(bright inspirational music)
- Hi, I'm Susan Taylor at Scripps Health
in San Diego, California.
You get those three dreaded words: you have cancer.
Now what?
Well first, we tell our patients
to (exhales deeply) take deep breath.
Let's look at the biopsy report,
let's get some imaging studies done
and meet with your medical team
to talk about the course of treatment.
So the course of treatment for many types
of cancer includes radiation therapy, and radiation therapy
has changed dramatically over the last 15, 20 years.
Here to talk about advancements in radiation therapy
are Dr. Ray Lin, who is the Medical Director
of Scripps Radiation Oncology and Dr. Prabhakar Tripuraneni,
who is Division Head of Scripps Radiation Oncology.
Thank you so much for being here.
All right, so let's start with the basics
for folks who are just beginning this journey.
What is radiation therapy?
- Radiation therapy is using various forms
of radiation therapy safely and effectively
to manage cancer, cure cancer,
and also use it in some of the types of diseases.
- [Susan] So explain what radiation therapy,
though, Doctor.
- Radiation therapy is one of the main modalities
for cancer care.
There's three main modalities:
one is surgery; one is systemic treatment
such as chemotherapy, hormone therapy, immunotherapy;
and one is radiation therapy.
And radiation therapy involves
using radiation beams to treat the cancer.
Rather than take it out physically by surgery,
we radiate that cancer and do--
- [Susan] You're zapping it.
- Zapping it, yeah.
- There are two major forms of radiation therapy.
Giving radiation therapy from outside,
external radiation therapy.
That's what most of the patients get,
the linear accelerators, et cetera.
And there's also bracytherapy.
That is internal radiation therapy
where we can put in radiation seeds,
or capsules, and do radiation therapy from inside out.
- So the radiation therapy, the treatment
has evolved greatly over the last 15 or 20 years.
Tell me how it's evolved, how it's changed.
- Radiation therapy has been around since 1895.
Radiation therapy has been around more than 100 years.
- [Susan] Wow.
- And around 1950s, there was invention
of a new machine called the linear accelerator, (crosstalk).
- [Susan] A linear accelerator?
- Linear accelerator, in Palo Alto, California,
that really opened up the Pandora's box
for radiation therapy.
I've been radiation therapy for the past 35 years.
Three major things happened in the past 35 years
that really put radiation therapy
in the forefront in the cancer management.
The basic radiation-producing apparatus,
linear accelerator, has been about the same.
The first major advance is incorporation of the computers.
These days, machines are really fast,
highly telomated to deal with radiation therapy precisely
where we want to treat or how we want to treat.
The second major advance is incorporating imaging equipment.
Our linear accelerators these days come
with X-ray machines built in
to take regular X-rays, CAT scans, and MRIs
that give us the ability to look
at the tumor just before I'm doing the treatment
so that we can safely and effectively
and precisely deal with the treatment.
The third thing that we already mentioned
is that we use chemotherapy, radiation therapy,
and immunotherapy together that becomes much more effective.
Often, if the effectiveness of radiation therapies,
let's say, 10 points, chemotherapy
by itself is only five points.
But using chemo and radiation therapy together,
we can get up to 20 points, so almost all cancers
these days that we treat them for cure,
we use combination of radiation therapy along
with some form of chemotherapy
and hormone therapy and immunotherapy.
- Yeah, I say look at the computer age.
Think of your iPhone.
It took a long time from a basic phone,
your dial-up phone at home, to go to a cell phone
than from the cell phone to go from 2D, 3D, 4D, 5D.
It's rapidly progressing, and I think
because of the computer age with better imaging
and better technology, radiation therapy
has advanced just like your cell phone,
from 2D to 3D to 4D, that quickly.
But it took a long time to get to 2D.
- So the radiation therapy of 15, 20, 30 years ago,
it was in a much broader range, you're saying?
So let's say say the tumor is here,
you had to radiate an area that was bigger,
and now you can be a lot more precise
with the area that you hit?
- Well, definitely, it was more coarse.
These days, the radiation beams are much more precise.
But also because we see the target much more precisely,
not just because the machines could create a much
more precise target, it's because we
can see the target much more precisely.
Because we have better imaging with MRIs and PET scans,
we can see on the computer where that tumor is
and arrange beams with various angles
to treat that target while sparing normal tissue.
