Transcription
Right, so this is the uh last session for morphology before spring. Uh, FC part two exam. I would like the FC support for two candidates to participate actively. Uh, next next Sunday, we will have last-minute advice for FC for two candidates. There will be no morphology, and then we will resume our morphology uh in April.
So let's go to our first case. If there is anyone waiting in the waiting room, please let them in. This is a 7-year-old child that presented to ED because of epistaxis, and he has previous multiple episodes of epistaxis as well. Okay, so this is power 10 for the card. And now I will show you our 15.
EE yes, any of the part two candidates? H. So the, so the first question for you is, let's say you are sitting an exam. Uh, the first question is, report the blood film. Okay. So the peripheral blood film showing the platelets. The platelets and there's a thrombocytopenia. However, there are large platelets. Plates are large in size and some are very giant in size. The granularity is okay, and there are no abnormal cells seen. And the WBC, we see neutrophils are evident and there's no inclusions in the neutrophils. And in the red cell, the red cells are normochromic, normocytic. Some are macrocytic and there are, there is anisocytosis as well, and no Howell-Jolly bodies have been seen. And, uh, macrocytosis seen. If you have no Howell-Jolly body, do not mention it. A, okay. Um, a typical lymphocyte. Right. And the findings are suggestive of, uh, uh, Bernard-Soulier syndrome. We can say, right? The findings are suggestive of Bernard-Soulier syndrome. You will fail this, uh, short question if you say this is Bernard-Soulier syndrome. How do you know that this is syndrome on a blood film? So, we will say inherited. No, not inherited as well. What will we say? Inherited. There's a macrothrombocytopenia in this patient, which has multiple causes. The impression is macrocytopenia, and we need to do further tests in this patient to exclude inherited bleeding disorders or acquired bleeding disorders. This looks like inherited because this is a 7-year-old child and he has multiple episodes of epistaxis and bleeding, and platelets are large and they are pro-thrombotic. Patient is chromo-something. Okay. What tests will you do next in the station? Um, so, uh, the additional tests, we will investigate for flow cytometry for CD42b. And I have not, I have not told you full blood count. So start from the basic. Okay. So, uh, we start with the, uh, CBC. And, uh, then flow cytometry. And, uh, uh, flow cytometry. There can be genetic studies. What do you want to check in the flow? In the CBC, there will be thrombocytopenia. There will be no underlying any abnormal cell or inclusions in the neutrophil. And the true thrombocytopenia. The size of the neutrophil, the granularity. Oh, sorry, the size of the platelets, the granularity of the platelets. And in the CBC, we will check MPV. Mhm. Then next test. CBC and MPV has been done. Next test. Anything before that? Very simple. Has already been done. Would you do light transmission aggregometry? Yeah. Okay. Light transmission. Yes. Then you would say I will go for flow cytometry and genetic studies. This patient is bleeding. What is the acute treatment? The active treatment will involve the the patient, uh, tranexamic acid. And, uh, if patient is severely bleeding, then we can have an H image. H image. 10 days to come to the hospital. This patient is bleeding acutely. What do you? No, desmopressin. No, seven is an option. Tranexamic acid and recombinant factor seven. Local my, tranexamic acid. No, seven. Random platelet. H. Platelet. I have told you before multiple times. It takes many days to come to the hospital. Yes, these will be considered as blunders and you will fail your short question. This is not Bernard-Soulier syndrome. You cannot diagnose anything on the on the blood film. They can only tell you the possibility that this is acute leukemia, this is APML likely, this is macrocytosis, this is likely Gray syndrome. This is likely, um, Le rest. Everything you confirm on investigations.
EE
This is a second case. Another 30-year-old male patient with, um, epistaxis. This is power 10. EE. Now I'm going to power 50.
