HEALTH

1. Wallaga University
School of Nursing & Midwifery
Department of Comprenssive
Nursing
Adult Health Nursing Program
Seminar presentation : Bone Cancer
By: 1. AshenafiTesfaye
2. Takele Mitiku

2. Presentation Outlines
Definition of bone Tumor/Cancer
Types of Bone tumor
Epidemiology of bone cancer
Pathophysiology of bone tumor
Risk factors and etiology of bone tumor
Clinical manifestation of bone tumor
Medical and nursing management of bone tumor
Nursing Intervention for Bone Cancer Patient.
Bone CA 2

3. Definition
• Bone cancer is an uncommon type of cancer that begins when cells in the
bone start to grow out of control.
• Is the term for several different cancers that develop in the bones.
• The type of cell and tissue where cancer begins determines the type of bone
cancer.
• Cancers that form in the bone itself are called primary bone cancers (most
serious type).
• Many tumors that begin in organs or other parts of the body can spread to
the bones, as well as other body parts.
• These growths are called secondary or metastatic bone cancers.
Bone CA 3

4. Cont…
Bone cancer can be either primary or secondary bone cancer.
The two types are quite different.
Primary bone cancer – means that the cancer starts in the bones.
It may develop on the surface of the bone, in the outer layer or from the center
of the bone.
As a tumor grows, cancer cells multiply and destroy the bone.
If left untreated, primary bone cancer can spread to other parts of the body.
Secondary (metastatic) bone cancer – means that the cancer started in another
part of the body, such as the breast or lung, and has spread to the bones.
Bone CA 4

5. …
Bone CA 5

6. Epidemiology
Bone cancers are rare.
Bone cancer can begin in any bone in the body, but it most
commonly starts in the pelvic bone or the long bones in legs
or arms, such as femur, or upper arm.
They make up less than 1% of cancers in the United States.
While they can develop at any age, they are more common
in children, teenagers and young adults than in older adults.
Bone CA 6

7. EPIDEMIOLOGY
Bone sarcomas are rarer than soft tissue sarcomas; they accounted for
only 0.2% of all new malignancies and 3010 new cases in the United
States in 2016.
Several benign bone lesions have the potential for malignant
transformation.
In 2012, their annual report revealed that the age-adjusted incidence
rate of primary malignant bone tumors was 1.44 per 100 000 persons
per year, accounting for approximately 0.7% of all malignancies in
China.

8. Epidemiology
The epidemiology of bone cancer in 0 - 39 year olds in northern
England, 1981 - 2002
Incidence rates (per million persons per year) for osteosarcoma were
2.5 at age 0 - 14 years; 4.5 at age 15 - 29 years and 1.0 at age 30 - 39
years.
Similarly, for Ewing sarcoma the incidence rates were 2.2; 2.9; 0.4
and for chondrosarcoma rates were 0.1; 1.2; 1.8 respectively.
 Incidence of osteosarcoma increased at an average annual rate of
2.5% but there was no change in incidence of Ewing sarcoma or
chondrosarcoma.

9. CLASSIFICATION
Benign Tumors
 The common benign bone tumors include:
Enchondroma, osteochondroma, chondroblastoma, and
chondromyxoid fibroma, of cartilage origin
Osteoid osteoma and osteoblastoma, of bone origin;
Fibroma and desmoplastic fibroma, of fibrous tissue origin;
Hemangioma, of vascular origin; and giant-cell tumor, of
unknown origin.

10. Malignant Tumors
 The most common malignant tumors of bone are plasma cell
tumors.
 The four most common malignant bone tumors are:
 osteosarcoma,
 chondrosarcoma,
 Ewing’s sarcoma and
 Undifferentiated pleomorphic sarcoma (UPS)


11. Cont.…
They are classified by the type of cell which occurs in
the Cancer.
• Osteosarcoma- From bone forming cell(osteoblast)
• Ewing’s sarcoma- From mesenchymal stem cell
• Chondrosarcoma - From cartilage-forming cells
(chondrocyte)

12. Rare malignant tumors include
 Chordoma
 Malignant giant-cell tumor,
 Adamantinoma (of unknown origin), and
 Hemangio endothelioma (of vascular origin).

