WEBVTT

NOTE duration: "01:03:00.980"


NOTE Confidence: 0.9094138

00:00:00.080 --> 00:00:02.259
Get started. Welcome to SmiloShares

NOTE Confidence: 0.8875561

00:00:02.879 --> 00:00:04.180
with Primary Care.

NOTE Confidence: 0.99945337

00:00:04.720 --> 00:00:05.859
Just an introduction

NOTE Confidence: 0.95627314

00:00:06.240 --> 00:00:07.460
to this series.

NOTE Confidence: 0.93868965

00:00:08.000 --> 00:00:10.000
Smilo Shares with Primary Care

NOTE Confidence: 0.93868965

00:00:10.000 --> 00:00:10.820
is a collaboration

NOTE Confidence: 0.99611235

00:00:11.280 --> 00:00:13.299
between primary care and oncology

NOTE Confidence: 0.9719274

00:00:13.679 --> 00:00:15.545
here at Yale. I'm Karen

NOTE Confidence: 0.9719274

00:00:15.545 --> 00:00:17.325
Brown, a primary care internist,

NOTE Confidence: 0.9719274

00:00:17.465 --> 00:00:18.585
and I work with Anne

NOTE Confidence: 0.9719274

00:00:18.585 --> 00:00:19.805
Chang, an oncologist

NOTE Confidence: 0.96666217

00:00:20.425 --> 00:00:22.025
and the associate cancer center

NOTE Confidence: 0.96666217

00:00:22.025 --> 00:00:23.564
director for clinical initiatives.

NOTE Confidence: 0.98524714

00:00:23.945 --> 00:00:25.305
We are happy to present

NOTE Confidence: 0.98524714

00:00:25.305 --> 00:00:27.325
today's topic, which is gammopathies.

NOTE Confidence: 0.99889493

00:00:28.529 --> 00:00:29.269
Our perspective

NOTE Confidence: 0.9988131

00:00:29.730 --> 00:00:31.990
in cancer care is distinct

NOTE Confidence: 0.9988131

00:00:32.050 --> 00:00:34.070
in primary care. We're constantly

NOTE Confidence: 0.9988131

00:00:34.210 --> 00:00:36.309
providing advice to prevent cancer,

NOTE Confidence: 0.9699438

00:00:36.610 --> 00:00:38.229
testing to screen for cancer,

NOTE Confidence: 0.9699438

00:00:38.449 --> 00:00:40.629
testing for cancer, and fortunately,

NOTE Confidence: 0.9666285

00:00:41.105 --> 00:00:43.185
far less often, actually finding

NOTE Confidence: 0.9666285

00:00:43.185 --> 00:00:43.925
new cancer.

NOTE Confidence: 0.9831371

00:00:44.465 --> 00:00:46.065
Diagnosing a new cancer, whether

NOTE Confidence: 0.9831371

00:00:46.065 --> 00:00:47.505
by screening or due to

NOTE Confidence: 0.9831371

00:00:47.505 --> 00:00:48.545
a patient complaint, is a

NOTE Confidence: 0.9831371

00:00:48.545 --> 00:00:49.425
time where we want to

NOTE Confidence: 0.9831371

00:00:49.425 --> 00:00:50.805
be as efficient as possible

NOTE Confidence: 0.9831371

00:00:51.025 --> 00:00:51.905
to get our patients to

NOTE Confidence: 0.9831371

00:00:51.905 --> 00:00:53.025
the treatment they need. We

NOTE Confidence: 0.9831371

00:00:53.025 --> 00:00:54.705
are delighted that doctor Chang

NOTE Confidence: 0.9831371

00:00:54.705 --> 00:00:56.225
and our oncology colleagues are

NOTE Confidence: 0.9831371

00:00:56.225 --> 00:00:56.725
interested

NOTE Confidence: 0.9994811

00:00:57.040 --> 00:00:58.880
and willing to explore this

NOTE Confidence: 0.9994811

00:00:58.880 --> 00:01:00.480
interface of care with us

NOTE Confidence: 0.9994811

00:01:00.480 --> 00:01:01.380
in this series.

NOTE Confidence: 0.9975195

00:01:01.920 --> 00:01:03.360
During the talk, please feel

NOTE Confidence: 0.9975195

00:01:03.360 --> 00:01:04.980
free to enter your questions

NOTE Confidence: 0.9975195

00:01:05.120 --> 00:01:06.180
into the chat,

NOTE Confidence: 0.918719

00:01:07.280 --> 00:01:08.160
and we will,

NOTE Confidence: 0.983315

00:01:09.040 --> 00:01:10.240
look at those at at

NOTE Confidence: 0.983315

00:01:10.240 --> 00:01:11.334
the end of the talk.

NOTE Confidence: 0.983315

00:01:11.334 --> 00:01:12.375
We'll we'll try to save

NOTE Confidence: 0.983315

00:01:12.375 --> 00:01:13.034
some time.

NOTE Confidence: 0.97480196

00:01:14.215 --> 00:01:15.735
I'd like to introduce my

NOTE Confidence: 0.97480196

00:01:15.735 --> 00:01:18.055
primary care colleague, doctor Drew

NOTE Confidence: 0.97480196

00:01:18.055 --> 00:01:18.555
Cutney.

NOTE Confidence: 0.99239445

00:01:19.015 --> 00:01:20.875
Doctor Cutney is board certified

NOTE Confidence: 0.99239445

00:01:20.935 --> 00:01:23.034
in internal medicine and pediatrics

NOTE Confidence: 0.97734445

00:01:23.334 --> 00:01:25.174
and a very valuable member

NOTE Confidence: 0.97734445

00:01:25.174 --> 00:01:26.959
of our Northeast Medical Group

NOTE Confidence: 0.97734445

00:01:26.959 --> 00:01:28.260
primary care community.

NOTE Confidence: 0.9799098

00:01:28.880 --> 00:01:30.400
My own first memory of

NOTE Confidence: 0.9799098

00:01:30.400 --> 00:01:31.440
him is he knew how

NOTE Confidence: 0.9799098

00:01:31.440 --> 00:01:32.800
to use Epic better than

NOTE Confidence: 0.9799098

00:01:32.800 --> 00:01:33.700
anybody else,

NOTE Confidence: 0.99852216

00:01:34.400 --> 00:01:36.340
before anybody else did.

NOTE Confidence: 0.84111416

00:01:37.200 --> 00:01:37.960
He practices,

NOTE Confidence: 0.9703027

00:01:38.400 --> 00:01:39.520
he's been with us since

NOTE Confidence: 0.9703027

00:01:39.520 --> 00:01:40.900
two thousand and eight and

NOTE Confidence: 0.9912426

00:01:41.305 --> 00:01:43.084
primary care in Trumbull, Connecticut

NOTE Confidence: 0.9912426

00:01:43.225 --> 00:01:44.045
at the Park

NOTE Confidence: 0.9819878

00:01:44.505 --> 00:01:46.665
Avenue Medical Center. And I'll

NOTE Confidence: 0.9819878

00:01:46.665 --> 00:01:47.945
turn it over to you

NOTE Confidence: 0.9819878

00:01:47.945 --> 00:01:49.305
and to introduce our other

NOTE Confidence: 0.9819878

00:01:49.305 --> 00:01:49.805
panelists.

NOTE Confidence: 0.9872957

00:01:50.585 --> 00:01:51.865
Great. Thanks so much for

NOTE Confidence: 0.9872957

00:01:51.865 --> 00:01:53.625
joining us tonight and for

NOTE Confidence: 0.9872957

00:01:53.625 --> 00:01:55.645
continuing to access this series

NOTE Confidence: 0.9501388

00:01:56.320 --> 00:01:56.820
online.

NOTE Confidence: 0.9784313

00:01:58.880 --> 00:02:00.400
And, I have the honor

NOTE Confidence: 0.9784313

00:02:00.400 --> 00:02:02.259
of introducing the hematologists

NOTE Confidence: 0.97770673

00:02:02.560 --> 00:02:03.920
tonight that are joining us,

NOTE Confidence: 0.97770673

00:02:03.920 --> 00:02:04.420
doctor,

NOTE Confidence: 0.9992006

00:02:05.119 --> 00:02:05.619
Sabrina

NOTE Confidence: 0.86630774

00:02:05.920 --> 00:02:06.420
Browning.

NOTE Confidence: 0.98672915

00:02:06.880 --> 00:02:08.340
That's on the right. She

NOTE Confidence: 0.98672915

00:02:08.480 --> 00:02:10.260
is assistant professor of medicine

NOTE Confidence: 0.92544955

00:02:11.275 --> 00:02:12.955
in hematology, and she received

NOTE Confidence: 0.92544955

00:02:12.955 --> 00:02:14.655
her medical degree from Yukon.

NOTE Confidence: 0.98759955

00:02:15.835 --> 00:02:17.275
And then her internship and

NOTE Confidence: 0.98759955

00:02:17.275 --> 00:02:18.955
residency completed at Yale New

NOTE Confidence: 0.98759955

00:02:18.955 --> 00:02:19.455
Haven

NOTE Confidence: 0.97382843

00:02:19.835 --> 00:02:21.915
Hospital. After residency, she served

NOTE Confidence: 0.97382843

00:02:21.915 --> 00:02:23.375
as an amyloid fellow

NOTE Confidence: 0.9996883

00:02:23.690 --> 00:02:24.590
at the internationally

NOTE Confidence: 0.99509203

00:02:24.889 --> 00:02:25.389
recognized,

NOTE Confidence: 0.8241737

00:02:25.850 --> 00:02:26.350
amyloidis

NOTE Confidence: 0.95550835

00:02:27.050 --> 00:02:27.550
amyloidosis

NOTE Confidence: 0.9631453

00:02:29.370 --> 00:02:30.590
center at BU,

NOTE Confidence: 0.90285164

00:02:31.450 --> 00:02:32.889
in Boston Medical Center. And

NOTE Confidence: 0.90285164

00:02:32.889 --> 00:02:34.010
then she returned to Yale

NOTE Confidence: 0.90285164

00:02:34.010 --> 00:02:35.610
New Haven Hospital to complete

NOTE Confidence: 0.90285164

00:02:35.610 --> 00:02:36.990
her her fellowship

NOTE Confidence: 0.9976137

00:02:37.605 --> 00:02:39.544
in medical oncology and hematology.

NOTE Confidence: 0.9135647

00:02:40.725 --> 00:02:42.245
She's a physician in the

NOTE Confidence: 0.9135647

00:02:42.245 --> 00:02:44.505
Smiling Multiple Myeloma and Gammopathies

NOTE Confidence: 0.9135647

00:02:44.725 --> 00:02:46.485
program, and her clinical and

NOTE Confidence: 0.9135647

00:02:46.485 --> 00:02:47.465
research interests

NOTE Confidence: 0.997943

00:02:47.845 --> 00:02:49.925
include evaluating new treatments for

NOTE Confidence: 0.997943

00:02:49.925 --> 00:02:50.825
multiple myeloma,

NOTE Confidence: 0.9807762

00:02:51.620 --> 00:02:52.120
amyloidosis,

NOTE Confidence: 0.99893194

00:02:52.580 --> 00:02:53.639
and other hematologic

NOTE Confidence: 0.99900854

00:02:54.020 --> 00:02:54.520
diseases.

NOTE Confidence: 0.9090108

00:02:56.500 --> 00:02:57.540
Also, I would like to

NOTE Confidence: 0.9090108

00:02:57.540 --> 00:02:59.460
introduce doctor Nofar Bahr, who's

NOTE Confidence: 0.9090108

00:02:59.460 --> 00:03:01.060
an assistant professor of medicine

NOTE Confidence: 0.9090108

00:03:01.060 --> 00:03:01.800
and hematology

NOTE Confidence: 0.99137217

00:03:02.419 --> 00:03:03.540
at the Yale School of

NOTE Confidence: 0.99137217

00:03:03.540 --> 00:03:05.880
Medicine. She completed her internship

NOTE Confidence: 0.99137217

00:03:06.100 --> 00:03:06.760
and residency

NOTE Confidence: 0.98926264

00:03:07.275 --> 00:03:08.555
at the, at the Mount

NOTE Confidence: 0.98926264

00:03:08.555 --> 00:03:10.334
Sinai hospital and her fellowship

NOTE Confidence: 0.98926264

00:03:10.394 --> 00:03:11.055
at Yale,

NOTE Confidence: 0.9870597

00:03:11.674 --> 00:03:13.595
and received her medical degree

NOTE Confidence: 0.9870597

00:03:13.595 --> 00:03:15.275
from the American medical program

NOTE Confidence: 0.9870597

00:03:15.275 --> 00:03:16.715
at Tel Aviv university in

NOTE Confidence: 0.9870597

00:03:16.715 --> 00:03:18.235
New York. She's a member

NOTE Confidence: 0.9870597

00:03:18.235 --> 00:03:20.460
of ASCO, the American Society

NOTE Confidence: 0.9870597

00:03:20.460 --> 00:03:21.120
of Hematology,

NOTE Confidence: 0.95498836

00:03:21.419 --> 00:03:23.440
the International Myeloma Society,

NOTE Confidence: 0.9996398

00:03:23.820 --> 00:03:25.260
and her research is focused

NOTE Confidence: 0.9996398

00:03:25.260 --> 00:03:26.480
on multiple myeloma

NOTE Confidence: 0.98931074

00:03:26.940 --> 00:03:28.880
and other plasma cell disorders.

NOTE Confidence: 0.97008514

00:03:29.820 --> 00:03:31.580
And she specializes in all

NOTE Confidence: 0.97008514

00:03:31.580 --> 00:03:34.080
treatment modalities for myeloma, including

NOTE Confidence: 0.97008514

00:03:34.139 --> 00:03:34.880
CAR T

NOTE Confidence: 0.97910523

00:03:35.215 --> 00:03:36.655
cell therapy and stem cell

NOTE Confidence: 0.97910523

00:03:36.655 --> 00:03:37.855
transplant. She'll talk a little

NOTE Confidence: 0.97910523

00:03:37.855 --> 00:03:40.415
bit about those as, well

NOTE Confidence: 0.97910523

00:03:40.415 --> 00:03:41.614
tonight. So we've got a

NOTE Confidence: 0.97910523

00:03:41.614 --> 00:03:42.435
great program,

NOTE Confidence: 0.9924224

00:03:44.495 --> 00:03:45.474
for you tonight.

NOTE Confidence: 0.9964973

00:03:45.935 --> 00:03:47.155
Save up your questions.

NOTE Confidence: 0.9849536

00:03:48.015 --> 00:03:49.555
You always have some excellent

NOTE Confidence: 0.9849536

00:03:49.614 --> 00:03:51.530
ones, and I will now

NOTE Confidence: 0.9849536

00:03:51.530 --> 00:03:53.470
turn it over to doctor

NOTE Confidence: 0.9849536

00:03:53.610 --> 00:03:54.810
Barr to sort of set

NOTE Confidence: 0.9849536

00:03:54.810 --> 00:03:56.090
us up with, what we're

NOTE Confidence: 0.9849536

00:03:56.090 --> 00:03:57.550
gonna do tonight. Thank you.

NOTE Confidence: 0.87998945

00:03:58.810 --> 00:04:00.110
Thank you, Anne.

NOTE Confidence: 0.9964571

00:04:00.650 --> 00:04:01.770
And thank you for having

NOTE Confidence: 0.9964571

00:04:01.770 --> 00:04:02.250
us.

NOTE Confidence: 0.9415364

00:04:03.050 --> 00:04:03.550
Today,

NOTE Confidence: 0.99804085

00:04:03.850 --> 00:04:05.130
some of the key points

NOTE Confidence: 0.99804085

00:04:05.130 --> 00:04:06.075
I wanna highlight

NOTE Confidence: 0.9837696

00:04:07.035 --> 00:04:09.114
is reviewing the reference ranges

NOTE Confidence: 0.9837696

00:04:09.114 --> 00:04:09.515
for,

NOTE Confidence: 0.9471642

00:04:09.915 --> 00:04:11.754
serum free light chains, and

NOTE Confidence: 0.9471642

00:04:11.754 --> 00:04:13.435
this could be, affected by

NOTE Confidence: 0.9471642

00:04:13.435 --> 00:04:14.735
age and renal dysfunction.

NOTE Confidence: 0.93600476

00:04:15.194 --> 00:04:16.475
Second, discuss some of the

NOTE Confidence: 0.93600476

00:04:16.475 --> 00:04:19.055
differences between IgA, IG,

NOTE Confidence: 0.96844053

00:04:19.360 --> 00:04:21.779
sorry, IgG, IgA versus IgM

NOTE Confidence: 0.96844053

00:04:21.920 --> 00:04:23.060
monoclonal gammopathies.

NOTE Confidence: 0.9786306

00:04:23.840 --> 00:04:25.360
Define low risk MGUS and

NOTE Confidence: 0.9786306

00:04:25.360 --> 00:04:26.720
discuss how this could be

NOTE Confidence: 0.9786306

00:04:26.720 --> 00:04:28.340
managed by the primary care

NOTE Confidence: 0.9786306

00:04:28.400 --> 00:04:28.900
physician.

NOTE Confidence: 0.9964666

00:04:29.440 --> 00:04:30.980
Discuss some red flags,

NOTE Confidence: 0.9813716

00:04:31.360 --> 00:04:33.520
that warrant more urgent referral

NOTE Confidence: 0.9813716

00:04:33.520 --> 00:04:34.180
to hematology.

NOTE Confidence: 0.95606196

00:04:34.915 --> 00:04:37.075
And also review this, EPIC

NOTE Confidence: 0.95606196

00:04:37.075 --> 00:04:38.214
monoclonal gammopathy

NOTE Confidence: 0.97447276

00:04:38.675 --> 00:04:40.375
pathway we've developed recently

NOTE Confidence: 0.8839699

00:04:40.755 --> 00:04:41.495
and provide,

NOTE Confidence: 0.9965969

00:04:41.875 --> 00:04:43.235
hopefully, you can provide us

NOTE Confidence: 0.9965969

00:04:43.235 --> 00:04:44.935
some feedback over time.

NOTE Confidence: 0.98552215

00:04:45.555 --> 00:04:46.915
So to begin, I wanna

NOTE Confidence: 0.98552215

00:04:46.915 --> 00:04:48.135
start with some background.

NOTE Confidence: 0.95458734

00:04:48.750 --> 00:04:51.310
And monoclonal gammopathies on for

NOTE Confidence: 0.95458734

00:04:51.310 --> 00:04:53.230
the most part, are driven

NOTE Confidence: 0.95458734

00:04:53.230 --> 00:04:55.550
by clonal or abnormal plasma

NOTE Confidence: 0.95458734

00:04:55.550 --> 00:04:57.010
cells within the bone marrow,

NOTE Confidence: 0.97611934

00:04:57.390 --> 00:04:59.089
and they secrete a monoclonal

NOTE Confidence: 0.97611934

00:04:59.310 --> 00:05:00.910
protein called an m spike

NOTE Confidence: 0.97611934

00:05:00.910 --> 00:05:01.810
or m protein

NOTE Confidence: 0.9744372

00:05:03.005 --> 00:05:04.045
as I show you here.

NOTE Confidence: 0.9744372

00:05:04.045 --> 00:05:05.005
And this is a picture

NOTE Confidence: 0.9744372

00:05:05.005 --> 00:05:06.765
of, either an IgG or

NOTE Confidence: 0.9744372

00:05:06.765 --> 00:05:07.425
an IgA.

NOTE Confidence: 0.9694439

00:05:07.964 --> 00:05:09.165
And you can see that

NOTE Confidence: 0.9694439

00:05:09.165 --> 00:05:10.285
a part of the whole

NOTE Confidence: 0.9694439

00:05:10.285 --> 00:05:10.785
antibody

NOTE Confidence: 0.9641216

00:05:11.404 --> 00:05:13.245
is also the the light

NOTE Confidence: 0.9641216

00:05:13.245 --> 00:05:14.545
genes, which is important.

NOTE Confidence: 0.9802624

00:05:15.710 --> 00:05:17.230
I'm I mentioned that most

NOTE Confidence: 0.9802624

00:05:17.230 --> 00:05:18.830
gammopathies are from plasma cells.

NOTE Confidence: 0.9802624

00:05:18.830 --> 00:05:20.350
There are several gammopathies that

NOTE Confidence: 0.9802624

00:05:20.350 --> 00:05:22.029
originate from b cells, clonal

NOTE Confidence: 0.9802624

00:05:22.029 --> 00:05:23.070
b cells, but for the

NOTE Confidence: 0.9802624

00:05:23.070 --> 00:05:24.690
most part, plasma cells.

NOTE Confidence: 0.9766178

00:05:26.110 --> 00:05:28.165
Now when you're thinking about

NOTE Confidence: 0.9766178

00:05:28.165 --> 00:05:29.305
a monoclonal gammopathy,

NOTE Confidence: 0.94791186

00:05:29.605 --> 00:05:30.985
this is the pair protein,

NOTE Confidence: 0.99716586

00:05:31.445 --> 00:05:31.945
evaluation.

NOTE Confidence: 0.9949124

00:05:32.565 --> 00:05:34.005
We do a serum protein

NOTE Confidence: 0.9949124

00:05:34.005 --> 00:05:34.505
electrophoresis,

NOTE Confidence: 0.96094537

00:05:34.885 --> 00:05:36.085
and I show you here

NOTE Confidence: 0.96094537

00:05:36.085 --> 00:05:37.365
what would be normal on

NOTE Confidence: 0.96094537

00:05:37.365 --> 00:05:38.725
the left and on the

NOTE Confidence: 0.96094537

00:05:38.725 --> 00:05:40.485
right, an abnormal spike in

NOTE Confidence: 0.96094537

00:05:40.485 --> 00:05:41.545
the gamma region.

NOTE Confidence: 0.96049064

00:05:42.240 --> 00:05:43.760
There is some differences with

NOTE Confidence: 0.96049064

00:05:43.760 --> 00:05:46.339
gammopathies. For example, IGAs often

NOTE Confidence: 0.96049064

00:05:46.560 --> 00:05:48.000
come in the beta region

NOTE Confidence: 0.96049064

00:05:48.000 --> 00:05:49.279
over here if you see

NOTE Confidence: 0.96049064

00:05:49.279 --> 00:05:50.800
this. And you see the

NOTE Confidence: 0.96049064

00:05:50.800 --> 00:05:52.160
two spikes that actually makes

NOTE Confidence: 0.96049064

00:05:52.160 --> 00:05:53.120
it a little bit more

NOTE Confidence: 0.96049064

00:05:53.120 --> 00:05:53.620
difficult,

NOTE Confidence: 0.9676373

00:05:54.320 --> 00:05:55.620
and often underrepresents

NOTE Confidence: 0.95637333

00:05:56.505 --> 00:05:58.265
IgA gammopathy, so just some

NOTE Confidence: 0.95637333

00:05:58.265 --> 00:05:59.485
key points there.

NOTE Confidence: 0.94700634

00:06:00.105 --> 00:06:00.845
The immunofixation

NOTE Confidence: 0.99862766

00:06:01.785 --> 00:06:02.285
below

NOTE Confidence: 0.9992015

00:06:02.585 --> 00:06:03.085
identifies

NOTE Confidence: 0.97786295

00:06:03.465 --> 00:06:04.905
the clone. Okay? So the

NOTE Confidence: 0.97786295

00:06:04.905 --> 00:06:07.005
SBAP quantifies it. The immunofixation

NOTE Confidence: 0.9372516

00:06:07.545 --> 00:06:09.225
identifies for example, here we

NOTE Confidence: 0.9372516

00:06:09.225 --> 00:06:10.500
see an IgG kappa.

NOTE Confidence: 0.9758394

00:06:11.060 --> 00:06:12.339
In addition to this, we

NOTE Confidence: 0.9758394

00:06:12.339 --> 00:06:13.460
also need to have a

NOTE Confidence: 0.9758394

00:06:13.460 --> 00:06:14.360
serum free,

NOTE Confidence: 0.98526984

00:06:14.900 --> 00:06:15.640
light chains.

NOTE Confidence: 0.9952439

00:06:16.260 --> 00:06:17.380
We do not check urine

NOTE Confidence: 0.9952439

00:06:17.380 --> 00:06:18.600
free light chains anymore.

NOTE Confidence: 0.98977566

00:06:19.060 --> 00:06:19.540
And,

NOTE Confidence: 0.95582944

00:06:19.940 --> 00:06:21.300
the importance of this one,

NOTE Confidence: 0.95582944

00:06:21.300 --> 00:06:23.025
it helps us with, some

NOTE Confidence: 0.95582944

00:06:23.025 --> 00:06:25.505
risk stratification diagnosis myeloma, but,

NOTE Confidence: 0.95582944

00:06:25.505 --> 00:06:27.525
also, there's a few patients,

NOTE Confidence: 0.9885211

00:06:28.145 --> 00:06:29.685
about twenty percent of myeloma,

NOTE Confidence: 0.99719524

00:06:30.065 --> 00:06:30.565
that

NOTE Confidence: 0.9549946

00:06:30.945 --> 00:06:32.785
presents only with light chain

NOTE Confidence: 0.9549946

00:06:32.785 --> 00:06:33.285
secretions.

NOTE Confidence: 0.95146126

00:06:33.585 --> 00:06:34.625
So you might miss a

NOTE Confidence: 0.95146126

00:06:34.625 --> 00:06:36.710
diagnosis of a if you're

NOTE Confidence: 0.95146126

00:06:36.710 --> 00:06:38.170
not checking the light chains.

NOTE Confidence: 0.97864056

00:06:39.110 --> 00:06:40.790
Additionally, it's important to note,

NOTE Confidence: 0.97864056

00:06:40.790 --> 00:06:41.670
and this is kind of

NOTE Confidence: 0.97864056

00:06:41.670 --> 00:06:43.210
not something you think about,

NOTE Confidence: 0.97864056

00:06:43.270 --> 00:06:45.690
but different labs have different

NOTE Confidence: 0.97864056

00:06:45.830 --> 00:06:46.870
ranges of,

NOTE Confidence: 0.93182474

00:06:47.910 --> 00:06:48.410
abnormalities

NOTE Confidence: 0.9029707

00:06:48.790 --> 00:06:50.250
be because the the

NOTE Confidence: 0.956639

00:06:51.104 --> 00:06:52.544
units are different. So for

NOTE Confidence: 0.956639

00:06:52.544 --> 00:06:54.865
example, Yale uses milligrams per

NOTE Confidence: 0.956639

00:06:54.865 --> 00:06:57.025
deciliter, but Quest, which some

NOTE Confidence: 0.956639

00:06:57.025 --> 00:06:58.785
of our our patients use,

NOTE Confidence: 0.956639

00:06:58.785 --> 00:07:00.485
uses milligrams per liter.

NOTE Confidence: 0.9771769

00:07:00.785 --> 00:07:01.925
So, like, sixty

NOTE Confidence: 0.9560067

00:07:02.384 --> 00:07:04.190
at Quest is six at

NOTE Confidence: 0.9560067

00:07:04.190 --> 00:07:05.630
Yale. So that's important to

NOTE Confidence: 0.9560067

00:07:05.630 --> 00:07:06.910
recognize, and some patients will

NOTE Confidence: 0.9560067

00:07:06.910 --> 00:07:08.430
say, oh my god. Eighty.

NOTE Confidence: 0.9560067

00:07:08.430 --> 00:07:09.570
But it's really eight.

NOTE Confidence: 0.9714458

00:07:10.430 --> 00:07:12.370
So it's important to compare

NOTE Confidence: 0.9714458

00:07:12.510 --> 00:07:14.350
apples and apples and not

NOTE Confidence: 0.9714458

00:07:14.350 --> 00:07:15.490
apples and oranges.

NOTE Confidence: 0.98287344

00:07:17.085 --> 00:07:19.725
The definition of abnormal light

NOTE Confidence: 0.98287344

00:07:19.725 --> 00:07:21.965
chain ratio depends on age.

NOTE Confidence: 0.98287344

00:07:21.965 --> 00:07:23.825
And here is some information

NOTE Confidence: 0.98287344

00:07:23.885 --> 00:07:25.185
from a recent analysis

NOTE Confidence: 0.99740875

00:07:25.725 --> 00:07:26.465
in Iceland

NOTE Confidence: 0.9499066

00:07:26.765 --> 00:07:28.625
where they are testing everyone

NOTE Confidence: 0.9499066

00:07:28.770 --> 00:07:30.150
for monoclonal gammopathy,

NOTE Confidence: 0.97265124

00:07:30.690 --> 00:07:31.970
and they saw that patients

NOTE Confidence: 0.97265124

00:07:31.970 --> 00:07:33.569
who are older tend to

NOTE Confidence: 0.97265124

00:07:33.569 --> 00:07:35.009
have a higher light chain

NOTE Confidence: 0.97265124

00:07:35.009 --> 00:07:36.449
ratio. As you can see

NOTE Confidence: 0.97265124

00:07:36.449 --> 00:07:38.129
here, the higher end is

NOTE Confidence: 0.97265124

00:07:38.129 --> 00:07:39.169
two point five and is

NOTE Confidence: 0.97265124

00:07:39.169 --> 00:07:40.530
a reference range of what's

NOTE Confidence: 0.97265124

00:07:40.530 --> 00:07:41.970
normal in our lab is

NOTE Confidence: 0.97265124

00:07:41.970 --> 00:07:43.349
one point six five.

NOTE Confidence: 0.9995599

00:07:44.835 --> 00:07:45.335
Additionally,

NOTE Confidence: 0.9541732

00:07:45.875 --> 00:07:48.115
creatinine clearance affects light chain

NOTE Confidence: 0.9541732

00:07:48.115 --> 00:07:49.475
ratios. You can see with

NOTE Confidence: 0.9541732

00:07:49.475 --> 00:07:51.875
that lower creatinine clearance or

NOTE Confidence: 0.9541732

00:07:51.875 --> 00:07:54.215
worse renal function, the ratio

NOTE Confidence: 0.9992424

00:07:54.595 --> 00:07:56.515
gets higher at three point

NOTE Confidence: 0.9992424

00:07:56.515 --> 00:07:57.875
three. So when you have

NOTE Confidence: 0.9992424

00:07:57.875 --> 00:07:58.375
someone

NOTE Confidence: 0.95731866

00:07:59.550 --> 00:08:01.150
with, normal IFE and a

NOTE Confidence: 0.95731866

00:08:01.150 --> 00:08:03.150
light chain ratio of two

NOTE Confidence: 0.95731866

00:08:03.150 --> 00:08:04.510
point five, well, it is

NOTE Confidence: 0.95731866

00:08:04.510 --> 00:08:06.050
abnormal in our lab.

