Transcription
Please admit your colleague in the meeting because I cannot see the screen. This is the first page.
So the scenario is this is a 12-year-old boy which is referred to the hospital for evaluation of easy bruising and prolonged bleeding after minor injury. There is no significant past medical history. His parents are from Venus. And the full blood count shows hemoglobin 135, white cell count of six, plated of 45.
And this is the this is 10. So let me see who are there. I'm not sure who is the ever path candidate in this case. So the ever path candidate, can you please take out your pen and paper because you have to write your report and further question we'll go to power 50. Can't see the full screen. We can't see the full screen. Only seen half of it. I think it's a full screen. I can't see. I'm only seeing half of it. What about the others? Full screen. Yeah. Yeah, we can see because I'm on two teams. All right. Okay. Yeah. No, it's okay. Sorry. This is your power technique. I will move slowly. That's clearly from beside the pinia. Mhm. There's a nuclear RBC there. It's a giant plate as well.
So Mark is our biomed scientist consultant. Thank you, Mark. Yeah, because the blood first goes to the lab. The lab staff usually report on them first. Yeah. Is that a how jolly body there? Mhm. Hypersplanism. You talk yourselves about what is your impression and would you like to refer this to theologist or not? Yes. Oh, yeah, definitely refer this. Yeah, I mean it's uh lucopenia there jolly bodies here. This I would not give this out. So you would definitely refer this to consultant. Those who are appearing or planning for FRC should answer this question on the paper. Please take a screenshot and then answer this question. Is the cogulation okay? Cogulation is okay. FT or they are fine. Yeah.
So now I need someone online to report this black thing. Uh red cell. Yeah. [Music] Yeah. So there is there is micro thrombocytoenia with some gain platelets, some target cells in the uh red cell and there is no uh major abnormality in the white blood cells. Mhm. There's no it's quite noticeable. There's no lymphocytes about now in the fells. Basels. Mhm. A nuclear RBC there. I don't think I've seen any nucleated red cell. There's a giant platelet there. A big platelet. Yeah. and how your body is I think yeah, this is not the complete report I'm expecting a complete report from because if you do not give complete report, the person who have seen this patient, they will call you. Okay, doctor, you have seen the blood stain. It's your advice. Okay. Okay. What is your impression? What should we do next? So, all right. Report the blood. Yeah. I mean there is suggestive features to suggest hypoinism and significant micro throboia. Mhm. Possible cause is uh immune thrombocytomania versus hereditary uh micro thrombocytoenia given the long history of clues. These are your further questions. Your defensial diagnosis, further investigation and what input you would like to deliver patient. You have only 9 minutes in the exam. Yeah. Differential diagnosis simoc hereditary thrombocytovenia microthosytovenia uh example bernoler gray platelet syndrome type 2b von brand and second differential is the immune thrombocytovenia. I would say unlikely given the prolonged three. Mhm. And I think my headlin as well can cause microcosmia. Yeah. What further test you would like to do? Uh we have done the blood film and coagulation screen. Yeah, I would want to do a calculation screen, renal function and liver function test. Calculation screen. Uh I mean looking for if there is any prolongation in the uh bleeding uh apt it might suggest a vulnerbrant disease and then I will do PFA platelet light transmission aggregometry. Your 9 minutes is over. Okay. And you are spending more minutes on this question. You will lose your time in morphology in the part two. All right. In in blood f reporting for the part two exam, you need to comment on the abnormality which is prominent in the blood which are the big thickness. Okay. Joint promocyenia in this patient and then other components. This patient the blood thin shows joint throatyenia. The patient had thromocytoenia and there are detected as well. Blood cell shows joy bodies and target cell and the word cells are open. Most likely impression is mechromocytoenia which need further evaluation further testing to find out whether it is inherited or acquired. And the second question was differential diagnosis. You have mentioned inherited causes solar syndrome may have been the acquired one which is less likely I feel. Then the other question was further investigations because we are suspecting macro completed disorder here and we have informed you that population screen no but if it is not given you can say I will do population screen to exclude uh prolong ep screen for type two uh plated uh type one disease uh plated function test which include light transmission for ner solar disease, the procytometry for the uh glycoprotein and genetic testing and what information you would like to give to your parent to the parent. We will explain the results of available investigation to the parent that we are suspecting inherited disorder likely this patient need to be transferred to a tertiary center for further testing and if diagnosis is confirmed then genetic constant. You have only 9 minutes for for two short question. Yes, this is easy. Someone come out from the from the exam center, he will say first case was nroo. It was an easy case and the result of fail. Why this question does not ask you what is this slide about? There are six other marks as well because of it people fail. People fail part two exam by five.5 marks as well. If you were there in the um last part two session in which we discussed the people result, we we have shown you the result of the people where people fail by.5. It is not only about the science sides are very easy. You see the macroenia clic. They do not only ask you the diagnostic. There are 10 marks. You need to answer all the question. This was Red like the glutenation there. I don't want to show you red. I want to.
