00:00:00: Egle Dieninyte: Hello everyone, my name is Egle and I'm the host of UEG podcast, educational and hopefully fun dive into GI world and beyond. What follows today is the roundtable discussion from our online course on esophageal cancer, recorded after the course lectures. Three specialists walking you through their own reasoning on the questions that aren't settled yet. Leading the discussion is Roos Pouw, gastroenterologist at Utrecht Medical Center in the Netherlands. She is joined by Ana Maria Bucalau from Hospital Université de Bruxelles in Belgium. And joining online, Jessie Elliott, upper GI surgeon at the Trinity St. James Cancer Institute in Dublin. Along the way, they discuss why operating on high-risk early cancers can mean operating on 80% of patients for nothing. Why perioperative chemotherapy is taking over from chemoradiation. And why ENSURE found that surveillance after esophagectomy catches recurrence earlier without anyone living longer and leaves patients more anxious. The full course publishes on 10th of September at gutflix.eu. Let's tune in to the discussion.

00:01:10: Roos Pouw: So, welcome to our roundtable discussion. There's a lot of improvement in the treatment of patients with esophageal cancer. And there's also a lot of exciting new developments and discussion points. And we thought. it would be very nice to discuss those amongst us. To take you a little bit with us in the train of thought when considering some options we have in these patients. And one of the things that we discussed before we, well, when we were preparing the presentation, is number of biopsies. Because the guidelines say that if you encounter early lesions, then it's just the advice to take one or two biopsies. But if you don't think you can treat it endoscopically anymore and it's more advanced then to take at least six biopsies. And Ana-Maria, you mentioned very interestingly that you take more biopsies. Could you explain why that is and how many you take?

00:02:06: Ana-Maria Bucalau: Yeah, so we're moving forward with the biopsy, with the numbers of biopsy. And this is due to the number of biomarkers that are increasing as well. So, our colleagues from histopathology, they need material. So, they need biopsies. They need material to evaluate. So, we do for metastatic disease. Now, we have a lot of biomarkers. We have the MSS-MSI, research HER2, PD-L1 expression with several scores. We have the claudin 18.2. And, of course, if we want to enroll patients to clinical studies, which is also very, very important, they need a lot of material. Sometimes we need to send them away. So, it's very important to have material, not to need to go back for another gastroscopy. So, when we know that it's a lesion that we will not resect by endoscopy, and when we know that we will need all these biomarkers, it's true that we went... Sometimes we do up to 16 biopsies. Some centers do a lot more for clinical studies. So, yeah. So, we... Six, it's kind of short, because we need to work on them. And it's always easier to take them at the first biopsy than to call the patient back. It's not always very easy for them. So, yeah. Let's say we usually take 12, but we can go even higher if necessary. And we know that sometimes we need to go back. For example, for HER2, about 30 to 35% of patients lose their positivity in HER2. So, afterwards, after the first line of treatment with trastuzumab, we can go back and also take a new biopsy. Of course, you don't need to take as much, but sometimes we need to. re-evaluate the HER2 status for second line or third line treatments.

00:04:36: Roos Pouw: Is it then, in that respect, also interesting to have histology instead of cytology if you puncture metastatic lesion?

00:04:45: Ana-Maria Bucalau: Yes. Yes. If we have metastatic lesion, it depends what metastatic lesion, because, of course, the liver is very rich in biopsy. But if we have a lymph node, of course, we can puncture. But for the PD-L1 scoring, it's true that it would be better to have a biopsy from the esophagus or the liver. And sometimes it can differ. For example, we are faced quite often with patients that have a certain status, like, for example, HER2 in the primary tumor and another status in the metastasis. We need a bit to juggle with all this information. But I think if we do the gastroscopy and we have a good lesion, we could take a lot of biopsy from that lesion.

00:05:51: Roos Pouw: And another interesting point we discussed when preparing the presentation was the use of endoscopic ultrasound during the staging. Because at least when I speak from the Netherlands point of view, most centers have left EUS as something you have to do during staging. Because we have. the diagnostic CT scans and the FDG PET. that's quite sensitive. So we really reserve EUS in the cases where we are in doubt of, for example, a lymph node. that's outside of the treatment field. But it's not standard anymore in all the patients. How is that in Belgium?

