Transcription
Okay. Right. This is the first case and this is a 56-year-old man with body X and HP of 110 presented to GP. The GP did some blood tests on him which showed anemia. The biomedical scientist has repaired a blood film model. This is power 10. If you have any biomedical scientists and they want to comment on the blood film, slight leukocytosis. I'll go to power. Uh, this was suspicious. Hairy cells, cytoplasm, thereenia. Like a plasma cell. It could be plasma cells. You think these are plasma cells? Some of them are plasma blasts. Okay. How, how do you recognize that this is a plasma cell? Yeah, I'll put it as uh medium to large cells with cytoplasmic projections. Is there any other feature because I can see medium to large cells with cytoplasmic projections in many cases? So if I am a biomedical scientist, a first-year trainee, how would you tell me what a plasma cell is and how they appear in the blood? Plasma cells are eccentric, yeah, and perhaps, uh, and deep basophilic cytoplasm. Is it normal for the plasma cell to appear in the blood? No. No. If anyone is waiting in the waiting room, please admit them. This session is for all. Yeah. So Mark, would you like to refer this to clinical? I definitely referred to the consultant. No, no second thoughts. I expect a bit more. Uh, yeah, you know, it's definitely a consultant job. Yeah. So right now the blood film has gone to hematology registrar or consultant. Um, I need a report on this blood film. I will try. Uh, a film shows increased white cell leukocytosis and those white cells are abnormal plasma cells, uh, having a deep basophilic cytoplasm, perinuclear halo, and round GP cell. Remember in mind, this is a GP blood cell. Okay. Uh, but I, right now I'm reporting the film. Then when I conclude, then I would address the GP, isn't it? You need to use such language that a GP can understand. If you write to a GP that this plasma cell contains high NC ratio or low NC ratio with more, a lot of her pro-like projection etcetera, etcetera, GP would say, what is this? He will call you. What have you written? A blood film. Okay. In the exam, in the exam, read the scenario whether you're dealing with a GP or this is the patient admitted in the hospital. Okay. Um, blood, blood film shows, uh, abnormal white cells which are abnormal plasma cells and, uh, they are increased in number and look like, uh, plasma blasts. And, uh, red cells are normochromic, platelets are reduced on film. Patient needs urgent bone marrow aspirate for further investigation. Bone marrow aspirate, um, flow cytometry and, uh, uh, further investigation for anemia, calcium, and, uh, MRI for lytic lesions and, uh, yes, and cytogenetics. And where, in the GP surgery or in the, no, in the referral to the hematology, uh, shire or secondary care for these investigations. You need to mention to GP that this patient needs admission for bone marrow biopsy and further investigation because your suspicion is plasma cell dyscrasia. Yeah. Mention the abnormality in the blood first. When you're reporting the blood film, mention the abnormality first. This patient contains leukocytosis. Most of them are plasma cyto, plasma cells with thrombocytopenia and red cell and anisocytosis as well. We have few جول bodies here as well. You need to mention everything that is present in the blood. Yes, like this, every every point matters in the exam. The suspicion is likely plasma cell dyscrasia, likely plasma cell myeloma. But you need to confirm that with further investigation like bone marrow biopsy for which this patient needs to be admitted urgently. You cannot leave plasma cell leukemia for a long time in the community to come to the hospital. This patient needs urgent admission. Why plasma cells are present in the blood film? Very, why they are in the blood? Uh, because in plasma cell leukemia, they lose the CD56, which is an adhesion molecule. So the plasma cells come into the peripheral blood. Okay. And sir, I have a question that. Yes. Yes. Yeah. In the report, once we are mentioning that, uh, suggestive of, uh, plasma cell leukemia or plasma cell myeloma, we will write it's leukemia. So we will write leukemia, right? If you are sure that these plasma cells are more than 5%. Okay. Then you will say most likely plasma cell leukemia. Yeah, it's too much. So we will write direct, right? Yeah, some people know how to calculate the number of cells in a blood film. I don't know personally. So if you are sure that these are more than 5% according to WHO 2022 new guidelines, then yes, this is possible. Routine and, uh, just a quick question. Uh, in a, in a