All right. The scenario about this patient for two candidates. Please write your answer on the paper. A six-month-old boy of African descent is referred for evaluation of chronic anemia and little toy. He required a blood transfusion at 3 months of age for symptomatic anemia. No family history of anemia. The patient has hepatitis AV 98. Most likely he has decent transfusion MCV 68 MC 360 counts are normal. The first question is report of blood pin, most likely diagnosis, defensive diagnosis and further investigation. Right. Take the screenshot and then you will go to this is power 10. Let's go to 50. Okay. Got a spices about. Mhm. Unless this could be a case of um uh autoimmune hemolytic anemia. Mhm. Possibly HS. Can't see any nuclear RBCs. Go through the person if there is any micro microsites neutropenia. Yeah. Would you like to refer this to them? Oh, yeah. Definitely refer this to consultant. Yeah. And your thought is that this a I think it's probably like um autoimmune him anemia or possibly a HSU. Probably there's a lot of ancytosis there. I don't know. Is a toxic granulation in the neutrfils perhaps as well? Right. So this blood has been recorded by laptop to clinical hematologist. Please report the blood film and answer the question. Okay, which you have taken the snapshot already. Those who are appearing in part two should write their answer on a paper in 6 minutes. So who want to answer this question? Can I attempt? Yes, go ahead. Yeah, this is uh peripheral blood smear has significant anemia and uh there is marked anisocytosis piculoytes. Uh there is polychromatia. [Music] Um these are the red cell abnormalities. Platelets looks adequate. White blood cells are uh neutrfils uh look normal with some granules full of granules. So and some red cells with hell jelly bodies. Mhm. So ellipttoides or oytes can see some spirites. So my impression is uh most likely some biculosoccytosis hereditary anemia considering he is requiring blood transfusions since age of three so [Music] some or hemoglobinopathy. There are no target cells so I cannot saymia or and there are no cle cells. So doesn't look like secure cell. So it may be some membrane related diseases of RBC. So that is uh my [Music] differential test I would like to do is um EMA binding test. Mhm. And uh genetic testing as well. Yeah, genetic testing also if you are suspecting her steroid confirm this on genetic and the differential diagnosis. Differential uh diagnosis pioytosis pylo ano picloytosis. There are no stomato sites not many or we can say occytosis. These all membrane related issues diseases mention few non causes of hemolysis like retinal membranopathy, enzyopathies and mention one or two immune related causes of emoly like autoimmune. They are your differential. It's not your top differential. This is just your differential. So this OI has heridity. The blood pin shows all sort of red cell morphology and sizes. There are metro sites, there are spicy, there are even tear drop cells as well. Pesto sides of the we we saw also the um whole jelly body as well because the patient has maggali so hyperunctioning clinic hyper functioning will be there as well. This is a case of uh herid herid. Not required to say this is heredity paropic static. You can see most likely this is a heredity paropic statosis because I need to confirm this on further investigation. You can't make any diagnosis on a blood. You need further testing, additional testing to confirm your diagnosis. But you have to tell them what is your most likely type of your most likely impression. Um can I ask question just for the last case? Um the The reticular site counts is 10% only. So do we expect that the reticular site to be high? If the hemolysis is going on in this patient, there were a lot of cerosides in this case. Mhm. And macroytes than the uh neutrfil contain a lot of granu. There may be some infection induced hemolysis going on. Okay. That's why the reticular side. Sure. Thanks. And if it is and if there is a viral infection then you will see erotic count low because the virus is suppress the suppress the yes. You are saying I made these scenarios for the first time because we have a new breath of FRC for two candidates and we will have a session regarding efforts for two learning efforts. for two on first of two. We will discuss uh something over there as well. But these are the uh you have a slide in the exam and you have scenario like this with further question. This is the slide number three. 