EE
Okay, so who is going for part two next? So report this blood film. Lee. Lee, can you hear us? Uh, hello. Hello. Can you hear me? Yes. Um, sorry, I just want a repeat of the stem piece, um, very quickly. So this is a 30-year-old young man presented to ED with epistaxis. Okay. Right. Shows hemoglobin of 110, white cell count of 21, and 55. Yep. Okay. So the peripheral blood shows, um, um, abnormal, uh, large, uh, promyelocytes with high NC ratio, bilobed nuclei, presence of granules, and, um, in some of the cells, I'm not entirely sure, but I think I saw some Auer rods as well from the nucleoli. And, um, the red cells show aniso, poikilocytosis with presence of red cell fragments, uh, some spherocytes and polychromasia, and genuine thrombocytopenia. The features are suspicious of, um, um, acute promyelocytic leukemia, uh, with a coexisting, uh, microangiopathic hemolytic anemia. Mhm. And so this H in the, in the to finish the report, I would put, um, U, this is a medical emergency and the patient should be started on ATRA as soon as possible and with an aggressive transfusion to correct the thrombocytopenia and coagulopathy. This patient needs urgent medical review. I mean, urgent hematology review. This is a hematological emergency, not medical. Medical team will not do anything. Okay. You have, you have reported correctly. What type of APML is this? High risk or low risk, and why? So if the white count is above 10, and it would be high risk. If the white count is below 10, but the platelet is below 40, it is intermediate risk. If the white count is below 10 and the platelet is below 40, it is low risk. Because the white count was above 10 in this case, am I correct? I forgot. You can see that there's a lot of, yeah. And, and I think in the blood film, it's likely to be a case with a high count. So this patient would be at high risk, um, and, uh, uh, we should consider cytoreduction, arrange, um, baseline evaluation prior to starting of chemotherapy, likely anthracycline. So this patient would require a baseline, um, uh, liver and renal function panel, an echocardiogram, and ECG. Question was, what type of APML is this? Okay. Yeah, it is hypergranular, hypervariant because you have only nine minutes. Short question to see the blood and to answer all the questions which are given under the question. Okay. So then they will ask you, what is the immediate treatment? Immediate treatment would include, um, admitting the patient, um, aggressive transfusion to correct the coagulopathy and thrombocytopenia, aiming at platelet count about 50 and fibrinogen above 1.5, um, starting ATRA at 45 mg per meter squared, um, uh, uh, watch out for tumor lysis syndrome, watch out for differentiation syndrome, and if there are signs or symptoms suggestive of that, consider, um, steroid treatment. Um, because this patient is higher risk, we need cytoreduction with anthracycline in addition to, um, ATRA. So arrange baseline echocardiogram, EKG, and, uh, U, liver and renal function prior to starting chemotherapy. This is a man. Ideally, we should discuss fertility preservation prior to chemotherapy. But in this case, um, because this is a medical emergency, we would counsel the patient that this shall override, um, um, or or or if time permits, we can still arrange, uh, sperm banking, saving sample prior to chemo. And, uh, the baseline evaluation prior to treatment also includes virology screen for hepatitis B and C and HIV and G6PD level. Close monitoring of, uh, uh, counts and coagulopathy, including fibrinogen and D-dimer, um, during the treatment. Uh, if there are signs of sepsis, perform cultures and start broad-spectrum antibiotics immediately. Um, yeah, I think that's pretty much I could squeeze in the nine minutes. You give this patient steroids? So if I think there are two approaches in the literature, either prophylactic steroids or, um, preemptive or or or at the onset of, um, uh, uh, detecting signs or symptoms of differentiation syndrome. Personally, I would prefer starting prophylactic steroids, given this is a high-risk case. In high-risk cases, we always give prophylactic steroids to prevent differentiation syndrome. Okay. Would you monitor electrolytes in this patient or not? Yes. So, uh, close monitoring for, um, the electrolytes for the possibility of tumor lysis syndrome. So this includes monitoring potassium, calcium, and phosphate, uh, blood gas, including pH and bicarbonate. Potassium and magnesium are the ones which are important. Okay. So potassium, calcium, phosphate, pH, bicarbonate, and magnesium. Okay. All right. Twice daily, according to our protocol, we take them twice daily when we start ATRA for the patient. Okay. Right. These, these will be the questions that they can