients visually maybe small asymmetries that the patient may not have appreciatedbut we bring this to light using printouts like this. and also a very neat system thatthis machine has is this simulation module so it actually allows patients to see andunderstand what different volumes and implants would look like on their bodies because youknow you may explain to a patient, would you like a b cup or c cup size but to everybody’s’mind b or c cup size is kind of arbitrary. we can say ok this is what you start off withbut this is what you would have in the middle if you had 200 cc of implants versus 300 ccand you can see the changes that it makes

to ones breast anatomy. i really think thistype of technology has helped revolutionize the consultation process and made our consultationsmore personalized and more informed. the third advancement in breast reconstruction is thatwe now have better surgical techniques of using the patient’s own tissue to recreatea breast. this drawing actually shows you the most common older technique for breastreconstruction where if we wanted to use the patients abdominal tissue we used to haveto pull up this abdominal tissue using the patients’ own abdominal muscle, tunnel itthrough, put it on their breast and build a breast mound. but as you can imagine thissurgery often left patients with a lot of abdominal weakness even bulge or hernias.

so now we have advanced techniques where wecan amass or hook up tiny blood vessels under the microscope. so now we can remove thatsame block of tissue just like we would remove in a tummy tuck from the patient so usingjust their skin and the fat we take it off their body altogether we transfer it to theirbreast just like you see in the picture, but we have to hook up the blood vessels, hookup now the blood vessels that used to live on their tummy to the blood vessels that liveon their chest by anastomosing this. this tissue now finds its new home and blood supplyin the breast and we can shape a very nice breast mound out of this. this technique iswhat uhn is well known for and that is called a deip flap. so the diep flap actually standsfor deep inferior epigastric perforator flap

and this is an intraoperative photo but basicallyjust trying to show you that this big block of tissue that you see is really just a patients’own fat and their own skin with a tiny blood vessel and the forceps are pointing to wherewe hook up the blood vessels. you can see in the picture on the left there, that’swhere the tiny sutures, so we use under the microscope to hook up the new blood vesselsunder the microscope. so i will show you some clinical photos. this is another patient ofmine who is 48 years old; she previously had a left mastectomy for a stage iib ductal carcinomaa year ago. so this is what she looked like after having had the mastectomy and she wasinterested in a reconstruction. this is her after using this diep flap so the tissue thatcame from her tummy and also to make these

more balances we also gave her a small breastlift on the other side. we also built her nipple and areola by tattooing the areolaand building a nipple inside. so really if you saw this woman in the gym, it is veryhard to know that she had undergone all this for cancer treatment and reconstruction. it’s a different patient of mine. she isan example of a patient who not only had a mastectomy but she also had a lot of radiation.so you can see that’s why her chest is so tan after the radiation. so this is her beforesurgery on the right and on the left is we used again the skin and fat from her abdomento recreate the breast mount and we made a nipple and areola for her. so obviously thescars are still there but in clothing she

is really very well balanced and also becausethis is her own tissue she feels quite normal. she doesn’t feel like she has had an implantor something that’s foreign in her body. so this is another example of a patient whohas had an immediate reconstruction. this patient on the right is before surgery, shewas just diagnosed with breast cancer and then the picture on the left is after undergoingbilateral, skin sparing mastectomy and reconstruction at the same time again using the diep flapfrom her abdomen. now i’m going onto another technique. soanother way that we can reconstruct a patients’ breast using their own tissue is by usingthe latissimus dorsi muscle. some of you may have heard of the latissimus dorsi muscleso in this picture it’s the muscle that

lives in you back, it’s the muscle thatallows you to do pull ups. when we use this type of reconstruction is when the patientdoesn’t have enough abdominal tissue to build their own breast but they have alsohad radiation to their chest so we can’t just put an implant in under irradiated skin.we have to bring in fresh tissue. so sometimes we bring in fresh tissue from their back usingthe latissimus dorsi but often times we have to use a tissue expander or an implant underneathat the same time to give us volume. so this is a patient of mine before surgery on theright. after having had a mastectomy and radiation so and she doesn’t have enough abdominaltissue for a full breast reconstruction so this is her by using the latissimus skin andthe muscle from her back we transferred it