72-year-old man with routine blood test having high white cell count. is you are being muted. You cannot hear me now. Yes, the connection lost but now okay. So is 130 white thumb is 65. Um this is the plated thumb. The last thing you report the blood differential diagnosis further investigation and indication of treatment and treatment option. So let's see the blood. This is power 10. And this is power. Mark, I have a question for you. Yeah, this this blood is 3 month old. But you can see the nuclei the nuclei in this like like something is eating these nuclei. What is the reason of it? I have inner blood side u blood side as well. Yeah. And when I see the white cell in them the white cell appear like like mo eaten like they crushed on they a bit no no they were okay previously with passage of time the nuclear material disappear. I don't know. Yeah. like they're going into smears or some of them. You can't find them in in France like that. But yeah, I know what you mean. It's quite unusual. They're not solid, are they? They're not solid. They don't look solid. They look just look mashed up. Yes. Right. So you have seen the scenario to bring it again to you. Okay. Very high. What do you think? So what was the what was the age again? Sorry. 65. 65. Yeah. It's a possible age. You know, could be it's probably CLL. Age is 72. And the white cell count is 65. Yeah, I would say this is probably a CLL. The right age for it. The cells are looked a bit mashed. There's one or two like smear cells there. The reds are okay. Plateless are fine. But yeah, I can see what you mean there. They're not uh you'd expect like small small mature lymphosytes perhaps more defined cells. Yeah. So let's ask the clinical hematologist then. Yeah. Yeah. Oh, sorry. Yes. Yes. Yeah. So u there is a population of white cells with um they're polymorphic with mature uh clumped chromatin. Um they looks high in number but I can see the scaring around the around the red cells as well. All of them almost like [Music] um like to find smear cells. There is there are smear cells is scattered. Go on with your report. Yeah. So um neutrfils looks mature uh well granulated um platelets looks um adequate in number and uh red cells looks normally morphology. So definitely I will send um what is your impression before sending? Yeah, impression with the smear cells. It could be um CLL but yeah I think this is um could be the fairest impression. Um better to say most likely impression is most lymphop proliferative disorder disorder. Okay, it can be CLL. It can be CD5 negative LPDD. It can be something early. Yes. So most likely impression uh could um um LPD for further investigations. What further investigation you will do? I will send the sample the preferable blood for flowcytometry. [Music] Um and then accordingly we can take it for forward. But we need to know what is the immunophenotyping. CD19 positive, 20 positive, 23 positive and 200. Do we have CD5? CD5 is positive. So it goes with CLL. Yeah. Yes. Right. The next question was okay indication of treatment and treatment option. So indication of treatment um will be if the patient develops cytoenius uh or if he has um uh doubling time of the lymphocytes u less than 6 months and if he has symptomatic organomegali or b symptoms. This what I can remember so far so and um option of treatment uh usually We discuss with the patient the options that if he want to go for oral for long life like BT uh kitinip uh BTK I mean a calbritinip or ibinip or if you want to have like a short course of 12 months of fibism up you need to clax but also we need to send for the TP53 and IGHB mutations. This can uh guide us further about the management as Well, so treatment options you have either fixed duration therapy or 12 months. Yeah. Or continuous therapy. Yeah. The fixed duration you have mentioned uh that there is when the continuous therapy you have mentioned the PTP inhibitor or zonut. Yeah. When O and V I are fixed duration and the single agent BTK inhibitor are the continuous one. It depends on patient uh fitness as well. Yes, if the patient is fit you can give them vital clock based therapy because it is intensive treatment. If the patient is not fit then you have to suggest PTKI. So you have to divide your answer like that. It depends on patient fitness. The patient is fit fixed duration. If patient is unfit then single agent continue chemotherapy. What I have question why why we are saying that the nucleus is mature. So how should we differentiate? The mature nucleus they appear very very dark. They are dark blue in color. While the immature nucleus we can see nuclei in them. And in myoid cases the nucleus is uh pinkish in color within nuclei in it. In lymphoid cases, the nucleus is bluish in color, light bluish in color with permanent nuclei. But if the nucleus is mature, it is very dark blue in color. You cannot see anything inside the nucle. So in this case, it was uh mature or immature. This was mature. Mature. Okay. Okay. All of them had very dark nucleus and you were not able to see anything like it. Okay. Thank you sir. Thank you. Uh Dr. Excuse me. Dr. Do patient require treatment at this stage if due that patient is asytomatic and only on the uh CTP count and uh the history mentioned no lagnopathy and no organome syndrome. So so only what andful um uh strategy for this patient for this particular patient. Yeah. For this particular patient, yeah, because he was asymptomatic, the scenario was mentioning to you that the