ask you in nine minutes. Other questions they can ask you, uh, will be, what are the side effects of ATRA in this patient? Yeah. So for side effects, um, common side effects include, um, headache, derangement in liver function, prolongation in, um, QTc interval. Some patients might develop, uh, dermatological side effects including, um, rash, um, and, um, in most circumstances, these could be mild and could be manageable. Um, and, uh, following treatment with ATRA, patient can also develop, um, um, differentiation syndrome, which should be managed accordingly. C, tumor lysis, H toxicity, and electrolyte disturbance. You already mentioned these are a few side effects that these patients can develop with. Yeah. In in practice, I, they do, they can also have derangement in liver function and, uh, prolongation in QTc, yeah, which is something that needs to be monitored closely for. Yes, we calculate QTc interval before every dose of ATRA and administer to the patient almost every day for these patients, and electrolytes and the, uh, coagulation profile every day as well. Yeah. Can I ask quickly about the, um, um, regimen in high risk and low risk? So for high risk, you give ATRA plus cytoreduction. And do you also give arsenic trioxide here? So high-risk patients would get arsenic plus idarubicin. Arsenic plus idarubicin. Yes. And the low-risk patients will get ATRA plus arsenic. So for high-risk patients, they do not have ATRA. For high-risk patients, ATRA, the regimen is called IDA. Okay. ATRA plus idarubicin. ATRA is the first line if you, okay. Yeah, yeah. So, so high-risk is ATRA plus idarubicin. Okay. And then low blood. If you see a blood film and it says Auer rods, yeah, you have to start ATRA. Yeah. Exactly. And on the same day, if you can confirm PML-RAR fusion on the same day or on the next day, you can add either idarubicin or arsenic accordingly. Idarubicin for high-risk patients when the white cell count is above 10, and arsenic for low-risk patients if the white cell count is less than 10. Right. So the arsenic trioxide is not used in high-risk patients then? No, no, no. All right. Okay, fine. If the patient, if the patient is intolerant to idarubicin or very severe reaction happens, then it becomes second line, then you do not have any other option. But the normal protocol in all of our trials is to start idarubicin in high-risk patients. Right. And, uh, arsenic and low-risk patients, ATRA plus arsenic and low-risk patients. Right. And what dose of, uh, do you usually use? No, no, idea. The pharmacologist tells us and no one, no one will ask you doses in the exam. Okay. Good. Thank you. The doses that you need to remember for the exam is only the DU doses and, okay. Thank you. Okay. So this is the 13. This is an, uh, 82-year-old patient who presented to the emergency department with progressive fatigue. The full blood count shows hemoglobin of 69, white cell count of four, platelet count of 200. The biomedical scientist told you that this patient has likely TTP because he has seen schistocytes in this blood. This is for 10. Now power 50.
EE
All right, so this is the film of 82-year-old with fatigue and anemia. Anyone going for part two should report this blood film. As if I can see your name, yeah. Uh, I can see that, uh, there are a fair number of schistocytes. Uh, there is a mild anisocytosis. Some, uh, target red blood cells are seen. Uh, in the, I can see there's thrombocytopenia as well. And in the WBC, so far I cannot see any abnormal, but there is, uh, lack of polychromasia. So I don't know if I should mention that or not. This is polychromatic cells. This one. And this one. This one. The big ones are present here. Yeah. Maybe, maybe. 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12. Not in this field. Yeah. In this field, probably. Yeah. Again, 8 to 10. Okay. Okay. Report the blood film. Let's see how you report it. Yeah. So, uh, red blood cell, there is mild anisocytosis, plenty of schistocytes, fragmented red cells, more than 1% polychromasia, and a few teardrop, sorry, few target red blood cells. And, uh, WBC is unremarkable, uh, and platelet counts are normal. So my impression is microangiopathic hemolytic anemia. Yeah. What can be the causes of? First, complete your report. Sorry. This was your impression. What will you suggest? Yeah, I will suggest coagulation screen and, uh, um, coagulation screen and ADAMTS13 assay. Why are you suspecting TTP in this patient? Yeah, this is one disease that I need to rule out in almost every patient of microangiopathic hemolytic anemia. Most likely in 82 years old, TTP is unlikely. But am I not supposed to rule out? I mean, at TTP in every patient where there is a MAHA? Then it becomes an emergency. If you're