 Okay, thank you for this kind introduction. My name is Hans Jacobs. I'm a laboratory specialist, medical immunologist in the Goudboud University Medical Center and I would like to congratulate MPE with the 10th anniversary. I truly treasure the nice collaboration that we have. My team develops myeloma diagnostics and only through discussions and collaboration with hematologists and patient organizations we can develop meaningful diagnostics that have a true positive impact on the life of patients with multiple myeloma. So in this masterclass I will discuss minimal residual disease testing, why we perform MRD evaluation, how we do that and how we might improve that in the future. In today's audience it is well known that multiple myeloma is caused by a clonal expansion of plasma cells in the bone marrow and in many patients the diagnosis is rather straightforward with the characteristic anemnesis. A bone marrow biopsy can for example visualize the abnormal clonal plasma cells and imaging may identify characteristic lytic lesions and cytotinetics can provide a prognostic profile and in addition to that the clonal plasma cells secrete a unique biomarker namely a monoclonal antibody and this so-called M protein can be detected in the blood using electrophoretic techniques the M protein can then be detected, characterized and also quantified and in case the patient produces only monoclonal light chains the M protein can be monitored either in the urine or with neflometric techniques in the blood. M protein diagnostics is performed to screen for and diagnose monoclonal commodities but more importantly M protein diagnostics is performed to monitor disease activity. For example in an M-GaS patient to monitor progression towards multiple myeloma and in the myeloma patients to monitor therapy responses. So the international myeloma working group has described and standardized guidelines or response criteria and here I indicated in red how important M protein diagnostics is in monitoring therapy responses. However as patients experience deeper responses because of better therapy there's an increased need for more sensitive diagnostics to be able to measure minimal residual disease. Now with the latest combinations of effective therapy over 50% of newly diagnosed patients achieve stringent complete responses which effectively means that our current methods are not sensitive enough to monitor any disease activity in the blood or urine of these patients. The iceberg metaphor illustrates that these patients are not cured but their disease burden is for a certain period of time below the detection limit of our current diagnostics. With further evolving of myeloma therapy the field slowly moves towards potential curative treatment which further increases the need to measure minimal residual disease. So as a response to that very effective methods have been developed to measure myeloma cells directly in bone marrow. With sensitive cellular methods such as multicolor flow cytometry and molecular methods such as next generation sequencing it became possible to measure extremely low disease burden and despite the physical burden of a bone marrow biopsy MRDEvaluation performed on bone marrow becomes more and more common in myeloma patient management especially in the setting of clinical trials. On the other hand because it's the most sensitive method on the one hand because it's the most sensitive method to monitor disease activity so this allows to be informed on therapy responses beyond stringent complete remission and this better allows prediction of biological and clinical relapses. MRD status is also the best biomarker to predict survival. Numerous studies have shown that myeloma patients who are MRD negative the blue line in this figure have on average a significantly longer survival compared to patients who test MRD positive than red. Moreover the MRD status is an independent prognostic marker and that means you can combine it with traditional prognostic markers such as ISS staging or cytogenetic information to receive even more detailed prognostic information for individual patients. And because MRD status so strongly correlates with survival the importance of MRD status in clinical studies also increases. Here I show a simplified design of a hypothetical clinical study in which myeloma patients are randomized into two groups to study the effectiveness of drug A compared to the effectiveness of a new drug B. And of course you could argue that the best proof of which of these two drugs is most effective is to measure overall survival in both groups. The disadvantage of that is that it takes many years before you can evaluate the overall survival. That is expensive for pharmaceutical companies that sponsor these trials but more importantly for patients and clinicians this will seriously delay the implementation of new effective therapies. To somewhat reduce this delay the time when patients experience relapse is the progression free survival often replaces overall survival as a primary endpoint in most clinical trials. However now that we realize that MRD status measured shortly after therapeutic intervention is a reliable surrogate biomarker for survival we observe the field slowly moves towards MRD evaluation as primary endpoint in clinical trials. And what we observe also more and more often is that MRD evaluation in clinical trial is not performed only to measure the effectiveness of drugs but also starts to decide what therapy regimen what a therapy regimen should look like. We already saw that patients who reach MRD negativity after a certain therapy have a much better prognosis compared to MRD positive patients. So in a variety of studies it is currently investigated if these MRD negative patients should be offered a less intense maintenance therapy or maybe these patients benefit from a treatment free observation period. At given intervals MRD evaluation is performed and only after a patient becomes MRD positive maintenance therapy is started. As the importance of MRD evaluation grew it became more and more important to harmonize and standardize these methods. International MRD consensus criteria were introduced stating that you can either use flow satometry or next generation sequencing as long as the methods are sensitive enough to be able to detect one myeloma cell in 100,000 normal bone marrow cells. And to be truly MRD negative imaging must be performed to make sure that there are no myeloma processes growing outside the bone marrow. And also a category was introduced with even better prognosis for patients with sustained MRD negativity which defines patients that have sustained MRD negativity even after one year. However of course bone marrow biases are not ideal for a repeated MRD monitor. On the one hand because we know that the disease can have a batchy distribution which effectively means that some parts of the bone marrow are more affected than others which could lead to sampling error. In some patients the myeloma cells may even grow outside the bone marrow which could give false negative results. And in addition to that