Академический Документы
Профессиональный Документы
Культура Документы
<http://www.ncbi.nlm.nih.gov/>
* Skip to main content
<#maincontent>
* Skip to navigation
<#navcontent>
* Resources
<http://www.ncbi.nlm.nih.gov/static/header_footer_ajax/submenu/#resources>
* How To
<http://www.ncbi.nlm.nih.gov/static/header_footer_ajax/submenu/#howto>
* About NCBI Accesskeys
<http://www.ncbi.nlm.nih.gov/guide/browsers/#accesskeys>
<http://www.ncbi.nlm.nih.gov/account/settings/>My NCBI
<http://www.ncbi.nlm.nih.gov/myncbi/>Sign in to NCBI
<http://www.ncbi.nlm.nih.gov/account/?back_url=http%3A%2F%2Fwww.ncbi.nlm.nih.gov
%2Fpmc%2Farticles%2FPMC4513434%2F%23__sec11title>Sign
Out
<http://www.ncbi.nlm.nih.gov/account/signout/?back_url=http%3A%2F%2Fwww.ncbi.nlm
.nih.gov%2Fpmc%2Farticles%2FPMC4513434%2F%23__sec11title>
PMC
<http://www.ncbi.nlm.nih.gov/pmc/>
US National Library of Medicine <http://www.nlm.nih.gov/>
National Institutes of Health <http://www.nih.gov/>
Search database
PMC
All Databases
Assembly
BioProject
BioSample
BioSystems
Books
ClinVar
Clone
Conserved Domains
dbGaP
dbVar
Epigenomics
EST
Gene
Genome
GEO DataSets
GEO Profiles
GSS
GTR
HomoloGene
MedGen
MeSH
NCBI Web Site
NLM Catalog
Nucleotide
OMIM
PMC
PopSet
Probe
Protein
Protein Clusters
PubChem BioAssay
PubChem Compound
PubChem Substance
PubMed
PubMed Health
SNP
SRA
Structure
Taxonomy
ToolKit
ToolKitAll
ToolKitBook
UniGene
Search term
Clear input
<#>
Search
*
*
*
*
Limits <http://www.ncbi.nlm.nih.gov/pmc/limits/>
Advanced <http://www.ncbi.nlm.nih.gov/pmc/advanced/>
Journal list <http://www.ncbi.nlm.nih.gov/pmc/journals/>
Help <http://www.ncbi.nlm.nih.gov/books/NBK3825/>
predictive values (NPV), false positive and negative rates, and accuracy
of each review. Both binomial 95%CI and asymptotic /P/-values were
calculated to determine the statistical significance of each observers
results compared to a null hypothesis of 50% (/i.e/., results expected
due to random chance). The association between clinical factors and the
accuracy of LN detection was also examined.
Go to: <#>
RESULTS
Study population
From 2007 to 2010, 64 stage I-III colon cancer patients met the
eligibility criteria of our study (Table (Table1).1
<http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4513434/table/T1/>). The
mean age of the cohort was 68 years, and 26 (41%) patients were male and
38 (59%) patients were female. Tumors were located in the sigmoid colon
(/n/ = 18, 28%), the ascending colon (/n/ = 16, 25%), or the cecum (/n/
= 14, 22%). On final pathology, 19 (30%) patients were stage I, 19 (30%)
were stage II, and 26 (40.6%) patients were stage III. LN- disease was
diagnosed in 38 patients and LN+ disease in 26 patients. In the LN+
cohort, 17 patients had N1 disease and 9 patients had N2 disease. All
patients in our study had 12 LNs removed with a median of 22 LNs.
Table 1
<http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4513434/table/T1/>
Table 1 <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4513434/table/T1/>
Patient demographic and final pathologic characteristics
Nodal identification by different reviewers
Outside radiology review only identified 14 of 26 LN+ patients and 25 of
38 LN- patients (Table (Table2).2
<http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4513434/table/T2/>). The
sensitivity, specificity, and accuracy for the original radiology review
for predicting LN disease were calculated, as were PPV, NPV, false
positive rate, and the false negative rate (Table (Table3).3
<http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4513434/table/T3/>). The
original radiology review had the lowest sensitivity and highest false
negative rate compared with the secondary radiologist and surgeon
review. Figure Figure22
<http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4513434/figure/F2/> shows
an example of a LN- CT by the original radiologist; however, this case
was LN+ on final pathology, secondary radiology, and secondary surgical
reads.