00:06:32: Ana-Maria Bucalau: So we do endoscopic ultrasound where possible. For example, if the lesion does not present the stenosis, because, of course, that would be very difficult to evaluate. But indeed, CT scan is actually the backbone. In metastatic disease, it's true that we don't always perform PET-CT. This is reserved for where we have doubt. Or, for example, for patients that will undergo preoperative treatment. So for ESO, for geo-preoperative, it's really important to have PET-CT, FDG. And in some countries, it's not always available. But it's true that if we have a lymph node, EUS is very, very important in order to go get it, to go biopsy and see if it has malignancy. But it's true that we use it quite, we use it often. And in the guidelines, it's true that it's mentioned in order to evaluate the T status and the N status, especially. The French guideline. and in the ESMO guideline, it is mentioned for staging. But, for example, I know that for superficial lesions, you left it completely behind because the endoscopes are now so performant that you can evaluate with near focus, with NBI. It's no longer required if it's clear cut on endoscopy. And speaking about endoscopy, so you presented the treatments with EMR and ESD. So when we choose one, when we choose the other, it's an ongoing question.

00:08:35: Roos Pouw: Yeah, it's an ongoing question. I think a very relevant one as well and interesting as well. Because we did EMR for years with very good outcomes. And then ESD is also being more and more applied and we're just getting better at it and people are learning it at an earlier stage. So the field of indications for ESD is also growing because like a couple of years ago when we resected a lesion and it turned out to be submucosal, usually the patients went for surgery anyway, so it didn't really matter if you did a nice en-bloc resection or a piecemeal resection because they had surgery anyway because of the presumed high risk of lymph node metastasis. But now we're. more and more also managing these patients endoscopically. And it's really relevant if you treat the patient to get the tumor out in one piece, preferably as radical as you can. And that's where ESD comes in because it just offers better opportunities to remove a tumor in one piece. So the indication field is also growing. And I think the discussion, when do you do ESD and when do you do EMR, it's difficult to break down because there's not a lot of randomized trials in this respect. So it's either small trials or retrospective data. But I think the main key message there is that if you have a flat lesion without suspicion on deep infiltration, it's okay to remove it with EMR or a piecemeal EMR. But if you have a lesion that is very bulky, so the Paris type 1 lesions that are, or a lesion that is suspicious for submucosal invasion. So it's also type 1 but also type 2C lesions. And lesions that are malignant and bigger than 2 centimeters. Or if you expect fibrosis. Those are very good indications to do upfront ESD to give the patient the best. chance for a radical endoscopic resection.

00:10:41: Ana-Maria Bucalau: And of course, we get in MDTs, it's not always a very clear cut between which patients we could follow, which patients must go to surgery. Because there are some patients that have some risk factors of recurrence or lymph node. How do you manage these high-risk patients that have been resected?

00:11:10: Roos Pouw: Yeah, so this is, I think, in every country probably the same. But from the past, we know that the patients who have the superficial mucosal cancer without lymphovascular invasion, that's well to moderately differentiated and radically removed, that those patients have a very low risk of lymph node metastasis. So for those cases, by now, just endoscopic treatment is very well accepted as a curative treatment. But if you talk about a bit more invasive cancer, so if there is submucosal invasion or if there are signs of poor differentiation or lymphovascular invasion, then when you look at the literature on that topic, which is mostly retrospective and mostly surgical, you see that the risk of lymph node metastasis goes up to about 41%, 46%, depending on what paper she used. So that has been a reason to refer these patients for surgery. for a very long time. Because it was thought they have a high risk of lymph node metastasis, it's better to take the esophagus and all the lymph nodes out. But surgery is, of course, quite invasive and knows a lot of complications. So, and also we're doing more and more endoscopic resections. We have more and more data on those patients that are being followed. And actually, when you look at the data, it's very interesting that the risk of lymph node metastasis, even in the group that has histological high risk features, is much lower than we thought. It's probably somewhere up to 16% and not 41% or 46%. So if you would operate the patients after your EMR or ESD, you would operate over 80% of patients for nothing. So there is a trend going on. Also looking into if we can follow these patients very strictly endoscopically, and then give them the appropriate treatment when they develop a lymph node metastasis. Also because surgery is not a guarantee for cure. So even if you operate the patients, they still have a risk of recurrence or dying from esophageal cancer. So there's a lot of retrospective data that a strict. endoscopic follow-up approach is probably safe in selected patients. And we're doing a prospective multicenter study at the moment. And also, so far, the outcomes are very good. So we do see patients with recurrences or lymph node metastasis, but the majority we can still find at a curable stage and then offer them one of the treatments that you've nicely discussed. And of course, up front, you have to discuss with the patient that, yeah, we have surgery. We have strict endoscopic follow-up. There might be a chance that we discover recurrence too late, but you avoid the risk of surgery. So it's a very delicate discussion you need to have with the patient.