patient is asymptomatic. So the staging according to the staging dry and benic stage. So this is a zero and one. So we have to monitor this patient and and if there no treatment this patient would need monitoring only if any indication of treatment appeared as the candidate mentioned like cytoinesic anemia massive spomegali massiveopathy plural eusion etc constitutional symptoms then you will consider this patient for treatment. Okay. So the CLL it has specific indication of treatment. Low grade lymphoma they have indications of treatment. You do not treat them all. If someone has follicular lymphoma not causing any problem you do not treat. But if someone has DBCL then yes you treat them. Similarly in hair leukemia and LPD uh in the CLL if the patient has diagnosis but asytomatic we do not we just monitor them. Thank you. This is 19-year-old boy admitted with uh inertian bleed and the white count white cell count is 600. I don't have a scenario for that. I was able to make three scenarios only. This is power 10. More you think that this is looks a bit lymphoid. Looks possibly. Yeah, I can see clear nuclei probably look infoblast. So now these are immature cells. You can see the nuclei permanent nuclei in them and the nuclear material is very thin. Yeah. And it fills the high n ratio [Music] nucleus basically fills the whole cell. Nuclei can nuclei can be present in reactive lymphosy as well. If you see the nuclei of infectious mononucleiosis they may have prominent nuclei as well. Nuclei may be present in prolymphosy as well because in CLL you have some population of prolymphosytes as well but their nuclear thickness is different than these that that ability to differentiate between such type of cell will come with passage of time when you see more and more blood. Yeah. So this one. So what do you think? I think it's an acute uh infoblastic leukemia. Definitely need cell markers. Probably an L1. So let's ask our clinical hematologist what they think. Well, I think there's a few like um cerebral um clover shaped ones there as well. Little bit but it's more lymphoblast. Yeah. So want to report this. So let's see what other Yeah. Okay. Yeah. So um there is U liquytosis uh with mainly um increase in monuclear cell um likely blast medium to medium to large cells um with open chromatine um minimal cytoplasm have got a a bit of bzophilic cytoplasm a granular um and I can see tou with nuclei as well of the cells. Um yeah, so um red cells um I can't see like many red cells but um slightly hemoglobin is 98 and count is 40. Yeah. So um anemic and stroytopia um impression is likely uh acute leukemia we but we'll need further investigation to confirm likely AL but we'll need further investigation to confirm closemetry. Okay. So you would like to do close for this patient. Yeah. Close autometry is telling you that CD19 is positive, CD 2 is negative, CD10 is positive. Yeah. And PDT is positive. Yeah. So it goes with uh BL. Mhm. Why this patient has hemorrhage? Yeah. So um it's probably as um feature of hyper viscosity maybe one will brand disease hyper viscosity one will brand thrombocytoenia thrombocytoenia it's disease not right assimilated invascular group from DIC DIC can be as well because this can be one of your partath question why this patient have bleeding complication. Okay. What are the prognostic factor in this patient? Right. Um so you mentioned like his age is 19 years old. So this is um good prognostic sign as uh usually the age is if more than I think 50 or 40 why the age poor the problem more than 40 is considered poor. Yes. And um I believe also um in terms of his white cell count uh this is you mentioned 600 which is um again this is a a poor risk feature intraraanial bleed incraanial bleed itself poor involvement is the poorest what else and disease related uh prognos nostic factors. Yes, we didn't have it in this scenario now, but like at other features uh like Philadelphia chromosome um negative Philadelphia negative ph positive positive. Yeah, PH positive is a poor risk factor. Yes. So BL positive this is a poor factor. Sorry. Um did you say in this scenario is negative or positive? There is not mentioned in this scenario mentioned. Yes. Yes. The question is what are the prognostic factor? So you would say high age high white cell count uh positive. Yeah. Uh is the poor prognostic factor? Disease related factors are the CNS involvement and then cytogenetic BCL positive and uh 119 411 classification is good prognostic hypodloity is good prognostic. Yeah. And 12 21 is a standard prognostic factor. Yeah. Okay. So now [Music] um the question is what origin intervention would you like to do in Yeah. uh for him because of the very high uh white cell count. Um I believe uh apheresis lucaresis lucaresis. Yeah. Neurosurgeons involvement because he has entertained leak and lucaresis to bring his tongue down to double digit. Yeah. Sorry. Can I ask lucaresis intraanial bleed is contraindication isn't it? No, that is complicated