Thank you. With that, I'd like to introduce Sunny Kau. And one of the important things in kidney cancer really is to get your diagnosis right. Like I showed you the picture of the kidney, is that kidney cancer? Are there different types within kidney cancer? Is it a urinary type of cancer? We are really fortunate to have a dedicated GU pathologist. And after a lot of search, we had Sunny Kau come to us from, she did a training in Indiana and then went to MGH and we've really been fortunate to have her be part of our team. Not many institutions have this dedicated GU pathologist. It's really what you look under the microscope to be able to tell you what your disease is. So Sunny is going to cover just the pathology from a pathologist's point of view. How can they help in making a diagnosis and touch a little bit about prognosis and what each different type of kidney cancer really means to us as clinicians in taking care of patients with kidney cancer. So thanks so much for agreeing to be part of our day-to-day Sunny. Thank you, Sandy, for that introduction. And I just wanted to say welcome and thanks for coming. Like Sandy said, I joined Stanford last year after finishing fellowship training at Mass General Hospital and GU pathology, which includes kidney cancer, is a big part of my passion and it's what I'm really enthusiastic about and I would love to share that passion with you guys as far as the pathology end. So the topic is diagnosis and prognostic factors of kidney cancer for today. And unfortunately, you can't say the whole day, but Sandy has my contact information and if you guys would like me to talk about a different topic another time or focus on something different, please give me feedback. I would love again to tailor this talk to whatever it is you guys are most interested in learning about pathology. All right, so goals and objectives for today is understand the role of pathologists in your care because what we do a lot of times is we do behind the scenes stuff.  And then of course, a little bit is left to understand the important prognostic factors of kidney cancer, what it is that is most important information that you should get out of your pathology report that helps your oncologist or your clinician in determining the best care management that is tailored to you based on your cancer, okay. So that's the goals and objectives for today. So the first things pathologists, when we get our specimen is we do a gross examination, right. So the surgeon hands us the specimen, we fix the specimen. So fixing means then we dump it in a solution, it hardens the actual organ that allows us to process it in a very efficient manner rather than just cutting it fresh. So cutting it fresh means, imagine you have a piece of tofu. It's like wiggly and it's very hard to cut, right. But once we put it into a formula and this special solution actually firms it, so it allows us to make very smooth and accurate cuts to best help us determine how far the kidney cancer has involved. Rather than wiggly, remember it's very hard to cut and things might not be as accurate. So that's the first process, we get your specimen, we fix it and then we start to cut it, right. So this is just an example of someone's tumor and remember everyone's tumor looks different, okay. So patient A's tumor is not gonna look exactly the same as patient B. Okay, so this is an example of what one, excuse me, what one patient's specimen looks like and as you can see down here, so let's see. So this end is actually the kidney and this cystic part is the tumor. So when we describe terms we use solid and cystic, that's one of the major descriptions in pathology and each, again, cystic tumors has different types of tumors can look cystic and again, different types of tumors can look solid. So the first time we, as pathologists evaluate is what is the consistency? What does it look like grossly? Because that helps in our mind because we have different differentials for different types of tumors that we see macroscopically. So this is a examination on the macroscopic levels that we can see using our bare eyes without any instrumentation. So we evaluate what does it look like and a very important part of a gross examination other than consistency is the size of the tumor, right? Because Sandy briefly listed the TNM staging of the tumor and part of that is determined based on the actual size of the tumor and that can be measured macroscopically. So you can see a ruler above and this tumor is roughly about 10 centimeters large. And here's another example of someone else's tumor. So as you can see, this tumor looks a little bit differently because rather than a cystic component, you see the tumor down here is more of this golden yellow with areas of hemorrhage right here. So the consistency is different, right? So this tumor is more of a solid consistency and with its golden yellow color, it's actually very characteristic of a clear cell, renal cell carcinoma. So again, gross examination is very important for us because it helps us formulate a differential diagnosis and in this case, the top of the differential diagnosis is clear cell, renal cell carcinoma, okay? So gross examination is very important. Again, the size is a very important determination of stage and this one is a smaller than the tumor that you've seen before. Again, the color is different. So in addition to that, we evaluate for the extent of involvement, right? Again, that plays into the stage. So what does the actual tumor involve? In this case, the tumor is, again, down here, this golden yellow stuff and you can see that it is within the cortex that Sandy talked about, this brown area and sometimes not this particular case, but sometimes