thinking about TTP, then this is an emergency. Right. It's not TTP because platelet count is normal. I'm so sorry. I will do the coagulation. Yeah. What investigation will you like? What suggestion will you do? You have seen the blood. You have done the impression. Okay. You have to write something in suggestion because otherwise the team will call you, doctor, you have reported the blood, then what should we do? So the differential diagnosis in a 92-year-old with MAHA would be a mechanical heart valves. It may be a, it may be a solid tumor malignancies causing like a liver tumor or something. It may be an infection causing DIC. So we need to rule out these investig, uh, this causes. So, so we will have to do a coagulation screen, a CRP, blood culture, a CT scan of neck, thorax, and abdomen, and an echocardiography. About hemolytic screen? Oh, yeah. I have to do a hemolytic screen as well. That is, urine for hemoglobin and reticulocyte count and LDH. First, we have to do a hemolytic screen to rule out whether this is immune or non-immune. The blood film shows red cell anisocytosis, multiple schistocytes, polychromatic cells, platelet counts are normal, two platelet plugs, normal white cell count. The impression is likely, um, hemolysis, MAHA, or hemolysis. The patient needs to do hemolytic screen, coagulation screen as you mentioned. You have correctly suggested that this can be a valve-related hemolysis. The next question can be in the exam, what are the different causes of MAHA? Okay. So that question will be age-specific. So if it is age-specific, then I will go with, uh, malignancy, then mechanical heart valves, then infections with DIC, and then autoimmune causes. Also mention infection, malignant hypertension, hemolytic uremic syndrome, TTP, which can be primary or secondary. Even in this age, it is possible as well. Drug-induced as well. Right. So what treatment would you advise? Yeah, that will depend upon the cause of the MAHA. Yes. Patient is having hemolysis. Would you advise something in terms of treatment or not? Yes. So, uh, while awaiting the investigations, we first have to know if the patient has an autoimmune hemolysis or not. Immune hemolysis, for example, hemolytic screen came out as negative, and this patient has a heart valve which was inserted in 2000, and there is a valve abnormality. Okay. But now this patient is having hemolysis. What treatment would you advise? The changing of the valve may take a week. We may have to discuss this case in a, in a, in a, in a multi-disciplinary meeting along with a cardiologist and a cardiothoracic surgeon. And that the patient is symptomatic with anemia, so he will need blood transfusions. But we need to arrange a replacement of the heart valve as soon as possible. You are not the one to arrange replacement of the heart. This is the cardiology job. This patient is having hemolysis. The doctor is asking you, what should I do for this patient? Blood transfusion. Okay. What else? Hematinic aid, folic acid. What else? So blood transfusion, folic acid, VTE prophylaxis for this patient because hemolytic patients are high risk of thrombosis as well. Right. If, if I'm prompting you like this in the exam, if they prompt you in the exam, for sure they will fail you. They do not like prompting in the exam. Okay. So with mechanical hemolysis in an 82-year-old patient, these can be the few questions. Report the blood film. What are the causes of, um, MAHA? What treatment would you advise? Or what investigation would you like to do? What advice will you give? These can be the questions for 10 marks, um, in short morphology. Right. And if the patient is young, 40 or 30 years old, then likely you can think about a TTP case if there is pro-thrombocytopenia or if they have given you any supportive investigations like renal function. But in elderly patients, it will be either mechanical hemolysis or it will be, uh, or it will be secondary TTP. And secondary TTP, you are not required to do the, um, discussion with the TTP consult. I want to ask a question. Since this, that the last film that we have shown is probably borderline for thrombocytopenia. Maybe, maybe the platelet count is around 1 to 1.5, maybe 1.5. So does that rule out TTP? I mean, we cannot say TTP without thrombocytopenia. The last film has a lot of platelet plugs. The platelet count was about 200. Okay. Okay. Was about 200 in this patient, and you, you had, you calculated there 8 to 10 platelets in each field. So that cannot be thrombocytopenia. This is another 30-year-old patient who presented to the emergency department with epistaxis again and fever as well. The full blood count shows hemoglobin of 120, white cell count of 16, and platelet count of 40. This is the power 10.