- Are you doing it in real time, that you can see it
as the beam is actually hitting the tumor?
Or do you have to immobilize the person, the patient,
on the table and then model it and calculate,
yeah, this is where it's gonna hit?
- Even if you immobilize the patient
and put the marks on the skin, there's still things
inside the body that want to move,
such as the heart, the lung, the prostate,
and bowel and all those things.
I know our machines, and most of the machines,
these high linear accelerators, we can take an X-ray
and a CAT scan just before the treatment
and see exactly where it is, how to modify
what you want to treat, to shift the beams
right on the fly, and where you're treating.
You can also take X-rays and modify what you're doing.
So that's the next major advance
in radiation therapy, the real-time image guidance.
- Yeah, at Scripps Health, we have machines
where we can actually treat in sub-millimeter precision
because machines are so precise these days.
- So you're talking about (laughs)--
- Sub-millimeter.
- Fraction of a millimeter.
- Fraction of a millimeter, which is great
because you wanna protect the nearby, surrounding
healthy tissue and the vital organs, right?
- That's exactly right.
- So is radiation therapy better on certain cancers
than other types of cancers?
- There are certain cancers that are more
what we call radioresponsive, more radioresponsive
to radiation therapy, such as lymphomas.
And then there are other cancers that are more
what we call radioresistant, like sarcomas.
But all cancers can be treated with radiation therapy.
You just have to manipulate the amount
of dose you get per day and how often to give it
to, based on the sensitivities of the tumor.
For instance, if a tumor is more sensitive,
you can give less dose per day.
But if a tumor is less sensitive to radiation,
you just have to give a higher dose per day.
So all cancers are sensitive to radiation,
but some are biologically sensitive,
where some are more biologically resistant.
- So the biologically sensitive ones would be...
- (in unison) Lymphoma.
- Seminoma, it's from--
- Seminoma is testicular cancer.
- Okay, and then the ones that are not so sensitive,
where you'd have to give a higher dose, would be--
- I'd say melanoma and sarcomas tend
to be less sensitive, and then the other tumors
are in between.
- Right, so a common-- - So we treat--
- common one would be breast cancer,
what about breast cancer?
- We treat just about every single cancer
with a different radiation therapy, starting
from brain tumors, throat cancers, lung cancers,
breast cancers, pancreatic cancer, prostate cancer.
And so actually, just about every single cancer
is treated with radiation therapy.
As we were saying a few minutes ago,
we diagnose about 1.6 million cancers
in the United States every year.
More than one million patients
actually get radiation therapy
as the sole treatment and part of the cancer management.
So that's a large number of patients, one million patients
actually get cancer radiation therapy.
And about a third to half of them
are cured solely because of radiation therapy.
It's a very safe and effective form
and highly curative form.
- So are there certain types of cancer
where you wouldn't need chemotherapy,
and you can just do the radiation?
- Absolutely.
- And those would be, for example?
- Prostate cancer.
Some of the very early lung cancers these days,
the data is showing that you can give
four to five radiation zaps, you can say,
four to five treatments with what's called radiosurgery,
which is just as equivalent in cure
as taking the lobe out surgically.
So radiation therapy has come a long way
where we have technology, where we can pinpoint
on very small tumors, even very large tumors,
and give an equivalent cure to surgery many times.
So when we talk about cancer care,
sometimes radiation's given, sometimes chemotherapy's given,
sometimes surgery's given, and sometimes
there's a combination of two or three of these things.
- Are there certain people who can, should have radiation,
and are there people who can, should not have radiation?
- Well, I would say it depends on the type of tumor.
I would say it depends on the location;
is it easier to take out, or is it easier to radiate?
And for certain cancers such as breast cancer,
if a woman has lupus or some kind of autoimmune disorders,
sometimes that will tip us towards giving surgery
rather than radiation therapy.
- [Susan] Because?
- Because of the skin reaction, the skin response
to radiation therapy.
And then there are certain patients
who we would tip towards radiation
because surgery would be harder on them.
- The number of patients that actually cannot
have radiation therapy because of lupus
is far and few between, maybe one
out of 1,000 patients or one out of 5,000 patients.
And I think if the cancer is localized, most
of the body sites, they can be
a candidate for radiation therapy.
And the advantage of radiation therapy
is you don't need to go through major surgery
and you get to keep what you have.