the tumor can actually go into the adjacent fat down here that you see in the blue so that's a higher stage, right? So extent ties into the stage and we can see that for the most part pretty accurately doing a gross examination. So sometimes tumor would go down here in the perinephric fat. Sometimes it would go into the hyalur fat, renal hyalur fat that's at the central portion of the kidney. Again, that's a higher stage. That's a locally advanced disease and then sometimes we would get lymph node specimens that we would dissect and again process. This is a very brief overview of how we handle the gross specimen, what are we looking for when we do a gross examination. So that's only the first part, we're not done yet. All right, see it's very complicated, right? This black box outspits the diagnosis but a lot happens in between. So after we do the gross examination, we have to do a histologic examination. So gross examination, we're doing that using our bare eyes without any instrumentation but how do we arrive in an actual diagnosis? We have to use a microscope to confirm our gross findings and also to subtype the tumor. Okay, so after we sample the actual kidney specimen, again a lot happens in between and then what happens is that we turn them into actual, these are called glass slides, right? So when we're talking about slides and pathology, this is what they look like. Each of them are labeled with the patient's name, labeled with the number and then, again, every patient's tumor is different so each patient is gonna have a different number of slides depending on the complexity of the actual tumor. So if it's a bigger tumor, we sample more sections. If it's a smaller tumor, it's a smaller number of sampling and then we turn them into glass slides and these are the things that we actually look under the microscope, okay? All right, so this is actually what it looks like under the microscope for this particular patient's tumor and you kind of see that it vaguely corresponds to what we're seeing on a gross examination, right? So gross examination, it looks very cystic, it's fibrous, there's a lot of spaces in between the tumor and you can see that reflected on an actual histologic examination. So this one correlates pretty well, okay? Now here, yes? So that, I would say, is about maybe a hundred times magnification, so if you imagine this is one, one X, one magnification, well no magnification at all and then that would be a hundred, okay? And we can go even further than a hundred. So this is again a 100, same magnification as before but you can see that it looks different, right? And that corresponds to a more solid tumor growth. So most of the times what we see on gross examination would correlate to what we see under the microscope, okay? So this is what, this is how we as pathologists look under the microscope and how it went from that large specimen to that small cellular level that we see, so that's how it translates into it, okay? So this is about a 200 to 400 magnification. So in addition to seeing things on a macroscopic level, we can see things on a cellular or a microscopic level and this is really an important part of the process where we determine, number one, the tumor type. So if you remember, a lot of the tumors can have the same look grossly. It's really when we look under the microscope that we can tell which exact subtype is that tumor. So this is an important process. Another thing that we do is we grade the tumor, right? So how does the grading come from? How do we grade it? And we grade it based on a cellular level. We look at the actual cell and a cell is composed of a nucleus that contains all the DNA material that you see here. So here's one nucleus. If you can see my arrow moving there. Here's another nucleus. This is another nucleus, right? So we grade kidney cancers based on the look of the nucleus and the nucleoli, which is the dot within the nucleus, what it looks like.   So grade is determined by the look of the tumor. Does it look to be a higher grade tumor? And we grade it as such. And of course, there's different complicated criterias that we use, but the uglier it looks, the higher grade it is. The more, but now the more lower grade looking, it's gonna be assigned a lower grade number, which is gonna be a one or two. Okay, so that's how we arrive at that. So you would get a pathology report, right? Lots of words. What is it? What does it mean? And for the most part, it's separated into these four sections. Of course, the most important part is gonna be the diagnosis, right? So the diagnosis, it's gonna be, which I'll talk about a little bit later, sorry. And then there's gonna be a common section and clinical history and gross description. So these are the four major parts of your pathology report. I'm gonna talk about what they mean for you. Okay, all right. So diagnosis is gonna be the bottom line results. Okay, so this is gonna be a baseline. What is the type of your tumor? What is the size? And what is the extent of involvement? Okay, this is gonna contain the most important part of your report is gonna be in the diagnosis line, bottom line, what is your tumor? Okay, the next section is gonna be a common section. So this is an area where we describe what the tumor looks like on a microscopic level. It's called an H and E description. So that's maybe not so important to you. And then we also document if there's any stains we use. So pathology isn't as simple as I've described it to be and it might not even be as simple as it sounds. But sometimes we would need to perform some special stains to help us determine the subtype of tumor. And we would document that if any is used. And the most important part of this comment