Table 2
<http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4513434/table/T2/>
Table 2 <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4513434/table/T2/>
Comparison of lymph node status prediction by computed tomography
against final pathologic examination for three observers
Figure 2
<http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4513434/figure/F2/>
Figure 2 <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4513434/figure/F2/>
Computed tomography image showing positive nodal disease. This computed
tomography image read by outside radiologist as lymph node (LN) negative
disease was confirmed to be LN positive by final pathology (arrow head).
Contiguous with the base of the appendix, *...*
Table 3
<http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4513434/table/T3/>
Table 3 <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4513434/table/T3/>
Statistical analysis of lymph node status prediction by computed
tomography against final pathologic examination for three observers (/n/
= 64)
The secondary radiologist correctly identified 23 of 26 LN+ cases and 22
of 38 LN- cases (Table (Table2).2
<http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4513434/table/T2/>). Of the
three observers, the secondary radiologist demonstrated the highest
sensitivity and accuracy for LN+ detection, 88% (95%CI: 76%-100%, /P/ <
0.01) and 70% (95%CI: 59%-82%, /P/ < 0.01), respectively. The accuracy
of the secondary radiologist was approximately 10% higher than that of
outside radiologist review (Table (Table33
<http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4513434/table/T3/>).
Surgeon review correctly predicted 18 of 26 LN+ patients and 25 of 38
LN- patients (Table (Table2).2
<http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4513434/table/T2/>). Of the
three observers, sensitivity and accuracy of the surgeon review were
better than the original radiology review, but not as high as the
secondary radiology review (Table (Table3).3
<http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4513434/table/T3/>). The
surgeon review had comparable specificity to original radiology review.
Clinical predictors of lymph node identification accuracy
Location of the tumor, sex, body mass index (BMI), and number of LN
examined on final pathology were analyzed to determine whether these
variables correlated with improved accuracy of LN detection on
preoperative CT scan reviewed by the secondary radiologist. LN detection
in female patients tended to be more accurate than male patients (76%
/vs/ 63%, /P/ = 0.27) and BMI < 25 also tended to improve accuracy of LN
detection (84% /vs/ 67%, respectively; /P/ = 0.16). Total number of LNs
examined and location of the tumor did not predict LN detection accuracy
(/P/ = 0.91 and /P/ = 0.87, respectively).
Go to: <#>
DISCUSSION
Given the promising outcomes of preoperative and perioperative therapies
in other gastrointestinal malignancies[4 <#B4>,12 <#B12>,13 <#B13>], NCT
for node-positive colon cancer remains of great interest. The
theoretical benefits of NCT include the reduction of micrometastatic
disease and tumor shedding during surgery, and use of tumor response to
neoadjuvant chemotherapy to guide further adjuvant therapies if needed
after surgery. In addition, patients may be better able to tolerate
full-dose chemotherapy regimens in the preoperative rather than
postoperative setting. To determine which patients may benefit most from
NCT, accurate preoperative imaging to assess nodal disease is essential.
<#__sec11title>
* COMMENTS
<#__sec12title>
* Footnotes
<#__fn-groupid931848title>
* References
<#__ref-listid924117title>
-----------------------------------------------------------------------Articles from World Journal of Gastrointestinal Surgery are provided
here courtesy of *Baishideng Publishing Group Inc*
PubReader format: click here to try
<http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4513434/?report=reader>
Formats:
* Article
* | PubReader
<http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4513434/?report=reader>
* | ePub (beta)
<http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4513434/epub/>
* | PDF (1.1M)
<http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4513434/pdf/WJGS-7-116.pdf>
* | Citation <#>
Share
* Share on Facebook Facebook
<https://www.facebook.com/sharer/sharer.php?u=http%3A%2F%2Fwww.ncbi.nlm.nih.