13. Cont…
Bone CA 13

14. Osteosarcoma
 Osteosarcoma (also called osteogenic sarcoma) is the most
common primary bone cancer.
 It starts in an early form of bone cells.
 It most often occurs in young people between the ages of 10 -30,
but about 1 in 10 osteosarcomas develop in people older than 60.
 It's rare in middle-aged people, and is more common in males than
females.
 These tumors develop most often in bones of the arms, legs,
pelvis. (UPTO DATE 2022)

15. Chondrosarcoma
Chondrosarcoma starts in early forms of cartilage cells.
It's the second most common primary bone cancer.
It's rare in people younger than 20, and the risk of
chondrosarcoma goes up as people get older.
Chondrosarcomas can start in any place there's cartilage.
Most develop in bones like the pelvic (hip) bones, legs, or
arms.
Some start in the trachea, larynx, chest wall, shoulder blades,
ribs, or skull.

16. Cont.…
 Benign (non-cancerous) tumors such as enchondromas and
 osteochondromas are more common in the cartilage than
are chondrosarcomas.
 These benign tumors rarely turn into cancer.
 People who have many of these tumors have a slightly
higher chance of developing cancer, but this isn't common.

17. Ewing tumor (Ewing sarcoma)
 Ewing tumors are the second most common type of
primary bone cancer in children, teens, and young
adults, and the third most common type of bone
cancer overall.
 These tumors are rare in adults older than 30.
 They occur most often in white people and are rare
among African Americans and Asian Americans.

18. Cont.…
• Most Ewing tumors develop in bones, but they can
start in other tissues and organs.
• The most common sites for this cancer are the hip
(pelvic) bones, the bones in the chest wall (such as
the ribs or shoulder blades), the bones of the spine,
and the long bones of the legs. (UPTO DATE 2022)

20. Fibrosarcoma of bone
• Fibrosarcoma is another type of cancer that
develops more often in soft tissues than it does in
bones.
• It usually occurs in middle-aged adults.
• Bones in the legs, arms, and jaw are most often
affected

21. Giant cell tumor of bone
• This type of primary bone tumor can be either benign or
malignant.
• The benign form is more common.
• These tumors are most common in people in their 20 and 30
age.
• Giant cell bone tumors typically affect the legs (usually near
the knees) or arms.

22. • They don’t often spread to distant parts of the body, but
after surgery they can come back (even more than once)
in the place where they started.
• With each recurrence, the tumor becomes a bit more
likely to spread to other parts of the body (most often to
the lungs)
• Rarely, a malignant giant cell bone tumor spreads to
other parts of the body without first recurring locally.

23. Chordoma
This uncommon type of bone tumor occurs in the
bones of the spine, most often at the bottom of the
spine (sacrum) or the base of the skull.
 It develops most often in adults older than 30.
 It's about twice as common in men as in women.

24. Cont.…
 Chordomas tend to grow slowly and often do not
spread to other parts of the body.
 They often come back in the same area if they are
not removed completely.
 If they do spread, they most often go to the lymph
nodes, lungs, or liver.

25. TUMORS METASTATIC TO BONE
Bone is a common site of metastasis for carcinomas of the
prostate, breast, lung, kidney, bladder, and thyroid and for
lymphomas and sarcomas.
Prostate, breast, and lung primaries account for 80% of all bone
metastases.
Metastatic tumors of bone are more common than primary bone
tumors.
Tumors usually spread to bone hematogenously, but local
invasion from soft tissue masses also occurs.

26. Cont.…
In descending order of frequency, the sites most often involved
are the vertebrae, proximal femur, pelvis, ribs, sternum, proximal
humerus, and skull
Bone metastases may be asymptomatic or may produce pain,
swelling, nerve root or spinal cord compression, pathologic
fracture, or myelophthisis (replacement of the marrow).
Symptoms of hypercalcemia may be noted in cases of bony
destruction.
Pain is the most frequent symptom.

27. It usually develops gradually over weeks, is usually
localized, and often is more severe at night.
When patients with back pain develop neurologic
signs or symptoms, emergency evaluation for spinal
cord compression is indicated
 Bone metastases exert a major adverse effect on
quality of life in cancer patients .