section is probably gonna be the synoptic table that we use. And I'm gonna go into the synoptic table in a little bit more detail later. Clinical history, this is usually provided by your surgeon, tells us the patient presents with blood in the urine, presents with back pain, things like that. And gross description, in my opinion, is probably the second or if not the most important part of the pathology report because it reflects how your tumor, how your specimen has been handled. So I have been a patient myself of some other sort of disease but and I've had specimens done before and the first thing I look right after the diagnosis is the gross description because I wanna know how the pathology department did as a job of sampling my tumor. Because like I said, it's usually, we determine the tumor type based on using microscopes, right? So we can't diagnose what we don't see on a microscope. We can't diagnose what's not been sampled. So for me, as a patient, I would always read the gross description. How was my specimen handled? Is it handled in an accurate way? Does it reflect the disease extent? So for instance, if it's a 10 centimeter tumor, the standard of practice is one, you sample one area of the tumor per centimeter. So if you have a 10 centimeter tumor, you would expect to see that 10 sections have been taken for your tumor, right? Because you want it to be, again, sampled in a fashion where we would be able to make a diagnosis. So that is a very important thing and we at Stanford make sure we do that. So that is adequately sampled is very important. So that's something that I would recommend that when you receive your pathology report, look at the diagnosis, but also read the gross description because that is a summary of what your specimen looks like, right? Again, everyone's is different. I would be curious to know what my tumor looks like and the information would be in the gross description. So that's a very important part. All right, so this is a synoptic table. So after looking at your tissue, after looking at the slides generated from your specimen, we would be able to come up with a list of information. So this is called a synoptic table and if for every single patient with kidney cancer, when we review the pathology specimen, we would always generate a summary table that is pertaining to your specimen, pertaining to your cancer, okay? The site, some people would have left kidney, right? Some people would have right kidney specimen type. There are two, it's called partial. So if we only take out a portion of your kidney, that's a partial nephrectomy. If we took out the entire kidney, that would be a radical nephrectomy. So on and so forth, right? And then we have the tumor type. Is it a clear cell renal cell carcinoma? Is it a papillary renal cell carcinoma? What exactly is the subtype of the tumor? That would be listed here. So it's now grade one through four. One and two are the lower grades, three and four are the higher grades. And that is very important in prognostic information. So basically this table contains a lot of the information that your clinician and your oncologist is using to determine your prognosis, okay? So again, this is a very important table and it's a summary. So you can see it clearly listed here. It talks about whether or not your tumor shows lymphatic invasion, lymphovascular invasion. Is it in the bloodstream? Does it involve your lymph nodes? What is your margin status? Did the surgeon take out the entire tumor, right? It would be listed here. And at the bottom, you can see that there's a TNM stage. And that is the most important information in determining your prognosis is based on the TNM stage. And that is called a pathologic stage that is incorporated into your imaging findings. Sometimes you serum tumor markers in determining the clinical stage, okay? So this again is a very important table that pertains information to each and individual patients with kidney cancer. So last but not least, prognosis. So like Sandy and I have said, prognosis really depends on number one, your tumor type. Some types of tumors behave better than other types of tumors. And then when you're comparing the same tumor type, how else are you gonna come up with prognostic information is based on the stage, right? So when you're comparing stage, you really are comparing tumors within the same tumor type and what is the extent. So I think of stage as the extent of your cancer. So how extensive is it? Is it confined to the kidney? Does it involve associated vascular tumor like renal vein? Does it involve the lymph nodes? Is it metastatic already? That information is your stage, okay? So again, I think of stage N is an extent of your cancer involvement. And that goes into determining your prognosis. Further prognostic markers are, again, tumor grade. So higher tumor grades tend to behave worse if you have tumor necrosis. So tumor necrosis is something that we see on this slide and it reflects tumor death. So is tumor proliferating at such a rate that it's dying quickly? Is there degeneration of the tumor that's a bad prognostic factor? So if you have that in your tumor, it means that it likely is going to behave in a worse fashion than comparing to someone's tumor without tumor necrosis. Same thing goes for sarcomatoid differentiation and also rabdoid differentiation. So these are all features that we can see under the microscope at a microscopic level. These things, unfortunately, for the most part cannot be seen at a macroscopic level at the gross examination. So that's why it's very important to do a good gross examination, sample adequate areas of your tumor and then making an accurate diagnosis using the help of a microscope. So