EE
All right, another volunteer. E. Okay, who is next? Hello. Uh, uh, can you please repeat the stem of this question? Is a 30-year-old female with fever, flu, and epistaxis. Four blood counts, hemoglobin of 120, white cell count of 16, and platelet count 40. Okay. The peripheral blood film is showing abnormal cells. Abnormal, most likely blast cells seen that have, that are very medium to large in size, and the cytoplasm is pale, basophilic, and agranular, and the nucleus, uh, is, uh, uh, nucleus is variable in shape and, okay, so nucleus is variable in shape, have a partially condensed chromatin with a visible prominent 1 to 2 nucleoli. With mutation claps. Okay. And, uh, the neutrophils are evident in the field. Then you please have ended in the cells. So, uh, the, uh, red blood cells are normocytic, normocytic with mild anisocytosis. Few schistocytes have been seen. And, uh, the platelets are low in number, thrombocytopenia. My suggestions will be, the differential diagnosis, it can be acute leukemia. Okay. The differential is acute leukemia in this patient. And here you think these are blasts? Um, yeah, uh, yeah, abnormal, abnormal cells. It can be a typical lymphocyte, but there's a visible nucleoli. Atypical lymphocytes can have visible nucleoli as well. Abnormal monocyte. This is an abnormal monocyte with a wide variation, low NC ratio, pale, vacuolated cytoplasm in the vacuolation and vacuoles in it. This is an abnormal. This patient has a lot of mature neutrophils. About this, the typical lymphocyte cells with a scalloping around the RBC. So how would you report this? Okay. So the abnormal lymphoid atypical lymphoid cells seen with abnormal monocyte as well. And, uh, the patient has neutrophils are evident with red cells are okay, and anisocytosis and thrombocytopenia. It can be infection, fever. It can be infectious mononucleosis with abnormal lymphocytes, fever. Yes. Why the patient has thrombocytopenia? Infection related. Can be infection. I cannot see. So again, there's an abnormal lymphocyte that are scalloping around the red cell and there's a vacuolation. There's no granules. Not granular. Granular. So scalloping does not mean always that this is abnormal lymphocyte. Scalloping can be present in leukemic cells as well. Last week we have shown you one blood film of monoblastic AML in a 19-year-old, which is still present on the channel. I forget which one is the film number, but that blood film contained blasts and pro-monocytes, etc., and it has scalloping as well. But here you can see the nucleus is a bit mature and the cytoplasm is quite a lot bluish. Patient has fever, blue, and thrombocytopenia is secondary to, uh, infection. So what investigation would you like to do in this patient? So, uh, the investigation can be, uh, the baseline investigation, U, LFT, CRP. And for infectious mononucleosis, we will rule out for Monospot test and, uh, uh, virology, EBV, CMV, and HIV as well. And EBV PCR or serology, whatever is available in your hospital. What is the treatment? Uh, uh, the treatment is symptomatic. Uh, the treatment is symptomatic. And, uh, if the patient is having superimposed bacterial infection, then we will have antibiotics as well. Otherwise, there's symptomatic treatment. What about epistaxis? For, uh, for epistaxis, there will be general measures and the hydration and the tranexamic acid. Okay. And it can be, need a platelet transfusion in severe cases. Patient is bleeding. The patient may need platelet transfusion. Local measures, tranexamic acid, and, uh, symptomatic treatment and forms of antibiotic for the infection. Or if you do viral serology in this patient, if flu is positive, then you can give them oseltamivir. This is the, um, this is a 56-year-old male patient with long-standing anemia and tiredness. His full blood count shows hemoglobin of 90, white cell count of 11, and platelet count of 120. This is power 10.
EE
Power 50 for EE.
EE
This may be a bit short case, but anyone want to try on this? Anyone please? Uh, okay. Uh, what, what was the age of this patient? I would like to try. 56. 56. So 56 with basopenia, right? With low hemoglobin, white cell count was 11, and so these are the abnormal lymphoid cells seen. Mhm. Mhm. The abnormal lymphoid cells were seen. There were medium in size with a low, with a low NC ratio, intermediate to low NC ratio, where the nucleus was clumped, no visible nucleoli have been seen. And these are atypical few lymphoid cells are large in size with a low NC ratio. Otherwise, MH, okay. Say this is a low NC ratio. The nucleus is round to oval with the no, no invisible, no visible nucleoli. And there's a thrombocytopenia. While the red cells are anisocytosis, teardrops, schistocytes, and acanthocytes have been seen. There are some cells, microcytic cells have been seen. This is a monocyte. How's the neutrophil? I cannot see the neutrophil. Neutrophils were low, lymphocytes were high. So there's neutropenia. So suggestive of some lymphoid disorder. Can you identify this, sir? Abnormal cell. Totally abnormal cell. It looks like a blast cell. Lymphoid blast. If I blast like, like what? Small, deep basophilic and visible. What about this? This