00:14:16: Ana-Maria Bucalau: And when you talk about strict endoscopic follow-up, what do you mean? At what kind of endoscopy and at what time point?

00:14:26: Roos Pouw: Yeah, so when we are sure that the patient doesn't have any metastasis or lymph node metastasis after the EMR or ESD, then we do endoscopy with EUS. In this case, EUS is relevant because you want to look at lymph nodes every three to four months during the first two years. Then every six months during the two years thereafter and then annually. And. we do a CT or PET CT every year to look at presence of distant metastasis. And we do this in a prospective registration now. And there's a lot of hospitals joining. So we can gather, I think, a good body of evidence to base proper advice on in the future.

00:15:09: Ana-Maria Bucalau: Yeah, the numbers will help in order to have robust data for this. But we're talking about adenocarcinoma here.

00:15:18: Roos Pouw: Yeah.

00:15:19: Ana-Maria Bucalau: Not squamous.

00:15:19: Roos Pouw: That's a very good point. For squamous, we just see it not that often in the West.

00:15:25: Ana-Maria Bucalau: In the West, yeah.

00:15:26: Roos Pouw: There's also initiatives looking in such an approach for squamous lesions. But usually when we find them in the West, they are a bit more advanced already. So this is even a smaller niche, at least in the Western world.

00:15:41: Ana-Maria Bucalau: And for example, for patients who have squamous cell carcinoma resected by ESD, because ESD is much more used than EMR for squamous cell carcinoma, I think. But after endoscopic resection, if it's not a curative resection for patients who are not fit for surgery, for example, for older patients, what do you propose? Do you think that chemoradiation could be a solution in order to diminish? that recurrence or the lymph node risk?

00:16:17: Roos Pouw: Yeah, I think that's a very interesting question. Because I know in Asia, they do radiotherapy on the wound and then the lymph node stations above and below. And I think we tend to offer these patients just a strict follow-up that we know from the adenocarcinomas. But this is, I think, also a field where we just need more data. Yeah. Yeah. And also maybe not just from Asia, but also in like a Western population, because we're not sure how transferable, of course, all the data is between countries. Yeah. That's true. Yeah. So there's a lot going on in the world of esophageal cancer treatment. And there have been some very exciting trials, I think, giving more treatment options for patients with squamous and adenocarcinoma. Could you tell us a bit more about that?

00:17:12: Ana-Maria Bucalau: Yeah. So when you're talking about squamous cell carcinoma, it's still pretty much the same in terms of neo adjuvant treatment. So we go for chemoradiation. That was already proved by the CROSS trial quite a long time ago. Five weeks of chemoradiation. And then re-evaluation at five, six weeks, and then surgery. And now we. had the results of the Checkmate 577 study that showed that if on the surgical specimen we still have a residual tumor, patients can benefit from adjuvant immunotherapy by nivolumab, which is a checkpoint inhibitor and anti-PD-1. It has been shown. So it was a phase three trial and the primary endpoint was DFS. So disease-free survival. This was positive. And in ASCO 2025, they also presented the overall survival data. And it's true that it was numerically higher, but in terms of statistical results, it was not significant. But still, it was pretty nice data. And we still use this treatment as an adjuvant treatment for a year after esophagectomy for squamous, but also for adenocarcinoma. But in adenocarcinoma, a lot has changed because we had the ESOPEC trial that compared chemoradiation and the FLOT regimen in a perioperative setting for these patients with locally advanced adenocarcinoma of the esophagus. And they had shown that in terms of overall survival, FLOT does better than CROSS. Of course, there have been some points that can still be discussed about this study. For example, local response, etc. But in terms of survival, which was what we were looking for, FLOT does. better than CROSS. And now talking about FLOT, we had the results also of the Matterhorn study, where the junction patients with adenocarcinoma can be treated with FLOT and Durvalumab. So it was for gastric and GI junction adenocarcinomas. And we see an improvement in EFS, so event-free survival, which was the primary endpoint, and also in overall survival that was presented recently. So yes, it has been a lot of movement. So now it's true that it's EMA approved. For example, they are, for example, in Belgium going for the reimbursement of Durvalumab. For now, it's still the FLOT. And it's true that we are going more and more towards a perioperative chemotherapy, even for patients with esophageal adenocarcinoma.