all of that comes together and that's a pretty long and gruesome process and that's why sometimes pathology reports can take a while, I know, but just be patient with us because we're doing our due diligence and making sure that every single patient receive the most accurate information that pertains to that particular patient. And again, everyone's tumor is different, so we wanna make sure that we evaluate each individual factors accurately, okay? All right, last but not least, after all of that pathology is how do we help the clinicians manage your disease, right? So what can we do on our pathology end that can help your urologists or your clinicians assess for exactly how the tumor is gonna behave and help assess whether or not the tumor will respond to other additional treatment modalities like drugs or chemotherapy. And unfortunately, currently, there is nothing on pathologist end, no specific stains that we can do or no molecular biomarkers that's done as a standard practice. Again, we do them still and we do them actually in a lot of them, but those are lumped under research. So they aren't really clinically validated as of yet, but hopefully that will be done soon in the future and then when that happens, pathologists will play a very important role in working with the oncologist and urologist in formulating a plan that is tailored to individual patients. But unfortunately, as of right now, there's not that much that's been validated as of yet, but everything is up and coming and a lot of research and resources are being spent on this area to help with that. So that ends my presentation and hopefully that hasn't gone too fast or and hopefully that helps you understand what we do behind the scenes. And again, if you have any questions or any feedback, you wanna know some more about a particular type of tumor, I can go into that in more detail next time. So thank you. Thank you. Any questions? Yes. Chemical, yes. No, I use that term as a special stain. So that doesn't, sometimes it correlates, but most of the times it does not. Yeah. The drug that we have today in the Voluma, it targets a protein called PD1 or PDL1. So when this drug initially came about, it was our hope that we could take an individual tumor, stain it for this PDL1 on the tumor cells or on the immune cells and have that help predict if somebody's going to respond to immunotherapy. Today it's been a little confusing and disappointing because as we show you in our immunotherapy slides, patients who test completely negative, they have a response as to people who stain positive as well. So there's something beyond just this staining that helps predict whether somebody's going to respond. So today till we understand more, we don't want patients to be excluded if they are going to benefit from it. So right now that's not being used as a marker and there are a lot of groups working on it because there are different immunotherapy drugs and every company has its own antibody and there's no harmonization between these various staining. So today it's not being used, but suddenly it's being looked at and there may be things beyond just PDL1 or PD1 that helps us pick up patient for a given time. My naive understanding of cancer is that often, especially during metastasis, the tumor itself involves and as a result of that might go to different sites and the different sites who may have a different histology. That is true, yes. So as a result of that, if you lined up, for example, just sampling a little bit like your idea of doing it at least one centimeter so that you can go on and get an adequate sample. Correct. And your point is that sampling is really important. If it's metastasized and if it's evolved, you want to go on and actually look for targeting and stuff, seems to me that present a problem. How do you deal with that kind of an issue where people that have metastatic treatments? Right, so in our experience is that we would get a biopsy at least to take a look at the morphology of the tumor that has already moved on from the kidney. And by that, we would be able to see how it looks like, what it looks like, whether or not it's the same tumor. Again, sometimes it might be different tumors from other sites. And then we would be able to hopefully correspond that with just confirming that it is metastatic tumor and what it looks like. And of course, in that, so sampling is a very, that's a very, very interesting aspect of it is because when we do, so taking out the whole tumor and sampling at one section per centimeter, it's totally different than having, let's say a three centimeter mass located somewhere that you can't take it out entirely, right? So that's a biopsy specimen. So biopsy is different than the resection specimens that I've shown you. Biopsy is usually someone taking a needle, poking it into a tumor and sucking a portion of that out. Will align with your sampling concern. That is correct. That is a very, very, very good concern. And the short answer to that is no, because we can't, because once every time the needle goes in, there's a risk of bleeding, right? So being poked 10 times have a higher risk of bleeding than being poked one or two times. So we just use our best judgment and we trust our clinicians to sample the best areas. A lot of times when they do the biopsy, they're doing it with a help of ultrasound. They're doing it with a help of a CT scan. So that helps us determining where is the best area to poke that needle once or twice, right? But you're absolutely right. That is one of our biggest concerns is do we have adequate sampling on a biopsy sample, which can be very, very limited. I believe that's mutated. You aren't going to know how effective it is if you