gov%2Fpmc%2Farticles%2FPMC4513434%2F>
* Share on Twitter Twitter
<https://twitter.com/intent/tweet?url=http%3A%2F%2Fwww.ncbi.nlm.nih.gov%2Fpm
c%2Farticles%2FPMC4513434%2F&text=Accuracy%20of%20computed%20tomography%20in%20n
odal%20staging%20of%20colon%20cancer%20patients>
* Share on Google Plus Google+
<https://plus.google.com/share?url=http%3A%2F%2Fwww.ncbi.nlm.nih.gov%2Fpmc%2
Farticles%2FPMC4513434%2F>
Save items
<#>
Add to Favorites
<http://www.ncbi.nlm.nih.gov/myncbi/collections/>View more options
<#>
* Create collection... <#>
* Manage collections... <http://www.ncbi.nlm.nih.gov/myncbi/collections/>
loading
Similar articles in PubMed
<#>
* [18F]fluoromethylcholine (FCH) positron emission tomography/computed
tomography (PET/CT) for lymph node staging of prostate cancer: a
prospective study of 210 patients.
<http://www.ncbi.nlm.nih.gov/pubmed/22520686>[BJU Int. 2012]/Poulsen
MH, Bouchelouche K, Hilund-Carlsen PF, Petersen H, Gerke O,
Steffansen SI, Marcussen N, Svolgaard N, Vach W, Geertsen U, et al.
//BJU Int. 2012 Dec; 110(11):1666-71. Epub 2012 Apr 23./
* The value of FDG positron emission tomography/computerised
tomography (PET/CT) in pre-operative staging of colorectal cancer: a
systematic review and economic evaluation.
<http://www.ncbi.nlm.nih.gov/pubmed/21958472>[Health Technol Assess.
2011]/Brush J, Boyd K, Chappell F, Crawford F, Dozier M, Fenwick E,
Glanville J, McIntosh H, Renehan A, Weller D, et al. //Health
Technol Assess. 2011 Sep; 15(35):1-192, iii-iv. /
* Integrated positron emission tomography and computed tomography in
preoperative lymph node staging of non-small cell lung cancer.
<http://www.ncbi.nlm.nih.gov/pubmed/24534208>[Chin Med J (Engl).
2014]/Xu N, Wang M, Zhu Z, Zhang Y, Jiao Y, Fang W. //Chin Med J
(Engl). 2014; 127(4):607-13. /
* Comparison of the validity of magnetic resonance imaging and
positron emission tomography/computed tomography in the preoperative
evaluation of patients with uterine corpus cancer.
<http://www.ncbi.nlm.nih.gov/pubmed/18201753>[Gynecol Oncol.
2008]/Park JY, Kim EN, Kim DY, Suh DS, Kim JH, Kim YM, Kim YT, Nam
JH. //Gynecol Oncol. 2008 Mar; 108(3):486-92. Epub 2008 Jan 16./
* PET-CT for assessing mediastinal lymph node involvement in patients
with suspected resectable non-small cell lung cancer.
<http://www.ncbi.nlm.nih.gov/pubmed/25393718>[Cochrane Database Syst
Rev. 2014]/Schmidt-Hansen M, Baldwin DR, Hasler E, Zamora J, Abraira
V, Roqu I Figuls M. //Cochrane Database Syst Rev. 2014 Nov 13;
11:CD009519. Epub 2014 Nov 13./
See reviews...
<http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=link&linkname=pubmed_pub
med_reviews&uid=26225194&log%24=relatedreviews&logdbfrom=pmc>See
all...