NOTE Confidence: 0.99717826

00:08:06.590 --> 00:08:07.710
If they're older or have

NOTE Confidence: 0.99717826

00:08:07.710 --> 00:08:09.389
renal dysfunction, it might actually

NOTE Confidence: 0.99717826

00:08:09.389 --> 00:08:10.130
be normal.

NOTE Confidence: 0.9859681

00:08:11.405 --> 00:08:12.845
So this is, the most

NOTE Confidence: 0.9859681

00:08:12.925 --> 00:08:14.125
this is the spectrum of

NOTE Confidence: 0.9859681

00:08:14.125 --> 00:08:15.185
monoclonal gammopathies.

NOTE Confidence: 0.99786246

00:08:15.565 --> 00:08:16.925
It's not all inclusive, but

NOTE Confidence: 0.99786246

00:08:16.925 --> 00:08:18.765
it's representing the most common

NOTE Confidence: 0.99786246

00:08:18.765 --> 00:08:19.265
gammopathies.

NOTE Confidence: 0.9973603

00:08:19.885 --> 00:08:21.085
You can see here at

NOTE Confidence: 0.9973603

00:08:21.085 --> 00:08:21.825
the end,

NOTE Confidence: 0.9775227

00:08:22.685 --> 00:08:24.125
multiple myeloma, which is the

NOTE Confidence: 0.9775227

00:08:24.125 --> 00:08:24.625
cancer.

NOTE Confidence: 0.991715

00:08:25.005 --> 00:08:25.745
But on

NOTE Confidence: 0.9655811

00:08:26.750 --> 00:08:28.430
the the right is the

NOTE Confidence: 0.9655811

00:08:28.430 --> 00:08:30.430
mono the first or initial

NOTE Confidence: 0.9655811

00:08:30.430 --> 00:08:32.190
precursor state of what we

NOTE Confidence: 0.9655811

00:08:32.190 --> 00:08:34.589
call MGUS, monoclonal gammopathy of

NOTE Confidence: 0.9655811

00:08:34.589 --> 00:08:35.649
undetermined significance.

NOTE Confidence: 0.9968049

00:08:36.510 --> 00:08:37.710
And then it goes through

NOTE Confidence: 0.9968049

00:08:37.710 --> 00:08:38.450
an intermediary

NOTE Confidence: 0.96757066

00:08:38.830 --> 00:08:40.610
stage of smoldering myeloma,

NOTE Confidence: 0.9352103

00:08:41.165 --> 00:08:42.684
with both of these, MGUS

NOTE Confidence: 0.9352103

00:08:42.684 --> 00:08:44.204
and smoldering, another name for

NOTE Confidence: 0.9352103

00:08:44.204 --> 00:08:45.184
smoldering, asymptomatic

NOTE Confidence: 0.97839504

00:08:45.564 --> 00:08:47.725
myeloma, these are precursor states

NOTE Confidence: 0.97839504

00:08:47.725 --> 00:08:49.584
and are not representing cancer

NOTE Confidence: 0.97839504

00:08:49.804 --> 00:08:50.684
and do not need to

NOTE Confidence: 0.97839504

00:08:50.684 --> 00:08:52.444
be treated. And these do

NOTE Confidence: 0.97839504

00:08:52.444 --> 00:08:53.964
not have CRAP criteria, which

NOTE Confidence: 0.97839504

00:08:53.964 --> 00:08:55.184
we'll talk about soon.

NOTE Confidence: 0.9478016

00:08:56.580 --> 00:08:58.339
The major difference when you're

NOTE Confidence: 0.9478016

00:08:58.339 --> 00:08:59.460
evaluating the bone marrow in

NOTE Confidence: 0.9478016

00:08:59.460 --> 00:09:00.500
these patients and part of

NOTE Confidence: 0.9478016

00:09:00.500 --> 00:09:01.160
the diagnosis

NOTE Confidence: 0.9864249

00:09:02.020 --> 00:09:03.320
is that there are less

NOTE Confidence: 0.9864249

00:09:03.540 --> 00:09:05.300
clonal plasma cells with MGUS

NOTE Confidence: 0.9864249

00:09:05.300 --> 00:09:07.059
and more clonal plasma cells

NOTE Confidence: 0.9864249

00:09:07.059 --> 00:09:07.880
with smoldering,

NOTE Confidence: 0.9840264

00:09:08.214 --> 00:09:09.575
less than ten or more

NOTE Confidence: 0.9840264

00:09:09.575 --> 00:09:11.255
than ten percent. And what's

NOTE Confidence: 0.9840264

00:09:11.255 --> 00:09:12.615
relevant for the patient is

NOTE Confidence: 0.9840264

00:09:12.615 --> 00:09:13.835
the risk for progression.

NOTE Confidence: 0.98209006

00:09:14.615 --> 00:09:15.915
One percent with MGUS,

NOTE Confidence: 0.9995045

00:09:16.295 --> 00:09:17.035
ten percent

NOTE Confidence: 0.97533315

00:09:17.415 --> 00:09:19.095
on average per year with

NOTE Confidence: 0.97533315

00:09:19.095 --> 00:09:19.595
smoldering.

NOTE Confidence: 0.96627736

00:09:21.240 --> 00:09:23.400
So I think most of

NOTE Confidence: 0.96627736

00:09:23.400 --> 00:09:24.600
you know that the definition

NOTE Confidence: 0.96627736

00:09:24.600 --> 00:09:25.260
of myeloma

NOTE Confidence: 0.9527952

00:09:25.560 --> 00:09:27.320
requires a clonal plasma cell

NOTE Confidence: 0.9527952

00:09:27.320 --> 00:09:29.480
clone of, clonal plasma cells

NOTE Confidence: 0.9527952

00:09:29.480 --> 00:09:30.280
on the bone marrow of

NOTE Confidence: 0.9527952

00:09:30.280 --> 00:09:31.800
more than ten percent in

NOTE Confidence: 0.9527952

00:09:31.800 --> 00:09:32.860
addition to

NOTE Confidence: 0.9685915

00:09:33.355 --> 00:09:34.635
one or more of the

NOTE Confidence: 0.9685915

00:09:34.635 --> 00:09:36.175
CRAP criteria, including

NOTE Confidence: 0.99727404

00:09:36.475 --> 00:09:38.495
high calcium level, renal insufficiency,

NOTE Confidence: 0.9974269

00:09:38.875 --> 00:09:40.975
anemia, and bony disease.

NOTE Confidence: 0.9803364

00:09:41.434 --> 00:09:43.195
However, about a decade ago

NOTE Confidence: 0.9803364

00:09:43.195 --> 00:09:44.895
now, the definition of myeloma

NOTE Confidence: 0.9803364

00:09:44.955 --> 00:09:45.934
actually changed,

NOTE Confidence: 0.9728267

00:09:46.779 --> 00:09:47.820
And now we have what's

NOTE Confidence: 0.9728267

00:09:47.820 --> 00:09:49.120
called the slim crab.

NOTE Confidence: 0.9927302

00:09:49.740 --> 00:09:50.540
So for those of you

NOTE Confidence: 0.9927302

00:09:50.540 --> 00:09:51.420
who don't know what the

NOTE Confidence: 0.9927302

00:09:51.420 --> 00:09:53.100
slim crab criteria is, I

NOTE Confidence: 0.9927302

00:09:53.100 --> 00:09:54.860
like to go backwards to

NOTE Confidence: 0.9927302

00:09:54.860 --> 00:09:56.640
review the spectrum of gammopathies

NOTE Confidence: 0.95409274

00:09:57.179 --> 00:09:58.620
to really understand where the

NOTE Confidence: 0.95409274

00:09:58.620 --> 00:09:59.925
slim crab came from.

NOTE Confidence: 0.96959275

00:10:00.404 --> 00:10:01.705
And here you can see

NOTE Confidence: 0.96959275

00:10:01.925 --> 00:10:03.524
that the clonal the the

NOTE Confidence: 0.96959275

00:10:03.524 --> 00:10:05.445
smoldering myeloma is actually a

NOTE Confidence: 0.96959275

00:10:05.445 --> 00:10:07.464
very heterogeneous group of patients.

NOTE Confidence: 0.9625206

00:10:08.245 --> 00:10:09.925
While on average, ten percent

NOTE Confidence: 0.9625206

00:10:09.925 --> 00:10:11.605
progressed to myeloma. There are

NOTE Confidence: 0.9625206

00:10:11.605 --> 00:10:13.684
some patients that behave like

NOTE Confidence: 0.9625206

00:10:13.684 --> 00:10:15.630
MGUS and will never progress,

NOTE Confidence: 0.9625206

00:10:15.770 --> 00:10:17.610
and some patients progress within

NOTE Confidence: 0.9625206

00:10:17.610 --> 00:10:19.130
one to two years and

NOTE Confidence: 0.9625206

00:10:19.130 --> 00:10:20.809
probably should be diagnosed as

NOTE Confidence: 0.9625206

00:10:20.809 --> 00:10:22.570
myeloma. And that is exactly

NOTE Confidence: 0.9625206

00:10:22.570 --> 00:10:24.170
where the slim criteria came

NOTE Confidence: 0.9625206

00:10:24.170 --> 00:10:25.950
from. Researchers identified

NOTE Confidence: 0.9994814

00:10:26.330 --> 00:10:26.830
factors

NOTE Confidence: 0.9992917

00:10:27.644 --> 00:10:29.245
that led to a risk

NOTE Confidence: 0.9992917

00:10:29.245 --> 00:10:30.785
of progression of myeloma

NOTE Confidence: 0.9523018

00:10:31.485 --> 00:10:33.644
at two years at eighty

NOTE Confidence: 0.9523018

00:10:33.644 --> 00:10:34.144
percent.

NOTE Confidence: 0.8814944

00:10:34.605 --> 00:10:35.725
And they said, we are

NOTE Confidence: 0.8814944

00:10:35.804 --> 00:10:36.704
this is unacceptable,

NOTE Confidence: 0.99294376

00:10:37.084 --> 00:10:38.365
and patients should be treated

NOTE Confidence: 0.99294376

00:10:38.365 --> 00:10:39.985
for myeloma. And this is

NOTE Confidence: 0.98946583

00:10:40.290 --> 00:10:42.050
sixty percent clonal plasma cells

NOTE Confidence: 0.98946583

00:10:42.050 --> 00:10:43.089
in the bone marrow or

NOTE Confidence: 0.98946583

00:10:43.089 --> 00:10:44.850
more, a light chain ratio

NOTE Confidence: 0.98946583

00:10:44.850 --> 00:10:45.750
over a hundred,

NOTE Confidence: 0.99922156

00:10:46.209 --> 00:10:46.950
and having

NOTE Confidence: 0.8756873

00:10:47.410 --> 00:10:49.089
more than one bony lesion

NOTE Confidence: 0.8756873

00:10:49.089 --> 00:10:51.170
on advanced imaging, like whole

NOTE Confidence: 0.8756873

00:10:51.170 --> 00:10:53.029
body MRI, PET scan.

NOTE Confidence: 0.99795693

00:10:54.985 --> 00:10:55.964
So with that,

NOTE Confidence: 0.9993771

00:10:56.505 --> 00:10:57.165
we will

NOTE Confidence: 0.9652113

00:10:57.945 --> 00:10:59.325
move forward to our cases.

NOTE Confidence: 0.9069736

00:11:01.865 --> 00:11:02.845
Thanks, Nafoor.

NOTE Confidence: 0.9334631

00:11:04.024 --> 00:11:05.385
So before we get into

NOTE Confidence: 0.9334631

00:11:05.385 --> 00:11:06.505
this case, just wanna give

NOTE Confidence: 0.9334631

00:11:06.505 --> 00:11:06.985
a brief,

NOTE Confidence: 0.87729573

00:11:10.000 --> 00:11:11.440
context of the four case

NOTE Confidence: 0.87729573

00:11:11.440 --> 00:11:12.240
that I'm gonna bring in,

NOTE Confidence: 0.87729573

00:11:12.240 --> 00:11:13.120
and and these are all

NOTE Confidence: 0.87729573

00:11:13.120 --> 00:11:14.420
cases from a panel.

NOTE Confidence: 0.95970446

00:11:15.680 --> 00:11:17.200
They're relatively fresh, which means

NOTE Confidence: 0.95970446

00:11:17.200 --> 00:11:18.480
that they they're they're either

NOTE Confidence: 0.95970446

00:11:18.480 --> 00:11:20.240
a new diagnosis of of

NOTE Confidence: 0.95970446

00:11:20.240 --> 00:11:20.740
monoclonal,

NOTE Confidence: 0.95284945

00:11:21.280 --> 00:11:23.275
gammopathy or it's a new

NOTE Confidence: 0.95284945

00:11:23.275 --> 00:11:24.315
patient to me that I

NOTE Confidence: 0.95284945

00:11:24.315 --> 00:11:25.375
had to get to know

NOTE Confidence: 0.95284945

00:11:25.675 --> 00:11:27.455
or it it's either

NOTE Confidence: 0.9561799

00:11:29.035 --> 00:11:30.175
a change in the clinical

NOTE Confidence: 0.9561799

00:11:30.235 --> 00:11:31.295
status that,

NOTE Confidence: 0.99734575

00:11:32.475 --> 00:11:33.695
has happened recently.

NOTE Confidence: 0.9690148

00:11:34.395 --> 00:11:35.595
And the one thing I

NOTE Confidence: 0.9690148

00:11:35.595 --> 00:11:35.995
just wanna,

NOTE Confidence: 0.8948984

00:11:36.690 --> 00:11:37.890
have you pay attention to

NOTE Confidence: 0.8948984

00:11:37.890 --> 00:11:39.490
is, you know, pay attention

NOTE Confidence: 0.8948984

00:11:39.490 --> 00:11:41.010
to crab cure crab criterias.

NOTE Confidence: 0.8948984

00:11:41.010 --> 00:11:42.290
We go through go through

NOTE Confidence: 0.8948984

00:11:42.290 --> 00:11:42.950
the cases,

NOTE Confidence: 0.91515297

00:11:43.809 --> 00:11:44.470
but, also,

NOTE Confidence: 0.99411744

00:11:44.850 --> 00:11:46.290
they don't fit a hundred

NOTE Confidence: 0.99411744

00:11:46.290 --> 00:11:47.510
percent by the book,

NOTE Confidence: 0.97677326

00:11:48.370 --> 00:11:49.650
necessarily. And I think that

NOTE Confidence: 0.97677326

00:11:49.650 --> 00:11:50.530
goes along with a lot

NOTE Confidence: 0.97677326

00:11:50.530 --> 00:11:51.910
of patients that we see.

NOTE Confidence: 0.8409526

00:11:52.465 --> 00:11:54.485
We're we're always, trying to,

NOTE Confidence: 0.7538867

00:11:56.945 --> 00:11:57.605
figure out

NOTE Confidence: 0.9404192

00:11:58.625 --> 00:12:00.405
what's going on from noise.

NOTE Confidence: 0.96928763

00:12:01.745 --> 00:12:02.245
And,

NOTE Confidence: 0.96770674

00:12:02.785 --> 00:12:04.025
their diseases vary,

NOTE Confidence: 0.9874134

00:12:04.465 --> 00:12:05.825
and don't go go by

NOTE Confidence: 0.9874134

00:12:05.825 --> 00:12:06.325
our

NOTE Confidence: 0.96769315

00:12:08.389 --> 00:12:09.990
strict criteria a hundred percent

NOTE Confidence: 0.96769315

00:12:09.990 --> 00:12:11.029
all the time. And but

NOTE Confidence: 0.96769315

00:12:11.029 --> 00:12:12.309
they do represent key points

NOTE Confidence: 0.96769315

00:12:12.309 --> 00:12:13.829
and pearls. So what that's

NOTE Confidence: 0.96769315

00:12:13.829 --> 00:12:15.910
what, with that, we'll jump

NOTE Confidence: 0.96769315

00:12:15.910 --> 00:12:17.589
into our first case. And,

NOTE Confidence: 0.96769315

00:12:17.750 --> 00:12:19.350
this is a fifty year

NOTE Confidence: 0.96769315

00:12:19.350 --> 00:12:20.709
old Hispanic female that was

NOTE Confidence: 0.96769315

00:12:20.709 --> 00:12:21.589
new to me in in

NOTE Confidence: 0.96769315

00:12:21.589 --> 00:12:23.655
twenty twenty one. And for

NOTE Confidence: 0.96769315

00:12:23.655 --> 00:12:24.955
the most part, she was,

NOTE Confidence: 0.99296826

00:12:26.215 --> 00:12:27.175
it was well known that

NOTE Confidence: 0.99296826

00:12:27.175 --> 00:12:27.895
she had MS,

NOTE Confidence: 0.96534085

00:12:28.215 --> 00:12:29.495
that was diagnosed in twenty

NOTE Confidence: 0.96534085

00:12:29.495 --> 00:12:29.995
nineteen,

NOTE Confidence: 0.9993316

00:12:30.934 --> 00:12:31.975
and we talked about that

NOTE Confidence: 0.9993316

00:12:31.975 --> 00:12:32.795
quite a bit.

NOTE Confidence: 0.9924876

00:12:33.255 --> 00:12:34.875
She had presented with incapacitating

NOTE Confidence: 0.9839241

00:12:35.415 --> 00:12:37.070
migraines at that point with

NOTE Confidence: 0.9839241

00:12:37.070 --> 00:12:39.170
vertigo, which prompted the MRI

NOTE Confidence: 0.80452096

00:12:39.710 --> 00:12:40.190
and,

NOTE Confidence: 0.91290164

00:12:40.670 --> 00:12:42.270
confirmed a diagnosis. And she

NOTE Confidence: 0.91290164

00:12:42.270 --> 00:12:43.330
started on Ocrevus,

NOTE Confidence: 0.93722993

00:12:45.630 --> 00:12:47.470
which is, for therapy every

NOTE Confidence: 0.93722993

00:12:47.470 --> 00:12:48.750
six months and had no

NOTE Confidence: 0.93722993

00:12:48.750 --> 00:12:50.350
disease progression and it was

NOTE Confidence: 0.93722993

00:12:50.350 --> 00:12:51.330
otherwise stable.

NOTE Confidence: 0.8078068

00:12:52.335 --> 00:12:53.775
Her her history, otherwise, is

NOTE Confidence: 0.8078068

00:12:53.775 --> 00:12:54.275
noncontributory.

NOTE Confidence: 0.9915323

00:12:55.135 --> 00:12:56.995
She had a cervical fusion,

NOTE Confidence: 0.9906359

00:12:58.255 --> 00:12:59.395
in twenty seventeen,

NOTE Confidence: 0.9561115

00:13:00.335 --> 00:13:01.054
and she had a c

NOTE Confidence: 0.9561115

00:13:01.054 --> 00:13:02.595
section nineteen ninety four.

NOTE Confidence: 0.96887463

00:13:03.302 --> 00:13:04.370
Her family history

NOTE Confidence: 0.86097354

00:13:05.150 --> 00:13:06.530
was notable just for hypertension,

NOTE Confidence: 0.86097354

00:13:06.590 --> 00:13:07.090
hyperlipidemia,

NOTE Confidence: 0.90708363

00:13:07.630 --> 00:13:09.090
heart disease, and substance

NOTE Confidence: 0.7676195

00:13:09.790 --> 00:13:10.290
addiction,

NOTE Confidence: 0.9933499

00:13:11.390 --> 00:13:13.550
and she herself was married.

NOTE Confidence: 0.9933499

00:13:13.550 --> 00:13:14.350
She had a son.

NOTE Confidence: 0.9600946

00:13:16.334 --> 00:13:17.375
She worked in an office

NOTE Confidence: 0.9600946

00:13:17.375 --> 00:13:19.295
setting. She, had a ten

NOTE Confidence: 0.9600946

00:13:19.295 --> 00:13:20.975
pack year tobacco history, but

NOTE Confidence: 0.9600946

00:13:20.975 --> 00:13:22.595
had quit in twenty eleven,

NOTE Confidence: 0.9104646

00:13:22.975 --> 00:13:24.195
and she's locally,

NOTE Confidence: 0.99926263

00:13:24.654 --> 00:13:25.714
born and raised.

NOTE Confidence: 0.988811

00:13:26.574 --> 00:13:27.394
Next slide.

NOTE Confidence: 0.99067754

00:13:29.380 --> 00:13:30.660
And so in the fall

NOTE Confidence: 0.99067754

00:13:30.820 --> 00:13:32.100
last fall in twenty twenty

NOTE Confidence: 0.99067754

00:13:32.100 --> 00:13:33.800
four, she came to me

NOTE Confidence: 0.9995102

00:13:34.179 --> 00:13:35.620
with six months of a

NOTE Confidence: 0.9995102

00:13:35.620 --> 00:13:36.520
chronic cough

NOTE Confidence: 0.9312499

00:13:37.300 --> 00:13:38.920
and this persistent,

NOTE Confidence: 0.90692043

00:13:40.515 --> 00:13:42.375
you know, frequent, really recurrent,

NOTE Confidence: 0.9995022

00:13:42.995 --> 00:13:43.495
bilateral

NOTE Confidence: 0.9242974

00:13:43.795 --> 00:13:46.035
otitis externa where her ears

NOTE Confidence: 0.9242974

00:13:46.035 --> 00:13:47.235
or her external ears were

NOTE Confidence: 0.9242974

00:13:47.235 --> 00:13:48.535
just swollen closed,

NOTE Confidence: 0.97662854

00:13:48.995 --> 00:13:49.815
very tender,

NOTE Confidence: 0.9444238

00:13:51.155 --> 00:13:52.675
really hurting. And she was

NOTE Confidence: 0.9444238

00:13:52.675 --> 00:13:53.815
at her wit's end,

NOTE Confidence: 0.9485955

00:13:54.434 --> 00:13:55.395
not only from the ears,

NOTE Confidence: 0.9485955

00:13:55.395 --> 00:13:56.279
but she had this cough

NOTE Confidence: 0.9485955

00:13:56.279 --> 00:13:57.320
that was relentless. A lot

NOTE Confidence: 0.9485955

00:13:57.320 --> 00:13:59.100
of abdominal pain, couldn't sleep,

NOTE Confidence: 0.9485955

00:13:59.399 --> 00:14:01.339
this dry cough, you know,

NOTE Confidence: 0.9964057

00:14:03.720 --> 00:14:04.220
just

NOTE Confidence: 0.99011576

00:14:05.079 --> 00:14:05.579
unmitigating.

NOTE Confidence: 0.9572034

00:14:06.440 --> 00:14:08.139
And she had seen neurology,

NOTE Confidence: 0.9572034

00:14:08.360 --> 00:14:09.800
ear, nose, and throat and

NOTE Confidence: 0.9572034

00:14:09.800 --> 00:14:11.740
immunology for these things.

NOTE Confidence: 0.961518

00:14:12.895 --> 00:14:14.095
And, when she was coming

NOTE Confidence: 0.961518

00:14:14.095 --> 00:14:14.895
to me, she was asking

NOTE Confidence: 0.961518

00:14:14.895 --> 00:14:15.795
me a lot of questions

NOTE Confidence: 0.961518

00:14:15.855 --> 00:14:17.615
about that workup. So the

NOTE Confidence: 0.961518

00:14:17.615 --> 00:14:18.735
SAR, we looked at the

NOTE Confidence: 0.961518

00:14:18.735 --> 00:14:20.575
cough, looked like a it

NOTE Confidence: 0.961518

00:14:20.575 --> 00:14:21.295
turned out to be a

NOTE Confidence: 0.961518

00:14:21.295 --> 00:14:22.835
really strong GERD trigger,

NOTE Confidence: 0.9989767

00:14:24.175 --> 00:14:24.675
and

NOTE Confidence: 0.8558431

00:14:25.580 --> 00:14:27.900
some allergic postnasal drip. So

NOTE Confidence: 0.8558431

00:14:27.900 --> 00:14:28.940
we addressed that. And then

NOTE Confidence: 0.8558431

00:14:28.940 --> 00:14:31.260
the the recurrent otitis through

NOTE Confidence: 0.8558431

00:14:31.260 --> 00:14:32.880
some Pseudomonas and,

NOTE Confidence: 0.94734573

00:14:33.660 --> 00:14:35.920
you know, sensitive staph oxycelin

NOTE Confidence: 0.94734573

00:14:35.980 --> 00:14:37.580
sensitive staph, and we just

NOTE Confidence: 0.94734573

00:14:37.580 --> 00:14:38.400
treated those

NOTE Confidence: 0.93580717

00:14:38.955 --> 00:14:40.555
accordingly. We got the cough

NOTE Confidence: 0.93580717

00:14:40.555 --> 00:14:42.875
under, control. In the years,

NOTE Confidence: 0.93580717

00:14:42.875 --> 00:14:44.175
we we had a regimen

NOTE Confidence: 0.93580717

00:14:44.315 --> 00:14:44.975
that that

NOTE Confidence: 0.9879346

00:14:45.355 --> 00:14:46.335
settled down.

NOTE Confidence: 0.98347986

00:14:47.035 --> 00:14:49.375
But during the subspecialty evaluation,

NOTE Confidence: 0.98347986

00:14:49.515 --> 00:14:50.895
she was found to have,

NOTE Confidence: 0.8557809

00:14:51.835 --> 00:14:53.775
so, suppressed b cell

NOTE Confidence: 0.8222955

00:14:54.340 --> 00:14:56.040
presence under flow cytometry,

NOTE Confidence: 0.9653889

00:14:57.140 --> 00:14:58.420
and she had a low

NOTE Confidence: 0.9653889

00:14:58.420 --> 00:15:00.600
I g g two subclass.

NOTE Confidence: 0.9418044

00:15:01.860 --> 00:15:03.460
And then, they they challenged

NOTE Confidence: 0.9418044

00:15:03.460 --> 00:15:04.520
that with a

NOTE Confidence: 0.87217504

00:15:04.980 --> 00:15:05.480
pneumococcal

NOTE Confidence: 0.99953395

00:15:05.780 --> 00:15:06.280
conjugate

NOTE Confidence: 0.910148

00:15:08.135 --> 00:15:09.575
vaccine and it and it

NOTE Confidence: 0.910148

00:15:09.735 --> 00:15:12.075
and and no antibody responded.

NOTE Confidence: 0.95748353

00:15:12.855 --> 00:15:14.695
So the the theory was

NOTE Confidence: 0.95748353

00:15:14.695 --> 00:15:15.895
that this was from her

NOTE Confidence: 0.95748353

00:15:15.895 --> 00:15:16.395
ocrevus,

NOTE Confidence: 0.90525013

00:15:16.855 --> 00:15:18.135
the suppressing her b cell

NOTE Confidence: 0.90525013

00:15:18.135 --> 00:15:19.895
colonies, and that in turn

NOTE Confidence: 0.90525013

00:15:19.895 --> 00:15:20.395
was

NOTE Confidence: 0.6441192

00:15:22.120 --> 00:15:22.940
causing return

NOTE Confidence: 0.92665595

00:15:23.240 --> 00:15:24.780
recurrent otitis externus.

NOTE Confidence: 0.956531

00:15:26.040 --> 00:15:27.560
The interesting thing here is

NOTE Confidence: 0.956531

00:15:27.560 --> 00:15:29.400
that on her SPEP and

NOTE Confidence: 0.956531

00:15:29.400 --> 00:15:30.140
her immunofixation,

NOTE Confidence: 0.9871132

00:15:32.280 --> 00:15:34.300
she had an IgA kappa

NOTE Confidence: 0.9946617

00:15:35.115 --> 00:15:37.775
monoclonal protein. So next slide.

NOTE Confidence: 0.90182406

00:15:39.435 --> 00:15:40.715
And, you know, the key

NOTE Confidence: 0.90182406

00:15:40.715 --> 00:15:42.155
points to eval is that

NOTE Confidence: 0.90182406

00:15:42.155 --> 00:15:43.615
she had she's not anemic.

NOTE Confidence: 0.90182406

00:15:43.675 --> 00:15:45.035
She had good new, renal

NOTE Confidence: 0.90182406

00:15:45.035 --> 00:15:46.635
function. She had noble calcium

NOTE Confidence: 0.90182406

00:15:46.635 --> 00:15:47.135
levels.

NOTE Confidence: 0.94670165

00:15:47.480 --> 00:15:49.020
There are no discrete monoclonal

NOTE Confidence: 0.94670165

00:15:49.240 --> 00:15:51.020
bands identified on the SPEP.

NOTE Confidence: 0.9899199

00:15:51.640 --> 00:15:52.140
But

NOTE Confidence: 0.98235655

00:15:52.840 --> 00:15:53.740
on the immunofixation,

NOTE Confidence: 0.98142284

00:15:54.600 --> 00:15:55.340
there were,

NOTE Confidence: 0.9227201

00:15:56.360 --> 00:15:57.980
there was IgA cap identified

NOTE Confidence: 0.9227201

00:15:58.280 --> 00:16:00.440
in three monoclonal components in

NOTE Confidence: 0.9227201

00:16:00.440 --> 00:16:01.845
that beta region that doctor

NOTE Confidence: 0.9227201

00:16:02.084 --> 00:16:03.305
Barr had mentioned earlier.

NOTE Confidence: 0.9988909

00:16:04.004 --> 00:16:06.024
And she had low immunoglobulin

NOTE Confidence: 0.83486587

00:16:06.404 --> 00:16:09.225
levels, IgA and IgG two,

NOTE Confidence: 0.8746695

00:16:09.685 --> 00:16:10.824
and she had elevated

NOTE Confidence: 0.97555256

00:16:11.285 --> 00:16:11.785
kappa

NOTE Confidence: 0.98679084

00:16:12.245 --> 00:16:13.845
light chain with an elevated

NOTE Confidence: 0.98679084

00:16:13.845 --> 00:16:15.204
ratio of three point nine

NOTE Confidence: 0.98679084

00:16:15.204 --> 00:16:15.704
five.