bone marrow sampling is an unpleasant procedure and negatively affects the quality of life of myeloma patients. Therefore our group set out to investigate whether it is possible to develop a blood test that is sensitive enough to measure minimal residual disease. As previously mentioned each myeloma patient produces a unique monoclonal antibody. The sensitivity of current and protein diagnostics is limited because each individual also produces normal antibodies. And in patients who respond well to therapy these normal antibodies strongly outnumber the monoclonal antibodies which hampers the sensitivity of current and protein diagnostics. So each M-protein has a unique rearranged variable region. It's illustrated here with a patient specific barcode. Using the genetic information of the clonal plasma cells we can read this barcode which is in fact a short stretch of protein that is unique for one specific patient and is only produced by the myeloma cells. So measurement of this barcode means that you measure directly accounts a specific biomarker which experiences no interferences of normal antibodies because they all have a different barcode. So our hypothesis was that targeted mass spectrometry measurement of this unique barcode makes it possible to measure deep responses and this non-invasive method allows dynamic M-protein monitoring to detect early relapses. The mass spectrometry method that can very sensitively measure short proteins is called SRM selected reaction monitoring. Since you know exactly how the barcode looks like you basically instruct the mass spectrometry to fragment all proteins in the serum of a patient and only measure the barcode. To quantify the M-protein concentration we synthesize a labeled barcode with an exact known concentration. We add this labeled calibrator to the patient's serum and the ratio of the intensity of the barcode and the calibrator can be used to calculate the exact M-protein concentration in the serum. On the lower left is a dilution experiment of the very first patient sample that we tested in which we diluted a patient's serum in normal serum and without method optimization we already achieved a thousand-fold more sensitive M-protein quantification compared to routine M-protein diagnostics. From that same patient we now started measuring real serum samples over time and the open orange samples show that with routine M-protein diagnostics we could not measure disease activity for almost two years. However, using mass spectrometry we could perfectly follow disease activity over time illustrated by the blue line and also detect relapse many months earlier illustrator with the blue arrow. In order for this method to be successful we have to be able to apply it on every patient who has multiple myeloma and to investigate this we collaborated with the Multiple Myeloma Research Foundation and we're allowed to look at the genetic information of the M-protein of 609 myeloma patients and we demonstrated that all 609 patients indeed had a unique barcode and from this barcode on average four to six unique fragments per patients could be used for mass spec analysis which means that in each patient we can select two barcode fragments which leaves us with an internal control in each measurement so if a patient responds to therapy both signals should go down and if a patient relapses both signals will go up. We developed this method together with our partners from the Erasmus Medical Center and we are still in the process of discovering the full potential of this method but we are quite impressed by the performances that we see so far. We can conclude for example that we experience no interference of therapeutic monoclonal antibodies of course we did not expect interference because each monoclonal antibody has a unique barcode and in fact with the mass spec method we can easily monitor several different barcodes so in one single run we can monitor both the M-protein concentration and the concentration of the therapeutic monoclonal antibodies and we also demonstrated that our method can be applied to other fluids than serums such as urine or cerebrospinal fluid. Together with our Dutch clinical partners from Hoven and our French clinical partners from IFM we were granted access to clinical studies to perform a method comparison of our mass spec method performed in blood versus MRD evaluation performed on bone marrow and so far the sensitivity to detect myeloma disease activity and the prognostic value of our mass spec method in serum seems competitive to MRD testing in bone marrow and those manuscripts are currently under review. In this presentation I explained very sensitive methods to monitor disease activity in bone marrow and why these MRD measurements become more and more important in the management of patients with multiple myeloma. I also discussed the ongoing efforts that investigate the potential of MRD evaluation in blood using mass spectrometry as patient-friendly alternative for MRD evaluation performed in bone marrow. Time will tell what the added clinical value of this method can be for individual patients and whether it can replace for a large part MRD monitoring performed on bone marrow aspirations. Today I talked about how we can use the M-protein to monitor disease. What personally also really intrigues me when studying M-proteins and I spent only one final slide on that is that in a minority of patients these M-protein itself can cause clinical problems. In most patients the M-protein itself never causes clinical problems even when it is treated at extremely high concentrations of 50 grams per liter. However in a minority of patients these M-proteins may deposit in organs such as the kidney the skin or the heart and cause severe clinical problems. The problem is that currently we cannot predict which proteins M-proteins are harmless and from which M-proteins we can expect clinical problems. Now that we are investigating M-proteins with mass spectrometry we can also look at other aspects of this protein. We can look for example at post-translational modifications such as sugar chains that can be added to certain proteins and we know that these glycans can impact the behavior of proteins. Interestingly the Mayo Clinic recently showed that glycosylation seems to be a risk factor for the patogenicity of M-proteins and I predict that in the near future we will be able to better predict whether or not an M-protein can cause clinical problems. In this last slide I would like to acknowledge the team with whom we developed and validated the mass spec MRD method and I highlighted the two brilliant PhD students Peter and Marina who perform most of the experiments that I showed today and I also provide an overview of the organizations that sponsored the mass spec MRD project such as the Dutch Cancer Society and the Dutch Organization of Scientific Research and all the organizations with whom we collaborate on this exciting project. With this I would like to conclude this presentation on MRD evaluation and I'm happy to take questions later on during the live panel discussion. Thank you.