For example, as simple as a skin cancer
on the tip of the nose, most surgeons
can do a wonderful job, but your nose gets messed up.
You can have four weeks of radiation therapy
and get to keep the nose exactly the way you have
right in there. (Susan laughs)
- So let's say I've been diagnosed with cancer,
and I come and I'm told that I need radiation therapy.
What is procedure, what happens
when a patient comes to see you for the first time?
- I think the most important thing
is actually to have a treatment plan.
That's where the radiation oncologist,
surgical oncologist, and medical oncologist
work together and devise a plan.
Sometimes, actually, radiation therapy's
the only treatment the patient is going to get.
Very often these days, actually,
it's a combination of multiple treatments.
Do you want to take on from there?
- Yeah, I would say after the plan is created,
patients undergo immobilization and simulation,
where we do a mapping of the target
where we immobilize the patient
so that they're treated in the same position each day.
Then a planning is done in the computer in the background
by a physicist and dosimetrist and radiation oncologist.
After we plan the treatment, what we do
with planning the treatment is we wanna minimize doses
to normal structures and deliver all the doses to the tumor.
After we plan the treatment,
the patient's scheduled for treatments.
And radiation takes about five to 10 minutes sometimes.
It's Monday through Friday treatment
anywhere between one day to up
to six to seven weeks, typically.
- [Susan] So what--
- When you do the simulation, I tell patients,
actually, we do a CAT scan of where we want to treat.
We reconstruct the CAT scan; I have a watchful view
on the computer.
I can slice and dice any way I want and,
as Ray said a few minutes earlier,
we can bring in the PET scans and MRIs
and actually fuse and see exactly where the tumor is
and then decide what we want to treat,
what we don't want to treat.
And then I have a whole group of people
that actually work within our department,
the medical radiation physicist,
the dosimetrist therapist, we are--
- What's a dosi, what is it called, dosimetr--
- A dosimetrist is someone who is trained
in planning and designing radiation fields
and creating doses for a radiation plan.
And a physicist is usually someone who supervises
a dosimetrist to do this, a medical physicist.
- So if I have a tumor on my lung,
then this team, they map out exactly where the tumor is,
where the radiation's going to hit the tumor,
at what angle - What angle.
it's gonna come in at.
- We create customized blocks because each angle
where the beam comes in, the beam's gonna see the tumor
from each angle differently.
So, for instance, let's say you have prostate cancer.
If a beam's coming through the front,
it's gonna hit the bladder, so you could customize the beam
where it treats less of the bladder from that angle.
- So that you don't have side effects
- Exactly. like urinary incontinence.
- From the side, you may want to customize
that beam so that it avoids the rectum.
So from every angle the beam could be created
in a special way and molded in a special way to give--
- That's the (crosstalk) advance, these machines actually.
The TrueBeam STx that we have is actually
such a highly sophisticated linear accelerator.
Once we design the plan right in there,
all the information is sent to the linear accelerator,
and as the machine is moving around,
it's constantly changing the shape of the beam
and how much intensity it's delivering.
On the top of it, we can do imaging before,
we can do imaging during, so that we can precisely
and accurately deal with radiation therapy
in a highly different fashion.
- So this TrueBeam STx technology,
and we've got some animation to show the folks about this.
The patient is lying there on the table, right?
They're not moving; the actual machine is moving
around the patient, and is the beam, is it 360 degrees?
Can you come in at any angle?
- It could be 360 degrees.
I think of it as, think of a beam
that's rotating around your body.
The beam goes through a checkerboard.
That checkerboard opens and closes
from each angle where the beam's going through
because what you wanna do is you wanna mold
that checkerboard to conform to the tumor.
You can also deliver a different dose
through each grid of the checkerboard
so that the areas near the center of the tumor
you can give a higher dose, the area
at the peripheral of the tumor
near a normal structure you can give
a lower dose through that grid.
So I think of it as a beam going around the body
but the beam goes through a grid,
which is like a checkerboard, that opens and closes.
- It's a highly sophisticated linear accelerator.
It's very high-end computing right there.
Think of like a cardiography between the imaging,
delivering the beam, constantly changing
where you're delivering and how you're delivering
and how much you're delivering,
and also motion management, all of them put together.
That's what the machine is doing seamlessly.