NOTE Confidence: 0.92135125

00:16:16.660 --> 00:16:17.940
She was seeing and this

NOTE Confidence: 0.92135125

00:16:17.940 --> 00:16:19.220
was this was kinda known

NOTE Confidence: 0.92135125

00:16:19.220 --> 00:16:20.340
to me, and then she

NOTE Confidence: 0.92135125

00:16:20.340 --> 00:16:22.120
was unprocessed going to hematology,

NOTE Confidence: 0.92135125

00:16:22.260 --> 00:16:23.380
went to hematology, got the

NOTE Confidence: 0.92135125

00:16:23.380 --> 00:16:24.360
bone marrow biopsy,

NOTE Confidence: 0.9945811

00:16:24.740 --> 00:16:25.860
and that came back with

NOTE Confidence: 0.9945811

00:16:25.860 --> 00:16:27.380
a less than ten percent

NOTE Confidence: 0.9945811

00:16:27.380 --> 00:16:28.840
clonal plasma cell.

NOTE Confidence: 0.982154

00:16:29.415 --> 00:16:29.915
And,

NOTE Confidence: 0.98855

00:16:30.535 --> 00:16:32.635
for further discussion, we have

NOTE Confidence: 0.9569644

00:16:33.175 --> 00:16:35.095
doctor Browning. Great. Thank you

NOTE Confidence: 0.9569644

00:16:35.095 --> 00:16:36.535
very much. So, you know,

NOTE Confidence: 0.9569644

00:16:36.535 --> 00:16:37.975
I think this is a

NOTE Confidence: 0.9569644

00:16:37.975 --> 00:16:38.795
a great case.

NOTE Confidence: 0.932937

00:16:39.175 --> 00:16:40.295
You know, I think with

NOTE Confidence: 0.932937

00:16:40.295 --> 00:16:41.515
this, patient

NOTE Confidence: 0.95894194

00:16:42.009 --> 00:16:42.889
appropriately in the setting of

NOTE Confidence: 0.95894194

00:16:42.889 --> 00:16:43.389
hypogammaglobulinemia

NOTE Confidence: 0.9468427

00:16:44.170 --> 00:16:46.029
and increased frequency of infections,

NOTE Confidence: 0.9552073

00:16:46.569 --> 00:16:48.009
both of which can occur,

NOTE Confidence: 0.9552073

00:16:48.250 --> 00:16:49.709
across the spectrum of monoclonal

NOTE Confidence: 0.9552073

00:16:49.769 --> 00:16:51.050
gammopathy. She had this pair

NOTE Confidence: 0.9552073

00:16:51.050 --> 00:16:52.110
of protein identified.

NOTE Confidence: 0.99456817

00:16:53.130 --> 00:16:54.250
And if you can advance

NOTE Confidence: 0.99456817

00:16:54.250 --> 00:16:54.910
the slide.

NOTE Confidence: 0.9255009

00:16:55.295 --> 00:16:56.035
So importantly,

NOTE Confidence: 0.99182165

00:16:56.495 --> 00:16:57.615
what we wanna talk through

NOTE Confidence: 0.99182165

00:16:57.615 --> 00:16:59.074
is what the patient's diagnosis

NOTE Confidence: 0.99182165

00:16:59.214 --> 00:17:00.574
is, and we'll go through

NOTE Confidence: 0.99182165

00:17:00.574 --> 00:17:02.274
the spectrum of monoclonal gammopathy.

NOTE Confidence: 0.9944618

00:17:02.815 --> 00:17:03.615
Again, she had a bone

NOTE Confidence: 0.9944618

00:17:03.615 --> 00:17:04.975
marrow biopsy showing less than

NOTE Confidence: 0.9944618

00:17:04.975 --> 00:17:06.755
ten percent clonal plasma cells,

NOTE Confidence: 0.9944618

00:17:06.895 --> 00:17:07.934
which in the absence of

NOTE Confidence: 0.9944618

00:17:07.934 --> 00:17:09.615
end organ damage is consistent

NOTE Confidence: 0.9944618

00:17:09.615 --> 00:17:10.355
with MGUS.

NOTE Confidence: 0.98462105

00:17:10.740 --> 00:17:11.780
So she had an IgA

NOTE Confidence: 0.98462105

00:17:11.780 --> 00:17:12.940
kappa MGUS. And we'll talk

NOTE Confidence: 0.98462105

00:17:12.940 --> 00:17:13.960
a little bit about

NOTE Confidence: 0.99558383

00:17:14.260 --> 00:17:15.220
when we think about doing

NOTE Confidence: 0.99558383

00:17:15.220 --> 00:17:16.500
a bone marrow and skeletal

NOTE Confidence: 0.99558383

00:17:16.500 --> 00:17:17.540
imaging and what type of

NOTE Confidence: 0.99558383

00:17:17.540 --> 00:17:18.900
skeletal imaging we are choosing

NOTE Confidence: 0.99558383

00:17:18.900 --> 00:17:19.940
now for our patients with

NOTE Confidence: 0.99558383

00:17:19.940 --> 00:17:20.440
MGUS.

NOTE Confidence: 0.99818563

00:17:21.460 --> 00:17:22.920
As already mentioned,

NOTE Confidence: 0.9134438

00:17:23.460 --> 00:17:24.680
IgA gamopathies

NOTE Confidence: 0.9996985

00:17:25.220 --> 00:17:25.960
are unique

NOTE Confidence: 0.973965

00:17:26.875 --> 00:17:27.835
in a couple of different

NOTE Confidence: 0.973965

00:17:27.835 --> 00:17:28.335
ways.

NOTE Confidence: 0.9379341

00:17:28.635 --> 00:17:30.234
The first being where we

NOTE Confidence: 0.9379341

00:17:30.234 --> 00:17:31.915
see the band migrating on

NOTE Confidence: 0.9379341

00:17:31.915 --> 00:17:32.575
the SPEP,

NOTE Confidence: 0.9890812

00:17:33.115 --> 00:17:34.395
in the beta region as

NOTE Confidence: 0.9890812

00:17:34.395 --> 00:17:35.595
opposed to the gamma region,

NOTE Confidence: 0.9890812

00:17:35.595 --> 00:17:36.635
which is where we see,

NOTE Confidence: 0.9890812

00:17:37.035 --> 00:17:38.415
the majority of our monoclonal

NOTE Confidence: 0.9890812

00:17:38.475 --> 00:17:40.255
gamopathies or monoclonal proteins.

NOTE Confidence: 0.999646

00:17:40.710 --> 00:17:42.090
And this may underestimate

NOTE Confidence: 0.9763716

00:17:42.630 --> 00:17:44.230
the, burden of,

NOTE Confidence: 0.99561626

00:17:44.710 --> 00:17:45.909
clonal plasma cells in the

NOTE Confidence: 0.99561626

00:17:45.909 --> 00:17:47.289
bone marrow. And so,

NOTE Confidence: 0.968089

00:17:47.669 --> 00:17:49.030
with an IgA MGUS, it's

NOTE Confidence: 0.968089

00:17:49.030 --> 00:17:50.230
important to remember, and we'll

NOTE Confidence: 0.968089

00:17:50.230 --> 00:17:51.669
talk through why, you know,

NOTE Confidence: 0.968089

00:17:51.669 --> 00:17:53.109
we never really refer to

NOTE Confidence: 0.968089

00:17:53.109 --> 00:17:54.390
an IgA MGUS or an

NOTE Confidence: 0.968089

00:17:54.390 --> 00:17:56.205
IgA gammopathy as low risk.

NOTE Confidence: 0.92466736

00:17:58.765 --> 00:18:00.365
So this scheme, again, you've

NOTE Confidence: 0.92466736

00:18:00.365 --> 00:18:00.865
seen,

NOTE Confidence: 0.97919244

00:18:01.565 --> 00:18:03.424
illustrates the spectrum of monoclonal

NOTE Confidence: 0.97919244

00:18:03.565 --> 00:18:04.065
gammopathy

NOTE Confidence: 0.8160597

00:18:04.445 --> 00:18:04.945
importantly,

NOTE Confidence: 0.98322517

00:18:05.484 --> 00:18:07.244
in our patient's case. If

NOTE Confidence: 0.98322517

00:18:07.244 --> 00:18:08.144
you can advance,

NOTE Confidence: 0.94710934

00:18:08.765 --> 00:18:10.125
Nofar, she had less than

NOTE Confidence: 0.94710934

00:18:10.125 --> 00:18:12.065
ten percent clonal plasma cells

NOTE Confidence: 0.9745544

00:18:12.409 --> 00:18:13.929
consistent with an MGUS with

NOTE Confidence: 0.9745544

00:18:13.929 --> 00:18:14.890
a one percent risk per

NOTE Confidence: 0.9745544

00:18:14.890 --> 00:18:16.429
year of progressing to myeloma.

NOTE Confidence: 0.9745544

00:18:16.650 --> 00:18:17.369
We could go to the

NOTE Confidence: 0.9745544

00:18:17.369 --> 00:18:18.109
next slide.

NOTE Confidence: 0.9954926

00:18:18.570 --> 00:18:19.789
So this table outlines,

NOTE Confidence: 0.987526

00:18:20.090 --> 00:18:21.710
in further detail the definition

NOTE Confidence: 0.987526

00:18:21.929 --> 00:18:22.669
of MGUS.

NOTE Confidence: 0.9747701

00:18:23.369 --> 00:18:25.690
Importantly, with non IgM MGUS

NOTE Confidence: 0.9747701

00:18:25.690 --> 00:18:26.830
and light chain MGUS,

NOTE Confidence: 0.9832062

00:18:27.135 --> 00:18:28.655
the risk of progression is

NOTE Confidence: 0.9832062

00:18:28.655 --> 00:18:30.815
to multiple myeloma or, light

NOTE Confidence: 0.9832062

00:18:30.815 --> 00:18:31.955
chain or AL amyloidosis.

NOTE Confidence: 0.9745453

00:18:32.335 --> 00:18:33.055
And this is as,

NOTE Confidence: 0.89882374

00:18:34.255 --> 00:18:36.115
indifferent from an IgM MGUS

NOTE Confidence: 0.8751872

00:18:36.655 --> 00:18:38.195
where if patients progress,

NOTE Confidence: 0.9338176

00:18:38.575 --> 00:18:39.809
the majority of the time,

NOTE Confidence: 0.9338176

00:18:39.809 --> 00:18:40.769
they progress to a a

NOTE Confidence: 0.9338176

00:18:40.769 --> 00:18:41.269
lymphoplasmacytic

NOTE Confidence: 0.97536385

00:18:41.809 --> 00:18:43.009
lymphoma or what we refer

NOTE Confidence: 0.97536385

00:18:43.009 --> 00:18:44.549
to as Waldenstrom macroglobulinemia

NOTE Confidence: 0.847583

00:18:45.649 --> 00:18:46.549
with an IGM

NOTE Confidence: 0.93557453

00:18:47.090 --> 00:18:49.269
IGM myeloma being very rare.

NOTE Confidence: 0.990511

00:18:49.570 --> 00:18:51.169
And, as you can see

NOTE Confidence: 0.990511

00:18:51.169 --> 00:18:52.725
across all three of these,

NOTE Confidence: 0.990511

00:18:52.784 --> 00:18:53.284
importantly,

NOTE Confidence: 0.99451846

00:18:53.825 --> 00:18:54.565
the clonal,

NOTE Confidence: 0.9843085

00:18:55.105 --> 00:18:56.385
bone marrow cells are less

NOTE Confidence: 0.9843085

00:18:56.385 --> 00:18:57.365
than ten percent.

NOTE Confidence: 0.9614547

00:18:58.065 --> 00:18:59.825
With non IgM MGUS and

NOTE Confidence: 0.9614547

00:18:59.825 --> 00:19:01.424
IgM MGUS serum m protein

NOTE Confidence: 0.9614547

00:19:01.424 --> 00:19:02.544
is less than three grams.

NOTE Confidence: 0.9614547

00:19:02.544 --> 00:19:04.140
And with light chain MGUS,

NOTE Confidence: 0.9614547

00:19:04.140 --> 00:19:05.340
we see an abnormal light

NOTE Confidence: 0.9614547

00:19:05.340 --> 00:19:06.859
chain ratio and a urine

NOTE Confidence: 0.9614547

00:19:06.859 --> 00:19:08.220
monoclonal protein less than five

NOTE Confidence: 0.9614547

00:19:08.220 --> 00:19:09.420
hundred milligrams on a twenty

NOTE Confidence: 0.9614547

00:19:09.420 --> 00:19:10.400
four hour urine.

NOTE Confidence: 0.90994495

00:19:10.940 --> 00:19:12.140
And, as you can see

NOTE Confidence: 0.90994495

00:19:12.140 --> 00:19:13.020
here on the table with

NOTE Confidence: 0.90994495

00:19:13.020 --> 00:19:14.220
IgM MGUS, there may at

NOTE Confidence: 0.90994495

00:19:14.220 --> 00:19:15.820
least initially be a slightly

NOTE Confidence: 0.90994495

00:19:15.820 --> 00:19:16.710
higher risk of progression,

NOTE Confidence: 0.9528308

00:19:17.525 --> 00:19:18.804
compared to the non IgM

NOTE Confidence: 0.9528308

00:19:18.804 --> 00:19:20.005
MGUS and the light chain,

NOTE Confidence: 0.9528308

00:19:20.164 --> 00:19:21.225
a little bit lower.

NOTE Confidence: 0.93079656

00:19:21.684 --> 00:19:22.244
And we could go to

NOTE Confidence: 0.93079656

00:19:22.244 --> 00:19:23.225
the next slide.

NOTE Confidence: 0.97521347

00:19:24.484 --> 00:19:26.565
So historically, the prevalence of

NOTE Confidence: 0.97521347

00:19:26.565 --> 00:19:28.484
MGUS in individuals over the

NOTE Confidence: 0.97521347

00:19:28.484 --> 00:19:29.765
age of fifty has been

NOTE Confidence: 0.97521347

00:19:29.765 --> 00:19:30.904
reported at three

NOTE Confidence: 0.98269916

00:19:31.330 --> 00:19:33.110
percent. Doctor Barr mentioned that

NOTE Confidence: 0.98269916

00:19:33.330 --> 00:19:34.630
there's a large population,

NOTE Confidence: 0.9766435

00:19:35.810 --> 00:19:37.810
population screening study that was

NOTE Confidence: 0.9766435

00:19:37.810 --> 00:19:39.650
performed in Iceland where approximately

NOTE Confidence: 0.9766435

00:19:39.650 --> 00:19:41.730
seventy five thousand, individuals were

NOTE Confidence: 0.9766435

00:19:41.730 --> 00:19:43.350
screened for monoclonal gammopathy.

NOTE Confidence: 0.946005

00:19:43.865 --> 00:19:44.825
And the prevalence that came

NOTE Confidence: 0.946005

00:19:44.825 --> 00:19:45.625
out of that study was

NOTE Confidence: 0.946005

00:19:45.625 --> 00:19:46.585
a bit higher at five

NOTE Confidence: 0.946005

00:19:46.585 --> 00:19:48.265
percent of individuals over the

NOTE Confidence: 0.946005

00:19:48.265 --> 00:19:49.145
age of fifty. And that

NOTE Confidence: 0.946005

00:19:49.145 --> 00:19:50.265
was that was called the

NOTE Confidence: 0.946005

00:19:50.265 --> 00:19:52.585
I ISTOP, my study, which

NOTE Confidence: 0.946005

00:19:52.585 --> 00:19:53.645
occurred in Iceland.

NOTE Confidence: 0.9946371

00:19:54.825 --> 00:19:56.760
Importantly, MGUS can occur up

NOTE Confidence: 0.9946371

00:19:56.760 --> 00:19:58.119
to four times more,

NOTE Confidence: 0.96220016

00:19:58.560 --> 00:20:00.360
is four times more common

NOTE Confidence: 0.96220016

00:20:00.360 --> 00:20:01.960
in black or African American

NOTE Confidence: 0.96220016

00:20:01.960 --> 00:20:03.400
individuals, and the prevalence may

NOTE Confidence: 0.96220016

00:20:03.400 --> 00:20:04.619
be high in that population.

NOTE Confidence: 0.9885469

00:20:05.320 --> 00:20:06.280
And then we talked about

NOTE Confidence: 0.9885469

00:20:06.280 --> 00:20:07.965
the uniqueness of IgA

NOTE Confidence: 0.97062194

00:20:08.284 --> 00:20:09.184
type gammopathy.

NOTE Confidence: 0.9641401

00:20:10.044 --> 00:20:11.325
It it has been shown

NOTE Confidence: 0.9641401

00:20:11.325 --> 00:20:13.244
in studies to potentially rise

NOTE Confidence: 0.9641401

00:20:13.244 --> 00:20:14.845
more slowly through the prevalence

NOTE Confidence: 0.9641401

00:20:14.845 --> 00:20:16.125
of it rising more slowly

NOTE Confidence: 0.9641401

00:20:16.125 --> 00:20:16.784
with age,

NOTE Confidence: 0.9930688

00:20:17.085 --> 00:20:17.885
although it's thought to be

NOTE Confidence: 0.9930688

00:20:17.885 --> 00:20:19.585
associated with more rapid progression.

NOTE Confidence: 0.9930688

00:20:19.645 --> 00:20:20.945
And in that same

NOTE Confidence: 0.9519808

00:20:21.270 --> 00:20:21.670
large,

NOTE Confidence: 0.78972656

00:20:22.070 --> 00:20:23.850
population screening study, the iStop

NOTE Confidence: 0.78972656

00:20:23.990 --> 00:20:24.650
M study,

NOTE Confidence: 0.9987103

00:20:25.830 --> 00:20:26.730
the investigators

NOTE Confidence: 0.98156667

00:20:27.030 --> 00:20:28.869
looked at, patients with IgA

NOTE Confidence: 0.98156667

00:20:28.869 --> 00:20:30.150
MGUS and compared to them

NOTE Confidence: 0.98156667

00:20:30.150 --> 00:20:31.670
to IgG MGUS and found

NOTE Confidence: 0.98156667

00:20:31.670 --> 00:20:32.810
that those with IgA

NOTE Confidence: 0.97855145

00:20:33.335 --> 00:20:34.875
had a a higher frequency

NOTE Confidence: 0.97855145

00:20:35.015 --> 00:20:36.955
of detecting clonal or abnormal

NOTE Confidence: 0.97855145

00:20:37.175 --> 00:20:38.455
plasma cells in the bone

NOTE Confidence: 0.97855145

00:20:38.455 --> 00:20:38.955
marrow.

NOTE Confidence: 0.9784549

00:20:40.135 --> 00:20:41.175
And so, again, we talked

NOTE Confidence: 0.9784549

00:20:41.175 --> 00:20:42.395
about how with IgA,

NOTE Confidence: 0.9525927

00:20:42.775 --> 00:20:44.175
the m protein may not

NOTE Confidence: 0.9525927

00:20:44.175 --> 00:20:45.575
be a true reflection of

NOTE Confidence: 0.9525927

00:20:45.575 --> 00:20:47.170
the disease burden. And so

NOTE Confidence: 0.9525927

00:20:47.170 --> 00:20:48.050
it's really important to look

NOTE Confidence: 0.9525927

00:20:48.050 --> 00:20:49.570
at IgA levels, serum free

NOTE Confidence: 0.9525927

00:20:49.570 --> 00:20:50.609
light chains, and we'll talk

NOTE Confidence: 0.9525927

00:20:50.609 --> 00:20:52.210
about further workup for our

NOTE Confidence: 0.9525927

00:20:52.210 --> 00:20:53.109
IgA gamopathies.

NOTE Confidence: 0.9897869

00:20:54.369 --> 00:20:56.310
So important when we're considering,

NOTE Confidence: 0.9961766

00:20:56.930 --> 00:20:58.710
the need for additional workup

NOTE Confidence: 0.9914236

00:20:59.215 --> 00:20:59.794
for MGUS,

NOTE Confidence: 0.8580538

00:21:00.575 --> 00:21:01.054
is,

NOTE Confidence: 0.98781306

00:21:01.615 --> 00:21:02.975
risk stratifying. And so we

NOTE Confidence: 0.98781306

00:21:02.975 --> 00:21:03.615
do that,

NOTE Confidence: 0.9836663

00:21:03.934 --> 00:21:06.195
with these three, different factors.

NOTE Confidence: 0.95506257

00:21:06.975 --> 00:21:08.595
Individuals who have an IgG

NOTE Confidence: 0.95506257

00:21:08.734 --> 00:21:10.894
type monoclonal gammopathy, a serum

NOTE Confidence: 0.95506257

00:21:10.894 --> 00:21:12.660
and protein in the, in

NOTE Confidence: 0.95506257

00:21:12.660 --> 00:21:13.860
the serum less than one

NOTE Confidence: 0.95506257

00:21:13.860 --> 00:21:15.140
point five grams in normal

NOTE Confidence: 0.95506257

00:21:15.140 --> 00:21:15.880
light chain,

NOTE Confidence: 0.94506645

00:21:16.340 --> 00:21:17.619
meet the criteria for low

NOTE Confidence: 0.94506645

00:21:17.619 --> 00:21:19.300
risk MGUS. And generally in

NOTE Confidence: 0.94506645

00:21:19.300 --> 00:21:20.900
these patients, we, in the

NOTE Confidence: 0.94506645

00:21:20.900 --> 00:21:22.600
absence of any evidence of

NOTE Confidence: 0.94506645

00:21:22.660 --> 00:21:24.100
the slim crab criteria or

NOTE Confidence: 0.94506645

00:21:24.100 --> 00:21:25.540
end organ damage, we are

NOTE Confidence: 0.94506645

00:21:25.540 --> 00:21:27.380
able to, withhold bone marrow

NOTE Confidence: 0.94506645

00:21:27.380 --> 00:21:29.355
biopsy aspiration and skeletal imaging.

NOTE Confidence: 0.94506645

00:21:29.355 --> 00:21:30.555
And there has been studies

NOTE Confidence: 0.94506645

00:21:30.555 --> 00:21:31.455
looking at this

NOTE Confidence: 0.96547794

00:21:31.835 --> 00:21:33.035
and show in those that

NOTE Confidence: 0.96547794

00:21:33.035 --> 00:21:34.175
meet all three criteria,

NOTE Confidence: 0.96353537

00:21:34.795 --> 00:21:35.915
if we do do not

NOTE Confidence: 0.96353537

00:21:35.915 --> 00:21:37.435
do a bone marrow, we

NOTE Confidence: 0.96353537

00:21:37.435 --> 00:21:38.795
miss less than one percent

NOTE Confidence: 0.96353537

00:21:38.795 --> 00:21:39.755
of patients that could have

NOTE Confidence: 0.96353537

00:21:39.755 --> 00:21:41.515
clinical or active myeloma. And

NOTE Confidence: 0.96353537

00:21:41.515 --> 00:21:42.015
this,

NOTE Confidence: 0.970451

00:21:43.130 --> 00:21:44.170
show it has shown in

NOTE Confidence: 0.970451

00:21:44.170 --> 00:21:46.110
studies also that this population

NOTE Confidence: 0.970451

00:21:46.170 --> 00:21:47.290
has an absolute risk of

NOTE Confidence: 0.970451

00:21:47.290 --> 00:21:48.730
progression at twenty years. It's

NOTE Confidence: 0.970451

00:21:48.730 --> 00:21:50.030
very low at two percent.

NOTE Confidence: 0.95677483

00:21:50.730 --> 00:21:51.850
Now all those that don't

NOTE Confidence: 0.95677483

00:21:51.850 --> 00:21:53.130
meet these criteria, we refer

NOTE Confidence: 0.95677483

00:21:53.130 --> 00:21:54.750
to as non risk, gammopathy.

NOTE Confidence: 0.9884831

00:21:55.050 --> 00:21:56.650
And these are patients where,

NOTE Confidence: 0.9988216

00:21:57.290 --> 00:21:58.575
we definitely want to at

NOTE Confidence: 0.9988216

00:21:58.575 --> 00:21:59.295
least see them in the

NOTE Confidence: 0.9988216

00:21:59.295 --> 00:22:00.915
hematology clinic to discuss

NOTE Confidence: 0.9397921

00:22:01.295 --> 00:22:02.255
whether or not they warrant

NOTE Confidence: 0.9397921

00:22:02.255 --> 00:22:03.295
a bone marrow biopsy,

NOTE Confidence: 0.9306488

00:22:03.615 --> 00:22:05.215
and skeletal image. And and

NOTE Confidence: 0.9306488

00:22:05.215 --> 00:22:06.434
historically for MGUS,

NOTE Confidence: 0.96757275

00:22:06.895 --> 00:22:07.775
for many years, we had

NOTE Confidence: 0.96757275

00:22:07.775 --> 00:22:09.455
been using skeletal surveys, which

NOTE Confidence: 0.96757275

00:22:09.455 --> 00:22:10.415
we know now have very

NOTE Confidence: 0.96757275

00:22:10.415 --> 00:22:12.429
poor sensitivity and specificity. And

NOTE Confidence: 0.96757275

00:22:12.429 --> 00:22:14.269
so guideline recommendations is is

NOTE Confidence: 0.96757275

00:22:14.269 --> 00:22:15.470
instead to use a low

NOTE Confidence: 0.96757275

00:22:15.470 --> 00:22:16.909
dose whole body CT, which

NOTE Confidence: 0.96757275

00:22:16.909 --> 00:22:17.970
we now have available,

NOTE Confidence: 0.98233527

00:22:18.830 --> 00:22:20.029
at the York Street campus

NOTE Confidence: 0.98233527

00:22:20.029 --> 00:22:20.850
for our patients.

NOTE Confidence: 0.9923006

00:22:21.549 --> 00:22:23.169
So in summary, in individuals

NOTE Confidence: 0.9923006

00:22:23.230 --> 00:22:24.669
who have a confirmed MGUS,

NOTE Confidence: 0.9923006

00:22:24.669 --> 00:22:25.789
whether that's a low risk

NOTE Confidence: 0.9923006

00:22:25.789 --> 00:22:26.289
MGUS,

NOTE Confidence: 0.9825854

00:22:27.335 --> 00:22:28.935
who don't warrant any further

NOTE Confidence: 0.9825854

00:22:28.935 --> 00:22:30.535
workup or patients who have

NOTE Confidence: 0.9825854

00:22:30.535 --> 00:22:31.815
a bone marrow biopsy and

NOTE Confidence: 0.9825854

00:22:31.815 --> 00:22:32.535
are found to have less

NOTE Confidence: 0.9825854

00:22:32.535 --> 00:22:33.975
than ten percent clonal plasma

NOTE Confidence: 0.9825854

00:22:33.975 --> 00:22:34.475
cells,

NOTE Confidence: 0.9924672

00:22:34.775 --> 00:22:35.515
our management,

NOTE Confidence: 0.9384459

00:22:35.895 --> 00:22:37.595
is observation and clinical,

NOTE Confidence: 0.94900125

00:22:38.055 --> 00:22:39.990
laboratory follow-up every six months

NOTE Confidence: 0.94900125

00:22:39.990 --> 00:22:41.510
initially in those patients who

NOTE Confidence: 0.94900125

00:22:41.510 --> 00:22:42.650
may be more stable

NOTE Confidence: 0.9884879

00:22:43.030 --> 00:22:44.150
over a longer period of

NOTE Confidence: 0.9884879

00:22:44.150 --> 00:22:45.510
time. We sometimes extend that

NOTE Confidence: 0.9884879

00:22:45.510 --> 00:22:47.210
out, to annual follow-up.

NOTE Confidence: 0.9816632

00:22:49.670 --> 00:22:50.550
So before we move to

NOTE Confidence: 0.9816632

00:22:50.550 --> 00:22:51.430
the next case, I wanted

NOTE Confidence: 0.9816632

00:22:51.430 --> 00:22:52.790
to introduce our SMILO multiple

NOTE Confidence: 0.9816632

00:22:52.790 --> 00:22:54.730
myeloma and gammopathies program,

NOTE Confidence: 0.9668539

00:22:55.484 --> 00:22:55.965
which,

NOTE Confidence: 0.9143327

00:22:56.285 --> 00:22:57.725
includes, in addition to doctor

NOTE Confidence: 0.9143327

00:22:57.725 --> 00:22:59.244
Barr and myself, doctor Natalia

NOTE Confidence: 0.9143327

00:22:59.244 --> 00:23:00.925
Neparizzi, doctor Terry Parker, and

NOTE Confidence: 0.9143327

00:23:00.925 --> 00:23:02.065
doctor Elaine Gorshine,

NOTE Confidence: 0.9434211

00:23:02.765 --> 00:23:04.285
who sees patients in at

NOTE Confidence: 0.9434211

00:23:04.285 --> 00:23:05.805
our SMILO North Haven location

NOTE Confidence: 0.9434211

00:23:05.805 --> 00:23:07.025
and Smilo Guilford.

NOTE Confidence: 0.9823208

00:23:07.799 --> 00:23:08.600
Many of you may be

NOTE Confidence: 0.9823208

00:23:08.600 --> 00:23:09.100
familiar,

NOTE Confidence: 0.96339494

00:23:09.480 --> 00:23:10.840
through Yale Medicine with the

NOTE Confidence: 0.96339494

00:23:10.840 --> 00:23:12.619
hematology eConsult program,

NOTE Confidence: 0.98355716

00:23:13.399 --> 00:23:14.600
that I think may be

NOTE Confidence: 0.98355716

00:23:14.600 --> 00:23:16.119
a good option specifically for

NOTE Confidence: 0.98355716

00:23:16.119 --> 00:23:17.720
patients who who have low

NOTE Confidence: 0.98355716

00:23:17.720 --> 00:23:19.000
risk MGUS or a question

NOTE Confidence: 0.98355716

00:23:19.000 --> 00:23:20.139
of light chain abnormality

NOTE Confidence: 0.97210234

00:23:20.695 --> 00:23:21.815
either due to age or

NOTE Confidence: 0.97210234

00:23:21.815 --> 00:23:23.595
CKD or a question of

NOTE Confidence: 0.97210234

00:23:23.815 --> 00:23:25.575
polyclonal gammopathy, which we didn't

NOTE Confidence: 0.97210234

00:23:25.575 --> 00:23:26.535
talk much about, but can

NOTE Confidence: 0.97210234

00:23:26.535 --> 00:23:28.615
be associated with, liver disease

NOTE Confidence: 0.97210234

00:23:28.615 --> 00:23:30.535
or chronic infection, connective tissue

NOTE Confidence: 0.97210234

00:23:30.535 --> 00:23:32.295
disorders, and importantly does not

NOTE Confidence: 0.97210234

00:23:32.295 --> 00:23:33.755
have any risk of progression

NOTE Confidence: 0.9971228

00:23:34.210 --> 00:23:35.730
to myeloma or other plasma

NOTE Confidence: 0.9971228

00:23:35.730 --> 00:23:36.470
cell dyscrasias.