28. Pathophysiology
 A tumor in the bone causes the normal bone tissue to react by
osteolytic response (bone destruction) or osteoblastic response
(bone formation).
 Primary tumors cause bone destruction, which weakens the
bone, resulting in bone fractures.
 Adjacent normal bone responds to the tumor by altering its
normal pattern of remodeling.
 The bone’s surface changes and the contours enlarge in the
tumor area.
Bone CA 28

29. Cont.…
 Malignant bone tumors invade and destroy adjacent
bone tissue
 Benign bone tumors, in contrast, have a symmetric,
controlled growth pattern and place pressure on
adjacent bone tissue.
 Malignant invading bone tumors weaken the structure
of the bone until it can no longer withstand the stress of
ordinary use; pathologic fracture commonly results.
Bone CA 29

30. Pathophysiology
Osteolytic lesions result when the tumor produces
substances that can directly elicit bone resorption
(vitamin D–like steroids, prostaglandins, or
parathyroid hormone–related peptide) or cytokines
that can induce the formation of osteoclasts
(interleukin 1 and tumor necrosis factor).

31. Cont.…

32. Etiology
1- Race and geographic factors:
 Ewing sarcoma could be called a disease of white
children.
 Race and ethnic origins carry different incidences.
 It has more frequent rates in the white race compared
to Africans and African Americans.

33. 2. Genetic and familial history:
 Another potential mechanism of carcinogenesis is loss
of tumor suppressor genes and their inactivation.
 These genes regulate cell growth and differentiation and
prevent tumor-specific uncontrolled proliferation.
 The p53 gene is a well-known tumor suppressor gene
located on chromosome 17p and its tumor association
has been proven.

34. CONT…
• More than 100 different genes and mutations of their gene
series have been identified to be associated with cancer.
• Tumor suppressor genes account for one portion of these and
the p53 gene is one of them.
• In human cancers, the p53 gene was identified as one of the
genes to most commonly undergo mutation.

35. Cont.…
 As they lose activity due to mutations, increased risk of
development of osteosarcomas and many other tumors usually
manifest as osteosarcomas and soft tissue sarcomas due to
abnormalities in the p53
 Phosphoprotein p53 is known to be necessary in the cell cycle
and carries vital importance in cell division.
 It also plays a role in DNA repair, DNA synthesis, cell
differentiation, and programmed cell death (apoptosis).

36. 3- Gender and hormones:
Malignant bone cancers are more common in males
than in females.
 Two-thirds of Ewing sarcoma patients are male.
Osteosarcoma is detected in females at a relatively
earlier age compared to males.
Aside from patients younger than nine years of age,
osteosarcoma is more frequent in males than females.

37. 5- Growth and Development stage:
 Osteosarcoma frequency peaks twice: in the
early adolescent period and over age 65.
 Ewing sarcoma is seen in childhood and
adolescence, and is rare in the elderly.
 Chondrosarcoma is the second most common bone
malignancy following osteosarcoma and is seen in
adulthood and rarely in childhood.

38. 6- Occupation:
 The relationship between malignant bone tumors and
occupation has not been studied as often as soft tissue
sarcomas.
 One European centered study reported increased risk of bone
tumors (osteosarcomas and chondrosarcomas) in metal
workers, tool manufacturers, and machine operators.
 This study also found increased risk of tumor development in
brick workers and carpenters.

39. Cont.…
Furthermore, products used in wood and mushroom
production were also found to significantly increase risk
of malignant bone tumor development.
Individuals classified as machine and equipment
manufacturers were also reported to be at high risk.
Males classified as military workers, and drivers were
also at risk of developing malignant bone tumors.

40. 7- Chemicals:
 The most important chemical causing malignant bone tumors is,
again, alkalizing agents used in cancer chemotherapy.
 Cytotoxic effects of alkalizing agents occurs through the
irreversible combination of electrophilic alkali root and the
target molecule’s nucleophilic portion.
 Chemotherapy (especially alkalizing agents) due to cancer
treatment during childhood increases risk of osteosarcoma
development

41. Cont.…
 One case of synovial sarcoma following chemotherapy was
reported.
 The patient underwent chemotherapy treatment due to
rhabdomyosarcoma in the right scapular muscle, and
developed osteosarcoma of the jaw and adrenocortical
carcinoma six years later.
 The reason was attributed to p53 genetic mutation.
 CGT (Cytosine Guanine Thymine) of codon 273 had
transformed to CAT (Cytosine Adenine Thymine).