And amazing, it can deal with the treatment
in about a minute or two.
Probably one of the fastest machines
that you can actually buy on the marketplace today.
- That is so wild.
So before, I remember my mom had breast cancer back in 1999.
And she had six weeks of radiation treatment,
five days a week, for six weeks.
And she had to lay there for a long time.
Now you're saying, with this TrueBeam STx technology,
talk about the amount of times per week and how many weeks
and how much they have to lay on the table.
It's a lot less in all those categories, isn't it?
- Well, it's a lot less time on the table
for almost all the radiation therapy equipment these days.
But it's also a lot fewer weeks
because, these days, we know that for certain cancers,
for let's say breast cancer, we used
to treat to six to seven weeks.
These days, we know that a lot, a good majority,
of the women can probably do it in three to four weeks
because there's data that shows that three to four weeks
of radiation therapy by giving a slightly higher dose
each day is probably equivalent to six
or seven weeks of radiation therapy.
And the reason why we can give slightly higher doses
of radiation each day is because the technology's better.
It's more sophisticated in delivering the treatment.
- [Susan] It's so much more precise.
- It's so much more precise that you
can give a higher dose in fewer treatments.
- For example, for prostate cancer,
typically, we used to give about 40 treatments, eight weeks.
If you think six weeks is bad,
that's eight weeks of treatment right in there.
With the older machines, you have to be on the table
for a good probably 20 minutes to 25 minutes right in there.
Almost half to 2/3 of patients
actually only get five treatments,
just one week of radiation therapy.
They're on the table no more than 15 minutes,
in and out so quickly right in there.
So I think with the advent of this TrueBeam STx
and the like linear accelerator right in there,
we're much more precise, we can safely
and constantly and accurately give a very high dose
to prostate and not give any damage
to the rectum or bowel that's surrounding.
- So, in just a couple of minutes, we're gonna talk about,
I want you to hold this thought for a second.
We're gonna talk about there's some recent news stories
about women getting radiation on their left breast
and then ending up with heart disease several years later.
And we're gonna talk about how radiation therapy
actually affects the heart, so hold that thought;
we'll come back to that in a couple of minutes.
Typically, the radiation treatments last what?
Is there a norm, is it two to three weeks,
or is one week or ten days, or it really depends
on where the tumor is? - Depends on the--
How do you determine how long it--
- So it depends on whether it's a curative treatment
or what's called a palliative treatment
to take away pain or discomfort.
Curative treatments tend to be a little bit longer.
Also, it depends on are we giving chemotherapy with it.
'Cause if we're giving chemotherapy
with it, it's usually a longer treatment
because we don't want to give a higher dose.
So it could last anywhere between, like I said,
one or two days to about six to seven weeks.
But the time on the table these days
is really short, maybe five to 10 minutes each day.
- So talk about 3D and 4D tumor imaging.
I know, in the past, 2D is one dimensional.
3D is you see the whole thing.
But 4D deals with
- (in unison) Motion.
- Motion management. - Motion, right.
So how does that work?
- That's where-- - Give me an example of that.
That's where the TrueBeam STx really come
in handy right in there.
Take prostate cancer as an example.
You put the patient on the table,
and then you do your X-ray measures or you do a CAT scan.
You see that the prostate has actually moved
either up or down or front or back right in there.
You can make all the adjustments,
and right on the table where the patient is lying down
on the table, right?
And you take one more set of X-rays to make sure
that you want to be exactly where it is right in there.
And then you start treating.
In certain cases, actually, you can image
during the treatment and make the proper adjustments,
actually, while you are treating.
And Ray's working on the management
of the breast cancer as the patients are breathing.
- Exactly, because what you wanna do
is when you're breathing and you have breast cancer,
and your chest is going up and down,
what you can do is you can learn
how to control the beam to have it on and off
based on the patient's breathing cycle.
Also, I think a 4D CT as, I think lung and liver cancer.
With your lung and your liver,
when you breathe, the tumor moves up and down like this.
Now in the old days, what we would do is,
as the tumor moves up and down, you have
to have a large target to get it.
But what we can do is
because-- - So you hit it no matter
where the tumor is, as you're breathing in and out.
- With 4D CT scan that we have at Scripps Health,
what happens is, as the tumor goes up and down,
we can see that the tumor moves different directions,
up and down, right and left, front and back.