NOTE Confidence: 0.9977487

00:23:37.010 --> 00:23:38.130
And then we also hold

NOTE Confidence: 0.9977487

00:23:38.130 --> 00:23:39.750
an MGUS clinic monthly,

NOTE Confidence: 0.8855741

00:23:40.130 --> 00:23:41.490
at our Smilow North Haven

NOTE Confidence: 0.8855741

00:23:41.490 --> 00:23:43.350
location, and, patients,

NOTE Confidence: 0.99473363

00:23:43.890 --> 00:23:44.790
in that clinic,

NOTE Confidence: 0.9812474

00:23:45.410 --> 00:23:46.850
usually are low risk MGUS

NOTE Confidence: 0.9812474

00:23:46.850 --> 00:23:48.055
or kind of less complicated

NOTE Confidence: 0.9812474

00:23:48.115 --> 00:23:49.475
MGUS patients, and the referral

NOTE Confidence: 0.9812474

00:23:49.475 --> 00:23:50.434
to that clinic is through

NOTE Confidence: 0.9812474

00:23:50.434 --> 00:23:51.635
the same referral process to

NOTE Confidence: 0.9812474

00:23:51.635 --> 00:23:53.655
our, gamopathies program.

NOTE Confidence: 0.92625034

00:23:54.994 --> 00:23:55.875
And so I'll turn it

NOTE Confidence: 0.92625034

00:23:55.875 --> 00:23:57.175
back over to doctor Kuttney.

NOTE Confidence: 0.99835527

00:23:58.275 --> 00:23:58.775
Great.

NOTE Confidence: 0.9762065

00:23:59.090 --> 00:24:00.690
Thank you, Sabrina. I think,

NOTE Confidence: 0.91042113

00:24:01.330 --> 00:24:02.530
those are some good pearls

NOTE Confidence: 0.91042113

00:24:02.530 --> 00:24:03.670
there. I love them.

NOTE Confidence: 0.96167934

00:24:04.290 --> 00:24:05.990
So this next case will,

NOTE Confidence: 0.9845625

00:24:06.770 --> 00:24:08.609
look at a sixty nine

NOTE Confidence: 0.9845625

00:24:08.609 --> 00:24:09.270
year old,

NOTE Confidence: 0.9746491

00:24:09.570 --> 00:24:10.070
male,

NOTE Confidence: 0.9888503

00:24:11.157 --> 00:24:12.345
with who came to me

NOTE Confidence: 0.9888503

00:24:12.345 --> 00:24:13.785
in the fall of last

NOTE Confidence: 0.9888503

00:24:13.785 --> 00:24:14.605
year as well,

NOTE Confidence: 0.8282463

00:24:15.545 --> 00:24:17.005
with per like, a progressive

NOTE Confidence: 0.97432375

00:24:17.865 --> 00:24:18.765
distal neuropathy,

NOTE Confidence: 0.85224015

00:24:20.265 --> 00:24:21.865
at least, over the you

NOTE Confidence: 0.85224015

00:24:21.865 --> 00:24:22.365
know,

NOTE Confidence: 0.93350416

00:24:23.305 --> 00:24:24.605
described as pins and needles

NOTE Confidence: 0.93350416

00:24:24.744 --> 00:24:25.705
in the feet and the

NOTE Confidence: 0.93350416

00:24:25.705 --> 00:24:26.205
hands.

NOTE Confidence: 0.9454508

00:24:26.859 --> 00:24:27.899
He described it as being

NOTE Confidence: 0.9454508

00:24:27.899 --> 00:24:28.779
his feet more than his

NOTE Confidence: 0.9454508

00:24:28.779 --> 00:24:29.820
hands and his left foot

NOTE Confidence: 0.9454508

00:24:29.820 --> 00:24:30.960
more than his right foot.

NOTE Confidence: 0.9439068

00:24:31.419 --> 00:24:33.100
And it was particularly worse

NOTE Confidence: 0.9439068

00:24:33.100 --> 00:24:34.559
in the evening with walking,

NOTE Confidence: 0.98546064

00:24:35.179 --> 00:24:35.659
and,

NOTE Confidence: 0.88297147

00:24:35.980 --> 00:24:37.840
there's absolutely no weakness,

NOTE Confidence: 0.95464224

00:24:39.100 --> 00:24:40.720
and you couldn't really identify,

NOTE Confidence: 0.95464224

00:24:40.940 --> 00:24:41.679
you know,

NOTE Confidence: 0.99488

00:24:42.125 --> 00:24:43.485
exactly when or or how

NOTE Confidence: 0.99488

00:24:43.485 --> 00:24:44.445
it had emerged. It was

NOTE Confidence: 0.99488

00:24:44.445 --> 00:24:45.565
just something that just kind

NOTE Confidence: 0.99488

00:24:45.565 --> 00:24:46.945
of slowly developed.

NOTE Confidence: 0.99918896

00:24:47.645 --> 00:24:48.145
And

NOTE Confidence: 0.9373897

00:24:49.005 --> 00:24:50.845
this past medical history is

NOTE Confidence: 0.9373897

00:24:50.845 --> 00:24:52.125
significant for a p c

NOTE Confidence: 0.9373897

00:24:52.445 --> 00:24:53.985
PBC induced cardiomyopathy,

NOTE Confidence: 0.99569285

00:24:55.600 --> 00:24:57.220
diagnosed in two thousand five,

NOTE Confidence: 0.99489045

00:24:58.240 --> 00:25:00.080
which progressed to, you know,

NOTE Confidence: 0.99489045

00:25:00.080 --> 00:25:00.580
paroxysmal,

NOTE Confidence: 0.96227014

00:25:01.359 --> 00:25:03.039
and atrial fibrillation in in

NOTE Confidence: 0.96227014

00:25:03.039 --> 00:25:03.859
twenty fourteen.

NOTE Confidence: 0.94859374

00:25:04.480 --> 00:25:05.440
They thought that was due

NOTE Confidence: 0.94859374

00:25:05.440 --> 00:25:06.559
to his, he he was

NOTE Confidence: 0.94859374

00:25:06.559 --> 00:25:08.340
a very high volume runner

NOTE Confidence: 0.9725561

00:25:08.879 --> 00:25:10.405
at the time. And,

NOTE Confidence: 0.9589908

00:25:10.885 --> 00:25:12.265
he was successfully ablated,

NOTE Confidence: 0.9747739

00:25:13.765 --> 00:25:15.605
and wanted to it's held

NOTE Confidence: 0.9747739

00:25:15.605 --> 00:25:16.265
in sinus

NOTE Confidence: 0.9170307

00:25:16.565 --> 00:25:17.385
rhythm since.

NOTE Confidence: 0.9859821

00:25:18.085 --> 00:25:19.525
His ulcer he did get

NOTE Confidence: 0.9859821

00:25:19.525 --> 00:25:21.365
diagnosed in twenty eleven with

NOTE Confidence: 0.9859821

00:25:21.365 --> 00:25:22.440
ulcerative colitis,

NOTE Confidence: 0.90954447

00:25:23.300 --> 00:25:24.580
and he was being managed

NOTE Confidence: 0.90954447

00:25:24.580 --> 00:25:26.420
with, Lialda four point eight

NOTE Confidence: 0.90954447

00:25:26.420 --> 00:25:27.320
grams per,

NOTE Confidence: 0.96268636

00:25:27.859 --> 00:25:28.359
deciliter

NOTE Confidence: 0.90264684

00:25:29.140 --> 00:25:31.240
sorry. Per day. I'm sorry.

NOTE Confidence: 0.8778027

00:25:32.420 --> 00:25:33.619
Yeah. He was a frequent

NOTE Confidence: 0.8778027

00:25:33.619 --> 00:25:35.240
sport shooter with the

NOTE Confidence: 0.7462059

00:25:35.540 --> 00:25:36.280
lead exposure,

NOTE Confidence: 0.79487145

00:25:36.705 --> 00:25:37.445
from intending

NOTE Confidence: 0.9086377

00:25:37.825 --> 00:25:39.205
the indoor shooting range,

NOTE Confidence: 0.9664523

00:25:40.225 --> 00:25:41.744
and, his serum level lead

NOTE Confidence: 0.9664523

00:25:41.744 --> 00:25:42.244
level,

NOTE Confidence: 0.968482

00:25:42.625 --> 00:25:44.005
was on baseline,

NOTE Confidence: 0.9780761

00:25:44.544 --> 00:25:46.005
twenty to twenty five,

NOTE Confidence: 0.99526566

00:25:46.784 --> 00:25:48.404
since we started checking it.

NOTE Confidence: 0.99526566

00:25:48.625 --> 00:25:50.065
He stopped attending that indoor

NOTE Confidence: 0.99526566

00:25:50.065 --> 00:25:51.365
range in twenty nineteen.

NOTE Confidence: 0.9975789

00:25:52.440 --> 00:25:53.419
And he was also

NOTE Confidence: 0.95966834

00:25:54.279 --> 00:25:55.080
at the time when I,

NOTE Confidence: 0.95966834

00:25:55.080 --> 00:25:55.879
you know, saw him for

NOTE Confidence: 0.95966834

00:25:55.879 --> 00:25:57.399
this neuropathy symptoms, he was

NOTE Confidence: 0.95966834

00:25:57.399 --> 00:25:58.200
taking a lot of zinc

NOTE Confidence: 0.95966834

00:25:58.200 --> 00:25:59.019
for his ulcerative

NOTE Confidence: 0.98368126

00:25:59.559 --> 00:26:01.500
colitis for whatever reason.

NOTE Confidence: 0.9021925

00:26:01.960 --> 00:26:02.779
Next slide.

NOTE Confidence: 0.9107463

00:26:05.545 --> 00:26:06.845
Other comorbid included

NOTE Confidence: 0.8339238

00:26:07.145 --> 00:26:07.545
some,

NOTE Confidence: 0.9695168

00:26:08.185 --> 00:26:08.685
BPH,

NOTE Confidence: 0.91831905

00:26:09.385 --> 00:26:10.285
you know, prostatic

NOTE Confidence: 0.8837208

00:26:10.984 --> 00:26:11.484
hyperplasia,

NOTE Confidence: 0.9996414

00:26:11.865 --> 00:26:12.925
and some tinnitus.

NOTE Confidence: 0.8912263

00:26:13.705 --> 00:26:14.345
He had,

NOTE Confidence: 0.94357437

00:26:14.984 --> 00:26:16.525
a couple of meniscus surgeries

NOTE Confidence: 0.94357437

00:26:16.825 --> 00:26:18.825
in the two thousands. I

NOTE Confidence: 0.94357437

00:26:18.825 --> 00:26:20.420
think both knees were affected.

NOTE Confidence: 0.9478451

00:26:20.800 --> 00:26:22.660
And, he's a software developer.

NOTE Confidence: 0.9137347

00:26:22.960 --> 00:26:24.320
He played the electric guitar,

NOTE Confidence: 0.9137347

00:26:24.320 --> 00:26:26.400
hence his tinnitus and, a

NOTE Confidence: 0.9137347

00:26:26.400 --> 00:26:28.260
little social alcohol, no elicits.

NOTE Confidence: 0.9110758

00:26:28.880 --> 00:26:30.180
He's married, three kids,

NOTE Confidence: 0.94734436

00:26:30.800 --> 00:26:33.520
distant smoking history, small amount,

NOTE Confidence: 0.94734436

00:26:33.520 --> 00:26:35.200
seven pack years. Spent a

NOTE Confidence: 0.94734436

00:26:35.200 --> 00:26:35.895
lot of time out

NOTE Confidence: 0.9931838

00:26:36.775 --> 00:26:37.175
outdoors.

NOTE Confidence: 0.8036153

00:26:37.734 --> 00:26:38.855
On the note on the

NOTE Confidence: 0.8036153

00:26:38.855 --> 00:26:39.915
family history,

NOTE Confidence: 0.9524099

00:26:40.615 --> 00:26:42.295
Crohn's disease and dementia, his

NOTE Confidence: 0.9524099

00:26:42.295 --> 00:26:43.494
mother and his father had

NOTE Confidence: 0.9524099

00:26:43.494 --> 00:26:45.095
type two diabetes, and his

NOTE Confidence: 0.9524099

00:26:45.095 --> 00:26:46.695
brother had Crohn's disease. And

NOTE Confidence: 0.9524099

00:26:46.695 --> 00:26:47.435
his sister,

NOTE Confidence: 0.89667684

00:26:48.310 --> 00:26:49.350
was suspected to have a

NOTE Confidence: 0.89667684

00:26:49.350 --> 00:26:50.950
non Hodgkin's lymphoma. I can

NOTE Confidence: 0.89667684

00:26:50.950 --> 00:26:51.770
really confirm

NOTE Confidence: 0.8341626

00:26:52.710 --> 00:26:54.090
the the details on that.

NOTE Confidence: 0.93093985

00:26:54.470 --> 00:26:55.350
And then we did an

NOTE Confidence: 0.93093985

00:26:55.350 --> 00:26:55.850
evaluation

NOTE Confidence: 0.9007949

00:26:56.150 --> 00:26:57.050
for his neuropathy.

NOTE Confidence: 0.99720347

00:26:58.710 --> 00:26:59.210
And

NOTE Confidence: 0.9988715

00:27:00.645 --> 00:27:01.145
the

NOTE Confidence: 0.5014536

00:27:01.925 --> 00:27:02.425
the

NOTE Confidence: 0.9402371

00:27:03.365 --> 00:27:04.885
notables are, like, you know,

NOTE Confidence: 0.9402371

00:27:04.885 --> 00:27:07.045
no anemia, normal creatinine, normal

NOTE Confidence: 0.9402371

00:27:07.045 --> 00:27:07.545
calcium.

NOTE Confidence: 0.98040515

00:27:08.085 --> 00:27:09.545
He had no no monoclonal

NOTE Confidence: 0.98040515

00:27:09.685 --> 00:27:10.905
bands on the SPEP.

NOTE Confidence: 0.92357856

00:27:12.260 --> 00:27:13.880
He had an IgA Lambda,

NOTE Confidence: 0.9931263

00:27:14.580 --> 00:27:16.680
that presented on the immunopixation

NOTE Confidence: 0.8773298

00:27:18.420 --> 00:27:20.119
and normal immunoglobulins,

NOTE Confidence: 0.9616365

00:27:20.740 --> 00:27:21.540
and then his,

NOTE Confidence: 0.8616984

00:27:23.300 --> 00:27:24.119
light chain,

NOTE Confidence: 0.91391903

00:27:26.135 --> 00:27:27.255
his lambda light chain of

NOTE Confidence: 0.91391903

00:27:27.255 --> 00:27:28.615
sixty one point two with

NOTE Confidence: 0.91391903

00:27:28.615 --> 00:27:29.095
a,

NOTE Confidence: 0.9779391

00:27:30.135 --> 00:27:32.075
a significantly decreased ratio

NOTE Confidence: 0.99782056

00:27:32.615 --> 00:27:34.315
of zero point zero three

NOTE Confidence: 0.9328003

00:27:34.775 --> 00:27:35.975
was there. And then end

NOTE Confidence: 0.9328003

00:27:35.975 --> 00:27:37.494
of note two, he had

NOTE Confidence: 0.9328003

00:27:37.494 --> 00:27:39.359
this Lyme antibody that was

NOTE Confidence: 0.94283706

00:27:40.080 --> 00:27:41.920
quite high at four point

NOTE Confidence: 0.94283706

00:27:41.920 --> 00:27:42.420
zero.

NOTE Confidence: 0.9782663

00:27:44.320 --> 00:27:45.520
I treated him for Lyme

NOTE Confidence: 0.9782663

00:27:45.520 --> 00:27:46.020
disease.

NOTE Confidence: 0.93871945

00:27:46.799 --> 00:27:48.100
Symptoms didn't change,

NOTE Confidence: 0.93580544

00:27:48.400 --> 00:27:49.600
so I repeated the,

NOTE Confidence: 0.7130627

00:27:50.480 --> 00:27:51.675
the serum free limed,

NOTE Confidence: 0.95079446

00:27:52.235 --> 00:27:53.915
light chains again because, hey,

NOTE Confidence: 0.95079446

00:27:53.915 --> 00:27:55.355
maybe they they got better,

NOTE Confidence: 0.95079446

00:27:55.355 --> 00:27:56.255
but they didn't.

NOTE Confidence: 0.9607179

00:27:57.835 --> 00:27:58.335
And,

NOTE Confidence: 0.7870825

00:27:58.795 --> 00:27:59.915
it referred them on to

NOTE Confidence: 0.7870825

00:27:59.915 --> 00:28:00.415
hematology.

NOTE Confidence: 0.8917166

00:28:01.595 --> 00:28:03.035
And he, you really he

NOTE Confidence: 0.8917166

00:28:03.035 --> 00:28:03.915
went on and got a

NOTE Confidence: 0.8917166

00:28:03.915 --> 00:28:05.115
bone marrow biopsy, and you

NOTE Confidence: 0.8917166

00:28:05.115 --> 00:28:06.815
had ten percent plasma cells

NOTE Confidence: 0.99421245

00:28:07.420 --> 00:28:08.080
with the

NOTE Confidence: 0.6512861

00:28:08.460 --> 00:28:09.280
lambda restriction.

NOTE Confidence: 0.9988009

00:28:09.900 --> 00:28:10.400
And

NOTE Confidence: 0.94254094

00:28:11.500 --> 00:28:12.960
we have a you know,

NOTE Confidence: 0.9472823

00:28:14.780 --> 00:28:15.980
and for discussion, we'll go

NOTE Confidence: 0.9472823

00:28:15.980 --> 00:28:17.660
back to doctor Browning. Great.

NOTE Confidence: 0.9472823

00:28:17.660 --> 00:28:19.260
Thank you. So I think

NOTE Confidence: 0.9472823

00:28:19.260 --> 00:28:19.755
what

NOTE Confidence: 0.99195814

00:28:20.155 --> 00:28:21.275
the difference we're seeing here

NOTE Confidence: 0.99195814

00:28:21.275 --> 00:28:22.635
compared to the first case

NOTE Confidence: 0.99195814

00:28:22.635 --> 00:28:23.755
is that this patient does

NOTE Confidence: 0.99195814

00:28:23.755 --> 00:28:25.915
have ten percent, clonal plasma

NOTE Confidence: 0.99195814

00:28:25.915 --> 00:28:27.135
cells in the bone marrow,

NOTE Confidence: 0.99723154

00:28:27.994 --> 00:28:29.355
which qualifies for at least

NOTE Confidence: 0.99723154

00:28:29.355 --> 00:28:30.415
smoldering myeloma.

NOTE Confidence: 0.9659392

00:28:31.275 --> 00:28:32.075
Looks like he had a

NOTE Confidence: 0.9659392

00:28:32.075 --> 00:28:33.115
PET scan that didn't show

NOTE Confidence: 0.9659392

00:28:33.115 --> 00:28:34.655
any bone lesions. So importantly,

NOTE Confidence: 0.93143654

00:28:35.269 --> 00:28:36.789
with smoldering myeloma, what we're

NOTE Confidence: 0.93143654

00:28:36.789 --> 00:28:37.990
looking to do again is

NOTE Confidence: 0.93143654

00:28:37.990 --> 00:28:39.750
to exclude the slim CRAB

NOTE Confidence: 0.93143654

00:28:39.750 --> 00:28:40.250
criteria.

NOTE Confidence: 0.9842558

00:28:41.509 --> 00:28:42.629
So no evidence of bone

NOTE Confidence: 0.9842558

00:28:42.629 --> 00:28:44.309
lesions. The light chain ratio

NOTE Confidence: 0.9842558

00:28:44.309 --> 00:28:45.269
was less than,

NOTE Confidence: 0.91376066

00:28:45.590 --> 00:28:46.250
a hundred.

NOTE Confidence: 0.972472

00:28:47.110 --> 00:28:48.149
And so, you know, he

NOTE Confidence: 0.972472

00:28:48.149 --> 00:28:50.355
meets criteria for a smoldering

NOTE Confidence: 0.972472

00:28:50.355 --> 00:28:51.955
or asymptomatic myeloma, which I

NOTE Confidence: 0.972472

00:28:51.955 --> 00:28:53.075
think what I think is

NOTE Confidence: 0.972472

00:28:53.075 --> 00:28:55.235
complicated or challenging is the

NOTE Confidence: 0.972472

00:28:55.235 --> 00:28:56.855
addition of the the neuropathy

NOTE Confidence: 0.972472

00:28:56.995 --> 00:28:58.135
and question of cardiac

NOTE Confidence: 0.8620783

00:28:58.515 --> 00:29:00.990
cardio cardiac disease, which certainly

NOTE Confidence: 0.8620783

00:29:00.990 --> 00:29:02.050
raises concern,

NOTE Confidence: 0.8965983

00:29:02.510 --> 00:29:03.790
specifically for late chain or

NOTE Confidence: 0.8965983

00:29:03.790 --> 00:29:04.530
AL amyloidosis,

NOTE Confidence: 0.99959016

00:29:04.910 --> 00:29:05.970
which can be seen

NOTE Confidence: 0.88864666

00:29:06.270 --> 00:29:08.270
more frequently in lambda tympic

NOTE Confidence: 0.88864666

00:29:08.270 --> 00:29:08.770
gammopathies.

NOTE Confidence: 0.9868015

00:29:09.630 --> 00:29:10.350
So I think we can

NOTE Confidence: 0.9868015

00:29:10.350 --> 00:29:11.150
go on to the next

NOTE Confidence: 0.9868015

00:29:11.150 --> 00:29:11.650
slide.

NOTE Confidence: 0.8826406

00:29:12.925 --> 00:29:14.045
So again in this case,

NOTE Confidence: 0.8826406

00:29:14.045 --> 00:29:15.005
the patient has,

NOTE Confidence: 0.9175693

00:29:15.485 --> 00:29:17.745
ten percent clonal plasma cells,

NOTE Confidence: 0.9871898

00:29:18.285 --> 00:29:20.045
significant for a smoldering myeloma.

NOTE Confidence: 0.9871898

00:29:20.045 --> 00:29:20.785
We've excluded

NOTE Confidence: 0.9330126

00:29:21.165 --> 00:29:22.525
CRAB criteria, and then he

NOTE Confidence: 0.9330126

00:29:22.525 --> 00:29:23.725
has no evidence of the

NOTE Confidence: 0.9330126

00:29:23.725 --> 00:29:25.345
slim criteria either.

NOTE Confidence: 0.9687636

00:29:26.980 --> 00:29:28.500
And so this figure here

NOTE Confidence: 0.9687636

00:29:28.500 --> 00:29:29.700
shows the difference in the

NOTE Confidence: 0.9687636

00:29:29.700 --> 00:29:30.900
risk of progression as you

NOTE Confidence: 0.9687636

00:29:30.900 --> 00:29:32.500
can see, compared to a

NOTE Confidence: 0.9687636

00:29:32.500 --> 00:29:33.780
one percent risk per per

NOTE Confidence: 0.9687636

00:29:33.780 --> 00:29:35.240
year initially with MGUS.

NOTE Confidence: 0.98324305

00:29:35.860 --> 00:29:37.380
In smoldering myeloma, we see

NOTE Confidence: 0.98324305

00:29:37.380 --> 00:29:38.580
at least initially about a

NOTE Confidence: 0.98324305

00:29:38.580 --> 00:29:39.860
ten percent risk per year

NOTE Confidence: 0.98324305

00:29:39.860 --> 00:29:40.520
of progression.

NOTE Confidence: 0.9670743

00:29:41.015 --> 00:29:42.055
As you can see, the

NOTE Confidence: 0.9670743

00:29:42.055 --> 00:29:43.575
line flattens out with the

NOTE Confidence: 0.9670743

00:29:43.575 --> 00:29:44.555
smoldering and asymptomatic

NOTE Confidence: 0.9779957

00:29:44.855 --> 00:29:46.455
myeloma. As doctor Barr mentioned,

NOTE Confidence: 0.9779957

00:29:46.455 --> 00:29:48.395
smoldering myeloma is very heterogeneous.

NOTE Confidence: 0.9882955

00:29:49.095 --> 00:29:50.295
And those patients who don't

NOTE Confidence: 0.9882955

00:29:50.295 --> 00:29:51.975
progress, you know, over time

NOTE Confidence: 0.9882955

00:29:51.975 --> 00:29:53.255
start to behave more like

NOTE Confidence: 0.9882955

00:29:53.255 --> 00:29:54.695
MGUS. And, you know, I

NOTE Confidence: 0.9882955

00:29:54.695 --> 00:29:56.055
think we often will alter

NOTE Confidence: 0.9882955

00:29:56.055 --> 00:29:57.539
our management to to fit

NOTE Confidence: 0.9882955

00:29:57.539 --> 00:29:58.039
that.

NOTE Confidence: 0.90923315

00:30:00.340 --> 00:30:02.179
So, the definition for the

NOTE Confidence: 0.90923315

00:30:02.179 --> 00:30:02.679
international

NOTE Confidence: 0.961891

00:30:03.139 --> 00:30:04.740
myeloma working group for smoldering

NOTE Confidence: 0.961891

00:30:04.740 --> 00:30:05.860
myeloma, again, we've gone over

NOTE Confidence: 0.961891

00:30:05.860 --> 00:30:06.740
this, but a a a

NOTE Confidence: 0.961891

00:30:06.740 --> 00:30:08.440
clonal plasma cell percentage

NOTE Confidence: 0.9879162

00:30:08.914 --> 00:30:10.515
of ten percent to sixty

NOTE Confidence: 0.9879162

00:30:10.515 --> 00:30:12.515
percent, over sixty percent being

NOTE Confidence: 0.9879162

00:30:12.515 --> 00:30:13.794
consistent with clinical or active

NOTE Confidence: 0.9879162

00:30:13.794 --> 00:30:14.294
myeloma,

NOTE Confidence: 0.9688197

00:30:14.674 --> 00:30:16.274
a monoclonal m protein greater

NOTE Confidence: 0.9688197

00:30:16.274 --> 00:30:17.554
than three, and a urinary

NOTE Confidence: 0.9688197

00:30:17.554 --> 00:30:18.835
m protein greater than five

NOTE Confidence: 0.9688197

00:30:18.835 --> 00:30:19.715
hundred. This is on a

NOTE Confidence: 0.9688197

00:30:19.715 --> 00:30:21.440
twenty four hour urine. Again,

NOTE Confidence: 0.9688197

00:30:21.440 --> 00:30:23.120
importantly, in our asymptomatic or

NOTE Confidence: 0.9688197

00:30:23.120 --> 00:30:25.120
smoldering myeloma patients, we're excluding

NOTE Confidence: 0.9688197

00:30:25.120 --> 00:30:26.480
the presence of slim crab

NOTE Confidence: 0.9688197

00:30:26.480 --> 00:30:27.220
or amyloid,

NOTE Confidence: 0.9222639

00:30:27.680 --> 00:30:28.820
and in particular,

NOTE Confidence: 0.9720468

00:30:29.440 --> 00:30:30.560
ensuring that there is no

NOTE Confidence: 0.9720468

00:30:30.560 --> 00:30:32.160
evidence of bone lesions. And

NOTE Confidence: 0.9720468

00:30:32.160 --> 00:30:33.680
we do that via advanced

NOTE Confidence: 0.9720468

00:30:33.680 --> 00:30:34.880
imaging either with a PET

NOTE Confidence: 0.9720468

00:30:34.880 --> 00:30:35.920
scan or a whole body

NOTE Confidence: 0.9720468

00:30:35.920 --> 00:30:37.255
MRI, both of which we

NOTE Confidence: 0.9720468

00:30:37.255 --> 00:30:39.275
have available here at Yale.