<http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=link&linkname=pubmed_pub
med&uid=26225194&log%24=relatedarticles&logdbfrom=pmc>
Links
<#>
* PubMed <http://www.ncbi.nlm.nih.gov/pubmed/26225194/>PubMed
PubMed citations for these articles
* Taxonomy
<http://www.ncbi.nlm.nih.gov/pmc/?Db=taxonomy&DbFrom=pmc&Cmd=Link&LinkName=p
mc_taxonomy&IdsFromResult=4513434>Taxonomy
Sharif S, Pitot HC, Shields AF, Landry JC, Ryan DP, Parda DS,
Mohiuddin M, Arora A, Evans LS, Bahary N, Soori GS, Eakle J,
Robertson JM, Moore DF Jr, Mullane MR, Marchello BT, Ward PJ,
Wozniak TF, Roh MS, Yothers G, Wolmark N
J Clin Oncol. 2014 Jun 20; 32(18):1927-34.
* Perioperative chemotherapy versus surgery alone for resectable
gastroesophageal cancer.
<http://www.ncbi.nlm.nih.gov/pubmed/16822992/>[N Engl J Med. 2006]
Cunningham D, Allum WH, Stenning SP, Thompson JN, Van de Velde CJ,
Nicolson M, Scarffe JH, Lofts FJ, Falk SJ, Iveson TJ, Smith DB,
Langley RE, Verma M, Weeden S, Chua YJ, MAGIC Trial Participants
N Engl J Med. 2006 Jul 6; 355(1):11-20.
* Preoperative chemoradiotherapy for esophageal or junctional cancer.
<http://www.ncbi.nlm.nih.gov/pubmed/22646630/>[N Engl J Med. 2012]
van Hagen P, Hulshof MC, van Lanschot JJ, Steyerberg EW, van Berge
Henegouwen MI, Wijnhoven BP, Richel DJ, Nieuwenhuijzen GA, Hospers
GA, Bonenkamp JJ, Cuesta MA, Blaisse RJ, Busch OR, ten Kate FJ,
Creemers GJ, Punt CJ, Plukker JT, Verheul HM, Spillenaar Bilgen EJ,
van Dekken H, van der Sangen MJ, Rozema T, Biermann K, Beukema JC,
Piet AH, van Rij CM, Reinders JG, Tilanus HW, van der Gaast A, CROSS
Group
N Engl J Med. 2012 May 31; 366(22):2074-84.
* Review Diagnostic precision of CT in local staging of colon cancers:
a meta-analysis.
<http://www.ncbi.nlm.nih.gov/pubmed/20696298/>[Clin Radiol. 2010]
Dighe S, Purkayastha S, Swift I, Tekkis PP, Darzi A, A Hern R, Brown G
Clin Radiol. 2010 Sep; 65(9):708-19.
* Prognostic value of preoperative radiological staging assessed by
computed tomography in patients with nonmetastatic colon cancer.
<http://www.ncbi.nlm.nih.gov/pubmed/21948813/>[Ann Oncol. 2012]
Huh JW, Jeong YY, Kim HR, Kim YJ
Ann Oncol. 2012 May; 23(5):1198-206.
* Preoperative computed tomography staging of nonmetastatic colon
cancer predicts outcome: implications for clinical trials.
<http://www.ncbi.nlm.nih.gov/pubmed/17353925/>[Br J Cancer. 2007]
Smith NJ, Bees N, Barbachano Y, Norman AR, Swift RI, Brown G
Br J Cancer. 2007 Apr 10; 96(7):1030-6.
* Accuracy of multidetector computed tomography in identifying poor
prognostic factors in colonic cancer.
<http://www.ncbi.nlm.nih.gov/pubmed/20564305/>[Br J Surg. 2010]
Dighe S, Blake H, Koh MD, Swift I, Arnaout A, Temple L, Barbachano
Y, Brown G
Br J Surg. 2010 Sep; 97(9):1407-15.
* Preoperative evaluation of local invasion and metastatic lymph nodes
of colorectal cancer and mesenteric vascular variations using
multidetector-row computed tomography before laparoscopic surgery.
<http://www.ncbi.nlm.nih.gov/pubmed/18043344/>[J Comput Assist
Tomogr. 2007]
Kanamoto T, Matsuki M, Okuda J, Inada Y, Tatsugami F, Tanikake M,
Yoshikawa S, Narabayashi I, Kawasaki H, Tanaka K, Yamamoto T,
Tanigawa N, Egashira Y, Shibayama Y
J Comput Assist Tomogr. 2007 Nov-Dec; 31(6):831-9.