to the front, she underwent bilateral mastectomyand both breasts have implants underneath. you can see the scar on her back even thoughit’s visible and in time again that linear scar fades a great deal and she has a verynice reconstruction in the front using her own tissue.our patients know that they have almost reached the end their breast reconstruction journeywhen they come to this final stage of nipple areolar reconstruction. so the nipple areolacomplex is generally recreated at a separate procedure usually 3 months after the breastmound has been created. this is a welcoming step for most patients because again thisdefines the end of their journey and at the same time as during the nipple areola we canusually do a balancing procedure on the other

breast to make things more symmetric or wecan do what i like to call little nips and tucks to really refine and make things aesthetic. there are different ways we can do the nippleareolar reconstruction. nipples can be made either by folding or using what is calledthe flap which is skin that is lifted from the breast and we make little tiny incisions,fold the skin together to create the nubbin or grafts which is tissue that is borrowedfrom elsewhere. so one common thing that we do is called a nipple share. so that’s ina patient who is just having a unilateral nipple made and the have a generous nippleon the other side. sometimes we can borrow a part of their own native nipple to shareon the other side and that actually generates

a very nice symmetric and natural result andin the past we’ve also been able to use the graft from the patients’ own labia butwe’ve been doing this less and less because there is sometimes pain from and delayed woundhealing from the labial donor site. the areola can also be made in different ways. tattooingcan be done and that can be done right here in our clinic or we can borrow skin grafts.so here are some pictures. so the first picture is the nipple that is made with a local flapso that is skin from the breast that has been folded together to make a nubbin and thenwe can tattoo on the outside or and then there is also pictures in there of when we sharethe nipple from the other side. so that’s generally what a nipple areola reconstructionlooks like.

this is a picture of what tattoos can looklike. so tattoos can look fairly good but the problem with tattoos is that they almostalways fade and 50% of them will require touch up at two years. we can do that right hereat our clinic or we can refer patients to a medical tattoo artist who can also do this.so i think lastly because i have some time, i’m going to just spend a few minutes talkingto you about some of the breast reconstruction research that i have worked on the last coupleof years. and also sharing with you how breasts reconstruction research can find its way toimprove clinical care. so one area of research that i’ve studiedis on identifying barriers to immediate reconstruction in ontario. just to give you some background;immediate reconstruction is when breast reconstruction

occurs at the same time surgery as the mastectomysurgery and because this type of surgery has been shown to improve the patients’ bodyimage and their quality of life after mastectomy, its increasingly considered a quality measurein breast cancer care. in the united states immediate breast reconstruction has reallybeen increasing and in most centres its upwards of 70% of mastectomies will occur with immediatereconstruction however in ontario where breast reconstruction is almost entirely an ohipfunded procedure we don’t currently know the rates or trends of immediate reconstruction.so this brought us to our research question; first of all what are the rates and trendsof the use of mastectomy with and without immediate reconstruction in the last decadein ontario. the second question is what demographic,

institutional or geographic barriers may beassociated with the utilization of immediate reconstruction in ontario. so to study these two questions and sincethe ontario government registers and collects information on every healthcare interactionthat us ontario citizens make with our ohip card and the government stores all of thisinformation in provincial registries and databases, we were able to tap into this enormous wealthof information for our research. after all of our data collection and cleaning we identifieda total of over 25000 patients in ontario who received mastectomy alone in the lastdecade and about 3000 patients who received mastectomy with immediate reconstruction atthe same time. so to answer our first question;

what are the rates and trends in the use ofmastectomy with and without immediate reconstruction. this figure shows you what we found. on thetop, the red line shows you that breast conserving surgery which is lumpectomy with radiationhas been declining by 33% between 2002 and 2012. you can see that the use of mastectomyalone shown in the middle blue line has also been on the decline by 12% however the useof mastectomy with immediate reconstruction has increased by 44% in the last decade. whenwe look at the method for immediate reconstruction we saw that interestingly the utilizationrate of implants as you see by the yellow line increased the greatest over the lastdecade by 100% while the use of the patients’ own tissue though has remained relativelysteady in the last decade.