haven't checked everything. Well, you know, I mean, there was a very elegant paper that came out several years ago where four patients with kidney cancer that had spread to the lung and multiple areas. The investigators went in and did a biopsy sample of every one of those, I mean, so it's a lot for a patient to go through, but it gave us remarkable insight into this disease where let's say a patient had two spots in the lung. Both of those spots were sampled and when they actually looked at it at a genomic level, they were completely different. So you can imagine clinically this happens a lot where we see patients who have a spot in their lung and the lymph nodes, we give them a drug, it works dramatically for the lung, but that pesky lymph node continues to grow bigger. So we now know that there is some difference in what they look like at a genomic level that they are not the same. And this is classic in lung cancer. We hope to be able to get that to kidney cancer one day where we can biopsy an individual tumor and show that it's now changed to a different type and that we would have a different drug for that patient. That's where biomarkers come in and individual mutations. So in kidney cancer, unfortunately despite having all of these drugs, we haven't come to that level yet, but that's where we hope to be able to get to where pathology and genomics is going to help us select patients for a given treatment, not just at the first time, but as the disease changed. So does drug therapy evolve and make your tumor look different that we would need to biopsy at every single time? And to that point, rather than just biopsying, there's a lot of effort now at just getting blood test. Can you just do a blood test and get circulating cell-free DNA from the tumor? So tumors are shed and we now have the ability to take a blood test and detect tumor DNA in the blood and that to be able to give us some insight. So that's the hope and that's where we hope to be able to get to where we can get in a less invasive way rather than put patients through an individual biopsy every single time. Yes. I understand that when we're diagnosed or given a treatment, that it's a good idea to get a second opinion. My question is, is it also a good idea to get a second opinion on the slides of our tumor? That is an excellent question. Do we have access to our slides to take to you or to some other specialist to make sure that the diagnosis of our type of cancer was correct? That is an excellent, excellent question and we do that on a regular basis. So for instance, if you're seen at hospital A and you're referred in to see Dr. Sandy here at Stanford, so when that happens we will acquire your slides that was seen at hospital A, we will take a look at that here at Stanford before your appointment with, say, Dr. Sandy. So yes, we will confirm your pathology that was diagnosed at an outside institution. Yes, so we absolutely would take a second look, confirm that the diagnosis is indeed accurate and that we agree. Yes, so absolutely. That is the standard practice for every single one. Yes. So it's actually Stanford's institutional policy that we don't just take somebody else's word and that we have that pathology confirmed. So that's part of the practice that's here, but I also wanted Sandy to briefly touch on what happens to people's tumors and how pathology saves them, because that's always a question that comes up. What happens, I mean, can we do stuff from a kidney that was removed five years ago? Oh yes, so pathology specimens, yes. So when we do the gross examination, we take areas that we think are pertinent to evaluating the extent of your tumor. And so the parts that we sample are what we think are the most important parts and we read the slides under the microscope to confirm that. And if we think there are additional areas that need to be sampled, we will go back, pull out the specimen and take some more. But after the whole process is completed, we've issued a pathology report, the specimen or the residual tissue that is left over will be kept for maybe two to three weeks and that will be discarded. Because the most important part is already preserved in what we call a paraffin block that is the tissue saved where we cut the glass slides from. And again, those are the most important sampled areas and those blocks are usually kept for at least 10 years or so. And remember, we have multiple for each patient. So we've saved a number of the most important tissue blocks from your specimen and that's kept for at least 10 years. Sometimes we keep it for 20 years if we have space but if we don't, it's being kept for at least 10 years and it's fixed in the way that the tissue will survive for a multitude of testings. Molecular testings, we can use the blocks for that. We can use special staining testing. So for instance, the blocks we saved today, we will be able to perform testing on that, say five years later, if there is a special molecular test or special stain that we can do to help manage your cancer or help deciding whether or not the drug will work for you, that tissue is still going to be there for at least 10 years. Just related to that, is that best practice or standard practice across the country? That is standard practice for at least 10 years. Yes, so for any accredited lab, that is standard practice. Yeah, but as far as keeping it longer than a certain number of years, then that is institutional based. So there's a minimum requirement of the length that the blocks need to be kept. Same thing for your slides too. So your slides are, I think, don't quote me on that, but maybe at least 20 years. So the slides are usually kept for like forever. We have slides back in 1990s still