normal, you know, clinical routine, I would have called this patient to come to the hospital myself rather than waiting for GP to refer. So, because I don't know the calcium, I don't know how the renal functions are, and I don't want to leave a plasma cell in clinic, in in outpatient setting. So, in exam, should we just write, uh, GP to send urgent referral or, uh, no, no, no. If you write this, like GP to send an urgent referral, it will take two to three weeks. Yes. So urgent admission means this patient needs admission today evening or tomorrow morning. Yeah. If I'm seeing this blood film now, okay, and I'm writing in the report that this patient needs urgent admission for bone marrow biopsy and other investigation, it means I have to call the patient to bring him to the hospital in the evening or tomorrow morning to be up for him. Great. Thank you. What are the poor cytogenetics in this patient? Uh, sir, uh, 414, uh, 1416, 1420, uh, these are the poor risk, high risk, and 17p, uh, deletion, and 1p deletion, and 1q plus. And plasma cell leukemia in itself carries a very poor prognosis. What are the updates in myeloma? Can you repeat the question? What are the new updates in myeloma? [Music] Yeah, I think, uh, non-eligible transplant, non-transplant eligible patients can have a cet treatment. I don't think it's been NICE approved now. I think it's IA tusim, uh, DRD or something. I can't remember the whole thing. It has been rejected by NICE, but something has been approved by NICE. Philosophy and runn and dam as a second line, you can give to the, it is approved. Loss, they have rejected the quarter plate, but, uh, accepted the valent. So it can be asked from you in viva, not in paper, but in viva, they can ask what are the updates in myeloma. If there are, if, if the question is about myeloma in your oncology, right, the diagnosis of the things are easy, but the problem is answering the part of the question. The part of the question carries marks as well. You should not lose any mark in the exam. In part two exam, every mark matters.
This is the second patient. This is again a 56-year-old man with pleural effusion and leukocytosis. Is admitted to ED with shortness of breath. Uh, full blood count shows hemoglobin 110, white cell count is 60, and the platelet count is 130. The blood film has gone to the biomedical scientist. Leukocytosis again. And I will make it for 50 now. Abnormal white cells, clutched cells. Okay. Yeah, there's a bit of cauliflower flower form nucleus there. Cells in there. There's a cluster form. AP cerebral form on the center is, but, but there is new cytoplasmic blebbing as well. And patient is, uh, uh, effusions. So it is lymphoproliferative morphologically, probably EPLL. But I would report like, uh, leukocytosis and lymphocytosis and, uh, lymphocytes show, um, high and zero, shows some of the nuclei are open chromatin nuclei, prominent cytoplasmic blebbing. Um, neutrophils are present. Uh, red cells are normochromic, but there is Howell-Jolly bodies in many, and, uh, platelets reduced on film. At least on this power, findings impression is finding suggestive of lymphoproliferative disorder, morphologically most likely, uh, T-PLL. Send urgent, uh, flow cytometry and, uh, uh, cytogenetics. When the blood is in, leave it for the biomedical scientists to report it first. Okay. Okay. When they, when they refer it to you, then please report it so that they are not, they do not feel that we are missed out. Okay. Okay. Yes, ma'am. Yeah, definitely referral. I can see the blebbing. I can see what the doctor thinks as well. But, uh, yeah, certain, uh, referral here. No, no messing about. This needs to urgent attention. Yes. So you mentioned cerebriform in this patient. Yeah, I saw one or two there. Yeah. So usually, um, the patient would have some pruritus, eczema, uh, dermatitis like history in the scenario. Uh, that would help you that maybe I'm dealing with, uh, uh, Sézary cells or cerebriform cells. Yeah. And in, in the presence of cerebriform cells, there should be eosinophils as well in the blood because CAP syndrome is a, is one of the causes of clonal eosinophilia or eosinophilia. Okay. So we have to link things like this. If this patient has SIT, effusions, mature lymphocytosis, no smudge cells in this blood film, proliferative disorder. But what it can be? So some of the neoplastic disorders, they come with effusions, um, and SIT is that is okay. So now you have referred this to the clinical hematologist. They have to report it. To report it. If you are sitting in a part three exam, anyone, uh, sorry, what's your question? I missed