so then we went onto question 2. what arethe different demographic, institutional or geographic barriers that are associated withimmediate reconstruction? we found that at the patient level with younger patients inhigher neighbourhood income, were all associated with the greater odds with receiving reconstruction.on the other hand, patients who had invasive cancer diagnosis or patients interestinglywho had just immigrated to canada in the last 10 years were at significantly lower oddsat receiving immediate reconstruction. also we found that it mattered at what type ofhospital you were treated at. so patients who were treated at a teaching hospital ora hospital that performed higher volume of breast cancer surgery; they were significantlymore likely to receive immediate reconstruction.

and lastly we looked at; does it matter whereyou live. it appeared that it does matter where you live. patients who ultimately receivedimmediate reconstruction had to travel a significantly greater distance from their home for theirimmediate reconstruction than those patients who opted to just undergo mastectomy alone.so what does this all mean? in conclusion we found that our current rates of immediatereconstruction in ontario still remain low. this is a rate similar to what the unitedstates experienced about 10 years ago. although immediate reconstruction has become an expectedcomponent of quality cancer care it’s still found to be a privilege surgical service that’sonly available to a smaller group of patients with favorable clinical and demographic characteristicswho are willing to travel further to undergo

surgery at a teaching hospital or a hospitalthat treats higher volumes of breast cancer. so the conclusion of this study is that thereremained a great deal of room for improvement in the delivery of immediate reconstructionin ontario and that possible improvements could be made at the patient level and aswell at the system level. so very lastly what’s exciting is that inresponse to this research finding i’ve been working very closely with cancer care ontarioand other major stakeholders for the last 2 or 3 years and we have actually developedstandardized provincial guidelines on breast reconstruction. so this document is on breastcancer reconstruction surgery for both immediate and delayed patients across ontario wherewe have provided very clearly defined patient

indications and appropriate surgical options.this guideline was just recently released in its final form in january of this yearand in fact tonight we actually have a 3 hour webinar to kick off to introduce this guidelineto all the breast cancer centres across ontario. so it’s very exciting to see that the yearsof research that we have compiled can actually filter its way to make a difference in individualpatients’ lives. so in conclusion, breast reconstruction may not be something that everypatient wants or is even a candidate to have, but those who will undergo this type of surgeryi think the benefits both emotional and physical can be life altering.thank you for your attention. so i’m happy to stand up here and answerany questions anybody may have.

q: if you are a patient that’s consideringmoving forward with this. what types of questions would you suggest asking your physician, askingthe surgeon that you are being connected with. a: so i think that’s an excellent question.that brings me to the next issue that i think that at princess margaret we have been intalks that we need to develop just a quick list. a sort of list of “these are the mustask questions before you leave a consultation” because 45 minutes of consultation can goby very very quickly and oftentimes you dive so deep into one area that you may forgetto ask about other areas. but in general i would say that it’s important to ask, tomake sure that your physician, your surgeon who is examining you understands all of theprevious treatments that you have had so the

previous surgeries that you have had, previousradiation or chemo that you have had and also its important for the surgeon to know whatyour personal preference is. everyone goes into the breast reconstruction process withdifferent expectations and different preferences and we don’t know that until you share thatwith us so if it’s important for you to undergo as few future surgeries as possiblethen you need to let us know that or if it’s important for you to use your own tissue thenwe gear a consultation towards that too. q: [how do you figure out what patients areeligible for immediate reconstruction?] a: so that’s one of the things that we wantedto highlight in our cco document and that’s what is contained in the document that weare going to be sharing with all the referring

physicians so the surgical oncologist, theradiation oncologist, the medical oncologists. so when we assess the patient and see if theyare a candidate for immediate reconstruction now we do require that we have as much oftheir cancer related information as possible so not everyone has answers to everything.to the fullest ability we want to know how big the tumour is, what is the likelihoodthat the patient will need radiation because that will help us determine whether the patientis a candidate for immediate reconstruction. that being said, our indication for how isa candidate for immediate reconstruction is expanding. in the past there may have beenonly 20% of patients who were eligible, now that’s expanding. even for patients whowill require radiation, we work more closely