NOTE Confidence: 0.9953363

00:30:40.054 --> 00:30:41.434
Similar to MGUS,

NOTE Confidence: 0.9504647

00:30:41.735 --> 00:30:43.655
we, in smoldering myeloma, once

NOTE Confidence: 0.9504647

00:30:43.655 --> 00:30:45.015
a definition once a a

NOTE Confidence: 0.9504647

00:30:45.015 --> 00:30:46.455
diagnosis is confirmed, we look

NOTE Confidence: 0.9504647

00:30:46.455 --> 00:30:47.995
to risk stratify our patients

NOTE Confidence: 0.9419375

00:30:48.295 --> 00:30:49.415
and most commonly do that

NOTE Confidence: 0.9419375

00:30:49.415 --> 00:30:50.235
with the IMWG

NOTE Confidence: 0.9409655

00:30:50.775 --> 00:30:52.315
two twenty twenty rule,

NOTE Confidence: 0.7846252

00:30:53.159 --> 00:30:53.659
with,

NOTE Confidence: 0.95652026

00:30:54.120 --> 00:30:55.799
high risk criteria being patients

NOTE Confidence: 0.95652026

00:30:55.799 --> 00:30:57.159
who have an m protein

NOTE Confidence: 0.95652026

00:30:57.159 --> 00:30:58.679
or a monoclonal protein in

NOTE Confidence: 0.95652026

00:30:58.679 --> 00:30:59.960
the serum being greater than

NOTE Confidence: 0.95652026

00:30:59.960 --> 00:31:01.179
two grams per deciliter,

NOTE Confidence: 0.994533

00:31:01.799 --> 00:31:03.159
having twenty percent or more

NOTE Confidence: 0.994533

00:31:03.159 --> 00:31:04.519
clonal plasma cells in the

NOTE Confidence: 0.994533

00:31:04.519 --> 00:31:06.395
bone marrow, and having an

NOTE Confidence: 0.994533

00:31:06.395 --> 00:31:07.695
involved or uninvolved

NOTE Confidence: 0.87182945

00:31:08.235 --> 00:31:09.455
involved over uninvolved,

NOTE Confidence: 0.9734176

00:31:09.755 --> 00:31:11.434
serum free lysine ratio of

NOTE Confidence: 0.9734176

00:31:11.434 --> 00:31:12.815
greater than twenty. So,

NOTE Confidence: 0.98062724

00:31:13.195 --> 00:31:14.395
in patients who have a

NOTE Confidence: 0.98062724

00:31:14.395 --> 00:31:15.054
a kappa,

NOTE Confidence: 0.94986373

00:31:15.515 --> 00:31:17.275
gamopathy, that's the kappa over

NOTE Confidence: 0.94986373

00:31:17.275 --> 00:31:17.775
lambda

NOTE Confidence: 0.9348925

00:31:18.190 --> 00:31:19.710
ratio. If in lambda, it's

NOTE Confidence: 0.9348925

00:31:19.710 --> 00:31:20.750
a reverse. And so having

NOTE Confidence: 0.9348925

00:31:20.750 --> 00:31:21.870
that above twenty is a

NOTE Confidence: 0.9348925

00:31:21.870 --> 00:31:23.150
high risk criteria. And then

NOTE Confidence: 0.9348925

00:31:23.150 --> 00:31:24.270
there's a a four,

NOTE Confidence: 0.9979031

00:31:24.830 --> 00:31:25.330
criteria

NOTE Confidence: 0.49571347

00:31:25.790 --> 00:31:26.290
model

NOTE Confidence: 0.9951019

00:31:26.590 --> 00:31:27.970
that includes cytogenetics

NOTE Confidence: 0.9470781

00:31:28.270 --> 00:31:29.230
that are high risk from

NOTE Confidence: 0.9470781

00:31:29.230 --> 00:31:30.190
the bone marrow, which are

NOTE Confidence: 0.9470781

00:31:30.190 --> 00:31:32.190
outlined here. So translocation fourteen

NOTE Confidence: 0.9470781

00:31:32.350 --> 00:31:34.005
before fourteen, fourteen sixteen,

NOTE Confidence: 0.5278481

00:31:34.725 --> 00:31:35.225
having

NOTE Confidence: 0.9689491

00:31:35.845 --> 00:31:36.345
a

NOTE Confidence: 0.86845964

00:31:36.885 --> 00:31:37.265
gain of one q or

NOTE Confidence: 0.86845964

00:31:37.265 --> 00:31:37.765
a deletion of thirteen q.

NOTE Confidence: 0.86845964

00:31:37.765 --> 00:31:38.645
And you can see here

NOTE Confidence: 0.86845964

00:31:38.645 --> 00:31:39.385
in the table,

NOTE Confidence: 0.93833375

00:31:40.005 --> 00:31:41.765
in particular, patients with high

NOTE Confidence: 0.93833375

00:31:41.765 --> 00:31:42.265
risk,

NOTE Confidence: 0.96795225

00:31:42.725 --> 00:31:45.285
smoldering myeloma, which, is three

NOTE Confidence: 0.96795225

00:31:45.285 --> 00:31:46.825
to four of these criteria,

NOTE Confidence: 0.9851897

00:31:47.670 --> 00:31:48.950
have a high risk of

NOTE Confidence: 0.9851897

00:31:48.950 --> 00:31:50.470
progression at two years to

NOTE Confidence: 0.9851897

00:31:50.470 --> 00:31:51.750
clinical or active myeloma with

NOTE Confidence: 0.9851897

00:31:51.750 --> 00:31:53.110
end organ damage of sixty

NOTE Confidence: 0.9851897

00:31:53.110 --> 00:31:53.930
three percent.

NOTE Confidence: 0.94334185

00:31:57.030 --> 00:31:58.310
So to touch very briefly

NOTE Confidence: 0.94334185

00:31:58.310 --> 00:32:00.070
on management of smoldering myeloma

NOTE Confidence: 0.94334185

00:32:00.070 --> 00:32:01.370
which is really evolving,

NOTE Confidence: 0.932354

00:32:02.735 --> 00:32:04.275
with our low or intermediate

NOTE Confidence: 0.932354

00:32:04.415 --> 00:32:06.515
risk, smoldering myeloma patients,

NOTE Confidence: 0.97520906

00:32:07.375 --> 00:32:09.055
we are routinely observing them.

NOTE Confidence: 0.97520906

00:32:09.055 --> 00:32:10.095
We do this a bit

NOTE Confidence: 0.97520906

00:32:10.095 --> 00:32:11.455
more frequently than we do

NOTE Confidence: 0.97520906

00:32:11.455 --> 00:32:12.655
at least initially with our

NOTE Confidence: 0.97520906

00:32:12.655 --> 00:32:13.935
MGUS patients. So we're seeing

NOTE Confidence: 0.97520906

00:32:13.935 --> 00:32:16.170
them and doing laboratory evaluation

NOTE Confidence: 0.97520906

00:32:16.230 --> 00:32:17.510
every three months. And then

NOTE Confidence: 0.97520906

00:32:17.510 --> 00:32:19.210
again, to exclude any presence

NOTE Confidence: 0.97520906

00:32:19.510 --> 00:32:20.950
or development of bone lesions,

NOTE Confidence: 0.97520906

00:32:20.950 --> 00:32:23.030
we get annual, advanced imaging

NOTE Confidence: 0.97520906

00:32:23.030 --> 00:32:24.150
usually with a whole body

NOTE Confidence: 0.97520906

00:32:24.150 --> 00:32:25.690
MRI or a PET scan.

NOTE Confidence: 0.9986887

00:32:26.310 --> 00:32:27.910
Again, the frequency of these

NOTE Confidence: 0.9986887

00:32:27.910 --> 00:32:28.410
evaluations

NOTE Confidence: 0.98871744

00:32:28.710 --> 00:32:29.750
may change over time if

NOTE Confidence: 0.98871744

00:32:29.750 --> 00:32:31.174
patients remain stable.

NOTE Confidence: 0.9948506

00:32:32.195 --> 00:32:33.235
In high risk,

NOTE Confidence: 0.99870944

00:32:33.634 --> 00:32:35.174
smoldering myeloma patients,

NOTE Confidence: 0.9833322

00:32:35.475 --> 00:32:36.674
this is where I think,

NOTE Confidence: 0.9833322

00:32:36.995 --> 00:32:37.955
you know, the field is

NOTE Confidence: 0.9833322

00:32:37.955 --> 00:32:39.174
continuing to evolve,

NOTE Confidence: 0.9801422

00:32:40.195 --> 00:32:41.715
and there are differing opinions,

NOTE Confidence: 0.9801422

00:32:41.715 --> 00:32:42.835
I think, within the field.

NOTE Confidence: 0.9801422

00:32:42.835 --> 00:32:44.514
But in patients with high

NOTE Confidence: 0.9801422

00:32:44.514 --> 00:32:46.500
risk, smoldering myeloma, especially younger

NOTE Confidence: 0.9801422

00:32:46.500 --> 00:32:47.700
patients, I think, you know,

NOTE Confidence: 0.9801422

00:32:47.700 --> 00:32:49.700
we really consider clinical trials,

NOTE Confidence: 0.9801422

00:32:50.019 --> 00:32:51.240
pretty pretty highly.

NOTE Confidence: 0.985082

00:32:52.179 --> 00:32:53.380
We do have some data

NOTE Confidence: 0.985082

00:32:53.380 --> 00:32:54.679
about potential benefit,

NOTE Confidence: 0.9763988

00:32:54.980 --> 00:32:56.899
progression free survival benefit with

NOTE Confidence: 0.9763988

00:32:56.899 --> 00:32:57.559
our immunomodulatory

NOTE Confidence: 0.92898726

00:32:58.179 --> 00:32:59.000
agent lenalidomide,

NOTE Confidence: 0.9359573

00:32:59.705 --> 00:33:00.825
and more recently have a

NOTE Confidence: 0.9359573

00:33:00.825 --> 00:33:02.185
study, a phase three study

NOTE Confidence: 0.9359573

00:33:02.185 --> 00:33:03.865
that was published looking at

NOTE Confidence: 0.9359573

00:33:03.865 --> 00:33:05.385
the anti CD thirty eight

NOTE Confidence: 0.9359573

00:33:05.385 --> 00:33:07.005
monoclonal antibody daratumumab,

NOTE Confidence: 0.98979783

00:33:07.705 --> 00:33:08.985
where there was evidence in

NOTE Confidence: 0.98979783

00:33:08.985 --> 00:33:10.985
high risk, smoldering myeloma of

NOTE Confidence: 0.98979783

00:33:10.985 --> 00:33:12.825
progression free survival benefit and

NOTE Confidence: 0.98979783

00:33:12.825 --> 00:33:14.925
a small overall survival benefit.

NOTE Confidence: 0.98979783

00:33:15.180 --> 00:33:16.140
And then there still is

NOTE Confidence: 0.98979783

00:33:16.140 --> 00:33:17.180
an option, you know, with

NOTE Confidence: 0.98979783

00:33:17.180 --> 00:33:18.620
these patients to observe them

NOTE Confidence: 0.98979783

00:33:18.620 --> 00:33:19.120
closely.

NOTE Confidence: 0.9718658

00:33:19.820 --> 00:33:20.960
You know, I think there

NOTE Confidence: 0.9718658

00:33:21.100 --> 00:33:22.700
there is some thought, again,

NOTE Confidence: 0.9718658

00:33:22.700 --> 00:33:24.300
with the heterogeneity that some

NOTE Confidence: 0.9718658

00:33:24.300 --> 00:33:26.140
patients will progress very quickly.

NOTE Confidence: 0.9718658

00:33:26.140 --> 00:33:27.900
I think in younger patients,

NOTE Confidence: 0.9718658

00:33:27.900 --> 00:33:29.465
doctor Barr will talk about

NOTE Confidence: 0.9718658

00:33:29.465 --> 00:33:31.725
our, therapy, which often includes

NOTE Confidence: 0.9718658

00:33:31.785 --> 00:33:33.465
four drugs. And so treating

NOTE Confidence: 0.9718658

00:33:33.465 --> 00:33:34.985
these high risk myeloma patients,

NOTE Confidence: 0.9718658

00:33:34.985 --> 00:33:36.425
especially young patients with one

NOTE Confidence: 0.9718658

00:33:36.425 --> 00:33:37.865
drug, there is some concern

NOTE Confidence: 0.9718658

00:33:37.865 --> 00:33:38.905
that we could be potentially

NOTE Confidence: 0.9718658

00:33:38.905 --> 00:33:40.425
undertreating them. And then I

NOTE Confidence: 0.9718658

00:33:40.425 --> 00:33:41.165
think importantly,

NOTE Confidence: 0.97819144

00:33:42.185 --> 00:33:43.970
is that patients with smoldering

NOTE Confidence: 0.97819144

00:33:43.970 --> 00:33:44.629
or asymptomatic

NOTE Confidence: 0.9696155

00:33:44.929 --> 00:33:46.210
myeloma, although they may be

NOTE Confidence: 0.9696155

00:33:46.210 --> 00:33:47.649
without symptoms, can have some

NOTE Confidence: 0.9696155

00:33:47.649 --> 00:33:49.190
increased risk of other

NOTE Confidence: 0.9545984

00:33:49.570 --> 00:33:50.070
associated,

NOTE Confidence: 0.92855287

00:33:51.169 --> 00:33:53.269
complications like infections, osteoporosis,

NOTE Confidence: 0.9986831

00:33:53.730 --> 00:33:55.250
thromboembolism, and the risk of

NOTE Confidence: 0.9986831

00:33:55.250 --> 00:33:56.149
secondary malignancies.

NOTE Confidence: 0.9735073

00:33:58.605 --> 00:33:59.805
So I think in conclusion

NOTE Confidence: 0.9735073

00:33:59.805 --> 00:34:00.945
with smoldering myeloma,

NOTE Confidence: 0.9889358

00:34:01.325 --> 00:34:02.625
it is a very heterogeneous

NOTE Confidence: 0.98957366

00:34:02.925 --> 00:34:04.365
disorder. We see some individuals

NOTE Confidence: 0.98957366

00:34:04.365 --> 00:34:05.885
that progress quickly and others

NOTE Confidence: 0.98957366

00:34:05.885 --> 00:34:07.165
who never progress and act

NOTE Confidence: 0.98957366

00:34:07.165 --> 00:34:08.765
more like MGUS, and we

NOTE Confidence: 0.98957366

00:34:08.765 --> 00:34:09.825
tailor our management,

NOTE Confidence: 0.9973197

00:34:10.285 --> 00:34:10.945
to that.

NOTE Confidence: 0.94591546

00:34:11.890 --> 00:34:14.210
And with patients that are

NOTE Confidence: 0.94591546

00:34:14.210 --> 00:34:15.330
behaving more like a low

NOTE Confidence: 0.94591546

00:34:15.330 --> 00:34:16.770
risk MGUS over time, there

NOTE Confidence: 0.94591546

00:34:16.770 --> 00:34:17.590
is a possibility,

NOTE Confidence: 0.98560745

00:34:18.050 --> 00:34:18.930
you know, to have them

NOTE Confidence: 0.98560745

00:34:18.930 --> 00:34:20.130
referred back to their primary

NOTE Confidence: 0.98560745

00:34:20.130 --> 00:34:22.790
care clinician, with close monitoring.

NOTE Confidence: 0.9792013

00:34:23.984 --> 00:34:24.864
Again, in this case, I

NOTE Confidence: 0.9792013

00:34:24.864 --> 00:34:25.605
think what's

NOTE Confidence: 0.9756764

00:34:25.984 --> 00:34:28.385
complicated is the concomitant peripheral

NOTE Confidence: 0.9756764

00:34:28.385 --> 00:34:29.585
neuropathy in the setting of

NOTE Confidence: 0.9756764

00:34:29.585 --> 00:34:31.265
monoclonal gammopathy, which I think

NOTE Confidence: 0.9756764

00:34:31.265 --> 00:34:33.184
also often will warrant a

NOTE Confidence: 0.9756764

00:34:33.184 --> 00:34:34.305
referral so that we can

NOTE Confidence: 0.9756764

00:34:34.305 --> 00:34:35.904
evaluate for more rare plasma

NOTE Confidence: 0.9756764

00:34:35.904 --> 00:34:37.444
cell dyscrasias or other neuropathic

NOTE Confidence: 0.9756764

00:34:37.664 --> 00:34:38.164
symptoms,

NOTE Confidence: 0.8868359

00:34:38.790 --> 00:34:40.070
specifically light chain or AL

NOTE Confidence: 0.8868359

00:34:40.070 --> 00:34:40.570
amyloidosis,

NOTE Confidence: 0.8351038

00:34:41.510 --> 00:34:42.890
POEM syndrome, cryoglobulinemia.

NOTE Confidence: 0.9571092

00:34:43.430 --> 00:34:45.370
And with IgM monoclonal gamopathies,

NOTE Confidence: 0.9571092

00:34:45.510 --> 00:34:46.810
again, we can see rare

NOTE Confidence: 0.9571092

00:34:47.030 --> 00:34:49.050
anti MAG neuropathies and Kanamad

NOTE Confidence: 0.9571092

00:34:49.190 --> 00:34:50.250
syndrome as well.

NOTE Confidence: 0.9677986

00:34:50.885 --> 00:34:52.085
So it is, I think,

NOTE Confidence: 0.9677986

00:34:52.244 --> 00:34:53.605
very reasonable in patients with

NOTE Confidence: 0.9677986

00:34:53.605 --> 00:34:54.105
unexplained

NOTE Confidence: 0.9207878

00:34:54.405 --> 00:34:56.185
new or progressive peripheral neuropathy

NOTE Confidence: 0.9207878

00:34:56.325 --> 00:34:58.244
to consider gammopathy panels. And

NOTE Confidence: 0.9207878

00:34:58.244 --> 00:34:58.744
then,

NOTE Confidence: 0.9893388

00:34:59.125 --> 00:34:59.844
you know, if there is

NOTE Confidence: 0.9893388

00:34:59.844 --> 00:35:02.005
a monoclonal monoclonal protein, refer

NOTE Confidence: 0.9893388

00:35:02.005 --> 00:35:03.285
them to our hematology clinic

NOTE Confidence: 0.9893388

00:35:03.285 --> 00:35:04.885
and our neurology colleagues as

NOTE Confidence: 0.9893388

00:35:04.885 --> 00:35:06.105
well for further evaluation.

NOTE Confidence: 0.9996549

00:35:09.380 --> 00:35:10.260
And I will turn it

NOTE Confidence: 0.9996549

00:35:10.260 --> 00:35:11.480
back over for case three.

NOTE Confidence: 0.90607595

00:35:11.780 --> 00:35:12.280
Great.

NOTE Confidence: 0.9664522

00:35:13.700 --> 00:35:15.219
Okay. So we've had two

NOTE Confidence: 0.9664522

00:35:15.219 --> 00:35:16.520
cases of IgA

NOTE Confidence: 0.89172095

00:35:17.059 --> 00:35:17.559
monoclonals,

NOTE Confidence: 0.9960437

00:35:17.940 --> 00:35:19.079
and we're gonna

NOTE Confidence: 0.97179013

00:35:19.535 --> 00:35:20.655
we're gonna give you an

NOTE Confidence: 0.97179013

00:35:21.015 --> 00:35:22.415
a a different one now.

NOTE Confidence: 0.97179013

00:35:22.415 --> 00:35:23.614
So this is an eighty

NOTE Confidence: 0.97179013

00:35:23.614 --> 00:35:24.915
five year old male,

NOTE Confidence: 0.97689617

00:35:26.015 --> 00:35:28.515
very active, very cognitively sharp.

NOTE Confidence: 0.97689617

00:35:28.735 --> 00:35:30.114
New patient to me in

NOTE Confidence: 0.97689617

00:35:30.335 --> 00:35:32.114
October of twenty twenty.

NOTE Confidence: 0.94114125

00:35:33.530 --> 00:35:34.910
He came to me with

NOTE Confidence: 0.94114125

00:35:34.969 --> 00:35:36.350
a history of hyperlipidemia,

NOTE Confidence: 0.99609536

00:35:37.210 --> 00:35:37.710
hypothyroidism,

NOTE Confidence: 0.95911884

00:35:38.250 --> 00:35:39.550
and some mild,

NOTE Confidence: 0.8760976

00:35:39.930 --> 00:35:41.230
aortic valve stenosis.

NOTE Confidence: 0.9647164

00:35:42.330 --> 00:35:43.850
He had a right shoulder

NOTE Confidence: 0.9647164

00:35:43.850 --> 00:35:45.690
and left hip replacement with

NOTE Confidence: 0.9647164

00:35:45.690 --> 00:35:47.405
the which with a subsequent

NOTE Confidence: 0.9647164

00:35:47.625 --> 00:35:48.685
right total shoulder

NOTE Confidence: 0.9935769

00:35:49.145 --> 00:35:50.605
in twenty twenty three.

NOTE Confidence: 0.63056517

00:35:52.665 --> 00:35:53.485
Never smoker,

NOTE Confidence: 0.9590077

00:35:53.864 --> 00:35:55.225
married with two kids. He's

NOTE Confidence: 0.9590077

00:35:55.225 --> 00:35:57.005
a retired salesman for industrial

NOTE Confidence: 0.9590077

00:35:57.065 --> 00:35:58.045
cable manufacturer.

NOTE Confidence: 0.9863356

00:35:59.150 --> 00:36:00.110
His mom died in her

NOTE Confidence: 0.9863356

00:36:00.110 --> 00:36:00.850
late thirties

NOTE Confidence: 0.9919469

00:36:01.310 --> 00:36:02.930
from postpartum complications.

NOTE Confidence: 0.9741139

00:36:03.630 --> 00:36:05.150
His father and oldest sister

NOTE Confidence: 0.9741139

00:36:05.150 --> 00:36:06.450
died from lung cancer.

NOTE Confidence: 0.9539061

00:36:07.310 --> 00:36:08.670
His older brother died from

NOTE Confidence: 0.9539061

00:36:08.670 --> 00:36:10.830
salivary gland tumor and his

NOTE Confidence: 0.9539061

00:36:10.830 --> 00:36:12.290
second brother of an unknown

NOTE Confidence: 0.9539061

00:36:12.350 --> 00:36:12.850
cause.

NOTE Confidence: 0.9850353

00:36:14.385 --> 00:36:15.585
Prior to coming to me

NOTE Confidence: 0.9850353

00:36:15.585 --> 00:36:16.565
in twenty eleven,

NOTE Confidence: 0.9825818

00:36:18.625 --> 00:36:20.705
more significantly, he developed a

NOTE Confidence: 0.9825818

00:36:20.705 --> 00:36:21.205
mild,

NOTE Confidence: 0.99151546

00:36:21.585 --> 00:36:22.085
macrocytic

NOTE Confidence: 0.8576134

00:36:22.545 --> 00:36:23.045
anemia,

NOTE Confidence: 0.91915953

00:36:24.225 --> 00:36:25.745
with a hemoglobin of thirteen

NOTE Confidence: 0.91915953

00:36:25.745 --> 00:36:27.750
point two, MCV of ninety

NOTE Confidence: 0.91915953

00:36:27.750 --> 00:36:28.810
eight. His SPEP

NOTE Confidence: 0.8928914

00:36:29.350 --> 00:36:30.550
at the time during the

NOTE Confidence: 0.8928914

00:36:30.550 --> 00:36:31.050
eval,

NOTE Confidence: 0.9850094

00:36:31.670 --> 00:36:33.290
showed a monoclonal band,

NOTE Confidence: 0.9710095

00:36:34.710 --> 00:36:36.710
consistent with IgM kappa at

NOTE Confidence: 0.9710095

00:36:36.710 --> 00:36:38.310
zero point eight milligrams per

NOTE Confidence: 0.9710095

00:36:38.310 --> 00:36:38.810
deciliter.

NOTE Confidence: 0.99032384

00:36:40.710 --> 00:36:41.850
Because the IgM

NOTE Confidence: 0.9996197

00:36:44.045 --> 00:36:44.545
monoclonal

NOTE Confidence: 0.91065764

00:36:44.844 --> 00:36:45.344
protein,

NOTE Confidence: 0.9434323

00:36:45.964 --> 00:36:46.844
he went on to bone

NOTE Confidence: 0.9434323

00:36:46.844 --> 00:36:48.525
marrow biopsy, which revealed a

NOTE Confidence: 0.9434323

00:36:48.525 --> 00:36:50.045
twenty to thirty percent low

NOTE Confidence: 0.9434323

00:36:50.045 --> 00:36:50.545
grade

NOTE Confidence: 0.89979726

00:36:50.924 --> 00:36:51.724
b cell,

NOTE Confidence: 0.99362737

00:36:52.045 --> 00:36:52.545
lymphoproliferative

NOTE Confidence: 0.57311213

00:36:54.364 --> 00:36:54.864
disorder

NOTE Confidence: 0.9560107

00:36:55.244 --> 00:36:56.864
with plasma cell differentiation,

NOTE Confidence: 0.91558707

00:36:57.640 --> 00:36:58.460
kappa restriction.

NOTE Confidence: 0.9715396

00:36:59.400 --> 00:36:59.900
And,

NOTE Confidence: 0.8882459

00:37:01.080 --> 00:37:02.219
we think about Waldenstroms

NOTE Confidence: 0.9631645

00:37:02.520 --> 00:37:03.340
with the IgM,

NOTE Confidence: 0.52990234

00:37:04.680 --> 00:37:05.180
chemotherapy.

NOTE Confidence: 0.98304725

00:37:06.280 --> 00:37:07.640
He didn't meet criteria for

NOTE Confidence: 0.98304725

00:37:07.640 --> 00:37:09.020
treatment at that time.

NOTE Confidence: 0.94031936

00:37:11.415 --> 00:37:13.255
So, he had his SPEP

NOTE Confidence: 0.94031936

00:37:13.255 --> 00:37:15.115
done every year. And

NOTE Confidence: 0.7784933

00:37:15.655 --> 00:37:16.635
it from

NOTE Confidence: 0.9743116

00:37:17.015 --> 00:37:18.795
twenty eleven through twenty nineteen,

NOTE Confidence: 0.9743116

00:37:18.855 --> 00:37:20.055
he was very stable at

NOTE Confidence: 0.9743116

00:37:20.055 --> 00:37:21.355
that zero point eight milligram

NOTE Confidence: 0.9743116

00:37:21.415 --> 00:37:22.075
per deciliter

NOTE Confidence: 0.5966123

00:37:22.935 --> 00:37:23.435
level.

NOTE Confidence: 0.99905175

00:37:24.830 --> 00:37:26.370
In twenty nineteen

NOTE Confidence: 0.9833167

00:37:26.750 --> 00:37:28.750
and twenty one, the level

NOTE Confidence: 0.9833167

00:37:28.750 --> 00:37:30.610
rose to one point zero.

NOTE Confidence: 0.98768026

00:37:31.070 --> 00:37:32.110
And then in twenty two,

NOTE Confidence: 0.98768026

00:37:32.110 --> 00:37:33.070
it went up again to

NOTE Confidence: 0.98768026

00:37:33.070 --> 00:37:34.510
one point four. And then

NOTE Confidence: 0.98768026

00:37:34.510 --> 00:37:35.969
in twenty twenty three,

NOTE Confidence: 0.99060965

00:37:36.270 --> 00:37:37.870
it rose to one point

NOTE Confidence: 0.99060965

00:37:37.870 --> 00:37:38.370
seven.

NOTE Confidence: 0.99842596

00:37:38.885 --> 00:37:39.464
His hemoglobin

NOTE Confidence: 0.99347913

00:37:39.844 --> 00:37:41.204
dropped from eleven to eight

NOTE Confidence: 0.99347913

00:37:41.204 --> 00:37:41.944
point four,

NOTE Confidence: 0.95511174

00:37:42.565 --> 00:37:44.585
and he does developing fatigue.

NOTE Confidence: 0.95511174

00:37:44.645 --> 00:37:46.405
So he's becoming symptomatic. He

NOTE Confidence: 0.95511174

00:37:46.405 --> 00:37:47.525
had no other causes for

NOTE Confidence: 0.95511174

00:37:47.525 --> 00:37:48.805
the anemia to explain the

NOTE Confidence: 0.95511174

00:37:48.805 --> 00:37:49.305
drop.

NOTE Confidence: 0.9015805

00:37:50.085 --> 00:37:50.724
His his,

NOTE Confidence: 0.96074516

00:37:51.380 --> 00:37:53.219
kappa light chain was three

NOTE Confidence: 0.96074516

00:37:53.219 --> 00:37:55.000
point eight, and his IgM

NOTE Confidence: 0.9695449

00:37:55.780 --> 00:37:57.700
antibodies were in the mid,

NOTE Confidence: 0.9695449

00:37:58.020 --> 00:37:59.940
two thousand six hundred twenty

NOTE Confidence: 0.9695449

00:37:59.940 --> 00:38:02.180
two. Excuse me. And at

NOTE Confidence: 0.9695449

00:38:02.180 --> 00:38:03.860
that point, decision was made

NOTE Confidence: 0.9695449

00:38:03.860 --> 00:38:05.160
to treat with rituximab,

NOTE Confidence: 0.97331357

00:38:06.135 --> 00:38:07.675
and we want to,

NOTE Confidence: 0.9694936

00:38:08.614 --> 00:38:09.975
pass over to doctor Barr

NOTE Confidence: 0.9694936

00:38:09.975 --> 00:38:10.875
to talk about

NOTE Confidence: 0.98133785

00:38:11.575 --> 00:38:13.275
IgM disease here.

NOTE Confidence: 0.9993745

00:38:14.375 --> 00:38:15.355
Yes. So

NOTE Confidence: 0.97016346

00:38:15.655 --> 00:38:16.855
you can see here that

NOTE Confidence: 0.97016346

00:38:16.855 --> 00:38:18.795
the spectrum of IgM gammopathies,

NOTE Confidence: 0.944953

00:38:19.680 --> 00:38:21.040
are very similar to the

NOTE Confidence: 0.944953

00:38:21.040 --> 00:38:22.640
IgG and IgAs where you

NOTE Confidence: 0.944953

00:38:22.640 --> 00:38:23.760
have the MGUS and you

NOTE Confidence: 0.944953

00:38:23.760 --> 00:38:25.380
have this middle stage of

NOTE Confidence: 0.944953

00:38:25.599 --> 00:38:26.099
asymptomatic

NOTE Confidence: 0.98848987

00:38:26.400 --> 00:38:27.140
or smoldering,

NOTE Confidence: 0.8856077

00:38:28.079 --> 00:38:28.579
Waldenstrom's

NOTE Confidence: 0.907299

00:38:28.880 --> 00:38:29.859
and then symptomatic

NOTE Confidence: 0.9869447

00:38:30.160 --> 00:38:30.660
Waldenstrom's

NOTE Confidence: 0.986005

00:38:31.280 --> 00:38:32.339
that needs therapy.

NOTE Confidence: 0.9998432

00:38:32.785 --> 00:38:33.685
So what defines

NOTE Confidence: 0.99082273

00:38:34.305 --> 00:38:35.205
needing therapy,

NOTE Confidence: 0.9363469

00:38:35.745 --> 00:38:37.665
is different in myeloma and

NOTE Confidence: 0.9363469

00:38:37.665 --> 00:38:39.285
the lymphoma. For example,

NOTE Confidence: 0.96924025

00:38:39.905 --> 00:38:41.425
for lymphomas, we look at

NOTE Confidence: 0.96924025

00:38:41.425 --> 00:38:42.805
b symptoms, like

NOTE Confidence: 0.9387025

00:38:43.185 --> 00:38:43.685
constitutional

NOTE Confidence: 0.89522743

00:38:43.985 --> 00:38:45.525
symptoms, weight law unexplained

NOTE Confidence: 0.9994718

00:38:45.825 --> 00:38:46.565
weight loss,

NOTE Confidence: 0.9988514

00:38:47.150 --> 00:38:49.170
fevers, night sweats, things like

NOTE Confidence: 0.9705023

00:38:49.870 --> 00:38:51.630
that, feeling just generally very

NOTE Confidence: 0.9705023

00:38:51.630 --> 00:38:52.130
poorly.