They move a different distance.
So what you can do is you can generate a bigger margin
where the distance is greater of movement,
a smaller margin where the distance is less.
So what we're trying to do is basically have
tighter margins, have more accurate treatments,
have high precision.
- So let's say you have a tumor on the lung,
and as you're breathing, it moves in and out of frame.
When it moves out of frame, what you're saying
is the machine actually turns on and off
as it's moving in and out of frame?
- That is what the future technology is,
and that's what we are currently working on.
- Okay, but that's not available currently
right now with the TrueBeam STx?
- We have versions of it where we could,
it's called respiratory gating.
Or with breast cancer, what we're working on is
as you breathe in and out, as the breast
and the target moves in and out
of the radiation field, we can turn the beam
on and off based on respiration.
- And so that's really much more targeted therapy
just to the area, and so how much less radiation do you get
with this kind of method? - The dose of
radiation therapy's the same, but the volume
that you're treating, it all depends upon
how much the tumor is moving.
If the tumor is moving, let's say,
an inch up and down right in there,
in those patients, actually, you significantly save
a portion of the lung at 5% of the lung or 10% of the lung.
If the tumor is not moving much
or moving only a few millimeters,
then it really doesn't make a difference.
- So there's not any way to say
on average you're getting, what, 10% less radiation
or 25% radiation, but 'cause it's targeted
right there 'cause of that 4D movement?
- It depends on the volume.
- It does?
- So the bigger the volume, the more important it is
to have a smaller target.
When you have a small target already,
it's probably not gonna matter as much as a bigger target
because a bigger target or where the target is.
If it's on the bottom of the lung
where there's a lot of breathing, a lot of movement
near the diaphragm, 4D gating is gonna be more important
than a tumor at the top of the lung.
- We talked about this a couple of minutes ago;
let's come back to this.
There have been news stories about women
getting radiation on the left breast
and then getting heart disease several years later.
So please address those concerns
and what is involved in all that.
- Yes, there was some literature recently
that looked back on women
who had breast cancer treatments years and years ago.
And they found out that women who had
left-sided breast cancer treatments
were more likely to get heart disease in the future.
Because what happens is the radiation beams
could hit some of the vessels around the heart,
and these vessels, they can develop plaque.
It's like hardening of the artery.
That can lead to an increased risk of heart disease.
But thankfully, Susan, these days, the radiation therapy
is no longer your mother's radiation therapy.
The equipment has become so much better,
so much more precise.
There are so many ways to treat breast cancers
now for the left side.
For instance, what you can do is, instead of lying
on your back where the beam goes across,
you can lie on your stomach where the breast hangs down
and treat from the bottom to avoid the heart.
We also talked about respiratory motion, respiratory gating.
Also, we talked about beams that have,
remember that checkerboard, that can open and close.
So if there's a grid where the beam's going in
that's close to the heart, you can simply block it.
So there's many ways to manipulate this.
As a matter of fact, last--
- So go back again, there's actually ways
that you can block the beam from a certain
part of the body. - Right, remember, it's
like a checker, so the beam goes through a checkerboard.
If part of the target is near the heart,
you simply block that part of that grid
that's near the heart so that's there no beam
that's going through the heart.
Also, like with respiratory motion,
you can manipulate the beam as patients breathe in and out,
as the heart moves in and out towards the chest.
But also, like I said, the way you immobilize the patient,
the way you position the patient,
whether on her back or on her stomach,
you can manipulate doses to the heart.
So I'm really happy to say that, these days
with modern radiation therapy, heart risk is fairly low.
As a matter of fact, last year,
in the Journal of Clinical Oncology,
there was a publication that stated
that, with modern radiation therapy,
the incidence of radiation therapy leading
to heart-related deaths
is only 0.3%
if you're a non-smoker.
Now, if you're a smoker, it's about 1%.
So if you have a low risk to begin with already,
radiation therapy doesn't really add much more risks.
- So when you look down the road, what do you see?
- Well, I'm really excited about
more targeted therapy, more immunotherapy.
So not just advancements in radiation therapy,
like Dr. Tripuraneni said,
with MRI-based linear accelerators.
In our field, I'm excited about the MRI base.
But just in other fields, targeted therapy, immunotherapy,
better surgery. - And that's immunotherapy
is using the body's immune system to
attack the cancer. - Exactly.