in between. Report the blood film because the blood film has been referred to you from biomedical scientists. Yeah. Okay. Uh, so this, um, peripheral blood shows, uh, leukocytosis, uh, with lymphocytosis, and lymphocytes are small to medium in sized, mature, uh, with the clumped chromatin and, uh, with cleft and cytoplasmic blebs also. And the red cells are shows anisocytosis with, uh, microcytosis, slightly polychrome, and Howell-Jolly bodies. And platelets are reduced. Um, so these findings are suggestive of lymphoproliferative disorder, most likely, and, uh, um, for confirmation, uh, we need, um, flow cytometry and, uh, uh, bone marrow aspirate, cytogenetics. What is the expected flow in this patient? Uh, expected, uh, flow, uh, could be, um, uh, uh, CD5 because it's, uh, T-PLL. So, uh, it will be, uh, T-cell, uh, markers will be positive. That will be CD, uh, 3, 5, uh, 3, 4, or, um, uh, there is, uh, CD7 positive. In T-PLL, uh, is the main marker, CD7. Yeah. What else that can help you in treatment as well? Yeah. CD52. And what is the cytogenetics? Uh, cytogenetics, um, I'm forget. I think, uh, there is, uh, yeah, for something, uh, inversion 14. Yeah, for inversion, uh, inversion 14. Yeah. For inversion 14. Yes. Yes. Yes. So this is a mature lymphocytosis, just like you will see in CLL as well. But the CLL cells are more smaller than these T-PLL cells, and you do not see any prolymphocytes here and no smudge cells here. Okay. Do not confuse it. In the exam, maybe you will not see this much of blebbing. In exam, they everything is rare. Only few cells will have blebbing. This slide is full of lymphocytes with blebbing. But, uh, if there are no Sézary cells, if there are no prolymphocytes, and all the cells are, uh, smaller to medium size with some blebs, or the patient has, uh, effusions or ascites, then yes, then it is most likely T-PLL you're dealing with. If they have given you flow cytometry, it will be very easy to pick up, pick it up. But if they ask you T-PLL, then there is a chance of mistake. Uh, this is a very easy blood film, but people do miss it, uh, because of the rarity of findings in the exam. Like, we when we have parasite blood film in the Plasmodium falciparum blood film, you will see a lot of parasites, but in the exam, each blood film will contain only one parasite that you need to pick up. So this is a T-PLL case. Remember the flow cytometry. Remember the cytogenetics and treatment options. Uh, these are the questions that they will ask you in the exam.
All right, this is the third case. This is again a young female presented to the emergency department because of fatigue and tiredness. She looks dehydrated as well. This is the power 10 blood film. White cell count, uh, sorry, hemoglobin is 99. White cell count is 11, and platelet count is 80. The blood is with the biomedical scientist. I can clearly see it from inside the film. Yeah. It's onto. Yes. Feel like maybe platelets slightly large. Target cells. But they, they actually look like contracted cells. So contracted cells. The spread. They actually look like contracted cells. Oh, these, these are spherocytes. This one. This one. There is no other. Yeah. And they are spherocytes. Okay. Okay. You clear the link as well. Yeah. So, what do you see? I think this section of the film has all the features. Yeah. Do we, do we have boot-shaped cells? No, she has no sickle cells. Yeah, I'm just looking up. Has a bet been done? Beta-thalassemia is normal. Fragmented. Where are the fragments? This one? Yes. Or this one. This one. Or this one. Or this one. Yes. Maybe this one. Yes. What's the, um, calculation like? What's the fibrinogen? Is normal. Fibrinogen is normal. Okay. So whenever your patient has anemia and thrombocytopenia, uh, your system must flag it up. This patient has anemia and thrombocytopenia. Yeah, I got a suspicion. It could be like something like TTP. It can be one syndrome. One syndrome. Yeah, it can be one. Now, why there is a fragmented RBC in event syndrome? So there should be spherocytes rather than fragmented. Did they do a reticulocyte count? Count looks high. You can see it here. This one. Yeah. So hemolysis. So what next question would come to your mind after seeing this blood film in terms of investigations? That hemolytic screen. And before that, before that, and for him, what thing will come to your mind? And I should to decide why, why there is hemolysis? This you need to see the renal function of the patient or not. Yes, sir. Make a to make a decision. If I tell you that this patient has a new AKI as well, would it change your decision or management or