NOTE Confidence: 0.9990904

00:38:52.510 --> 00:38:53.570
We look at symptomatic

NOTE Confidence: 0.97213995

00:38:54.190 --> 00:38:56.210
cytopenias, which are mainly from

NOTE Confidence: 0.9897936

00:38:56.510 --> 00:38:58.770
crowding of, the bone marrow

NOTE Confidence: 0.9994931

00:38:59.225 --> 00:39:00.364
from the lymphoma

NOTE Confidence: 0.9201309

00:39:00.825 --> 00:39:01.885
or from hepatosplenomegaly,

NOTE Confidence: 0.9942563

00:39:02.505 --> 00:39:04.045
which can also cause cytopenias.

NOTE Confidence: 0.95831126

00:39:04.905 --> 00:39:05.965
Obviously, hyperviscosity

NOTE Confidence: 0.9273298

00:39:06.505 --> 00:39:07.864
is very concerning. It should

NOTE Confidence: 0.9273298

00:39:07.864 --> 00:39:09.085
be treated right away.

NOTE Confidence: 0.996916

00:39:10.585 --> 00:39:12.125
Also, if you have progressive

NOTE Confidence: 0.992071

00:39:12.690 --> 00:39:13.750
bulky lymphadenopathy,

NOTE Confidence: 0.92908

00:39:14.210 --> 00:39:15.650
that would be criteria for

NOTE Confidence: 0.92908

00:39:15.650 --> 00:39:16.150
treatment

NOTE Confidence: 0.5645033

00:39:16.450 --> 00:39:17.109
for glabalinemia

NOTE Confidence: 0.85575056

00:39:17.810 --> 00:39:18.310
called,

NOTE Confidence: 0.6637225

00:39:18.770 --> 00:39:19.670
agglutin disease

NOTE Confidence: 0.92499787

00:39:20.290 --> 00:39:21.829
and significant neuropathy.

NOTE Confidence: 0.959113

00:39:22.369 --> 00:39:24.050
It's important to to also

NOTE Confidence: 0.959113

00:39:24.050 --> 00:39:25.829
know that not all neuropathy

NOTE Confidence: 0.959113

00:39:25.969 --> 00:39:27.965
would warrant therapy. Sometimes people

NOTE Confidence: 0.959113

00:39:27.965 --> 00:39:29.105
have very mild,

NOTE Confidence: 0.9467677

00:39:30.205 --> 00:39:31.905
case and they're fully functional

NOTE Confidence: 0.9467677

00:39:32.045 --> 00:39:33.005
and we just kind of

NOTE Confidence: 0.9467677

00:39:33.005 --> 00:39:34.285
watch them because, again, you

NOTE Confidence: 0.9467677

00:39:34.285 --> 00:39:35.325
have to assess the risk

NOTE Confidence: 0.9467677

00:39:35.325 --> 00:39:37.245
and benefit. Waldenstrom is also

NOTE Confidence: 0.9467677

00:39:37.245 --> 00:39:38.685
not it it's not a

NOTE Confidence: 0.9467677

00:39:38.685 --> 00:39:39.165
curable,

NOTE Confidence: 0.9997282

00:39:39.565 --> 00:39:40.065
cancer.

NOTE Confidence: 0.9734962

00:39:41.670 --> 00:39:43.030
So when you assess someone

NOTE Confidence: 0.9734962

00:39:43.030 --> 00:39:44.250
with IgM gumopathy,

NOTE Confidence: 0.98847944

00:39:44.950 --> 00:39:46.790
your your questioning and what

NOTE Confidence: 0.98847944

00:39:46.790 --> 00:39:48.310
you're looking for is quite

NOTE Confidence: 0.98847944

00:39:48.310 --> 00:39:50.070
different from when you're assessing

NOTE Confidence: 0.98847944

00:39:50.070 --> 00:39:52.089
someone with non IgM gumopathy.

NOTE Confidence: 0.84936464

00:39:58.484 --> 00:39:58.984
Good.

NOTE Confidence: 0.90127563

00:40:00.805 --> 00:40:02.425
And then, you know, to

NOTE Confidence: 0.8876916

00:40:02.885 --> 00:40:03.704
to take,

NOTE Confidence: 0.94463533

00:40:04.885 --> 00:40:05.765
to move on from an

NOTE Confidence: 0.94463533

00:40:05.765 --> 00:40:06.265
IGM,

NOTE Confidence: 0.93750656

00:40:08.405 --> 00:40:08.905
discussion,

NOTE Confidence: 0.9719832

00:40:09.560 --> 00:40:11.320
We have, this next case,

NOTE Confidence: 0.9719832

00:40:11.320 --> 00:40:12.760
which was a fifty two

NOTE Confidence: 0.9719832

00:40:12.760 --> 00:40:14.700
year old gentleman from Ecuador,

NOTE Confidence: 0.9576979

00:40:16.840 --> 00:40:18.380
who's new to me,

NOTE Confidence: 0.96360403

00:40:19.080 --> 00:40:20.680
really this past December. But

NOTE Confidence: 0.96360403

00:40:20.680 --> 00:40:21.180
in

NOTE Confidence: 0.9380195

00:40:22.600 --> 00:40:23.980
June of twenty two

NOTE Confidence: 0.9995446

00:40:24.594 --> 00:40:25.415
twenty twenty

NOTE Confidence: 0.97143066

00:40:25.715 --> 00:40:27.235
two, he went to his

NOTE Confidence: 0.97143066

00:40:27.235 --> 00:40:29.315
PCP, had a urologic symptom,

NOTE Confidence: 0.97143066

00:40:29.315 --> 00:40:30.675
but on the side said,

NOTE Confidence: 0.97143066

00:40:30.675 --> 00:40:31.635
oh, by the way, my

NOTE Confidence: 0.97143066

00:40:31.635 --> 00:40:32.915
neck pain my neck hurts,

NOTE Confidence: 0.97143066

00:40:32.915 --> 00:40:34.295
you know, for last week.

NOTE Confidence: 0.9511657

00:40:34.675 --> 00:40:35.955
And I, you know, just

NOTE Confidence: 0.9511657

00:40:35.955 --> 00:40:37.315
changed my mattress. You know?

NOTE Confidence: 0.9511657

00:40:37.315 --> 00:40:38.215
What do I do?

NOTE Confidence: 0.9856816

00:40:38.719 --> 00:40:39.219
And,

NOTE Confidence: 0.5997861

00:40:39.920 --> 00:40:40.420
the,

NOTE Confidence: 0.9434595

00:40:41.039 --> 00:40:42.160
you know, looked in you

NOTE Confidence: 0.9434595

00:40:42.160 --> 00:40:44.000
know, looked into it, said

NOTE Confidence: 0.9434595

00:40:44.000 --> 00:40:45.520
no no red flags on

NOTE Confidence: 0.9434595

00:40:45.520 --> 00:40:46.819
discussion exam, etcetera.

NOTE Confidence: 0.85684395

00:40:47.279 --> 00:40:47.760
He,

NOTE Confidence: 0.96295625

00:40:48.319 --> 00:40:49.359
looked over his chart. He

NOTE Confidence: 0.96295625

00:40:49.359 --> 00:40:50.900
had no past medical history,

NOTE Confidence: 0.96295625

00:40:51.039 --> 00:40:51.779
no surgeries.

NOTE Confidence: 0.9433325

00:40:53.355 --> 00:40:54.635
Social wise, he was married

NOTE Confidence: 0.9433325

00:40:54.635 --> 00:40:56.635
with two kids, immigrated in,

NOTE Confidence: 0.9433325

00:40:56.875 --> 00:40:58.395
two thousand five, and he

NOTE Confidence: 0.9433325

00:40:58.395 --> 00:40:59.855
works as a graphic artist.

NOTE Confidence: 0.8183143

00:41:01.114 --> 00:41:01.614
So,

NOTE Confidence: 0.91302717

00:41:01.995 --> 00:41:03.375
you know, you know, conservative

NOTE Confidence: 0.91302717

00:41:03.435 --> 00:41:05.455
care was instructions were provided,

NOTE Confidence: 0.91302717

00:41:05.594 --> 00:41:07.035
and he was advised to

NOTE Confidence: 0.91302717

00:41:07.035 --> 00:41:08.070
come back to the clinic

NOTE Confidence: 0.91302717

00:41:08.070 --> 00:41:08.969
and and,

NOTE Confidence: 0.9582188

00:41:09.750 --> 00:41:10.969
if if things improve.

NOTE Confidence: 0.9988723

00:41:12.150 --> 00:41:13.370
But four weeks later

NOTE Confidence: 0.8281833

00:41:13.830 --> 00:41:14.570
in July,

NOTE Confidence: 0.98155874

00:41:15.510 --> 00:41:16.790
he went to the emergency

NOTE Confidence: 0.98155874

00:41:16.790 --> 00:41:18.469
room at Bridgeport Hospital with

NOTE Confidence: 0.98155874

00:41:18.469 --> 00:41:19.850
worsening neck pain

NOTE Confidence: 0.9482502

00:41:20.150 --> 00:41:21.030
and right,

NOTE Confidence: 0.99962705

00:41:21.510 --> 00:41:22.570
ear numbness

NOTE Confidence: 0.999733

00:41:23.405 --> 00:41:24.705
and right arm pain.

NOTE Confidence: 0.96046066

00:41:25.885 --> 00:41:27.405
He had a subjective fever.

NOTE Confidence: 0.96046066

00:41:27.405 --> 00:41:28.445
He had cough. He had

NOTE Confidence: 0.96046066

00:41:28.445 --> 00:41:30.045
congestion. So he was tested

NOTE Confidence: 0.96046066

00:41:30.045 --> 00:41:31.565
for COVID. He was positive.

NOTE Confidence: 0.96046066

00:41:31.565 --> 00:41:32.464
He was discharged

NOTE Confidence: 0.9877606

00:41:33.005 --> 00:41:33.744
with molnupiravir

NOTE Confidence: 0.9713002

00:41:34.364 --> 00:41:36.065
and, PCP follow-up.

NOTE Confidence: 0.972169

00:41:36.605 --> 00:41:37.930
The next day, he had

NOTE Confidence: 0.972169

00:41:37.930 --> 00:41:39.450
a phone call, video visit

NOTE Confidence: 0.972169

00:41:39.450 --> 00:41:41.070
with his primary care doc,

NOTE Confidence: 0.94643813

00:41:41.530 --> 00:41:43.070
mentioned the neck pain again.

NOTE Confidence: 0.94643813

00:41:43.130 --> 00:41:44.830
She ordered an X-ray,

NOTE Confidence: 0.970037

00:41:45.850 --> 00:41:47.050
but the patient didn't get

NOTE Confidence: 0.970037

00:41:47.050 --> 00:41:48.910
it done for whatever reason.

NOTE Confidence: 0.9801669

00:41:49.290 --> 00:41:49.790
And,

NOTE Confidence: 0.9562404

00:41:50.650 --> 00:41:51.714
he went back to his

NOTE Confidence: 0.9562404

00:41:51.714 --> 00:41:53.155
primary care doc saying, hey.

NOTE Confidence: 0.9562404

00:41:53.155 --> 00:41:54.195
I have this neck pain.

NOTE Confidence: 0.9562404

00:41:54.195 --> 00:41:55.175
It's still here.

NOTE Confidence: 0.9322308

00:41:55.635 --> 00:41:56.675
And I think she said,

NOTE Confidence: 0.9322308

00:41:56.675 --> 00:41:57.714
well, where's the X-ray? He

NOTE Confidence: 0.9322308

00:41:57.714 --> 00:41:58.515
said I didn't get it

NOTE Confidence: 0.9322308

00:41:58.515 --> 00:42:00.195
done. So he and then

NOTE Confidence: 0.9322308

00:42:00.195 --> 00:42:01.234
he went and got it

NOTE Confidence: 0.9322308

00:42:01.234 --> 00:42:02.835
done. And he had a

NOTE Confidence: 0.9322308

00:42:02.835 --> 00:42:04.535
c three h, indeterminate,

NOTE Confidence: 0.95633256

00:42:04.915 --> 00:42:06.535
you know, compression fracture,

NOTE Confidence: 0.9711281

00:42:08.730 --> 00:42:10.270
and an MRI was ordered,

NOTE Confidence: 0.9766864

00:42:10.650 --> 00:42:12.570
for follow-up. And, two weeks

NOTE Confidence: 0.9766864

00:42:12.570 --> 00:42:14.010
later, he got that done.

NOTE Confidence: 0.9766864

00:42:14.010 --> 00:42:14.510
And,

NOTE Confidence: 0.9814962

00:42:15.210 --> 00:42:16.330
you see here at the

NOTE Confidence: 0.9814962

00:42:16.330 --> 00:42:17.390
c three level,

NOTE Confidence: 0.959565

00:42:18.090 --> 00:42:19.770
under the red circle, he's

NOTE Confidence: 0.959565

00:42:19.770 --> 00:42:20.590
got a

NOTE Confidence: 0.9942938

00:42:21.265 --> 00:42:22.484
pathologic fracture.

NOTE Confidence: 0.9872383

00:42:22.785 --> 00:42:24.645
It's a burst fracture. It's,

NOTE Confidence: 0.9651003

00:42:25.185 --> 00:42:26.785
you know, moving posteriorly and

NOTE Confidence: 0.9651003

00:42:26.785 --> 00:42:28.005
then pinching the cervical

NOTE Confidence: 0.92266506

00:42:28.785 --> 00:42:29.685
spinal cord.

NOTE Confidence: 0.69751334

00:42:31.744 --> 00:42:32.244
Yeah.

NOTE Confidence: 0.9781718

00:42:32.545 --> 00:42:34.469
He had multiple lesions throughout

NOTE Confidence: 0.9781718

00:42:34.469 --> 00:42:35.130
his vertebrae,

NOTE Confidence: 0.9538086

00:42:35.750 --> 00:42:37.050
a rib and a humeral

NOTE Confidence: 0.9538086

00:42:37.110 --> 00:42:38.869
head, and, no other signs

NOTE Confidence: 0.9538086

00:42:38.869 --> 00:42:40.489
of a of a alternative,

NOTE Confidence: 0.9930794

00:42:41.190 --> 00:42:42.890
you know, cancer identified.

NOTE Confidence: 0.9921521

00:42:43.510 --> 00:42:44.730
And then he had,

NOTE Confidence: 0.9858501

00:42:45.350 --> 00:42:45.930
he had

NOTE Confidence: 0.9581549

00:42:46.310 --> 00:42:47.350
a mild you know, he

NOTE Confidence: 0.9581549

00:42:47.350 --> 00:42:49.110
had anemia, normalcytic anemia of

NOTE Confidence: 0.9581549

00:42:49.110 --> 00:42:50.864
twelve point eight, normal calcium,

NOTE Confidence: 0.9581549

00:42:50.925 --> 00:42:51.665
normal creatinine.

NOTE Confidence: 0.8519264

00:42:52.525 --> 00:42:53.965
He had a, he had

NOTE Confidence: 0.8519264

00:42:53.965 --> 00:42:55.965
a identifiable monoclonal protein on

NOTE Confidence: 0.8519264

00:42:55.965 --> 00:42:56.925
the s PEP that was

NOTE Confidence: 0.8519264

00:42:56.925 --> 00:42:58.465
IgG kappa on immunofixation,

NOTE Confidence: 0.9240193

00:42:59.565 --> 00:43:02.125
elevated kappa light chain, elevated

NOTE Confidence: 0.9240193

00:43:02.125 --> 00:43:03.425
kappa light chain ratio.

NOTE Confidence: 0.90812814

00:43:03.960 --> 00:43:05.000
One six eight, he had

NOTE Confidence: 0.90812814

00:43:05.000 --> 00:43:06.460
elevated IgG immunoglobulins,

NOTE Confidence: 0.93351704

00:43:07.480 --> 00:43:08.839
and he had some pain

NOTE Confidence: 0.93351704

00:43:08.839 --> 00:43:10.140
proteins on the urine,

NOTE Confidence: 0.9959524

00:43:10.920 --> 00:43:11.420
electrophoresis.

NOTE Confidence: 0.923504

00:43:12.440 --> 00:43:12.839
But,

NOTE Confidence: 0.95884824

00:43:13.719 --> 00:43:15.480
clinical course, he went through

NOTE Confidence: 0.95884824

00:43:15.480 --> 00:43:16.619
a c three corpectomy

NOTE Confidence: 0.9448575

00:43:17.400 --> 00:43:17.900
and,

NOTE Confidence: 0.9192874

00:43:18.359 --> 00:43:19.820
with an interview vertebral,

NOTE Confidence: 0.88610774

00:43:20.335 --> 00:43:21.155
device placement.

NOTE Confidence: 0.9229574

00:43:21.855 --> 00:43:22.815
Well, you know, a few

NOTE Confidence: 0.9229574

00:43:22.815 --> 00:43:24.815
days later by posterior cervical

NOTE Confidence: 0.9229574

00:43:24.815 --> 00:43:25.315
fixation,

NOTE Confidence: 0.85929954

00:43:26.655 --> 00:43:27.135
tissue,

NOTE Confidence: 0.9475543

00:43:27.535 --> 00:43:29.295
pathology from the burst fracture

NOTE Confidence: 0.9475543

00:43:29.295 --> 00:43:31.075
showed sheets of plasma cells,

NOTE Confidence: 0.8872246

00:43:31.455 --> 00:43:32.495
you know, CD one thirty

NOTE Confidence: 0.8872246

00:43:32.495 --> 00:43:33.855
eight, you know, capilloid chain

NOTE Confidence: 0.8872246

00:43:33.855 --> 00:43:34.355
restriction.

NOTE Confidence: 0.9798291

00:43:36.119 --> 00:43:36.859
And then

NOTE Confidence: 0.88892114

00:43:37.160 --> 00:43:38.440
few days later, had his

NOTE Confidence: 0.88892114

00:43:38.440 --> 00:43:39.079
bone marrow,

NOTE Confidence: 0.96321493

00:43:39.480 --> 00:43:41.640
biopsy done and, twenty percent

NOTE Confidence: 0.96321493

00:43:41.640 --> 00:43:42.140
kappa,

NOTE Confidence: 0.94670016

00:43:42.759 --> 00:43:43.980
plasma cells identified.

NOTE Confidence: 0.970786

00:43:44.839 --> 00:43:46.539
And back to doctor Barr.

NOTE Confidence: 0.94686085

00:43:49.415 --> 00:43:50.455
Sorry. I was so excited

NOTE Confidence: 0.94686085

00:43:50.455 --> 00:43:51.735
to talk about myeloma that

NOTE Confidence: 0.94686085

00:43:51.735 --> 00:43:53.114
I speeded ahead.

NOTE Confidence: 0.92930037

00:43:53.895 --> 00:43:55.415
So so this patient does

NOTE Confidence: 0.92930037

00:43:55.415 --> 00:43:57.015
have a diagnosis of multiple

NOTE Confidence: 0.92930037

00:43:57.015 --> 00:43:57.975
myeloma. He has,

NOTE Confidence: 0.92236656

00:43:58.695 --> 00:44:00.455
definitely bony lesions. It has

NOTE Confidence: 0.92236656

00:44:00.455 --> 00:44:01.735
some anemia. And, actually, in

NOTE Confidence: 0.92236656

00:44:01.735 --> 00:44:02.875
fact, the most common

NOTE Confidence: 0.8708662

00:44:03.210 --> 00:44:05.210
presenting, CRB criteria is bony

NOTE Confidence: 0.8708662

00:44:05.210 --> 00:44:06.190
lesions and anemia.

NOTE Confidence: 0.975446

00:44:06.730 --> 00:44:08.410
I think the key features

NOTE Confidence: 0.975446

00:44:08.410 --> 00:44:09.849
here is this kind of

NOTE Confidence: 0.975446

00:44:09.849 --> 00:44:12.410
persistent progressive bony pains that

NOTE Confidence: 0.975446

00:44:12.410 --> 00:44:14.430
in a young patient, someone

NOTE Confidence: 0.975446

00:44:14.650 --> 00:44:15.849
might not think is is

NOTE Confidence: 0.975446

00:44:15.849 --> 00:44:16.215
that,

NOTE Confidence: 0.9670511

00:44:16.695 --> 00:44:18.535
you know, concerning, especially we

NOTE Confidence: 0.9670511

00:44:18.535 --> 00:44:19.415
see a lot of patients

NOTE Confidence: 0.9670511

00:44:19.415 --> 00:44:20.935
who are shoveling snow and

NOTE Confidence: 0.9670511

00:44:20.935 --> 00:44:21.975
have some back pain, but

NOTE Confidence: 0.9670511

00:44:21.975 --> 00:44:23.335
that does not go away.

NOTE Confidence: 0.9670511

00:44:23.335 --> 00:44:24.475
You know? So it's like

NOTE Confidence: 0.9683598

00:44:24.775 --> 00:44:26.375
something that continues, something that

NOTE Confidence: 0.9683598

00:44:26.375 --> 00:44:27.895
needs to be evaluated for

NOTE Confidence: 0.9683598

00:44:27.895 --> 00:44:29.355
sure with more, imaging.

NOTE Confidence: 0.9860038

00:44:30.050 --> 00:44:31.890
So myeloma is not curable,

NOTE Confidence: 0.9860038

00:44:31.890 --> 00:44:33.270
and, of course, that's devastating

NOTE Confidence: 0.9860038

00:44:33.410 --> 00:44:34.070
for patients,

NOTE Confidence: 0.9926589

00:44:34.530 --> 00:44:35.190
to hear.

NOTE Confidence: 0.9839311

00:44:36.450 --> 00:44:37.730
And as I show you

NOTE Confidence: 0.9839311

00:44:37.730 --> 00:44:39.670
here, it's categorized by multiple

NOTE Confidence: 0.9839311

00:44:39.730 --> 00:44:40.230
relapses.

NOTE Confidence: 0.99961114

00:44:40.930 --> 00:44:41.590
The first

NOTE Confidence: 0.9844238

00:44:42.844 --> 00:44:43.344
remission

NOTE Confidence: 0.8520949

00:44:43.645 --> 00:44:45.585
or response to therapy

NOTE Confidence: 0.9500332

00:44:45.964 --> 00:44:47.505
is often the longest one.

NOTE Confidence: 0.9812915

00:44:47.805 --> 00:44:49.505
And you don't really have,

NOTE Confidence: 0.9612172

00:44:49.885 --> 00:44:51.984
numbers here, but on average,

NOTE Confidence: 0.9612172

00:44:52.045 --> 00:44:52.785
these patients

NOTE Confidence: 0.9518996

00:44:53.244 --> 00:44:54.605
have a first duration of

NOTE Confidence: 0.9518996

00:44:54.605 --> 00:44:56.385
response of about five years.

NOTE Confidence: 0.9518996

00:44:56.444 --> 00:44:57.900
So it's quite good.

NOTE Confidence: 0.98232806

00:44:58.600 --> 00:44:59.880
And then once they relapse,

NOTE Confidence: 0.98232806

00:44:59.880 --> 00:45:01.239
they get another therapy, and

NOTE Confidence: 0.98232806

00:45:01.239 --> 00:45:02.920
then each with each relapse,

NOTE Confidence: 0.98232806

00:45:02.920 --> 00:45:03.660
it shortens.

NOTE Confidence: 0.9891733

00:45:04.280 --> 00:45:04.920
We do,

NOTE Confidence: 0.9243378

00:45:05.400 --> 00:45:06.920
kind of classify as early

NOTE Confidence: 0.9243378

00:45:06.920 --> 00:45:08.760
relapse and late relapse mainly

NOTE Confidence: 0.9243378

00:45:08.760 --> 00:45:10.214
for kind of treatments

NOTE Confidence: 0.98405594

00:45:10.535 --> 00:45:12.394
different treatments that are approved

NOTE Confidence: 0.98405594

00:45:12.454 --> 00:45:14.075
for these particular situations,

NOTE Confidence: 0.8766614

00:45:15.575 --> 00:45:16.954
and a little bit relevant

NOTE Confidence: 0.9938719

00:45:17.255 --> 00:45:18.375
for a few slides from

NOTE Confidence: 0.9938719

00:45:18.375 --> 00:45:19.815
now. So in terms of

NOTE Confidence: 0.9938719

00:45:19.815 --> 00:45:20.315
epidemiology,

NOTE Confidence: 0.98102903

00:45:20.614 --> 00:45:21.734
it's definitely not the most

NOTE Confidence: 0.98102903

00:45:21.734 --> 00:45:23.815
common cancer, so fourteenth most

NOTE Confidence: 0.98102903

00:45:23.815 --> 00:45:24.714
common cancer.

NOTE Confidence: 0.9716225

00:45:25.590 --> 00:45:26.870
It's usually seen in the

NOTE Confidence: 0.9716225

00:45:26.870 --> 00:45:28.630
elderly, median age of sixty

NOTE Confidence: 0.9716225

00:45:28.630 --> 00:45:29.130
nine,

NOTE Confidence: 0.94743115

00:45:29.590 --> 00:45:31.130
more commonly seen in individual

NOTE Confidence: 0.94743115

00:45:31.190 --> 00:45:32.570
of African American descent.

NOTE Confidence: 0.9672474

00:45:33.270 --> 00:45:34.790
The median survival, I can

NOTE Confidence: 0.9672474

00:45:34.790 --> 00:45:36.250
see here in the,

NOTE Confidence: 0.9995542

00:45:36.790 --> 00:45:37.290
green

NOTE Confidence: 0.9627027

00:45:38.555 --> 00:45:39.935
graph here, has

NOTE Confidence: 0.99997413

00:45:40.235 --> 00:45:40.735
steadily

NOTE Confidence: 0.998558

00:45:41.515 --> 00:45:42.015
improved

NOTE Confidence: 0.99654484

00:45:42.475 --> 00:45:43.935
for the last two decades.

NOTE Confidence: 0.99654484

00:45:44.155 --> 00:45:44.655
Okay?

NOTE Confidence: 0.95677096

00:45:45.755 --> 00:45:47.035
And it it it does

NOTE Confidence: 0.95677096

00:45:47.035 --> 00:45:49.035
depend on risk. And right

NOTE Confidence: 0.95677096

00:45:49.035 --> 00:45:50.255
now, we're looking here,

NOTE Confidence: 0.8510101

00:45:50.840 --> 00:45:51.640
or we don't we don't

NOTE Confidence: 0.8510101

00:45:51.640 --> 00:45:53.880
actually have twenty twenty five

NOTE Confidence: 0.8510101

00:45:53.880 --> 00:45:55.980
with the most recent evaluation

NOTE Confidence: 0.8510101

00:45:56.120 --> 00:45:57.340
from the SEER database

NOTE Confidence: 0.88116914

00:45:57.719 --> 00:45:59.100
is twenty twenty one,

NOTE Confidence: 0.98738766

00:45:59.640 --> 00:46:00.840
showing you that at five

NOTE Confidence: 0.98738766

00:46:00.840 --> 00:46:02.360
years, if you were diagnosed

NOTE Confidence: 0.98738766

00:46:02.360 --> 00:46:03.560
in twenty twenty one, the

NOTE Confidence: 0.98738766

00:46:03.560 --> 00:46:04.060
chance

NOTE Confidence: 0.9703067

00:46:04.360 --> 00:46:05.719
of being alive at five

NOTE Confidence: 0.9703067

00:46:05.719 --> 00:46:07.135
years is sixty two percent.

NOTE Confidence: 0.9703067

00:46:07.135 --> 00:46:07.935
But I can tell you

NOTE Confidence: 0.9703067

00:46:07.935 --> 00:46:09.614
this is very much an

NOTE Confidence: 0.9703067

00:46:09.614 --> 00:46:10.114
underrepresentation

NOTE Confidence: 0.9782482

00:46:11.295 --> 00:46:12.655
of our survival in our

NOTE Confidence: 0.9782482

00:46:12.655 --> 00:46:13.155
patients,

NOTE Confidence: 0.99633044

00:46:13.455 --> 00:46:14.735
and this is probably more

NOTE Confidence: 0.99633044

00:46:14.735 --> 00:46:16.255
close to seventy five to

NOTE Confidence: 0.99633044

00:46:16.255 --> 00:46:17.075
eighty percent.

NOTE Confidence: 0.99910647

00:46:18.495 --> 00:46:19.635
High risk patients

NOTE Confidence: 0.9853432

00:46:20.489 --> 00:46:20.989
probably,

NOTE Confidence: 0.9890452

00:46:21.850 --> 00:46:23.130
do die within the first

NOTE Confidence: 0.9890452

00:46:23.130 --> 00:46:24.410
five years, but if you're

NOTE Confidence: 0.9890452

00:46:24.410 --> 00:46:25.450
not high risk, you do

NOTE Confidence: 0.9890452

00:46:25.450 --> 00:46:26.810
have that benefit of of

NOTE Confidence: 0.9890452

00:46:26.810 --> 00:46:28.350
longer duration of survival.

NOTE Confidence: 0.9994081

00:46:29.610 --> 00:46:31.550
Majority of the reason why

NOTE Confidence: 0.9994081

00:46:31.610 --> 00:46:33.150
our patients are living longer

NOTE Confidence: 0.9994081

00:46:33.290 --> 00:46:34.830
is because of new therapies.

NOTE Confidence: 0.94288844

00:46:36.114 --> 00:46:37.635
So the initial therapy for

NOTE Confidence: 0.94288844

00:46:37.635 --> 00:46:38.135
myeloma,

NOTE Confidence: 0.98589534

00:46:39.155 --> 00:46:41.235
can be quite cumbersome. So

NOTE Confidence: 0.98589534

00:46:41.235 --> 00:46:43.415
it actually involves three different

NOTE Confidence: 0.98589534

00:46:43.475 --> 00:46:45.095
parts. The first is induction.

NOTE Confidence: 0.98589534

00:46:45.395 --> 00:46:47.015
We use several drugs together.

NOTE Confidence: 0.95234907

00:46:47.715 --> 00:46:48.775
And after you get

NOTE Confidence: 0.9557765

00:46:49.650 --> 00:46:50.930
here, you see burden of

NOTE Confidence: 0.9557765

00:46:50.930 --> 00:46:51.430
disease,

NOTE Confidence: 0.9971866

00:46:52.609 --> 00:46:54.130
and then it goes down

NOTE Confidence: 0.9971866

00:46:54.130 --> 00:46:54.869
with induction.