with their radiation oncologist that we canformulate a plan. if it’s really important to the patients to have immediate reconstructionwe can provide that for them but as long as the radiation oncologist knows that we havedone that. q: just on that radiation thing. i have twoquestions. one; if you haven’t done anything yet and you are going to start and you needradiation, you’re still saying that there might be a possibility of getting siliconeand radiation? a: yes, yes that’s right. q: second quick question. what if you’repast that and they already did a lumpectomy but you have lots of breast left is radiationcompletely precluded as you need a mastectomy

later or can they work with smaller implants? a: oh ya! so if you have had radiation inthe past and now you want to undergo a mastectomy. so absolutely we see lots of patients likethat so they can have mastectomy and there are still option for reconstruction. theremay be a little fewer options than if you had never had radiation but there are certainlystill options that are safe. q: just along that line, if you want to saysomething about the oncoplastic procedures that you’re doing? a: so that’s a good point. so the otherthing that we’re working on with our radiation oncologist as well as our surgical oncologistis developing a program for oncoplastic breast

reconstruction. so what oncoplastic reallymeans is in the past if you had to have a lumpectomy and radiation the surgical oncologistor your breast surgeon would just do the lumpectomy and you have a scar and what every the lumpectomylooks like that’s the way it’s going to look like and then you have the radiation.well now we’ve learned that a lot of times, depending on where the lumpectomy is on thebreast and depending on your breast anatomy, sometimes we have a subgroup of patients whoare really unhappy with the way they look after the lumpectomy and radiation. so ifyou’ve had a mastectomy and radiation and you come to see us to help you look betterat that point we have more limited tools. so up front now we know we can identify beforesurgery, depending on your breast size, depending

on where the lumpectomy is going to take place.if we know that probably it’s going to generate a scar that is not so great and the patientis not going to be happy then as a plastic surgeon we get consulted and we come in atthe time of consultation and we can design patterns using our traditional knowledge ofbreast reduction and breast lift surgery and design surgeries to better place the scaror better place a tissue so that things look more aesthetic at that time and the you goand have the radiation and you still come out looking like you had some kind of aestheticsurgery rather than a more debilitating and deforming scar. q: are the doctors supposed to be giving methe option before you have your mastectomy.

in my case i was offered; do you want haveimplants done right after surgery? they said it’s better to wait after all my treatmentswere done. a: so that again that’s something that ourcco guidelines will touch on. for most patients who have dcis cancer or early breast cancerwe do make sure that we offer them consultation with a plastic surgeon to talk about immediatereconstruction. for patients who have more advanced cancer, larger breast cancer or metastaticbreast cancer where it’s gone to other parts of the body then our focus, all of us together,is getting the cancer treated and dealt with first. have all of your chemo, have your surgery,have your radiation done up front and then we say about a year after radiation we cando a delayed reconstruction. we’re all in

agreement because we think that the oncologictreatment must take priority. q: would a patient be undergoing chemotherapyat the same time as breast reconstruction in some cases? a: in some cases the oncology team will askthe patient if they’ve had neoadjuvant chemo so before surgery they’ll undergo theirchemotherapy then we wait the 6 – 8 weeks in between and then we do surgery so mastectomywould be with immediate reconstruction but with other patients it’s still mastectomywith reconstruction at the same time and then after they heal from that, 4 weeks after thatthey will have chemo and then after chemo they have radiation. so that’s why we docall it a journey because it is a long time

from beginning to end. q: you were just mentioning earlier aboutoncoplasty and i was wondering at which stage it is done. is it possible to have after theradiation or before? a: so we try to do it before radiation becausethe problem with radiation is that radiation is very effective at killing any leftovercancer cells but it’s also very effective at killing normal cells. so after you’vehad radiation and we start moving tissue around, you are going to have significantly highercomplication rates. so we try to do all that tissue rearrangement before they receive radiation. q: is it done as two separate surgeries? isit done at the time of the lumpectomy?