For instance, I recently treated a patient
who had widespread melanoma throughout the body.
But we know that, by giving radiation therapy to one
of the melanoma tumors, and then by injecting immunotherapy
into her, all her tumors disappeared.
Because what happens is the radiation therapy causes
some kind of inflammatory response or immune reaction
where, when you give the immunotherapy,
it potentiates, it makes the immunotherapy work even better.
So the immunotherapy and the radiation,
even though we meant to attack one tumor,
ended up attacking all the tumors in this person's body.
So the advancements in treatment have come a long way.
As a matter of fact, according
to the American Cancer Society,
since 1991, the incidence of cancer-related deaths
have dropped 26% for prostate cancer.
Less than 50%, greater than 50% decrease
in deaths related to prostate cancer.
Greater than 50% decrease in deaths
related to rectal cancer.
Breast cancer deaths have decreased by 1% a year since 1995.
These are really exciting statistics.
- That's hopeful.
Just go back and give some perspective.
Were there any side effects to radiation
15, 20, 30 years ago compared to any side effects
to it today or looking down the road?
- Much less side effects these days
because you're more targeted.
There are much more side effects.
Before, you had many more skin burns,
many more for prostate cancer.
Much more diarrhea, much more loose bowel movements,
and burning with urination.
These days for prostate cancer,
we hardly see any side effects with radiation therapy.
So much less side effects.
- Simply, simply we treat a much small radius to treat,
because we know exactly where to treat
and we can track it, we can image it.
So just to give an example for prostate cancer.
In the beginning of my career,
just to treat prostate cancer, I used to treat it
with a liter of the body, 1,000 CC.
These days I treat prostate cancers
maybe no more than 85, 100 CC, 1/10 of the volume.
And we give much higher doses.
Some surrounding structures, rectum, bladder,
hardly get any dose or a very small dose
of radiation therapy.
So side effects are much lesser, effectiveness
is much higher, patients doing much better.
- And Susan, I have to say that one
of the really important things in cancer care in the future
is looking at who doesn't need treatments as well.
Because we know that not all cancers are the same.
Some people will never die of their cancers,
so not all patients with prostate cancers need treatment.
These days, what we can do is, for certain cases
of breast cancer, we can look on a molecular level
of patient's breast cancer whether she would benefit
from chemotherapy, whether she would benefit
from long-term hormone blocker, whether she
would even benefit from radiation therapy.
Because if you look at the molecularly, these cells,
we can have an idea of who's gonna benefit
from treatments and who doesn't really need treatments
because the cancer's not really
that aggressive. - It's something that you
will live with as opposed to something you will die from.
- That's exactly right.
So I think that not only do we have better cures,
we really have to think of who doesn't need treatment.
Because we want better cures, but we
also want good quality of life for our patients.
- What's the most rewarding part of your job?
- Seeing the patient, holding their hands,
offering the best treatment, and take them
through treatment, and when they come back
to see me year after year.
32 years, 34 years, that's the most rewarding part.
And see their family, kids, grandkids.
Sometimes actually they bring them just
to introduce, this is my doctor.
- [Susan] Aww. (laughs) - That's the
most rewarding part of being a doctor.
- I recently had a patient that we sent
to hospice six years ago.
I gave her palliative radiation therapy.
I just thought, "Well, she's older,
"she's frail, let's just do a little bit
"of radiation, a little bit of palliation."
She showed up at my door for followup
a few weeks ago, really shocked me.
I said, "Where have you been all these years?"
(Susan laughs)
- She said, "I traveled the world
- [Susan] Aww. because you saved my life."
- Nothing better than that.
Dr. Lin, Dr. Tripuraneni, thank you so much
for joining us; we really appreciate it.
- Thank you Susan.
- Thank you.
- At Scripps, we have hundreds
of doctors who provide cancer care.
If you would like more information
about radiation therapy at Scripps Health,
just click on the link or go to scripps.org/videos.
If you want more critical information about your health,
please subscribe to our Scripps Health YouTube channel
and also follow us on social media @scrippshealth.
I'm Susan Taylor; thanks so much for joining us.
It's our mission at Scripps to help you heal,
enhance, even save, your life.
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For more infomation >> Jennie: Megan Fechter is making her colorful mark on the world with Painted Parcels - Duration: 6:17. 
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