00:20:49: Roos Pouw: So we're very lucky that Jessie is able to join us online as a surgeon, because the surgeon obviously plays a very important role in management of patients with esophageal cancer. So Jessie, what is your idea on when you choose a total gastrectomy versus esophagectomy for distal esophageal cancers, especially when I'm discussing also this with the patients and looking at risk of complications and quality of life after surgery?

00:21:26: Jessie Elliott: Thanks, Roos. That's a great question. So I think. one thing that's really important, and given this is a UEG course, I would really like to highlight that one of the most important things that our gastroenterology colleagues can do when they're performing both the first endoscopy and also the restaging endoscopy for these patients after neoadjuvant therapy is to provide really accurate measurements of the top and bottom of the tumour relative to the squamous columnar junction and relative to the diaphragmatic indentation and the extent to which the tumour extends or not into the cardia. And to be quite, how do I say, to judge this very carefully, because sometimes I find you see quite a bit of submucosal extension in the cardia, which is not super obvious on first look. And this very detailed assessment at endoscopy gives all the measurements that the surgeon will need to be able to decide which type of operation is best. So for junctional tumours, so for squamous tumours and esophageal tumours, it is almost always an esophagectomy. And the proximal extent we talked about may change, but you will need to perform an esophagectomy if it's true esophageal tumour. But for OG junction tumours, so usually my rule of. thumb is that a type 1 OG junction tumour requires a transthoracic esophagectomy if possible. So that would usually be a two-stage esophagectomy. And then for a type 3 OG junction tumour, if it really doesn't have any much esophageal involvement, I will be planning to do extended total gastrectomy for that patient. So taking out the whole stomach and the distal esophagus and the proximal margin is extremely important in those cases. So very often we will be seeking a frozen section on the esophagus to ensure that the margin is clear before we start doing the reconstruction. So that would be an extended total gastrectomy, which is basically just a gastrectomy with a bit of extra esophagus removed and a standard Roux-en-Y reconstruction. And then for type 2 OG junction tumours, it's a little bit more complicated. So the literature is not very clear about whether we should be performing a two-stage esophagectomy or whether we should be performing an extended total gastrectomy for these patients. And that is the reason why the CARDIA trial has been set up. So the CARDIA trial is looking at two-stage esophagectomy versus extended total gastrectomy for patients with Siewert type II. OG junction tumours. So the trial is being led by Christiane Bruns from Cologne and Richard van Hillegersberg from Utrecht. And essentially patients are randomised between those two types of surgical approach. And the trial is looking at all different outcomes, including early postoperative complications, but also survival, oncological outcomes, recurrence patterns, and quality of life, which is really, really important obviously in these patients. So my personal experience is that probably if the patient is very fit and they can tolerate having a two-stage esophagectomy, the eating may be a little bit better after a esophagectomy with gastric conduit as compared with an extended total gastrectomy in the longer term after surgery. I think they have a little bit less dumping syndrome and associated problems like weight loss. But we really need clinical trial data to answer this question rather than just our kind of idea. So this is what the CARDIA trial is going to answer. And I think it should probably finish recruitment within the next year. And we're very happy to be participating in that trial. So yeah, the main thing is about the Siewert classification. And although it's hard to classify some tumours into type 1, 2, or 3, because many tumours are partly type 1, partly type 2, for example. So I think the classification is a little bit difficult to apply, especially in big tumours. The measurements are extremely important. And so as endoscopists, that's what we're really looking for, for the surgical planning, is a detailed assessment of the measurements relative to the landmarks that are there. And also the presence of any background Barrett's esophagus, which in my view probably slightly leans you towards doing an esophagectomy.

00:26:09: Roos Pouw: That's very interesting.

00:26:10: Ana-Maria Bucalau: Yeah, very interesting. And do you think there's still a role and a place for transhiatal esophagectomy these days with all these new techniques?