anything like that? Yes. Uh, it can be the, uh, cause of hemolytic uremic syndrome as a differential of treating food in young patients. This patient has, this patient has anemia, thrombocytopenia. There are several fragments in this film only, and patient has AKI. Previously she was normal. Why I would think that there is a hemolytic uremic syndrome? I should think about TTP in this patient. There are a lot of fragments. Patient has new AKI, there is anemia, thrombocytopenia. Should I think about TTP? Mr. Yes. Yeah, definitely. What should be my first action as a clinical hematologist? According to the discuss with TTP center, with consultant TTP, and send the ADAMTS13 antibody and antigen level and agree on diagnosis. So according to the BSH 2024 TTP guidelines, if you are suspecting a TTP in a patient, okay, whether it is primary or secondary, you need to discuss with the TTP consultant, okay, which is from Sheffield area in our, in our DNA, in our area, and agree on diagnosis. If you agree that this is a primary TTP, this patient would need intervention. If this is a secondary TTP, no need of intervention in this patient, just symptomatic people, right? So do not miss such things in the exam. These things are pass and fail things in the exam. If you have seen so much fragments, this film contains 7, 8, 9 fragments almost. Patient has anemia, thrombocytopenia, or they have given you, uh, history of confusion or, uh, fever or, uh, abnormal, abnormal renal function. First thing in your mind should be that this is likely TTP, and I need to discuss it with TTP center because this is a hematological emergency. If you do not mention this in your blood film, you are gone. You will see that this blood film contains, uh, anemia, red cell fragments, NRBC with other features of red cell anisocytosis like target cells, spherocytes. There is thrombocytopenia. Neutrophil count is a bit on the higher side. The suspicion is of ma, likely TTP. This is a hematological emergency. Need to be discussed with, uh, I need to discuss it with the TTP center to agree upon diagnosis as per BSH guidelines. Yeah, you are done. So exam is about skill, not only about knowledge. You know, you know this is TTP. You know how to treat it. Okay. You know more about caplacism than me. You know more about plasma exchange than me. But you need to write your knowledge in the correct place in the exam, then you will pass the exam. Exam is about skills plus knowledge, not only about knowledge.
So this is a 46-year-old female diagnosed with TTP. Uh, what urgent steps would you take in this patient? Arrange for plasma exchange and start steroids. Um, review by, uh, intensive care if she needs intubation and, uh, shift, uh, under blue light. If there is any delay in the plasma exchange, then start plasma, uh, SD plasma, 30 ml per kg. And, uh, yes, what else? Pregnancy testing. Pregnancy test. What else? Yeah, not given. You will not give here. You will give it in the TTP center. And now the patient is with you. What will you do? Inform her about the diagnosis first. But we are dealing with TTP. Okay. Okay. Okay. And this patient would need urgent intervention in the form of plasma exchange and the TTP center, or if there is a delay, plasma infusion after consenting. When you say after consenting, maybe this patient is, you have a witness, and she says, I don't want plasma infusion or plasma exchange, and you have only option of caplacism, which will be given in the TTP center. High steroids. She is anemic. If she's symptomatic, you need to give her some blood transfusion. Folic acid to this patient. Inform your ICU and anesthetic team to insert a central line in this patient so that she is ready for plasma exchange or other intervention when she goes to the TTP center. Centrophenine, which is important in to decide the prognosis in the patient, and urine pregnancy test, which we have mentioned already. So these are immediate interventions. Do not jump to the treatment and from the patient as well. Okay. Uh, so that the patient knows what she's being treated for. What is the prognosis? Please. But before that, you also do the renal function to assess the effect of the hemolysis on the kidneys. Right. So whenever a patient comes to the hospital in UK, routine tests are taken from everyone, which include full blood count, um, and the coagulation screen, renal function test, liver function test, urine, and electrolytes. When the full blood count is abnormal, it automatically, uh, needs a blood film in the patient. So these tests are already done on arrival in the patient in emergency. Okay. Thank you.