Nicolson M, Scarffe JH, Lofts FJ, Falk SJ, Iveson TJ, Smith DB, Langley
RE, Verma M, Weeden S, Chua YJ, MAGIC Trial Participants
N Engl J Med. 2006 Jul 6; 355(1):11-20.
[PubMed <http://www.ncbi.nlm.nih.gov/pubmed/16822992/>] [Ref list <#B12>]
Preoperative chemoradiotherapy for esophageal or junctional cancer.
van Hagen P, Hulshof MC, van Lanschot JJ, Steyerberg EW, van Berge
Henegouwen MI, Wijnhoven BP, Richel DJ, Nieuwenhuijzen GA, Hospers GA,
Bonenkamp JJ, Cuesta MA, Blaisse RJ, Busch OR, ten Kate FJ, Creemers GJ,
Punt CJ, Plukker JT, Verheul HM, Spillenaar Bilgen EJ, van Dekken H, van
der Sangen MJ, Rozema T, Biermann K, Beukema JC, Piet AH, van Rij CM,
Reinders JG, Tilanus HW, van der Gaast A, CROSS Group
N Engl J Med. 2012 May 31; 366(22):2074-84.
[PubMed <http://www.ncbi.nlm.nih.gov/pubmed/22646630/>] [Ref list <#B13>]
Review Diagnostic precision of CT in local staging of colon cancers: a
meta-analysis.
Dighe S, Purkayastha S, Swift I, Tekkis PP, Darzi A, A Hern R, Brown G
Clin Radiol. 2010 Sep; 65(9):708-19.
[PubMed <http://www.ncbi.nlm.nih.gov/pubmed/20696298/>] [Ref list <#B14>]
Prognostic value of preoperative radiological staging assessed by
computed tomography in patients with nonmetastatic colon cancer.
Huh JW, Jeong YY, Kim HR, Kim YJ
Ann Oncol. 2012 May; 23(5):1198-206.
[PubMed <http://www.ncbi.nlm.nih.gov/pubmed/21948813/>] [Ref list <#B10>]
Accuracy of multidetector computed tomography in identifying poor
prognostic factors in colonic cancer.
Dighe S, Blake H, Koh MD, Swift I, Arnaout A, Temple L, Barbachano Y,
Brown G
Br J Surg. 2010 Sep; 97(9):1407-15.
[PubMed <http://www.ncbi.nlm.nih.gov/pubmed/20564305/>] [Ref list <#B15>]
Preoperative evaluation of local invasion and metastatic lymph nodes of
colorectal cancer and mesenteric vascular variations using
multidetector-row computed tomography before laparoscopic surgery.
Kanamoto T, Matsuki M, Okuda J, Inada Y, Tatsugami F, Tanikake M,
Yoshikawa S, Narabayashi I, Kawasaki H, Tanaka K, Yamamoto T, Tanigawa
N, Egashira Y, Shibayama Y
J Comput Assist Tomogr. 2007 Nov-Dec; 31(6):831-9.
[PubMed <http://www.ncbi.nlm.nih.gov/pubmed/18043344/>] [Ref list <#B16>]
Preoperative diagnosis of lymph node metastases of colorectal cancer by
FDG-PET/CT.
Tsunoda Y, Ito M, Fujii H, Kuwano H, Saito N
Jpn J Clin Oncol. 2008 May; 38(5):347-53.
[PubMed <http://www.ncbi.nlm.nih.gov/pubmed/18424814/>] [Ref list <#B7>]
Accuracy of high-resolution magnetic resonance imaging in preoperative
staging of rectal cancer.
Akasu T, Iinuma G, Takawa M, Yamamoto S, Muramatsu Y, Moriyama N
Ann Surg Oncol. 2009 Oct; 16(10):2787-94.