is a case of plasma cell leukemia. We picked up platelets because they are not so frequent in the blood film. The film number one on the channel is also plasma cell leukemia, but that film is full of plasma cells. It was very easy to pick that one. But this patient has very scattered plasma cells in the peripheral blood, and he was tired as well. He thought that there may be one plasma cell on the thin side, it may be a reactive one. But on the thick side, he has many plasma cells. And when we did the flow cytometry for this patient, it came out that he has 24% plasma cells in the peripheral blood. What is the first-line treatment options for this patient? Body therapy and sorry, can you say again? First-line treatment option in plasma cell leukemia. We have to base, uh, body-based therapy. Body is my best therapy. If you say like this, you will fail the question. Kemen, what are the first-line treatment options for plasma cell leukemia? Um, I, well, so I think the decision would be, what, well, what is it, Duma-based in a quadrate treatment? DTH? Yes. In the UK, we treat plasma cell leukemia on the line of multiple myeloma. But when you answer this question, you will say the treatment options are according to transplant eligibility or non-eligibility. Right. Okay. Yeah. Depending on whether this is a transplant eligible or non-transplant eligible. He is young, he's 56. Yeah. But he may have other comorbidities. So you will say either transplant eligible or non-transplant eligible. If this patient is transplant eligible, then I have DD protocol. If this patient is not transplant eligible, then I have these options for this. Then your question will be answered. Right. Okay. And they can ask you, what are the high-risk cytogenetics in multiple myeloma or in plasma cell dyscrasia? So the high-risk cytogenetics include, um, amplification 1q, um, translocation, um, 14, 14, 16, 16, 14, 16. Yep. Mhm. And translocation, uh, 414. Mhm. Deletion 17p. And intrachromosomal translocation 1420. Yes. Right. The last question they can ask you, what bispecifics are available for multiple myeloma currently in the UK? So the bispecifics that I know of include, uh, talquetamab and teclistamab. Um, which, where I practice, they are available as an under compassionate program or self-financed, um, item from third line onwards, and these patients have to be triple class refractory. I have to confess that I don't know if they are available in the UK. Which one? Teclistamab and talquetamab. Yeah, use them regularly. Even district hospitals are using. Okay. Hospitals are using, um, and both are available. Right. Yes. Okay. And how do you choose between these bispecifics and, um, CAR T-cell therapy? CAR T-cell has been stopped for multiple myeloma. Sorry, CAR T-cell has been stopped for multiple myeloma. Oh, is it? I think none of the tertiary centers are doing CAR T-cell now for myeloma. They are offering bispecifics. Okay. I see. Mostly, mostly it is the El, because the safety data is good. But on trial, the patients are also used. The patients are also getting, uh, belantamab is also available. But because of the keratopathy related side effects, yeah, most of the consultants are avoiding it. But it is still available. Work is going on on belantamab, and maybe next year you will see belantamab as second line. Right. Okay. Because myeloma is a very evolving topic. A lot of things are coming in it. Yeah. And, yes, so remember the, uh, first-line options for plasma cell dyscrasia. Remember the names of the bispecifics. Yeah. Can I ask, sorry, just one question for belantamab. Do you classify it as a, um, BCMA conjugated with cytotoxic? So is it still classified as bispecific or not? I think BCMA is a bispecific. Yeah. So belantamab is a monoclonal antibody against the BCMA, which is conjugated with the, um, MMAF. Right. So is it, can we classify that as an antibody-drug conjugate instead of a bispecific agent? I think so. You can classify it as a monoclonal antibody. Yeah. It's not bispecific. So bispecific would be, um, talquetamab, uh, teclistamab, and, uh, elranatamab. Three of them. Right. Yes. So is bispecific? Then, then, then teclistamab and talquetamab. Talquetamab. Yep. Yeah, I agree. And there is any other? That's the three that I know of, to be honest. Yes, these three. Yep. Okay. So the current, um, so for transplant eligible, fit patients, um, in the case of plasma cell leukemia, do you, do you treat them as high-risk disease and therefore, uh, sort of, do you choose triplet or quadruplet? Quadruplet. And just like multiple myeloma, and we transplant them if they are, if they are transplanted. So quadruplet. Yes. DVTD. DVTD. Yeah, that's what I use as well. Okay. Great. DVTD. Good. Yeah. And if they are not transplant eligible, then you have other options like, um, DD or VCD. Simply. What is the fourth option for? Right. Um, transplant ineligible. Yes. And for the transplant ineligible ones, do you also do consolidation therapy post-transplant? Yes. And the maintenance therapy? Same, same. Yes. Same. Yes. Okay. Maintenance in the end. And same protocol as we use for multiple myeloma. Yes. Okay. Thank you. Right. So this one.