in APML. APML only. Okay. Yeah, that's fine. Because there the APML patient usually come with DIC and low fibromyis will lead to more hypoprogen. All right. In in APML we do not do lucoparis. And this patient this patient is going to die from interpanal memory. If we do not reduce the count is 600 and it will eat everything all the one factor in the body. Right. Last question. Um now the team is planning treatment for for this patient. Do you know any treatment protocol to offer to this patient? He is 19 years old. 19 years old. Um yeah. So uh it is obviously like it would be like of course like MDT approach and um um like offer clinical prayer we're available but it will be like ukal 14 GB 19. I think it's Yukon 19 in the pediatric population. Yukon 19. He is not a pediatric person. He's 19. 19 years old. Yeah. So this I was teaching this to my student yesterday. These are different protocol that they use in 14 19 and all together. He can be this one as well. all together 0 to 29 years a PH negative. Okay. And uh you can offer 14 you can offer 19 as well as you need to remember the names of this protocol and the stage at which they can be offered to the patient. What is included inside this protocol? You are not required to remember. This will be too much. Yeah. Um can I ask Amir um from this film? Sorry, he took the film out. I was just um that's fine. Just to how we differentiate this isl not AML. I mean we know the ALL is having hand mirror but there is no hand mirror here. So how you say this? I mean from the film this is AL not AL. It's a cute look. Yeah immature but any specific feature? I think there was few um but like not really like quite typical but there I found like one or two like the hand mirror. M first of all Mhm. you you do not say on a blood st that this is AML or you just say this is acute leukemia most likely acute leukemia. Mhm. We have seen many cases where we think that this is AML and the PL come out to be AL and many cases where we think this is AL because of the patient age uh and the PL come out to be AML or Botenotypic disease. Okay. So we do not differentiate on the basis of blood. You just say this is uh acute leukemia. Yes. In in AML. Mhm. The cytoplasm will contain a lot of granu. Okay. I can make it big because myoid population usually contain granu. Mhm. Okay. While the in lymphoid population in all the granu in bal there is no granules in the cytoplasm. The plasm is usually empty. Okay. Okay. And then tal usually come with um mediastinal mouth. The patient has usually a big medastinal mouth. This is one um likely when you that this patient may have TL or secondly uh they have hand mirror projections like this one. This one is a hand mirror like cytoplasmic production because of the neighboring cells. This this cell is squeezed. I'm just telling you that the hand mirror projection is like this. Mhm. They have big they have cytoplasm which has hand m projection or a tennis projection. Some some people say like that. Um but if your patient is young has the diastinal mass and there are cytoplasmic projections then you think that this may be likely TL but you need to confirm this on close second. If your patient is patient does not have anyone but the white cell count is high and all these cells are like this with minimal fat plasm less granules then you think that maybe this is B Mhm. But if the patient has uh nuclear material which is pinkish in color, this one is blueish which is a pinkish in color with permanent nuculoid minimal cytoplasm. But you may think that maybe this is acute leukemia but still uh you will say this is acute leukemia. I need to confirm this on close. When you send your close automatic to diagnostic center, they give you the provisional report on the same day. Then you have a feeling that okay, I'm dealing with AML or I'm dealing with okay thank you. Thank you very much. Uh just a quick question. Is that a same case? Mhm. Yeah. Just in terms of the intercraanial bleed um that you said like it is probably because of Bob brand. Um in terms of the management um do we besides the neurosurgeon um involvement do we need like to say we check for the levels or there is anything from him perspective to be done um for the bleeding and the B brand or just like it it would be like the cyto reduction and um this is the main thing treating that the line cause no specific no brand no reduction you will do lucaresis in this patient Patient with a white cell count of 700 or 800 having endial bleed you would do lucoparesis to reduce the uh cell count to double figure. Usually with one cycle all the counts will come down to yes double figure. Okay. And once the varsel count is um reduced then there will be no there will be no um deficiency of monol in this patient. Yeah. But because this patient has endopenal bleed you will top up the patient with transfusion to make it above 100. Sure. You will see what is the fibbrronogen count in this patient. If it is less than two according to our