a: it’s done at the same surgery as thelumpectomy. it’s together and we don’t increase the or time we just rearrange things;we are both there at the same time working. q: let’s say you get a lumpectomy and youdon’t like the way it looks can you then… would that make it possible to get oncoplastyand then radiation or? a: ya i guess at that time it’s all semantics.it wouldn’t be what we call oncoplastic but yes you could see us for rearrangementbut typically you need to have lumpectomy within 6 – 8 weeks you need to have radiationso there isn’t time for revision surgery in between. that’s why we try to do everythingin one surgery so that you have only one recovery. so it’s something probably we don’t advisebecause we don’t advise delaying radiation.

q: i have some patients and they come withtissue expanders…what is the difference between? …how do you decide to give themtissue expanders and not when you give reconstruction? a: tissue expander is a form of reconstruction.it’s just a staged approach. we call it immediate reconstruction if the reconstructionbegins at the same time as the mastectomy so we begin the reconstruction by puttingin a tissue expander. a tissue expander just basically saves your skin and acts as a spacerinside so that we preserve the skin because again the tissue expander and any type ofreconstruction we do, it can’t go just underneath your mastectomy skin because the mastectomyskin gets very traumatized after the mastectomy. the safest place for it is underneath yourchest muscle. so we put that tissue expander

underneath your chest muscle. normally youcan imagine there is no room underneath your chest muscle; it’s directly stuck to yourchest wall so we artificially create that room by putting in a tissue expander or aspacer. that’s a little small at the time of surgery and after surgery they come seeus every two weeks and we gradually inflate, inflate to make that space and save the skinand create a breast mound and then 3 months after the tissue expander is fully inflatedwe take it out and put in a permanent implant so it’s still immediate reconstruction becauseit is reconstruction it’s just not the final reconstruction. q: i usually get patients who get tissue expansionsand when they come for radiation we tell them

not to have any more expansions. a: yes. q: so once the radiation is finished theycan actually go and do their... a: then we can take out the tissue expanderand put in the final implant. that’s right. q: do they have the choice between the expanderor putting it behind the chest wall or just underneath the skin? a: we never put it just underneath the skinbecause again the skin is so traumatized and if you put an implant or tissue expander justunderneath the skin, we know that it can get infected, it can push the skin out and itcan actually make the skin not survive so

it’s not a safe thing to do that’s whywe routinely put it under the chest muscle. q: i also wasn’t offered the choice of immediatereconstruction and post mastectomy, post radiation chemo. i wanted to know, and you may havealready covered this. sorry. are the options basically the diep, the latissimus and howdo you feel about the fat grafting with implants? a: you’ve had a total mastectomy? i wouldsay that the options would be the diep using the tummy or the latissimus with the tissueexpander followed by an implant. at this point we don’t recommend fat grafting for an entirebreast. i think it’s still very experimental. q: so fat grafting to prepare the skin andthen still the expander with it. a: it an individual consideration. it justdepends on how large you want to go and it

depends on the quality of the skin after radiation.that’s again still i would say an experimental form of reconstruction. it’s not the normand so for individuals who really want that we really have see if they are a candidate.q: and it’s done here at the princess margaret? a: it’s done here but we have to assessindividual by individual and it’s something that we’d have to really discuss and makesure that the patient understands the pros and cons and that’s not by any means thenorm for reconstruction. q: and then the diep, i guess because i nolonger have cancer in my body and the diep is a long process only because of the waitlist. a: the wait list used to be an issue and it’san issue in some places but i think at our

institution, at uhn we`ve really done a goodjob of having more or resources and availability to do diep flaps so i would say dependingon the surgeon its anywhere between a couple of months to upwards of two year waitlistbut i would say it’s not always that you have to wait two years. q: so the average is about a year a: average, i would say 6 months to a year.hi shelly. q: is the link available for the webinar tonightavailable? a: sandy will send it in. thank you sandy. michelle: are there any more questions? thankyou so much.