We have another 40-year-old female which presented to the emergency department with shortness of breath and bilateral pedal edema. She was under GP for investigation of full breakdown that was persistently abnormal for many years. Please, please, what was abnormal for many years? Please? Sorry. Yeah. What was abnormal for many years? You see nothing. Soap were abnormal in this patient, but now she has presented to the emergency department with shortness of breath and bilateral pedal edema. This is power 10 of the blood. Hemoglobin is 130. White cell count is 11. Eosinophil count is five, and platelet count is normal. This is power. Biomedical scientist, please. Okay. That's okay. Nothing striking at the moment. What's the CRP like? The CRP is less than five. All right. Okay. Uh, the look, it looks bigger. Has she got any travel history? No travel history. But this is a good point. If any patient has eosinophilia in the exam, always look for any travel history. If this patient has any travel to South America or African countries or South Asian countries, because one of the differential of the is this patient has no travel history. Okay. The platelets are also large. Mhm. So what do you guys think, uh, from the BMS side? Well, morphologically wise, I don't know the, you see more type of the granules in your synapse, bigger, more plain, perhaps, but it's not, don't like it's reactive. No travel history. It doesn't look like anything like leukemia. It's a tricky one, really. Um, that does look abnormal. That does look abnormal because the granules will be more prominent. There are vacuoles here as well. If it's large, full of granules with vacuoles, this is the feature of dysplastic neutic, right? Yeah. Okay. All right. Want to refer it to the consultant hematology registrar. Yeah. As if it was dysplastic. Yeah. I would definitely. Yeah. Could be starting something. Oh, right. Consulting hematology or registrar. This, this is the blood made with you. Okay. Um, the patient history is in front of you and the blood film with you as well. Report the blood film and suggest actions. Sir, sir, could it be, um, a chronic leukemia? You need to report the blood like if Path exam, this is the blood in you. You have seen power 10 and power 50. You have the scenario in front of you. How would you report it? [Music] So the, the blood film, the red cells, um, uh, appear to be normal, normochromic, normal. And the white cells are predominantly eosinophils, which likely shows, uh, eosinophilia. And the history that was given that there is abnormal eosinophil for years, which means it's, uh, more than six months. So likely pointing to a chronic, uh, disorder. So, uh, I think, um, I will think more of a chronic, uh, leukemia. We also need to clarify if there is any history of, uh, in the family or in the patient as well. Fine. Atopic as, um, generative to allergy, atopic conditions would not lead to dysplastic eosinophilia. Yes, they will have, but not dysplastic. And, and maybe it may be like fine. This is again a pass/fail question in the exam. Sir, can I report? Yes. Yeah. So, uh, blood film shows leukocytosis with eosinophilia, uh, with many, uh, of them eosinophils showing the dysplastic features. Um, red blood cells are normocytic with slightly hypocromic, and, uh, platelets are adequate. Uh, these findings are, uh, suggestive of either primary or secondary eosinophilia. Uh, for confirmation of diagnosis, need to send, uh, this peripheral blood for FISH analysis. PDGFR A, B, PDGFR B, and FGF FR1, and serum tryptase level, and immunophenotyping. Still, you have not passed this question. Okay. What was the scenario? Yeah. Then the shortness of breath may be a pointer to organ infiltration. Yeah. Which may, uh, which may indicate with infiltration of the hearts. Now you have get. We will admit. Yeah. So this patient has likely infiltration of the organs that is causing cardiomyopathy or lung infiltration. This patient would need, uh, admission and urgent intervention in the form of high-dose methylprednisolone because this is now an emergency. Infiltration of pericardium and lung is a hematological emergency, and that patient needs high doses of steroid. This patient will die if you do not give him steroid. This patient is under investigation for a long time for eosinophilia. So no cause found, uh, in this patient. Okay. If she had any cause, uh, we would know that, but no cause found for many years in this patient. But, sorry, what was the count? Count five. Five. Okay. Sorry, miss. Yeah. Okay. But he has this high count since long, since many years. We would have investigated the patient for eosinophilia, no cause in this patient, and now she has presented with shortness of breath and peripheral edema, which means the has infiltrated the pericardium. Yeah. Which means emergency. Yeah. And this needs high doses of steroids. Now you will call it as idiopathic hypereosinophilic syndrome. Patient is symptomatic now. Okay. And no cause of eosinophilia is there. So this is idiopathic hypereosinophilic syndrome. What is the second line and third line treatment in hypereosinophilic syndrome? And immunosuppressive, immunomodulatory, modulatory or cytoreductive therapy after a negative pregnancy test. So if you are going for the exam, remember, uh, write it down what are the hematological emergencies. You should not miss them. Please, these slides look very simple, but this is a pass and fail, that's it. But what they are asking is not simple. That's why exam is a skilled exam and quick exam.