42. 8- Physical factors:
 It is known that high dose of radiation significantly increases
the risk of soft tissue sarcomas and bone tumors.
 In this group, ionizing radiation (radiotherapy) comes
foremost.
 Ionizing radiation (X and gamma rays, alpha and beta particles,
protons, neutrons) has been found to cause somatic mutations
resulting in tumors in humans and animal experiments

43. • The most common malignancy in bone soft tissue due to
radiotherapy is osteosarcoma and malignant fibrous
histiocytosis.
• It has been reported that ionizing radiation is
responsible for 2% of osteosarcomas.
• Radiotherapy treatment applied to the pelvic region for
various malignant causes has been shown to cause high
risk of secondary sarcoma development.

44. 9- Viruses:
• Some viruses are cancerogenic. Up to 150 cancer-causing
viruses have been found in animals.
• One-third of these are DNA viruses, while the rest are RNA-
viruses.
• DNA viruses include Papovaviruses and Herpes viruses, Epstein
Barr virus (EBV), Hepatitis B, and Papilloma virus.
• RNA viruses include: mouse breast cancer, and mouse
leukemia virus.

45. 10- Predisposing lesions:
• There are bone lesions that may potential become malignant despite
being benign.
• Paget’s disease is a risk factor for osteosarcoma.
• Fibrous dysplasia, Mafucci syndrome (hereditary multiple ectosis), and
Ollier disease (multiple enchondromatosis) patients carry risk of
developing chondrosarcoma.
• Some bone lesions such as osteochondroma, enchondroma, and
exostosis are reported to be associated with increased chondrosarcoma
incidence, though are rarely encountered in practice.

46. Cont.…
 Bone infarction and chronic osteomyelitis both carry
potential to turn into secondary sarcoma.
 Malignancy (such as malignant fibrous histiocytoma)
rarely develops from within bone infarction margins.
 Insufficiency fractures or stress fractures may
sometimes stimulate osteogenic sarcoma originating
from proximal tibial metaphysis.

47. Cont.…
 Posttraumatic osteolysis is identified in pubis of
osteopenic elderly women and distal clavicular ends of
athletes, especially weight-lifters.
 These two conditions may stimulate malignant bone
tumor development with presence of radiological
findings.

48. 11- Immunologic factors:
 The difficulty of researching cancer incidence in immune deficiency is
that both illnesses are rare.
 Because bone cancers are also uncommon among all malignancies, it is
even more challenging to establish the relationship between immune
deficiency and bone cancers, and studies on this subject are limited.
 There are few publications which demonstrate the association between
the immune system and cancer development.
 The immune system may easily identify foreign tissue antigens;
the organism may not easily dispose of tumor tissue.

49. Clinical manifestation
A patient may be asymptomatic or may have pain
(mild and severe),
Disabilities, and obvious bone growth.
 Weight loss,
Malaise and
Fever may be present.
 The tumor may be diagnosed only after pathologic
fracture has occurred.
Neurologic deficits (e.g. progressive pain, weakness, paresthesia, paraplegia,
urinary retention) may occur if the spinal cord compression occurs

50. Cont.…
swelling over the affected part of the bone
 stiffness or tenderness in the bone
 It may be worse at night or during activity
unexplained weight loss
 tiredness.

51. Diagnostic Evaluation
 History, physical examination
 Blood tests: – including a full blood count
 Bone Biopsy – removal of some cells and tissues from the affected bone for
examination under a microscope.
The biopsy may be done in one of two ways.
 In a core needle biopsy, a local anaesthetic is used to numb the area, then a
thin needle is inserted into the bone under CT guidance.
 An open or surgical biopsy is done under general anesthesia.
The surgeon will cut through the skin to expose the bone and take a tissue
sample

52. Imaging
X-rays : – painless scans of the bones, which can reveal bone
damage or the creation of new bone
CT or MRI scans: – a special computer is used to scan and
create pictures to highlight any bone abnormality; it takes about
an hour to perform
PET (Positron Emission Tomography) scan: – you will be
injected with a small amount of radioactive glucose solution to
highlight any cancerous areas on the scan; it may take around 90
minutes to perform

59. Bone Cancer Treatment
 The treatment of bone cancer is administered by
cancer specialists or oncologists
 Treatment plans are designed to meet the unique
needs of each person with cancer

60. Bone Cancer Treatment
Decisions relating to the treatment of bone cancer are
based on the following elements
 Size and location of the tumor
 Stage of cancer
 Type of bone cancer
 Ability to completely remove the tumor by surgery
 Age of the person
 Over all health of the person affected

61. Treatment Options for bone cancer are
three in number
Surgery
Chemotherapy
Radiotherapy

62. Treatment option: Surgery
• Resection-bone tumor and some of the neighboring
normal tissue are removed.
• Curettage-tumor of bone is scraped with out
removing a section of bone.
• Amputation - cancer and the member is partially or
wholly removed.