*
Resources
* Chemicals & Bioassays
<http://www.ncbi.nlm.nih.gov/guide/chemicals-bioassays>
* Data & Software <http://www.ncbi.nlm.nih.gov/guide/data-software>
* DNA & RNA <http://www.ncbi.nlm.nih.gov/guide/dna-rna>
* Domains & Structures
<http://www.ncbi.nlm.nih.gov/guide/domains-structures>
PubMed <http://www.ncbi.nlm.nih.gov/pubmed/>
Bookshelf <http://www.ncbi.nlm.nih.gov/books/>
PubMed Central <http://www.ncbi.nlm.nih.gov/pmc/>
PubMed Health <http://www.ncbi.nlm.nih.gov/pubmedhealth/>
BLAST <http://blast.ncbi.nlm.nih.gov/Blast.cgi>
Nucleotide <http://www.ncbi.nlm.nih.gov/nucleotide/>
Genome <http://www.ncbi.nlm.nih.gov/genome/>
SNP <http://www.ncbi.nlm.nih.gov/snp/>
Gene <http://www.ncbi.nlm.nih.gov/gene/>
Protein <http://www.ncbi.nlm.nih.gov/protein/>
PubChem <http://pubchem.ncbi.nlm.nih.gov/>
*
Featured
*
*
*
*
*
*
*
*
*
*
*
*
NCBI Information
*
*
*
*
*
*
*
NLM
<http://www.nlm.nih.gov/>
NIH
<http://www.nih.gov/>
DHHS
<http://www.dhhs.gov/>
USA.gov
<http://www.usa.gov/>
Copyright <http://www.ncbi.nlm.nih.gov/About/disclaimer.html> |
Disclaimer
<http://www.ncbi.nlm.nih.gov/About/disclaimer.html#disclaimer> | Privacy
<http://www.nlm.nih.gov/privacy.html> | Browsers
<http://www.ncbi.nlm.nih.gov/guide/browsers/> | Accessibility
<http://www.nlm.nih.gov/accessibility.html> | Contact
<http://www.ncbi.nlm.nih.gov/About/glance/contact_info.html>
National Center for Biotechnology Information
<http://www.ncbi.nlm.nih.gov/>, U.S. National Library of Medicine
<http://www.nlm.nih.gov/> 8600 Rockville Pike, Bethesda MD, 20894 USA
External link. Please review our privacy policy
<http://www.nlm.nih.gov/privacy.html>.
PreferencesTurn off <#>
External link. Please review our privacy
<http://www.nlm.nih.gov/privacy.html>.
External link. Please review our privacy
<http://www.nlm.nih.gov/privacy.html>.
External link. Please review our privacy
<http://www.nlm.nih.gov/privacy.html>.
External link. Please review our privacy
<http://www.nlm.nih.gov/privacy.html>.
External link. Please review our privacy
<http://www.nlm.nih.gov/privacy.html>.
External link. Please review our privacy
<http://www.nlm.nih.gov/privacy.html>.
External link. Please review our privacy
<http://www.nlm.nih.gov/privacy.html>.
External link. Please review our privacy
<http://www.nlm.nih.gov/privacy.html>.
External link. Please review our privacy
<http://www.nlm.nih.gov/privacy.html>.
External link. Please review our privacy
<http://www.nlm.nih.gov/privacy.html>.
External link. Please review our privacy
<http://www.nlm.nih.gov/privacy.html>.
External link. Please review our privacy
<http://www.nlm.nih.gov/privacy.html>.
External link. Please review our privacy
<http://www.nlm.nih.gov/privacy.html>.
External link. Please review our privacy
<http://www.nlm.nih.gov/privacy.html>.
External link. Please review our privacy
<http://www.nlm.nih.gov/privacy.html>.
External link. Please review our privacy
<http://www.nlm.nih.gov/privacy.html>.
policy
policy
policy
policy
policy
policy
policy
policy
policy
policy
policy
policy
policy
policy
policy
policy
policy
policy
policy
policy
policy
policy
policy
policy
policy
policy
policy
policy
policy
policy
policy
policy
policy
policy
policy
policy
policy
policy
policy
policy
policy
policy
policy
policy
policy
policy