trust protocol then you will give this patient fibbronogen concentrate or piate. Some trust says less than one some says less than 1.5. Yeah. Perfect. You will top of the patient with blood product with uh fibbrinogen concentrate. Uh because as one of the collection can have can have DIC as well. uh that's why there isopathy we will address according in DRC we keep the plated count about 50 but here this patient has interpenal bleed it should be about 100 we keep the fabbranogen count about two says about 1.5 if you have cry precipitate give precipitate if you haveen concentrate give perfect. Thanks. This is a 50-year-old man referred to hematology because of lympadinopathy. This is the plas. In that cell nuclearize prominent probably a little flick of the lymphoma. I think the the trainee will be very happy in your hospital. [Laughter] Well, you're making a man now experience. Look how looks okay. Yeah, that's okay. Yes. It's a prominently ficular right. So let's see what our hematologist say. So who want to report this blood fan quick? Let's pick here someone Tam Hussein. and uh Fatima Fatima Shak. Yeah. Yes. Please report the blur then. So yeah, so the blood film is showing um population of mature um lymphocytes uh small to medium size um with clifted nucleus. Um uh I can also see um anemia and my thromboscytoenia. Yeah. Anemia and my thromboscytoenia. And what is your impression? So my impression here will be u likely um um feature suggestive of um LPD um likely follicular lymphoma. uh we will need to send immunosphenotyping um and do further testing. So one of your colleague is asking you why why you say this is policular for are there any feature that you think is specific for lymphoma. I can also notice here in this field there is somehow jolly bodies. Um yeah regarding the features of policular lymphoma the the appearance of the nucleus um it it appears like clefted I think they call it a bean shaped bean shaped nucleus. I'll go to power 100. Yeah, there is clear cliff here. This is the club. Oh, this is the club that is present in molecular lymphoma cell and these cells are small to medium. Some some cells are of RBC size. Some cells are bigger than RBC. Yeah. Okay. What is the expected flow cytometry? Uh so I think it will be uh CD5 negative CD 10 positive um foroscytosis um and BCL Yeah. And then we will send for the BCL6. What else could be positive or negative in terms of flow mode? Uh so so flow CD uh CD5 negative 10 positive and then uh B markers uh CD 20 20 uh 19 20 uh 22 75 uh 79B should be positive. What is the expected cytogenetics in this patient? PC uh PCL6 um 14 uh 14 Oh yeah 148 cross location 1418 1418 oh and what are the indications of treatment in this patient? So patient presented with lymphodenopathy. Um so there will be um if if there is um if this lymph nodes is causing compression to any of the vital structures that will be an indication. If they have cytoines um that will also be an indication. Um yeah, and um there criteria yeah I think I think it will be the staging of the patient itself whether it's a if it's advanced stage three to four um on an arbor staging. So G criteria read the G criteria for the uh indication of treatment in particular lymphoma that say this is advanced stage disease. What are the options of chemotherapy with you? Yeah. So we need an MD approach for the case. Um we need to check the patient functional status, coorbidities, um um current medications and drug history. Um and then um the the key regimes will be either archop or or rcvp um after assessing their cardiac function or arbenda will be also an option. Yes. The chemotherapy are either toximab based or abnotism. Okay. And they can be either our bender or CVP or or our top chop. Usually patient goes with uh our bender according to my trust protocol because if these patient relapse in the future and they convert into DLBC, we will have a top option available. Okay. Okay. This will be last one question sir for stage four three and four follicular lymphoma with negative criteria uh still we need to treat or no if there is no indication then we don't even if it is stage three and four even if it is okay thank you sir if it is a single big lump For example, a big lump here. It is compromising your vascul then we would treat. If it is stage four disease but it is not causing any problem to the patient, no constitution symptoms, no cytoenia, no messomegali, no massopathy, it does not complete the uh criteria of the gift. Then you just watch me wait. Go on. What? Uh Dr. What about the maintenance problem? You have to give the maintenance therapy. uh after the after the uh first line chemotherapy is given the maintenance therapy for 2 years three 3 months for 2 years you have to give after first line okay anyone Anyone want to say anything? No. Then enjoy. Next Sunday we will have part one part two related uh session. If you are registered then see you next Sunday. Thank you. Thank you everyone. Thank you. Thank you so much.