63. Cont.…
 Removal of metastases-We sometimes /removed
metastases to the lungs.
 Reconstruction-It helps to restore the structure and
function of bone.

64. Chemotherapy
It most often used to treat Ewing's sarcoma and
osteosarcoma.
It is administered prior to surgery or radiation
therapy to reduce the tumor size, neoadjuvant
It is given after surgery to destroy any remaining
cancer cells and reduce the Risk of recurrence of
cancer, adjuvant

65. Chemotherapy…
It uses as the primary treatment, with or with out
radiation therapy to destroy cancer cells(impossible
to remove by surgery)
It may be given in some cases to:
- treat are currency of bone cancer
- relieve pain or control the symptoms of bone
cancer advanced stage.

66. Cont.…
The chemotherapeutic agents most often used to treat
bone cancer are:
 High-dose methotrexate (HDMTX) Etoposide
(ETO)
 Doxorubicin (Adriamycin) (DOXO)
 Cyclophosphamide(CTX; Vincristine(VCR
 Fosfamide (IFX or IFO)

67. Treatment option: Radiotherapy
 Use is made of radiation or high energy particles to kill
cancer cells.
 Administered in the presence of a bone cancer:
- Prior to surgery or chemotherapy to reduce the/size of
the tumor
- after surgery or chemotherapy to destroy cancer cells
that remain and reduce the risk of recurrence of cancer

68. Primary Bone Tumors
• Limb-sparing (salvage) procedures are used to remove the tumor and
adjacent tissue; prosthesis, total joint arthroplasty, or bone tissue from the
patient (autograft) or from a cadaver donor (allograft) replaces the resected
tissue.
• Chemotherapy is started before and continued after surgery in an effort to
eradicate micrometastatic lesions.
• Soft-tissue sarcomas are treated with radiation, limb-sparing excision, and
adjuvant chemotherapy.
• Complications may include infection, loosening or dislocation of the
prosthesis, allograft nonunion, fracture, devitalization of the skin and soft
tissues, joint fibrosis, and recurrence of the tumor.
Bone CA 68

69. Secondary Bone Tumors
The treatment of metastatic bone cancer is palliative.
The therapeutic goal is to relieve the patient’s pain and discomfort while
promoting quality of life.
Structural support and stabilization may be needed to prevent pathologic
fracture; large bones with metastatic lesions may be strengthened by
prophylactic internal fixation, arthroplasty, or methylmethacrylate (bone
cement) reconstruction to minimize associated disability and pain.
 Patients with metastatic disease are at higher risk than other patients for
postoperative pulmonary congestion, hypoxemia, deep vein thrombosis
(DVT), and hemorrhage.
Bone CA 69

70. Cont…
Hypercalcemia resulting from breakdown of bone must be recognized and
treated promptly.
Intravenous hydration with normal saline solution, diuresis, mobilization,
and medications such as bisphosphonates, pamidronate, and calcitonin are
used.
Assist the patient to increase activity and ambulation to prevent loss of bone
mass due to inactivity.
Hematopoiesis may be disrupted by tumor invasion of the bone marrow or
by treatment (chemotherapy or radiation).
Blood component therapy restores hematologic factors.
Bone CA 70

71. Cont…
 Pain can result from multiple factors, including the osseous
metastasis, surgery, chemotherapy or radiation side effects, and
arthritis.
Opioid, nonopioid, and nonpharmaceutical interventions including
external beam radiation to involved metastatic sites using
systemically administered “bone-seeking” isotopes (eg, strontium
89) for multiple metastases may be used.
Chemotherapy is used to control the primary disease.
Bone CA 71

72. Complication
The major skeletal complications associated with
bone metastases include:
 Cancer-induced bone pain,
 Hypercalcemia,
 Pathological bone fractures,
 Metastatic epidural spinal cord compression, and