NOTE Confidence: 0.9729434

00:46:55.329 --> 00:46:56.849
Some patients get a high

NOTE Confidence: 0.9729434

00:46:56.849 --> 00:46:58.849
dose chemotherapy and stem cell

NOTE Confidence: 0.9729434

00:46:58.849 --> 00:47:00.469
transplant if they're eligible,

NOTE Confidence: 0.9842211

00:47:01.089 --> 00:47:02.609
and then everyone goes on

NOTE Confidence: 0.9842211

00:47:02.609 --> 00:47:04.194
to getting maintenance. And we

NOTE Confidence: 0.9842211

00:47:04.194 --> 00:47:05.895
continue therapy for myeloma

NOTE Confidence: 0.96996415

00:47:06.515 --> 00:47:07.015
ongoing

NOTE Confidence: 0.92883235

00:47:07.315 --> 00:47:09.075
forever, which now as patients

NOTE Confidence: 0.92883235

00:47:09.075 --> 00:47:10.055
are living longer,

NOTE Confidence: 0.9351023

00:47:10.355 --> 00:47:12.275
is creating more problems. And

NOTE Confidence: 0.9351023

00:47:12.275 --> 00:47:13.315
we're trying to,

NOTE Confidence: 0.9242104

00:47:14.355 --> 00:47:15.395
figure this out who we

NOTE Confidence: 0.9242104

00:47:15.395 --> 00:47:16.375
can stop therapy,

NOTE Confidence: 0.9967793

00:47:17.395 --> 00:47:17.895
for.

NOTE Confidence: 0.9997052

00:47:18.770 --> 00:47:19.989
We know that achieving

NOTE Confidence: 0.99830145

00:47:20.450 --> 00:47:21.349
deep responses

NOTE Confidence: 0.94857025

00:47:22.450 --> 00:47:23.270
as we can

NOTE Confidence: 0.9221967

00:47:23.570 --> 00:47:25.670
measure by minimal residual disease

NOTE Confidence: 0.9221967

00:47:25.890 --> 00:47:26.390
negativity

NOTE Confidence: 0.85090435

00:47:28.450 --> 00:47:31.190
achieves good duration response and

NOTE Confidence: 0.8677885

00:47:31.635 --> 00:47:33.175
overall outcomes of survival.

NOTE Confidence: 0.98083866

00:47:33.635 --> 00:47:35.255
And with our newer therapies

NOTE Confidence: 0.98083866

00:47:35.315 --> 00:47:37.015
that we're using in induction

NOTE Confidence: 0.95894307

00:47:37.715 --> 00:47:39.155
and even in maintenance, we're

NOTE Confidence: 0.95894307

00:47:39.155 --> 00:47:40.755
achieving higher rates of MRG

NOTE Confidence: 0.95894307

00:47:40.755 --> 00:47:42.295
negativity, and this is why

NOTE Confidence: 0.95894307

00:47:42.435 --> 00:47:44.055
our our patients are overall

NOTE Confidence: 0.95894307

00:47:44.195 --> 00:47:45.575
doing much better.

NOTE Confidence: 0.9886436

00:47:46.460 --> 00:47:48.140
However, unfortunately, again, it is

NOTE Confidence: 0.9886436

00:47:48.140 --> 00:47:50.059
not curable, so patients do

NOTE Confidence: 0.9886436

00:47:50.059 --> 00:47:50.559
progress.

NOTE Confidence: 0.95236987

00:47:51.260 --> 00:47:53.339
And patients who progress several

NOTE Confidence: 0.95236987

00:47:53.339 --> 00:47:53.839
times

NOTE Confidence: 0.7280697

00:47:54.539 --> 00:47:55.039
historically

NOTE Confidence: 0.96889013

00:47:56.059 --> 00:47:58.380
have horrible prognosis, and this

NOTE Confidence: 0.96889013

00:47:58.380 --> 00:47:59.119
is historically

NOTE Confidence: 0.9974191

00:47:59.735 --> 00:48:01.355
four years ago. Okay?

NOTE Confidence: 0.98052347

00:48:01.975 --> 00:48:03.415
This is showing you patients

NOTE Confidence: 0.98052347

00:48:03.415 --> 00:48:05.175
who have had three late

NOTE Confidence: 0.98052347

00:48:05.175 --> 00:48:05.675
relapses.

NOTE Confidence: 0.99983966

00:48:06.375 --> 00:48:07.594
The chance of them

NOTE Confidence: 0.9696924

00:48:08.455 --> 00:48:09.895
responding to the next line

NOTE Confidence: 0.9696924

00:48:09.895 --> 00:48:10.635
of therapy

NOTE Confidence: 0.9869402

00:48:10.935 --> 00:48:12.635
is only thirty percent.

NOTE Confidence: 0.99204475

00:48:13.070 --> 00:48:14.190
And even if they do

NOTE Confidence: 0.99204475

00:48:14.190 --> 00:48:15.810
respond, they tend to progress

NOTE Confidence: 0.99204475

00:48:15.950 --> 00:48:18.369
with within several months, usually

NOTE Confidence: 0.94002974

00:48:18.670 --> 00:48:19.890
less than six months,

NOTE Confidence: 0.99002826

00:48:20.190 --> 00:48:22.270
and they often die within

NOTE Confidence: 0.99002826

00:48:22.270 --> 00:48:22.930
a year.

NOTE Confidence: 0.9975624

00:48:24.110 --> 00:48:25.230
What do we have today?

NOTE Confidence: 0.9975624

00:48:25.230 --> 00:48:26.450
This is quite different.

NOTE Confidence: 0.98798025

00:48:27.435 --> 00:48:28.395
We are now in the

NOTE Confidence: 0.98798025

00:48:28.395 --> 00:48:29.935
era of T cell redirection

NOTE Confidence: 0.98798025

00:48:30.075 --> 00:48:31.355
therapies, which is a type

NOTE Confidence: 0.98798025

00:48:31.355 --> 00:48:32.094
of immunotherapy

NOTE Confidence: 0.9990453

00:48:32.955 --> 00:48:33.455
that

NOTE Confidence: 0.9397976

00:48:34.075 --> 00:48:35.515
engages the T cells or

NOTE Confidence: 0.9397976

00:48:35.515 --> 00:48:36.735
uses T cells

NOTE Confidence: 0.9995069

00:48:37.195 --> 00:48:38.255
to identify

NOTE Confidence: 0.91566366

00:48:38.875 --> 00:48:40.175
the cancer, myeloma,

NOTE Confidence: 0.99422526

00:48:40.635 --> 00:48:41.535
through an antigen,

NOTE Confidence: 0.9428156

00:48:42.020 --> 00:48:42.920
which is a cell,

NOTE Confidence: 0.95134246

00:48:43.460 --> 00:48:44.500
a marker on the cell

NOTE Confidence: 0.95134246

00:48:44.500 --> 00:48:45.960
surface of the myeloma,

NOTE Confidence: 0.99603534

00:48:46.660 --> 00:48:47.719
identifies it,

NOTE Confidence: 0.9968002

00:48:48.339 --> 00:48:49.880
attacks it, kills it.

NOTE Confidence: 0.9708339

00:48:50.180 --> 00:48:51.780
So this is done through

NOTE Confidence: 0.9708339

00:48:51.780 --> 00:48:53.780
two different ways. One is

NOTE Confidence: 0.9708339

00:48:53.780 --> 00:48:54.839
called a bispecific

NOTE Confidence: 0.86350036

00:48:55.380 --> 00:48:56.440
T cell engager,

NOTE Confidence: 0.95112985

00:48:56.925 --> 00:48:58.364
which is basically an antibody,

NOTE Confidence: 0.95112985

00:48:58.364 --> 00:48:59.245
as you can see, shaped

NOTE Confidence: 0.95112985

00:48:59.245 --> 00:49:00.065
like a myeloma,

NOTE Confidence: 0.9738915

00:49:01.965 --> 00:49:03.025
monoclonal protein,

NOTE Confidence: 0.97937125

00:49:03.405 --> 00:49:04.785
which one of the arms

NOTE Confidence: 0.97937125

00:49:04.925 --> 00:49:06.125
binds to the T cell

NOTE Confidence: 0.97937125

00:49:06.125 --> 00:49:07.245
and the other one binds

NOTE Confidence: 0.97937125

00:49:07.245 --> 00:49:08.545
to the myeloma cell.

NOTE Confidence: 0.98902714

00:49:09.469 --> 00:49:11.150
The other T cell redirection

NOTE Confidence: 0.98902714

00:49:11.150 --> 00:49:12.349
therapy is a CAR T

NOTE Confidence: 0.98902714

00:49:12.349 --> 00:49:14.030
cell, which is basically a

NOTE Confidence: 0.98902714

00:49:14.030 --> 00:49:15.410
T cell that's engineered

NOTE Confidence: 0.99942136

00:49:16.430 --> 00:49:16.930
to

NOTE Confidence: 0.9870452

00:49:17.309 --> 00:49:19.170
have a receptor that recognizes

NOTE Confidence: 0.9870452

00:49:19.390 --> 00:49:20.670
the myeloma and kills it.

NOTE Confidence: 0.9870452

00:49:20.670 --> 00:49:21.469
And the T cells are

NOTE Confidence: 0.9870452

00:49:21.469 --> 00:49:22.829
kind of superstar T cells

NOTE Confidence: 0.9870452

00:49:22.829 --> 00:49:23.730
because they have

NOTE Confidence: 0.8250132

00:49:25.395 --> 00:49:25.895
costimulatory

NOTE Confidence: 0.99884206

00:49:26.275 --> 00:49:28.375
molecules once they get stimulated.

NOTE Confidence: 0.9954756

00:49:30.355 --> 00:49:31.475
So why are we so

NOTE Confidence: 0.9954756

00:49:31.475 --> 00:49:32.915
excited about these t cell

NOTE Confidence: 0.9954756

00:49:32.915 --> 00:49:35.175
redirection therapies? Again, historically,

NOTE Confidence: 0.9997865

00:49:35.875 --> 00:49:36.695
these patients

NOTE Confidence: 0.97184324

00:49:37.219 --> 00:49:39.059
who received these therapies on

NOTE Confidence: 0.97184324

00:49:39.059 --> 00:49:40.500
clinical trials would have had

NOTE Confidence: 0.97184324

00:49:40.500 --> 00:49:41.700
a thirty percent chance of

NOTE Confidence: 0.97184324

00:49:41.700 --> 00:49:43.059
response. And indeed, a lot

NOTE Confidence: 0.97184324

00:49:43.059 --> 00:49:44.099
of the treatments we use

NOTE Confidence: 0.97184324

00:49:44.099 --> 00:49:45.940
now upfront, they got approved

NOTE Confidence: 0.97184324

00:49:45.940 --> 00:49:47.219
by the FDA because of

NOTE Confidence: 0.97184324

00:49:47.219 --> 00:49:48.660
a thirty percent response rate,

NOTE Confidence: 0.97184324

00:49:48.660 --> 00:49:49.779
and we were excited about

NOTE Confidence: 0.97184324

00:49:49.779 --> 00:49:50.279
that.

NOTE Confidence: 0.96380603

00:49:50.875 --> 00:49:52.555
And, again, these patients who've

NOTE Confidence: 0.96380603

00:49:52.555 --> 00:49:53.695
progressed three times,

NOTE Confidence: 0.9603104

00:49:54.395 --> 00:49:55.995
they usually, even if they

NOTE Confidence: 0.9603104

00:49:55.995 --> 00:49:56.495
respond,

NOTE Confidence: 0.98518115

00:49:56.875 --> 00:49:58.495
progress within a few months.

NOTE Confidence: 0.9884454

00:49:58.955 --> 00:49:59.995
So this is a busy

NOTE Confidence: 0.9884454

00:49:59.995 --> 00:50:00.795
slide, but I want you

NOTE Confidence: 0.9884454

00:50:00.795 --> 00:50:02.075
to focus on two things.

NOTE Confidence: 0.9884454

00:50:02.075 --> 00:50:03.675
The first is in the

NOTE Confidence: 0.9884454

00:50:03.675 --> 00:50:05.355
orange box, the percent of

NOTE Confidence: 0.9884454

00:50:05.355 --> 00:50:06.980
page patients responding.

NOTE Confidence: 0.99255073

00:50:08.160 --> 00:50:09.680
First, I show you here

NOTE Confidence: 0.99255073

00:50:09.680 --> 00:50:11.380
three different types of bispecific

NOTE Confidence: 0.8380375

00:50:11.760 --> 00:50:12.660
T cell engagers,

NOTE Confidence: 0.95830524

00:50:13.040 --> 00:50:14.320
and in the second box

NOTE Confidence: 0.95830524

00:50:14.320 --> 00:50:15.520
is the two types of

NOTE Confidence: 0.95830524

00:50:15.520 --> 00:50:17.619
CAR T cell therapy products.

NOTE Confidence: 0.97246194

00:50:18.160 --> 00:50:18.960
And you can see on

NOTE Confidence: 0.97246194

00:50:18.960 --> 00:50:20.180
the bottom in gray,

NOTE Confidence: 0.9969404

00:50:20.664 --> 00:50:22.285
the chance of patients responding

NOTE Confidence: 0.9969404

00:50:22.344 --> 00:50:23.565
is more than double

NOTE Confidence: 0.92941284

00:50:24.105 --> 00:50:25.464
in the bispecific t cell

NOTE Confidence: 0.92941284

00:50:25.464 --> 00:50:25.964
engagers

NOTE Confidence: 0.9536843

00:50:26.585 --> 00:50:28.424
and even close to a

NOTE Confidence: 0.9536843

00:50:28.424 --> 00:50:28.924
hundred

NOTE Confidence: 0.94659275

00:50:29.384 --> 00:50:30.585
in the in this CAR

NOTE Confidence: 0.94659275

00:50:30.585 --> 00:50:31.964
T cell product, ciltasil,

NOTE Confidence: 0.9664064

00:50:32.265 --> 00:50:34.105
ninety seven percent. Only one

NOTE Confidence: 0.9664064

00:50:34.105 --> 00:50:35.250
of the patients did not

NOTE Confidence: 0.9664064

00:50:35.330 --> 00:50:36.710
respond in this clinical trial.

NOTE Confidence: 0.9796004

00:50:37.489 --> 00:50:38.630
So this is great.

NOTE Confidence: 0.9994422

00:50:38.930 --> 00:50:39.430
Unprecedented.

NOTE Confidence: 0.97240174

00:50:40.290 --> 00:50:42.210
Now in blue, our bar

NOTE Confidence: 0.97240174

00:50:42.210 --> 00:50:43.270
is showing you

NOTE Confidence: 0.99895585

00:50:43.650 --> 00:50:45.030
the number of months

NOTE Confidence: 0.99629706

00:50:45.650 --> 00:50:47.250
where fifty percent of the

NOTE Confidence: 0.99629706

00:50:47.250 --> 00:50:47.750
population

NOTE Confidence: 0.8792691

00:50:48.930 --> 00:50:50.370
progressed or in the other,

NOTE Confidence: 0.9388267

00:50:51.545 --> 00:50:53.305
the half the the cup

NOTE Confidence: 0.9388267

00:50:53.305 --> 00:50:54.685
half full, half empty,

NOTE Confidence: 0.99814045

00:50:54.985 --> 00:50:56.525
fifty percent did not progress

NOTE Confidence: 0.99814045

00:50:56.585 --> 00:50:58.525
at this time point. And

NOTE Confidence: 0.9829358

00:50:58.905 --> 00:51:00.665
comparing to the six months

NOTE Confidence: 0.9829358

00:51:00.665 --> 00:51:01.725
or less historically,

NOTE Confidence: 0.9989712

00:51:02.585 --> 00:51:03.785
you can see these agents

NOTE Confidence: 0.9989712

00:51:03.785 --> 00:51:05.725
are doing far superiorly

NOTE Confidence: 0.85478485

00:51:06.760 --> 00:51:07.500
with celtacel

NOTE Confidence: 0.95994663

00:51:07.880 --> 00:51:09.640
going on about three years.

NOTE Confidence: 0.95994663

00:51:09.640 --> 00:51:10.860
So on average,

NOTE Confidence: 0.9888999

00:51:11.160 --> 00:51:12.520
patients have a duration of

NOTE Confidence: 0.9888999

00:51:12.520 --> 00:51:14.060
response of three years.

NOTE Confidence: 0.9284438

00:51:14.360 --> 00:51:16.460
Again, unbelievable in these patients.

NOTE Confidence: 0.9994464

00:51:16.920 --> 00:51:18.920
And because these are so

NOTE Confidence: 0.9994464

00:51:18.920 --> 00:51:21.080
useful and efficacious in this

NOTE Confidence: 0.9994464

00:51:21.080 --> 00:51:21.820
late relapse,

NOTE Confidence: 0.987465

00:51:22.545 --> 00:51:24.464
They've been tested earlier and

NOTE Confidence: 0.987465

00:51:24.464 --> 00:51:26.145
were approved in early relapse

NOTE Confidence: 0.987465

00:51:26.145 --> 00:51:27.684
and are now being tested

NOTE Confidence: 0.9749034

00:51:28.145 --> 00:51:29.765
in frontline therapy

NOTE Confidence: 0.90347004

00:51:30.065 --> 00:51:30.805
and even,

NOTE Confidence: 0.9946417

00:51:32.145 --> 00:51:34.005
testing against transplant.

NOTE Confidence: 0.95922196

00:51:34.704 --> 00:51:36.065
We'll we'll know more in

NOTE Confidence: 0.95922196

00:51:36.065 --> 00:51:37.444
maybe five to ten years.

NOTE Confidence: 0.965149

00:51:39.310 --> 00:51:40.190
So CAR T is a

NOTE Confidence: 0.965149

00:51:40.190 --> 00:51:41.950
little bit different than other

NOTE Confidence: 0.965149

00:51:41.950 --> 00:51:43.570
therapies we use because,

NOTE Confidence: 0.9982357

00:51:43.950 --> 00:51:44.609
it requires

NOTE Confidence: 0.99024874

00:51:44.910 --> 00:51:45.410
manufacturing.

NOTE Confidence: 0.98925525

00:51:45.869 --> 00:51:46.829
So I just wanted to

NOTE Confidence: 0.98925525

00:51:46.829 --> 00:51:47.950
show you what this entails,

NOTE Confidence: 0.98925525

00:51:47.950 --> 00:51:48.829
what patients have to go

NOTE Confidence: 0.98925525

00:51:48.829 --> 00:51:50.349
through. First, we have to

NOTE Confidence: 0.98925525

00:51:50.349 --> 00:51:51.390
collect the T cells from

NOTE Confidence: 0.98925525

00:51:51.390 --> 00:51:53.150
the patients through apheresis, then

NOTE Confidence: 0.98925525

00:51:53.150 --> 00:51:54.494
they get shipped off to

NOTE Confidence: 0.98925525

00:51:54.494 --> 00:51:55.234
the manufacturer.

NOTE Confidence: 0.9325528

00:51:55.775 --> 00:51:56.594
They separate,

NOTE Confidence: 0.8948768

00:51:56.895 --> 00:51:58.594
the T cells. They they

NOTE Confidence: 0.8948768

00:51:58.654 --> 00:51:59.154
genetically

NOTE Confidence: 0.9995767

00:51:59.454 --> 00:52:00.994
modify them to express

NOTE Confidence: 0.93545735

00:52:01.614 --> 00:52:03.795
the chimeric T cell receptor,

NOTE Confidence: 0.981893

00:52:04.094 --> 00:52:05.295
then they grow, and then

NOTE Confidence: 0.981893

00:52:05.295 --> 00:52:05.954
they get

NOTE Confidence: 0.99869806

00:52:06.309 --> 00:52:07.589
brought back to the patient

NOTE Confidence: 0.99869806

00:52:07.589 --> 00:52:08.410
and infused

NOTE Confidence: 0.964941

00:52:08.710 --> 00:52:10.170
like a regular blood transfusion

NOTE Confidence: 0.91380024

00:52:10.469 --> 00:52:11.450
similar to that.

NOTE Confidence: 0.9505602

00:52:12.710 --> 00:52:14.069
This here show you a

NOTE Confidence: 0.9505602

00:52:14.069 --> 00:52:15.670
highlight of what this CAR

NOTE Confidence: 0.9505602

00:52:15.670 --> 00:52:16.069
T,

NOTE Confidence: 0.9609516

00:52:16.469 --> 00:52:17.829
what what the receptor looks

NOTE Confidence: 0.9609516

00:52:17.829 --> 00:52:19.109
like. So there's a binding

NOTE Confidence: 0.9609516

00:52:19.109 --> 00:52:20.390
domain. Again, this is to

NOTE Confidence: 0.9609516

00:52:20.390 --> 00:52:21.049
a protein

NOTE Confidence: 0.99101996

00:52:21.575 --> 00:52:22.395
called BCMA.

NOTE Confidence: 0.8366745

00:52:23.335 --> 00:52:25.095
IDACel has two binding domains

NOTE Confidence: 0.8366745

00:52:25.095 --> 00:52:26.695
and I and, sorry, cilta

NOTE Confidence: 0.8366745

00:52:26.695 --> 00:52:27.815
cell has two binding domains

NOTE Confidence: 0.8366745

00:52:27.815 --> 00:52:29.435
and IDACel has one.

NOTE Confidence: 0.96935946

00:52:31.975 --> 00:52:34.075
Now a major difference between

NOTE Confidence: 0.96935946

00:52:34.340 --> 00:52:36.120
CAR T and the bispecific

NOTE Confidence: 0.96935946

00:52:36.340 --> 00:52:38.100
T cell engagers also is

NOTE Confidence: 0.96935946

00:52:38.100 --> 00:52:40.020
how you administer it, which

NOTE Confidence: 0.96935946

00:52:40.020 --> 00:52:41.719
is relevant for patients. So

NOTE Confidence: 0.96935946

00:52:41.860 --> 00:52:42.360
bispecifics,

NOTE Confidence: 0.9659695

00:52:42.900 --> 00:52:44.100
we don't stop therapy. We

NOTE Confidence: 0.9659695

00:52:44.100 --> 00:52:45.140
give it every week or

NOTE Confidence: 0.9659695

00:52:45.140 --> 00:52:46.340
every two weeks and sometimes

NOTE Confidence: 0.9659695

00:52:46.340 --> 00:52:47.860
every four weeks depending on

NOTE Confidence: 0.9659695

00:52:47.860 --> 00:52:49.445
the product. But CAR T

NOTE Confidence: 0.9659695

00:52:49.445 --> 00:52:50.745
is a one time treatment,

NOTE Confidence: 0.9659695

00:52:50.965 --> 00:52:52.425
which is really,

NOTE Confidence: 0.98507553

00:52:52.885 --> 00:52:54.165
nice for patients who've been

NOTE Confidence: 0.98507553

00:52:54.165 --> 00:52:55.445
treated for many, many years

NOTE Confidence: 0.98507553

00:52:55.445 --> 00:52:55.945
continuously.

NOTE Confidence: 0.999136

00:52:57.925 --> 00:52:59.844
So just to close on

NOTE Confidence: 0.999136

00:52:59.844 --> 00:53:00.505
the myeloma

NOTE Confidence: 0.94556504

00:53:01.539 --> 00:53:02.819
category, you know, a lot

NOTE Confidence: 0.94556504

00:53:02.819 --> 00:53:04.579
of patient care happens with

NOTE Confidence: 0.94556504

00:53:04.579 --> 00:53:05.640
us, so you don't,

NOTE Confidence: 0.9834907

00:53:06.099 --> 00:53:07.140
see it as much, but

NOTE Confidence: 0.9834907

00:53:07.140 --> 00:53:07.940
you do see them once

NOTE Confidence: 0.9834907

00:53:07.940 --> 00:53:09.059
in a while. And there

NOTE Confidence: 0.9834907

00:53:09.059 --> 00:53:10.599
are some comorbidities

NOTE Confidence: 0.9752068

00:53:11.380 --> 00:53:11.859
that,

NOTE Confidence: 0.9824227

00:53:12.259 --> 00:53:14.180
can be exacerbated by our

NOTE Confidence: 0.9824227

00:53:14.180 --> 00:53:16.019
treatment. Steroids are often used

NOTE Confidence: 0.9824227

00:53:16.019 --> 00:53:17.160
in many of our regimens,

NOTE Confidence: 0.9824227

00:53:17.435 --> 00:53:18.975
so this could worsen hypertension,

NOTE Confidence: 0.9824227

00:53:19.195 --> 00:53:20.715
diabetes. I mean, we might

NOTE Confidence: 0.9824227

00:53:20.715 --> 00:53:21.994
need more support from you

NOTE Confidence: 0.9824227

00:53:21.994 --> 00:53:24.015
guys to help manage that.

NOTE Confidence: 0.9824227

00:53:24.075 --> 00:53:24.575
Carfizumab,

NOTE Confidence: 0.8946852

00:53:24.875 --> 00:53:26.255
which is the second generation

NOTE Confidence: 0.8946852

00:53:26.315 --> 00:53:28.494
proteasome inhibitor, could also,

NOTE Confidence: 0.9995449

00:53:28.875 --> 00:53:29.775
lead to hypertension

NOTE Confidence: 0.9681011

00:53:30.155 --> 00:53:31.215
and heart failure.

NOTE Confidence: 0.97495013

00:53:31.910 --> 00:53:33.270
And many of our treatments

NOTE Confidence: 0.97495013

00:53:33.270 --> 00:53:34.730
increase the risk for infections,

NOTE Confidence: 0.94056463

00:53:35.830 --> 00:53:37.290
often not opportunistic.

NOTE Confidence: 0.9839188

00:53:37.750 --> 00:53:38.950
But now with the t

NOTE Confidence: 0.9839188

00:53:38.950 --> 00:53:40.890
cell redirection therapies, we are

NOTE Confidence: 0.9839188

00:53:41.030 --> 00:53:42.489
seeing some more opportunistic

NOTE Confidence: 0.96460515

00:53:42.790 --> 00:53:44.630
infections. So it's important to,

NOTE Confidence: 0.9800873

00:53:46.025 --> 00:53:47.465
to recognize that. And with

NOTE Confidence: 0.9800873

00:53:47.465 --> 00:53:48.665
an infection, let us know

NOTE Confidence: 0.9800873

00:53:48.665 --> 00:53:49.705
what's going on so we

NOTE Confidence: 0.9800873

00:53:49.705 --> 00:53:51.085
can further assess.

NOTE Confidence: 0.97166383

00:53:51.785 --> 00:53:52.525
And lastly,

NOTE Confidence: 0.9535863

00:53:53.065 --> 00:53:54.585
I wanna end by showing

NOTE Confidence: 0.9535863

00:53:54.585 --> 00:53:56.425
you the gammopathy pathway that

NOTE Confidence: 0.9535863

00:53:56.425 --> 00:53:57.325
is in EPIC.

NOTE Confidence: 0.9910754

00:53:57.945 --> 00:53:58.344
And,

NOTE Confidence: 0.9930741

00:53:58.745 --> 00:53:59.864
it's a busy slide, but

NOTE Confidence: 0.9930741

00:53:59.864 --> 00:54:00.505
I want you to know

NOTE Confidence: 0.9930741

00:54:00.505 --> 00:54:01.165
it's there

NOTE Confidence: 0.9681988

00:54:02.130 --> 00:54:02.630
As

NOTE Confidence: 0.95573646

00:54:03.410 --> 00:54:04.609
and you can see that

NOTE Confidence: 0.95573646

00:54:04.609 --> 00:54:05.809
it guides you through if

NOTE Confidence: 0.95573646

00:54:05.809 --> 00:54:07.250
you have a monoclonal protein

NOTE Confidence: 0.95573646

00:54:07.250 --> 00:54:08.549
on SBEP or not.

NOTE Confidence: 0.9117834

00:54:09.809 --> 00:54:11.269
And showing you the monoclonal

NOTE Confidence: 0.9117834

00:54:11.410 --> 00:54:11.910
gammopathy,

NOTE Confidence: 0.9113701

00:54:12.849 --> 00:54:14.835
screen panel here, which makes

NOTE Confidence: 0.9113701

00:54:14.835 --> 00:54:16.355
sure you're ordering all the

NOTE Confidence: 0.9113701

00:54:16.355 --> 00:54:18.275
pair protein evaluation that we

NOTE Confidence: 0.9113701

00:54:18.275 --> 00:54:18.775
need

NOTE Confidence: 0.865188

00:54:19.315 --> 00:54:20.935
and also some key information

NOTE Confidence: 0.99946916

00:54:21.315 --> 00:54:23.255
about when to refer urgently,

NOTE Confidence: 0.99780804

00:54:23.715 --> 00:54:25.175
when to not refer urgently,

NOTE Confidence: 0.99780804

00:54:25.395 --> 00:54:27.155
when to repeat labs, and

NOTE Confidence: 0.99780804

00:54:27.155 --> 00:54:27.655
reassess.

NOTE Confidence: 0.9716801

00:54:29.920 --> 00:54:31.700
So to close our,

NOTE Confidence: 0.9957744

00:54:32.880 --> 00:54:33.620
talk today,

NOTE Confidence: 0.99950856

00:54:34.000 --> 00:54:35.620
these are just some summary

NOTE Confidence: 0.9333817

00:54:36.080 --> 00:54:37.780
points that we wanna highlight.

NOTE Confidence: 0.9529122

00:54:38.320 --> 00:54:39.440
First, we showed you how

NOTE Confidence: 0.9529122

00:54:39.440 --> 00:54:40.800
it's important to recognize whether

NOTE Confidence: 0.9529122

00:54:40.800 --> 00:54:42.260
it's normal light chain ratio,

NOTE Confidence: 0.9529122

00:54:42.515 --> 00:54:44.835
how, how age and, renal

NOTE Confidence: 0.9529122

00:54:44.835 --> 00:54:45.335
dysfunction

NOTE Confidence: 0.9944134

00:54:45.795 --> 00:54:46.935
can affect these.

NOTE Confidence: 0.9777016

00:54:47.475 --> 00:54:49.075
We showed you what low

NOTE Confidence: 0.9777016

00:54:49.075 --> 00:54:51.075
risk MGUS is, what is

NOTE Confidence: 0.9777016

00:54:51.075 --> 00:54:51.735
the definition,

NOTE Confidence: 0.99865645

00:54:52.835 --> 00:54:54.515
and that this often can

NOTE Confidence: 0.99865645

00:54:54.515 --> 00:54:55.875
be managed by primary care

NOTE Confidence: 0.99865645

00:54:55.875 --> 00:54:56.375
doctors

NOTE Confidence: 0.82775253

00:54:56.755 --> 00:54:57.255
if

NOTE Confidence: 0.8900984

00:54:58.160 --> 00:55:00.100
or co managed with us.