The last slide, it is an aspirate. Hopefully, it will project normally. Then you guys are free and go to the sea and jump into the sea. Power four first. This is a 40-year-old man presented to emergency department because of large engine mass. For some reason, my microscope do not like, uh, aspirates. This is power four, just to show you the particles. This is a particle system. 45 power 10. This is power. Yeah, it's interesting. I don't usually look at aspirates, but it's interesting to see the clumps. Never seen that before. Yeah, this is the condition in which the cells like to be in clumps. Yeah. So the, the, the bone marrow looks at, um, um, particular type of cellular, and these cells, I don't know, they are not appearing, uh, like hematopoietic cells, and they in clumps, islands. Yeah. Power 50 now. What is cells with handmade appearance? Appear lymphoid. It seems like seems like Burkitt cells. Yeah. Yeah. I think they are Burkitt with, uh, cytoplasmic inclusions. Mhm. Yeah. Very deeply psychic down. Yeah. You see vacuolations on the circumference. Vacuolations deeply. A 40-year-old man with a large mass. Does it go with, does it go with Burkitt or not, sir? Are not so much nominated. Sorry, can you say it a bit louder, please? Uh, these are heterogeneous, uh, cell populations, small to medium and large in size, and highly basic cytoplasm. Few cells showing, uh, no doubt, regulations, but not all the cells, and, uh, high NC ratio. And my differential, uh, is hybrid lymphoma. Mhm. So advise, uh, for the further investigation like, uh, flow cytometry, biopsy, and, uh, the biopsy. Okay. IHC. Cytogenetics. What cytogenetics would you like? And what IHC would you like? IHC for the CD10, CT20, and, uh, CD10 is positive, 20 positive. Sorry, CD10 is positive and 20 is positive. What about, uh, B cell 2, BCL6, and BCL6 is positive? Then make it positive. Ki67. This can be the, this can be double hit or triple hit. 67 large, 99. So it is Burkitt, then it is Burkitt. For I will try to project the film for you. I can see it very clearly in my microscope, but, uh, projecting it in the camera, on the camera is a bit challenging. Starry sky. Yes, I want to project the starry sky appearance, but my microscope is not that much advanced as in the hospitals should be. This is power four, and this is power 10. These are the Burkitt cells. This one, this one, which give you star sky appearance. Regular, but seeing fine on camera is a bit challenging. This much I can show you that these are a lot of starry sky macrophages. Macrophages giving a starry sky appearance. Hopefully, you would have seen that. If not, go to your labs and HMDS, they will have a store of veterinary points. And power 50 is a bit too high for starry sky to see. I always see fine on power four and power 10, and that's it. This is one of the macrophages. They appear better on power 10. I'm going to go back to power. Hopefully, they appear better here. This one, this one, this one. These are all macrophages which give you a starry sky appearance when you see them under the Okay. So what is the management or I should say what are the urgent interventions in this patient? Admit the patient. Tumor lysis for tumor lysis syndrome. And if, uh, if, uh, then blood product support. If neutropenic, then, uh, GCSF. And after that, specific. Tell the patient, please tell the patient that we are dealing with something. Do not jump in a treatment. Okay. Here you need to tell the patient that, uh, we have a diagnosis of Burkitt lymphoma, which is a high-grade lymphoma that would need urgent intervention in the form of chemotherapy. We need to do certain tests on you before starting chemotherapy. Do not jump on the tissue directly. This is a, a bad judgment. Yes, this is Burkitt lymphoma. But if they ask you what are the urgent interventions in this patient, it will be a two-mark question. But they would expect you to write a lot of things. Okay. In the part two exam, inform the patient. What is the diagnosis? What is the prognosis? Okay. What tests you would like to do? You do not explain them. Just name them and then mention the name of the treatment. You cannot do fertility preservation here because this is a high-grade lymphoma, and you cannot wait for a week or two for the patient to be seen in fertility clinic. By that time, patient would have died. Offer him, uh, chemotherapy. Okay. And tumor lysis syndrome. If you do not mention tumor lysis syndrome in this lymphoma, uh, you will fail the question because the patient will die because of tumor lysis, not because of lymphoma, but because of tumor lysis. What chemotherapy will you offer to this patient? Orthodox MRI back. Mhm. If that is not available, then or the EPOCH or the good or hyper. Yeah. Second. So these were the five cases for morphology today. Next weekend, we have, uh, two transfusion and hemostasis session. This week was no. So these sessions will happen on alternate Sundays because now I have a gang of two people that I have to deal with. If you have any question, you can ask now, otherwise, you can conclude this. What is the, uh, transplant option in this patient when we consider in this patient? Burkitt lymphoma patients, they are very good in responding to the chemotherapy. Rarely you will see any patient in your lymphoma unit for autografting or in stem cell transplant unit for allogeneic stem cell transplant. If they relapse, then yes, it is the option or the option is autografting, but otherwise, uh, Burkitt lymphoma patients, they respond, um, very nicely to the chemotherapy. Rarely you will see any patient who, any patient of Burkitt lymphoma to receive autograft or thank you. Thank you. Thank you. Thank you so much. Thank you. Okay. Okay. Thank you. Thank you so much for this time, and I wish to have you next time again. Thank you so much. Thank you.