73. Nursing Management and intervention
The nursing care of a patient who has undergone excision of a
bone tumor is similar in many respects to that of other patients
who have had skeletal surgery.
Vital signs are monitored, blood loss is assessed, and
observations are made to assess for the development of
complications such as DVT, pulmonary embolus (PE),
infection, contracture, and disuse atrophy.
The affected part is elevated to reduce edema, and the
neurovascular status of the extremity is assessed.
Bone CA 73

74. Relieving Pain
Accurate pain assessment is the foundation for pain management.
 Pharmacologic and non pharmacologic pain management techniques
are used to relieve pain and increase the patient’s comfort level.
 Intravenous or epidural analgesics are used during the early
postoperative period.
Later, oral or transdermal opioid or nonopioid analgesics are indicated
to alleviate pain.
External radiation or systemic radioisotopes may be used to control
pain.

75. Providing Patient Education
 Patient and family teaching about the disease process and
diagnostic and management regimens is essential.
 Explanation of diagnostic tests, treatments (eg, wound care),
and expected results (eg, decreased range of motion, numbness,
change of body contours) helps the patient deal with the
procedures and changes.
Bone CA 75

76. Preventing Pathologic Fracture
Bone tumors weaken bone to a point at which normal activities or even
position changes can result in fracture.
 The affected extremities must be supported and handled gently. External
supports (eg, splints) may be used for additional protection.
Elective surgery (eg, open reduction with internal fixation, joint replacement)
may prevent pathologic fracture.
Prescribed weight-bearing restrictions must be followed. The nurse and
physical therapist teach the patient how to use assistive devices safely and
how to strengthen unaffected extremities.
Bone CA 76

77. Promoting Coping Skills
 The nurse encourages the patient and family to verbalize their
fears, concerns, and feelings, while offering support.
 Referral to psychiatric advanced practice nurse, psychologist,
counselor, or spiritual advisor may be indicated.
Bone CA 77

78. Promoting Self-Care
Assist the patient in dealing with changes in body
image due to surgery and possible amputation; provide
realistic reassurance about the future and resumption
of role-related activities, and encourage self-care and
socialization.
Encourage the patient to be as independent as
possible.
Bone CA 78

79. Monitoring and Managing Potential Complications
Delayed Wound Healing
Wound healing may be delayed because of tissue trauma from surgery,
previous radiation therapy, inadequate nutrition, or infection.
Assess the patient’s nutritional status by monitoring weight, percentage of
weight loss, and evaluating the serum albumin or pre albumin level.
An unintentional weight loss of 10% of usual body weight in 3 months is a
risk factor for malnutrition.
 Wound healing will increase the patient’s requirements for calories, protein,
vitamins, and minerals.
Bone CA 79

80. Cont.…
Minimize pressure on the wound site to promote circulation
to the tissues.
Reposition the patient at frequent intervals to reduce the
incidence of skin breakdown and pressure ulcers.
Therapeutic beds may be needed to prevent skin breakdown
and to promote wound healing after surgical reconstruction
and skin grafting.
Bone CA 80

81. Inadequate Nutrition
 Anorexia, nausea, and vomiting are frequent side effects of
chemotherapy and radiation therapy; these may interfere with
adequate nutrition.
 Antiemetics and relaxation techniques reduce the adverse
gastrointestinal (GI) effects of chemotherapy.
 Stomatitis is controlled with anesthetic or antifungal
mouthwash.
 Adequate hydration is essential.
 Nutritional supplements, enteral or parenteral nutrition, may be
prescribed to achieve adequate nutrition.
Bone CA 81

82. References
1. Handbook for Focus on Adult Health Medical-Surgical Nursing (Linda Honan
Pellico, Andrea Rothman Mann) (z-lib.org)
2. Ethiopia Disease Prevention And Control Directorate National Cancer Control
Plan Guidlines 2016-2020
3. Who Guidelines For The Pharmacological And Radiotherapeutic Management Of
Cancerpain In Adults And Adolescents.
4. Brunner_&_Suddarth’s_Textbook of Medical surgical 2018.14 Edition
5. MedScape
6. www.cancer.org/cancer/ewing-tumor.html &
www.cancer.org/cancer/osteosarcoma.html
Bone CA 82

83. Thank YOU