NOTE Confidence: 0.8702384

00:55:00.640 --> 00:55:02.420
When to urgently refer patient,

NOTE Confidence: 0.8702384

00:55:02.480 --> 00:55:03.300
CRAB criteria,

NOTE Confidence: 0.8827658

00:55:03.600 --> 00:55:04.100
certainly,

NOTE Confidence: 0.88301235

00:55:05.920 --> 00:55:07.440
things that make it in

NOTE Confidence: 0.88301235

00:55:07.440 --> 00:55:08.420
IgM, gammopathies,

NOTE Confidence: 0.980696

00:55:08.880 --> 00:55:10.880
things that kind of, are

NOTE Confidence: 0.980696

00:55:10.880 --> 00:55:12.885
red flags is new progressive

NOTE Confidence: 0.980696

00:55:13.025 --> 00:55:14.165
neuropathy or

NOTE Confidence: 0.99967706

00:55:14.545 --> 00:55:15.365
other symptoms

NOTE Confidence: 0.6042528

00:55:15.745 --> 00:55:16.245
diagnose,

NOTE Confidence: 0.9947832

00:55:16.545 --> 00:55:17.605
diagnosing Waldenstrom.

NOTE Confidence: 0.96759784

00:55:18.065 --> 00:55:18.885
And lastly,

NOTE Confidence: 0.9709831

00:55:19.745 --> 00:55:20.385
it would be,

NOTE Confidence: 0.96052325

00:55:21.105 --> 00:55:22.385
wonderful if you can look

NOTE Confidence: 0.96052325

00:55:22.385 --> 00:55:23.905
at the gammopathy pathway if

NOTE Confidence: 0.96052325

00:55:23.905 --> 00:55:25.125
you have a positive,

NOTE Confidence: 0.9717196

00:55:25.745 --> 00:55:27.460
finding and tell us if

NOTE Confidence: 0.9717196

00:55:27.460 --> 00:55:29.160
it was helpful or unhelpful.

NOTE Confidence: 0.9770712

00:55:29.540 --> 00:55:31.540
How can we, improve this

NOTE Confidence: 0.9770712

00:55:31.540 --> 00:55:32.739
pathway? And, also, there is

NOTE Confidence: 0.9770712

00:55:32.739 --> 00:55:33.960
some education material

NOTE Confidence: 0.9987841

00:55:34.260 --> 00:55:35.000
for MGUS

NOTE Confidence: 0.99868834

00:55:35.300 --> 00:55:36.520
to bring to the patient

NOTE Confidence: 0.9827881

00:55:37.140 --> 00:55:38.200
to reduce anxiety.

NOTE Confidence: 0.9509367

00:55:40.525 --> 00:55:43.025
That was terrific. A real,

NOTE Confidence: 0.959647

00:55:43.805 --> 00:55:45.005
everything you know need to

NOTE Confidence: 0.959647

00:55:45.005 --> 00:55:46.125
know from a to z

NOTE Confidence: 0.959647

00:55:46.125 --> 00:55:47.825
or maybe a to IGG.

NOTE Confidence: 0.959647

00:55:47.885 --> 00:55:48.945
I I don't know. IGM.

NOTE Confidence: 0.8861655

00:55:50.445 --> 00:55:51.565
We have a couple of

NOTE Confidence: 0.8861655

00:55:51.565 --> 00:55:53.185
questions, and we are

NOTE Confidence: 0.97187036

00:55:54.339 --> 00:55:55.380
getting near the end of

NOTE Confidence: 0.97187036

00:55:55.380 --> 00:55:56.819
the hour. One is the

NOTE Confidence: 0.97187036

00:55:56.819 --> 00:55:58.599
usual, is there a CME

NOTE Confidence: 0.97187036

00:55:58.660 --> 00:55:59.780
code? And and, Renee, if

NOTE Confidence: 0.97187036

00:55:59.780 --> 00:56:01.000
you can just type in,

NOTE Confidence: 0.93871

00:56:01.940 --> 00:56:02.900
that I I I think

NOTE Confidence: 0.93871

00:56:02.900 --> 00:56:03.940
what we found before is

NOTE Confidence: 0.93871

00:56:03.940 --> 00:56:05.540
if you're if you're here,

NOTE Confidence: 0.93871

00:56:05.540 --> 00:56:06.500
we end up getting you

NOTE Confidence: 0.93871

00:56:06.500 --> 00:56:07.000
credit,

NOTE Confidence: 0.9985588

00:56:07.859 --> 00:56:08.900
as long as your name

NOTE Confidence: 0.9985588

00:56:08.900 --> 00:56:09.400
shows.

NOTE Confidence: 0.9137064

00:56:10.325 --> 00:56:12.005
But one question from doctor

NOTE Confidence: 0.9137064

00:56:12.005 --> 00:56:13.864
Zarku Power is, is there

NOTE Confidence: 0.9819666

00:56:14.484 --> 00:56:16.484
is there robust research to

NOTE Confidence: 0.9819666

00:56:16.484 --> 00:56:17.765
link the risk of multiple

NOTE Confidence: 0.9819666

00:56:17.765 --> 00:56:19.065
myeloma to pesticides,

NOTE Confidence: 0.8983154

00:56:19.844 --> 00:56:22.025
agent orange, or other chemicals?

NOTE Confidence: 0.9256466

00:56:22.404 --> 00:56:24.400
There are sets of two

NOTE Confidence: 0.9256466

00:56:24.400 --> 00:56:26.000
patients in her panel who,

NOTE Confidence: 0.97958684

00:56:27.360 --> 00:56:29.280
have asked her opinion on

NOTE Confidence: 0.97958684

00:56:29.280 --> 00:56:31.120
that, pertaining to themselves and

NOTE Confidence: 0.97958684

00:56:31.120 --> 00:56:32.480
relatives. And if there's no

NOTE Confidence: 0.97958684

00:56:32.480 --> 00:56:34.260
robust research, why not?

NOTE Confidence: 0.95213217

00:56:39.075 --> 00:56:41.075
So, I'll say agent orange,

NOTE Confidence: 0.95213217

00:56:41.075 --> 00:56:41.575
definitely.

NOTE Confidence: 0.9977315

00:56:42.915 --> 00:56:44.135
That's a definite risk

NOTE Confidence: 0.9848274

00:56:45.235 --> 00:56:45.895
factor. Pesticides?

NOTE Confidence: 0.99954206

00:56:47.715 --> 00:56:48.855
I don't think so.

NOTE Confidence: 0.99808335

00:56:49.315 --> 00:56:50.614
I'm not I'm not familiar

NOTE Confidence: 0.99808335

00:56:50.675 --> 00:56:52.275
either with pesticides. One one

NOTE Confidence: 0.99808335

00:56:52.275 --> 00:56:53.340
thing I did wanna add

NOTE Confidence: 0.9743939

00:56:54.300 --> 00:56:55.420
is there is emerging evidence

NOTE Confidence: 0.9743939

00:56:55.420 --> 00:56:57.739
looking at connections, associations with

NOTE Confidence: 0.9743939

00:56:57.739 --> 00:56:59.760
components of metabolic syndrome, specifically

NOTE Confidence: 0.9743939

00:56:59.900 --> 00:57:01.980
obesity and diabetes, and both

NOTE Confidence: 0.9743939

00:57:01.980 --> 00:57:03.760
development and progression of monoclonal

NOTE Confidence: 0.9743939

00:57:03.900 --> 00:57:04.960
gammopathy and,

NOTE Confidence: 0.98361975

00:57:05.500 --> 00:57:06.780
you know, some studies looking

NOTE Confidence: 0.98361975

00:57:06.780 --> 00:57:08.555
at the potential for preventative

NOTE Confidence: 0.98361975

00:57:08.775 --> 00:57:09.275
interventions,

NOTE Confidence: 0.9949601

00:57:09.895 --> 00:57:10.855
because they you know, I

NOTE Confidence: 0.9949601

00:57:10.855 --> 00:57:11.355
think

NOTE Confidence: 0.9948442

00:57:11.655 --> 00:57:12.614
the thought is just kind

NOTE Confidence: 0.9948442

00:57:12.614 --> 00:57:13.974
of the the level of

NOTE Confidence: 0.9948442

00:57:13.974 --> 00:57:15.175
inflammation, but I think we

NOTE Confidence: 0.9948442

00:57:15.175 --> 00:57:16.375
we don't know exactly what

NOTE Confidence: 0.9948442

00:57:16.375 --> 00:57:17.435
the connection is.

NOTE Confidence: 0.9709729

00:57:24.119 --> 00:57:25.240
Drew, do you have any

NOTE Confidence: 0.9709729

00:57:25.240 --> 00:57:26.760
other questions for our panelists?

NOTE Confidence: 0.9709729

00:57:26.760 --> 00:57:27.960
You've been knee deep in

NOTE Confidence: 0.9709729

00:57:27.960 --> 00:57:29.160
this, and and you have

NOTE Confidence: 0.9709729

00:57:29.160 --> 00:57:30.619
an internist opportunity

NOTE Confidence: 0.9930219

00:57:31.079 --> 00:57:32.460
to be face to face.

NOTE Confidence: 0.9930219

00:57:32.680 --> 00:57:33.980
Any additional ones?

NOTE Confidence: 0.9215401

00:57:35.885 --> 00:57:37.244
I think I think I

NOTE Confidence: 0.9215401

00:57:37.244 --> 00:57:38.445
had a couple of of

NOTE Confidence: 0.92640543

00:57:39.325 --> 00:57:40.445
I guess I guess the

NOTE Confidence: 0.92640543

00:57:40.445 --> 00:57:40.945
IGA,

NOTE Confidence: 0.97478634

00:57:41.325 --> 00:57:42.285
like, we had two cases

NOTE Confidence: 0.97478634

00:57:42.285 --> 00:57:43.645
here with IGA. We had,

NOTE Confidence: 0.97478634

00:57:43.645 --> 00:57:45.165
you know, nothing detected on

NOTE Confidence: 0.97478634

00:57:45.165 --> 00:57:46.605
the SPEP. We know that

NOTE Confidence: 0.97478634

00:57:46.605 --> 00:57:47.744
the IGA migrates,

NOTE Confidence: 0.99195516

00:57:48.045 --> 00:57:49.425
you know, through the,

NOTE Confidence: 0.9417568

00:57:50.540 --> 00:57:51.520
into the beta,

NOTE Confidence: 0.82337135

00:57:54.619 --> 00:57:56.060
you know, the beta we

NOTE Confidence: 0.82337135

00:57:56.060 --> 00:57:57.020
we went blank on my

NOTE Confidence: 0.82337135

00:57:57.020 --> 00:57:58.619
knee on the term here.

NOTE Confidence: 0.82337135

00:57:58.619 --> 00:58:00.400
The beta region.

NOTE Confidence: 0.99303395

00:58:01.180 --> 00:58:01.580
Is there

NOTE Confidence: 0.94326633

00:58:02.460 --> 00:58:03.820
I guess the question is,

NOTE Confidence: 0.94326633

00:58:03.820 --> 00:58:04.320
like,

NOTE Confidence: 0.6731271

00:58:06.765 --> 00:58:08.785
the it it I

NOTE Confidence: 0.92007965

00:58:09.085 --> 00:58:10.125
guess, if it's high it's

NOTE Confidence: 0.92007965

00:58:10.125 --> 00:58:11.505
high risk. Right? So

NOTE Confidence: 0.9984812

00:58:12.444 --> 00:58:13.345
how do you

NOTE Confidence: 0.9371736

00:58:13.724 --> 00:58:15.484
when you're going by IGA

NOTE Confidence: 0.9371736

00:58:15.484 --> 00:58:15.984
levels

NOTE Confidence: 0.9888191

00:58:16.444 --> 00:58:18.204
and light chain levels to

NOTE Confidence: 0.9888191

00:58:18.204 --> 00:58:19.825
see if there's any progression

NOTE Confidence: 0.9888191

00:58:19.964 --> 00:58:20.785
of the disease,

NOTE Confidence: 0.99856967

00:58:21.560 --> 00:58:22.840
Is that always a hundred

NOTE Confidence: 0.99856967

00:58:22.840 --> 00:58:23.820
percent reliable?

NOTE Confidence: 0.9137905

00:58:26.360 --> 00:58:27.720
It does so does does

NOTE Confidence: 0.9137905

00:58:27.800 --> 00:58:29.000
I know there there when

NOTE Confidence: 0.9137905

00:58:29.000 --> 00:58:29.800
you do a bone marrow

NOTE Confidence: 0.9137905

00:58:29.800 --> 00:58:31.000
biopsy, you're more likely to

NOTE Confidence: 0.9137905

00:58:31.000 --> 00:58:31.740
see, like,

NOTE Confidence: 0.97772807

00:58:32.920 --> 00:58:35.180
more plasma cells in IgA,

NOTE Confidence: 0.98854715

00:58:36.635 --> 00:58:38.494
right, relative to IgG. So

NOTE Confidence: 0.97998583

00:58:38.875 --> 00:58:39.675
do do you see a

NOTE Confidence: 0.97998583

00:58:39.675 --> 00:58:41.775
direct correlation between the IgA,

NOTE Confidence: 0.9646881

00:58:43.035 --> 00:58:44.974
protein or the or the

NOTE Confidence: 0.9646881

00:58:45.035 --> 00:58:45.535
or

NOTE Confidence: 0.8757453

00:58:45.835 --> 00:58:46.974
the free light chain,

NOTE Confidence: 0.99532175

00:58:48.474 --> 00:58:48.974
quantification

NOTE Confidence: 0.92601025

00:58:49.355 --> 00:58:49.855
and,

NOTE Confidence: 0.86007875

00:58:50.795 --> 00:58:51.855
cell you know, like,

NOTE Confidence: 0.9006056

00:58:52.740 --> 00:58:54.740
progression of disease. Is that

NOTE Confidence: 0.9006056

00:58:54.740 --> 00:58:56.040
is that reliable?

NOTE Confidence: 0.9672707

00:58:56.660 --> 00:58:57.780
That that's that's a very

NOTE Confidence: 0.9672707

00:58:57.780 --> 00:58:59.160
good question. I mean, generally,

NOTE Confidence: 0.9672707

00:58:59.300 --> 00:59:00.840
we we look at everything.

NOTE Confidence: 0.677733

00:59:01.780 --> 00:59:02.280
In

NOTE Confidence: 0.9735742

00:59:02.660 --> 00:59:04.660
when patients progress, even if

NOTE Confidence: 0.9735742

00:59:04.660 --> 00:59:05.700
they have myeloma or if

NOTE Confidence: 0.9735742

00:59:05.700 --> 00:59:06.820
they're MGUS and they're going

NOTE Confidence: 0.9735742

00:59:06.820 --> 00:59:08.525
up, the IgA typically goes

NOTE Confidence: 0.9735742

00:59:08.525 --> 00:59:09.345
up first.

NOTE Confidence: 0.9693324

00:59:09.724 --> 00:59:11.265
And then the m spike

NOTE Confidence: 0.9693324

00:59:11.325 --> 00:59:13.164
will rise later, several months

NOTE Confidence: 0.9693324

00:59:13.164 --> 00:59:14.525
later. So that's why we

NOTE Confidence: 0.9693324

00:59:14.525 --> 00:59:15.345
look at both.

NOTE Confidence: 0.95966476

00:59:16.684 --> 00:59:18.365
The again, the trend holds

NOTE Confidence: 0.95966476

00:59:18.365 --> 00:59:19.964
true for the most part.

NOTE Confidence: 0.95966476

00:59:19.964 --> 00:59:21.244
When the there's more clonal

NOTE Confidence: 0.95966476

00:59:21.244 --> 00:59:22.525
plasma cells, there's gonna be

NOTE Confidence: 0.95966476

00:59:22.525 --> 00:59:23.480
more clonal,

NOTE Confidence: 0.94748884

00:59:24.180 --> 00:59:25.700
protein or or IGA or

NOTE Confidence: 0.94748884

00:59:25.700 --> 00:59:26.680
or light chains.

NOTE Confidence: 0.9193427

00:59:27.060 --> 00:59:28.660
But it might not be,

NOTE Confidence: 0.9191227

00:59:29.220 --> 00:59:30.420
like, a a one to

NOTE Confidence: 0.9191227

00:59:30.420 --> 00:59:31.640
one representation,

NOTE Confidence: 0.9952472

00:59:32.180 --> 00:59:33.560
but the trends hold true.

NOTE Confidence: 0.99967474

00:59:34.180 --> 00:59:34.680
Okay.

NOTE Confidence: 0.9968604

00:59:35.380 --> 00:59:36.119
That helps.

NOTE Confidence: 0.84547234

00:59:38.955 --> 00:59:39.695
I think

NOTE Confidence: 0.9984507

00:59:40.155 --> 00:59:41.435
I think it's really important

NOTE Confidence: 0.9984507

00:59:41.435 --> 00:59:42.875
for, like, primary care docs

NOTE Confidence: 0.9984507

00:59:42.875 --> 00:59:43.375
to

NOTE Confidence: 0.9986771

00:59:43.835 --> 00:59:44.335
recognize

NOTE Confidence: 0.93201077

00:59:44.715 --> 00:59:46.555
that low risk category. You

NOTE Confidence: 0.93201077

00:59:46.555 --> 00:59:47.995
know, the three criteria where

NOTE Confidence: 0.93201077

00:59:47.995 --> 00:59:48.975
it's the IgG,

NOTE Confidence: 0.9685509

00:59:49.675 --> 00:59:51.195
m protein, the less than

NOTE Confidence: 0.9685509

00:59:51.195 --> 00:59:52.175
one point five

NOTE Confidence: 0.9295749

00:59:52.599 --> 00:59:54.060
milligrams on the SPEP,

NOTE Confidence: 0.97687113

00:59:54.440 --> 00:59:55.900
and then the the normal

NOTE Confidence: 0.87676525

00:59:56.200 --> 00:59:58.040
serum prelate chain ratio. So

NOTE Confidence: 0.87676525

00:59:58.040 --> 00:59:58.619
I think,

NOTE Confidence: 0.87775004

00:59:59.079 --> 01:00:00.280
you know, we see something

NOTE Confidence: 0.87775004

01:00:00.280 --> 01:00:01.160
like this and we're like,

NOTE Confidence: 0.87775004

01:00:01.160 --> 01:00:01.980
oh my gosh.

NOTE Confidence: 0.94643784

01:00:02.280 --> 01:00:03.880
I don't want this to

NOTE Confidence: 0.94643784

01:00:03.880 --> 01:00:05.725
be my own, you know,

NOTE Confidence: 0.94643784

01:00:05.785 --> 01:00:07.805
monitoring, you know, responsibility.

NOTE Confidence: 0.9834773

01:00:08.265 --> 01:00:08.765
But,

NOTE Confidence: 0.9952945

01:00:09.705 --> 01:00:10.585
I think that's a key

NOTE Confidence: 0.9952945

01:00:10.585 --> 01:00:12.045
nugget for me,

NOTE Confidence: 0.9953785

01:00:12.345 --> 01:00:13.625
looking at this talk and

NOTE Confidence: 0.9953785

01:00:13.625 --> 01:00:14.845
going through this talk.

NOTE Confidence: 0.97708994

01:00:16.265 --> 01:00:17.385
The difference you know, the

NOTE Confidence: 0.97708994

01:00:17.385 --> 01:00:17.885
IGM,

NOTE Confidence: 0.96668136

01:00:18.240 --> 01:00:19.460
you have to think Waldenstrom's,

NOTE Confidence: 0.9185387

01:00:19.920 --> 01:00:21.200
you know, and then the

NOTE Confidence: 0.9185387

01:00:21.200 --> 01:00:22.480
IGA not the is always

NOTE Confidence: 0.9185387

01:00:22.480 --> 01:00:23.360
a low risk, needs a

NOTE Confidence: 0.9185387

01:00:23.520 --> 01:00:24.560
needs that biopsy. I think

NOTE Confidence: 0.9185387

01:00:24.560 --> 01:00:25.860
those are key take homes

NOTE Confidence: 0.8880806

01:00:26.320 --> 01:00:27.040
from my,

NOTE Confidence: 0.99915934

01:00:27.520 --> 01:00:28.020
standpoint.

NOTE Confidence: 0.95531255

01:00:32.444 --> 01:00:33.964
I guess the question going

NOTE Confidence: 0.95531255

01:00:33.964 --> 01:00:35.484
back to the toxins too,

NOTE Confidence: 0.9991154

01:00:35.885 --> 01:00:36.204
which

NOTE Confidence: 0.9297201

01:00:37.565 --> 01:00:38.525
and and the,

NOTE Confidence: 0.901636

01:00:39.005 --> 01:00:41.164
monoclonal the the monoclonal proteins.

NOTE Confidence: 0.901636

01:00:41.164 --> 01:00:42.305
But can

NOTE Confidence: 0.8280789

01:00:43.260 --> 01:00:44.380
they get the gentleman in

NOTE Confidence: 0.8280789

01:00:44.380 --> 01:00:46.140
this case who developed the,

NOTE Confidence: 0.91839135

01:00:46.620 --> 01:00:47.760
IgA Lambda

NOTE Confidence: 0.86720645

01:00:48.300 --> 01:00:49.420
and with the false positive

NOTE Confidence: 0.86720645

01:00:49.420 --> 01:00:50.320
Lyme, etcetera,

NOTE Confidence: 0.9876349

01:00:51.660 --> 01:00:53.740
he blames things on his

NOTE Confidence: 0.9876349

01:00:53.740 --> 01:00:55.600
COVID vaccine. Right? So,

NOTE Confidence: 0.972268

01:00:56.035 --> 01:00:58.195
yeah, COVID vaccine, he developed

NOTE Confidence: 0.972268

01:00:58.195 --> 01:01:00.275
this neuropathy, and we found

NOTE Confidence: 0.972268

01:01:00.275 --> 01:01:01.335
this this issue.

NOTE Confidence: 0.9438778

01:01:01.715 --> 01:01:03.555
He developed ulcerative colitis after

NOTE Confidence: 0.9438778

01:01:03.555 --> 01:01:05.095
his COVID vaccine. So he's

NOTE Confidence: 0.9438778

01:01:05.155 --> 01:01:07.395
a he's he's moving towards

NOTE Confidence: 0.9438778

01:01:07.395 --> 01:01:08.835
that realm. I'm not saying

NOTE Confidence: 0.9438778

01:01:08.835 --> 01:01:09.895
anything is

NOTE Confidence: 0.95148027

01:01:10.510 --> 01:01:11.470
is is you know, I'm

NOTE Confidence: 0.95148027

01:01:11.470 --> 01:01:12.830
not I'm not buying that

NOTE Confidence: 0.95148027

01:01:12.830 --> 01:01:14.030
story a whole lot, but

NOTE Confidence: 0.95148027

01:01:14.190 --> 01:01:15.150
at all. But, you you

NOTE Confidence: 0.95148027

01:01:15.150 --> 01:01:16.290
know, thinking of,

NOTE Confidence: 0.8169333

01:01:17.070 --> 01:01:18.450
yeah, I know, thinking of,

NOTE Confidence: 0.8965371

01:01:20.510 --> 01:01:21.710
antibody like, is there a

NOTE Confidence: 0.8965371

01:01:21.710 --> 01:01:22.850
correlation between

NOTE Confidence: 0.91346484

01:01:23.335 --> 01:01:24.855
any autoimmune syndrome or kind

NOTE Confidence: 0.91346484

01:01:24.855 --> 01:01:26.375
of stimulation of b cells

NOTE Confidence: 0.91346484

01:01:26.375 --> 01:01:28.295
in some way and increase

NOTE Confidence: 0.91346484

01:01:28.295 --> 01:01:30.055
risk of of of these

NOTE Confidence: 0.91346484

01:01:30.055 --> 01:01:30.555
disorders?

NOTE Confidence: 0.95440114

01:01:31.575 --> 01:01:33.335
Like, you know, COVID vaccine,

NOTE Confidence: 0.95440114

01:01:33.335 --> 01:01:34.235
we're stimulating,

NOTE Confidence: 0.9958652

01:01:34.855 --> 01:01:35.515
you know,

NOTE Confidence: 0.94261336

01:01:37.150 --> 01:01:37.970
antibody production,

NOTE Confidence: 0.8695551

01:01:38.830 --> 01:01:40.030
but not saying causation. But

NOTE Confidence: 0.8695551

01:01:40.030 --> 01:01:41.090
is there any

NOTE Confidence: 0.9874629

01:01:41.390 --> 01:01:42.670
is there any discussion of

NOTE Confidence: 0.9874629

01:01:42.670 --> 01:01:43.970
that, or is there any

NOTE Confidence: 0.93866307

01:01:47.390 --> 01:01:48.910
similar concerns being brought to

NOTE Confidence: 0.93866307

01:01:48.910 --> 01:01:49.410
your

NOTE Confidence: 0.73311377

01:01:50.035 --> 01:01:50.535
attention.

NOTE Confidence: 0.99903727

01:01:50.995 --> 01:01:51.875
Yeah. I I think these

NOTE Confidence: 0.99903727

01:01:51.875 --> 01:01:53.075
are questions we get as

NOTE Confidence: 0.99903727

01:01:53.075 --> 01:01:54.035
well. I mean, I think

NOTE Confidence: 0.99903727

01:01:54.035 --> 01:01:54.695
there is

NOTE Confidence: 0.98838633

01:01:54.995 --> 01:01:56.355
thought to be association with

NOTE Confidence: 0.98838633

01:01:56.355 --> 01:01:56.855
autoimmune

NOTE Confidence: 0.9638353

01:01:57.555 --> 01:01:59.235
inflammatory disorders where there's kind

NOTE Confidence: 0.9638353

01:01:59.235 --> 01:02:00.835
of constant stimulation of b

NOTE Confidence: 0.9638353

01:02:00.835 --> 01:02:02.295
cells like like you're saying.

NOTE Confidence: 0.95691055

01:02:02.990 --> 01:02:04.030
You know, I'm not aware.

NOTE Confidence: 0.95691055

01:02:04.030 --> 01:02:05.329
I I there was,

NOTE Confidence: 0.97372556

01:02:05.869 --> 01:02:07.390
a small study presented as

NOTE Confidence: 0.97372556

01:02:07.390 --> 01:02:08.829
an abstract looking at change

NOTE Confidence: 0.97372556

01:02:08.829 --> 01:02:10.510
in monoclonal protein after COVID

NOTE Confidence: 0.97372556

01:02:10.510 --> 01:02:12.050
vaccines, and there was none.

NOTE Confidence: 0.97372556

01:02:12.190 --> 01:02:14.050
No evidence of progression. So,

NOTE Confidence: 0.97372556

01:02:14.349 --> 01:02:15.435
I'm not aware of anything

NOTE Confidence: 0.97372556

01:02:15.435 --> 01:02:16.715
kinda larger than that, but

NOTE Confidence: 0.97372556

01:02:16.715 --> 01:02:17.675
that's a question that comes

NOTE Confidence: 0.97372556

01:02:17.675 --> 01:02:18.955
up a lot from our

NOTE Confidence: 0.97372556

01:02:18.955 --> 01:02:19.995
patients. But, you know, that

NOTE Confidence: 0.97372556

01:02:20.075 --> 01:02:21.275
and from that small information,

NOTE Confidence: 0.97372556

01:02:21.275 --> 01:02:22.075
I don't think we think

NOTE Confidence: 0.97372556

01:02:22.075 --> 01:02:23.595
there's connection. At least in

NOTE Confidence: 0.97372556

01:02:23.595 --> 01:02:25.035
patients that have have MGUS,

NOTE Confidence: 0.97372556

01:02:25.035 --> 01:02:26.315
you know, don't progress to

NOTE Confidence: 0.97372556

01:02:26.315 --> 01:02:27.455
to something more.

NOTE Confidence: 0.91171926

01:02:27.940 --> 01:02:28.980
Yeah. I mean, that's that's

NOTE Confidence: 0.91171926

01:02:28.980 --> 01:02:30.740
good. Just, cut us off

NOTE Confidence: 0.91171926

01:02:30.740 --> 01:02:32.520
because we passed our hour.

NOTE Confidence: 0.90725774

01:02:33.220 --> 01:02:35.560
Yeah. And I so appreciate

NOTE Confidence: 0.90725774

01:02:35.780 --> 01:02:36.840
all of the preparation

NOTE Confidence: 0.98803085

01:02:37.220 --> 01:02:38.260
that you all did to

NOTE Confidence: 0.98803085

01:02:38.260 --> 01:02:39.000
bring us

NOTE Confidence: 0.941911

01:02:39.300 --> 01:02:40.900
all of this information. This

NOTE Confidence: 0.941911

01:02:40.900 --> 01:02:42.500
is really helpful. And, if

NOTE Confidence: 0.941911

01:02:42.500 --> 01:02:43.375
there are others who you

NOTE Confidence: 0.941911

01:02:43.375 --> 01:02:44.655
think may be interested, please

NOTE Confidence: 0.941911

01:02:44.655 --> 01:02:45.395
feel free,

NOTE Confidence: 0.98879576

01:02:46.015 --> 01:02:47.455
to share the link, to

NOTE Confidence: 0.98879576

01:02:47.455 --> 01:02:49.135
watch afterwards. We thank you

NOTE Confidence: 0.98879576

01:02:49.135 --> 01:02:49.875
for attending,

NOTE Confidence: 0.9988616

01:02:51.135 --> 01:02:52.655
and we'll see you next

NOTE Confidence: 0.9988616

01:02:52.655 --> 01:02:54.195
month when we have colorectal

NOTE Confidence: 0.9993314

01:02:54.495 --> 01:02:56.495
cancer prevention and screening as

NOTE Confidence: 0.9993314

01:02:56.495 --> 01:02:57.555
our hot topic.

NOTE Confidence: 0.9194515

01:02:58.545 --> 01:03:00.385
Thanks, everyone. Bye bye. Very

NOTE Confidence: 0.9194515

01:03:00.385 --> 01:03:00.885
much.