00:26:23: Jessie Elliott: So thanks, Ana-Maria. Yeah, it's a good question. And it's very, I suppose, controversial in the surgical field at the moment. So, you know, in recent times, a new technique has been developed to sort of potentially replace the transhiatal esophagectomy. So this new technique is either called a robotic-assisted cervical esophagectomy or a minimally invasive cervical esophagectomy. And essentially what it involves is doing like a minimally invasive abdominal phase, freeing the lower esophagus, doing the transhiatal dissection, creating your gastric conduit. And then a left neck approach, as would usually be done open in a transhiatal esophagectomy, but it involves a minimally invasive surgery. So going mediastinoscopically into the mediastinum with laparoscopic instruments in a MICE or in a RACE procedure, robotic-assisted cervical esophagectomy, docking the robot onto the patient's left neck and then using either a standard robot or there's a robot designed for single incision surgery that can be used to go down into the mediastinum and free the esophagus this way. I think there's only probably that I'm aware of two or three centres in Europe who have started providing this approach. And there are a few centres in the Far East that have been doing it for a longer period of time. I think from the initial data that I've seen, the rate of recurrent nerve palsy is higher with that approach than it is with a standard transhiatal esophagectomy. But of course, the potential benefit is that you may be able to clear some lymph nodes in the mediascumum, which are not normally taken out during a transhiatal esophagectomy. So I think it's probably too early for RACE or MICE procedures to become standard of care. And I think my. personal view is that there's still a place for transhiatal esophagectomy in patients with junctional tumour where you can get above it clearly from the abdomen, but the patient is not well enough to have a transthoracic operation due to impaired pulmonary function or previous right-sided or left-sided thoracic surgery that make a transthoracic approach very complicated. So I think there's still a role for it, but mainly for impaired pulmonary function or previous thoracic surgery rather than as a standard approach. And I think the other thing that we need to be extra careful about is that a lot of the data, the good data on transhiatal esophagectomy comes from the days when neoadjuvant chemoradiation was the standard of care. And we now know that we're using less and less radiation in the neoadjuvant setting, particularly for adenocarcinomas, which may impact the safety profile of a transhiatal esophagectomy. So I think in time we will see whether neoadjuvant FLOT on a transhiatal esophagectomy is a good combination. And it may be that that additional radiotherapy in the previous cross-regimen is kind of complementary to a transhiatal esophagectomy. But I think only time will tell. So in our practice, we. still use a transhiatal approach for patients with poor pulmonary function who are high-risk surgical candidates or who can't have a transthoracic operation for technical reasons like previous left-sided extensive lung resection, for example. Okay.

00:30:01: Roos Pouw: And what are your thoughts about following the patients after surgery? Is there an indication to actively follow these patients and actively look for those patients who might develop metastasis? Do we just wait until the patient has complaints and then do additional investigations? What are your thoughts on that?

00:30:22: Jessie Elliott: Okay. Yeah, I totally agree. It's an area of significant controversy at the moment. So when we look at the guidelines between, say, the NICE guidelines in the UK and the NTCP guidelines in the US, the ESMO guidelines in Europe, and we can see that every guideline says something quite different about how we should follow up patients after surgery. So it's a big area of controversy. So given, and the reason for the controversy is that there hasn't been any good quality data to address this question until recently. So we recently, on the basis of the kind of absence of good quality data, we set up a study called Ensure, which we. led from the Trinity St James's Cancer Institute here in Dublin. And Ensure study was a European observational study looking at the impact of intensive surveillance follow-up as compared with standard clinical follow-up in patients who'd had surgery for esophageal and junctional cancers. And what we found in Ensure, which was a non-randomized study, is that about half of centers around Europe are using CT scans for regular follow-up, and about 20%, 19%, are using endoscopy for follow-up. So it's quite variable. And then other things like PET-CT and tumor markers and nutritional screening are all much more variable again and largely used by a minority of centers. So we then looked at patient outcomes with these different approaches. And what we found was that patients undergoing intensive surveillance follow-up, we were able to detect recurrences at an earlier stage. So the recurrences were more likely to be oligometastatic. And actually, in some groups, this translated to more tumor-directed treatment and obviously less symptomatic presentation of cancer recurrence. But when we looked at the survival outcomes, we found no difference in overall survival after adjusting for confounders between the groups with an intensive surveillance follow-up approach as compared with standard. clinical follow-up. So, and interestingly, there was no difference in quality of life. But patients in the intensive surveillance follow-up group reported greater cancer-related anxiety and cancer worry, and largely, probably because they were attending the hospital appointments very frequently and kind of reinforcing this kind of illness identity and patient identity, rather than just getting back to their normal lives. So the data from the observational data suggests that there's no clear oncological benefit, although we may pick up the recurrences earlier. Now, that data is probably now maybe not fully up to date, because in recent years, we've got more access to targeted therapies, like immunotherapy, for example, than we would have had during the time period of the NSHIR study. And as a result, we wanted to address this and kind of put the question to bed with our randomized controlled trials. So we're currently running kind of two parallel randomized controlled trials. So it's a partnership between the University of Oxford, led by Sheraz Markar, who's leading a big UK trial, which is actually finished recruitment, which is fantastic. And then our team at the Trinity St. James Cancer Institute are leading the kind of EU. version of the trial, which is currently taking place in Ireland, Sweden, Norway, Germany and Italy. And we're randomizing patients according to into intensive surveillance follow-up or standard clinical follow-up. And I think this will, you know, answer the question fully and also answer the question in the context of the most modern targeted therapy options and salvage options, such as, you know, stereotactic radiosurgery for lung metastasis, for example. So I think that trial is going to be really exciting when it comes out. And we'll be able to see how it works across different health systems because we're trialing it in the UK system, which is like a government funded system, as well as in the EU, which is a variety of different types of health systems across the different participating countries. I think it'd be very interesting to see how those results compare with one another.

00:35:12: Ana-Maria Bucalau: Yes, very, very interesting. It's true that we all have the guidelines say how to follow these patients, but it's true that every center, every country adapts it according to their local habits, let's say. And so what do you think are, how do we predict the risk and the outcomes? Are there any models that we can follow? Do we know which patients recur more? What are your thoughts on that?

00:35:48: Jessie Elliott: Yeah. So I think one of the big kind of benefits of doing these clinical trials will be that we'll be able to use the trial data across, between the two trials, we're going to have 1,900 patients recruited. And I think we'll be able to start developing some really nice predictive models, looking at where this hyper surveillance approach has the biggest impact and the best kind of survival impact. Because it may be that, for example, patients who are unlikely to be fit or able for further treatment, maybe those patients don't benefit from an intensive surveillance follow-up approach, whereas perhaps younger patients or patients with, you know, a positive biomarker for biomarker-directed therapy may benefit from having a recurrence diagnosed in an earlier stage. So I think it'll be really interesting to explore that within the trial data set. The other thing that we've been working on using the previous data from Ensure is we've been, I suppose, stockpiling all the CT scans that happened for patients in that study. And we're in the process currently. of analyzing those CT scans together with the Big Data Institute in Oxford to determine if there can be, like, an AI algorithm that we can train to identify either the presence of a cancer recurrence or the risk of a cancer recurrence based on looking at these scans, either at baseline or in follow-up. So it may be that it's possible to predict a cancer recurrence using, like, AI-based image analysis at an earlier stage rather than tailoring it based simply on clinical metadata like age and ASA grade and things like this. So that will be really interesting to see if there's something in the scans that we can't see with our naked eye, that we can't classify, but that the AI algorithm can see and can help to use to predict risk in a given patient. So that's our Ensure Machine Learning study, and it'll be a spin-off then, a validation study within SARONG and SARONG-II trials, which are the big surveillance trials we're running across the UK and Europe. So watch this space. And if you're interested in getting involved, we would love to hear from your centres because these trials are. still open.

00:38:19: Ana-Maria Bucalau: Thank you very much for joining us today. So I hope you enjoyed our discussion. Thank you, Roos. Thank you, Jessie.

00:38:27: Jessie Elliott: So thank you so much for inviting me to come and join you today. It's a real pleasure to be able to take part in this along with the UEG, along with my great friends, Rose and Anna Maria. So please don't hesitate to reach out to me if you have any questions. I'd love to hear from you. And until next time.

00:38:47: Ana-Maria Bucalau: Thank you, Jessie. Don't forget to go on Gutflix. Everything is available. Other courses as well. It's free. It's fun. And we'll see you for the next course. Thank you.