in our warehouse, so. But yes, there is at least a minimum number that those samples need to be kept. Yes. Has the pathology practice changed enough over like the last 10 years that if you have slides that are 10 years old, that there would be any reason to ask for a new report from those slides? Wow, the answer is very complicated and that's tumor dependent. So yes, you're absolutely right. A lot has changed in the diagnosis of kidney cancer and I would say the last five years. So now with the help of a lot of the molecular tests, different staining available to us to help in the diagnosis of kidney cancer, some of the kidney cancers that was diagnosed as unclassified before, meaning that we don't know what the cancer is, now we actually have names for them because of the advancement in pathology and the molecular studies. So, but that's only true for a limited number of cases for, like I said, the unclassified types. So if you had a tumor that was diagnosed as clear cell renal cell carcinoma five years ago, it's still going to be a clear cell renal cell carcinoma five years later. It's only in that very limited area where we couldn't classify it before, but now we maybe can based on the new advancements. But the clear cut tumor types, papillary will remain is still papillary, clear cell is still clear cell. So yes and no. Okay. Any other questions for Sunny? The subtypes have changed, however, significantly? Well, we've added more subtypes. So before the classic kidney cancers are clear cell, papillary, chromophobe, and probably, you know, some other random types, oncocytoma, but now it's bloomed to where we've added maybe five or 10 more subtypes that we can now recognize that we couldn't before based on molecular tests, the new molecular tests and also new stains that we have now. So I would say the subtypes have expanded, yes, but as far as what's most important, which is the stage, again, that's the extent of your tumor involvement, that hasn't changed much. My surgery was 12 years ago. And it was papillary. Mm-hmm. I had the pathology run twice. Mm-hmm. It was run once at the hospital where it was done, was we're in a second time at Cal Pacific. Mm-hmm. But the subtype of the papillary was diagnosed differently both times. What do you mean? And there was only one sample out of a 12 centimeter tumor as far as I'm given to understand. Okay. One sample, like one tissue block? As far as I understood it, yes. Okay. Well, I can't speak to the practice done at another institution, but like I said, the standard practice that we do nowadays is at least one sample per centimeter of the mass. So I can't say anything much else to how it was done 12 years ago, unfortunately. Well, thank you, Sonny. Thank you so much. Thanks for all the questions. Thanks.


Twenty-fourth of September is International River Day. Now, it's in the middle of River Alley. I will be at Maheshwar, I'll be on a river bank in Madhya Pradesh. All of you, and you must tell all your friends and family that you must make a pilgrimage to one nearest river in your area. If you know where there is a river, okay? Because we made a little survey and we found below twenty years of age, eighty percent of the population has never seen a river. They have not seen a river. Of course they've seen an online river. They have not seen a real river. Will you do this? This is important. This is important that you make a simple pilgrimage to some river and you may find some of the rivers are filled in the sewer that runs in front of your home or whatever, those things that you fall into in Mumbai. It doesn't matter. But you must make a pilgrimage to a river on twenty-fourth. Make this annual pilgrimage till our rivers flow clean and wonderful. You must make this happen.


Everybody forced here ripping 2021 upper-deck SP authentic hockey hobby 4 box number 3 It's a random team style break and you can always find these results at latent sports cards comm Thanks everybody for joining good luck Here we go. I know I said it quick, but always Always you can find the results on the website Anytime quick the results quick link at the bottom of the page or you can search for the results as well the search bar Use the search bar on the side it kind of just searches the entire site So be aware of that get a bounty in the first pack Kyle Connor for the jets Yeah, what's up mark? Yeah, I'd uh mark Shifley. Yeah are there sometimes I watch from a switch And I just don't even pay attention to the ads Look pay attention next time right for the devils Nico. He sure devils color match Nico Professional fighters. What do we got here? We got what do we got we've got for the black Hawks and Ian Mitchell future watch patch auto to 100 nice hit Hawks Ian Mitchell Real nice Player war not game war will player warn There you go Love those future watch patch autos man. Those are so nice But the car designs and just about every upper-deck product are just are so nice Tyler Sagan Yeah, the the white look is great We've got Quinn Hughes on the celebrated moments for Vancouver Jordan Stahl true leaders Celebrated moments is Kareel Capri saw for the wild Sean monahan red for the blues Ryan O'Reilly blues red Ben the job. We got an auto coi vula future watch auto for the Islanders to 999 Auto coi vula It's a fun name To be fair most of the Finnish names are fun Cal foot level one on the bounty car there for the bolts Wearing those throwback unis Rasmus Dallin Tim Stutza celebrated moments for the Senators leaders Alexander Ovechkin Steven Stamkos Red for the Prez peccarine Make David celebrated moments. I almost used a photo of him celebrating like that as the thumbnail tonight Couldn't find a good enough one though at your cane box to get a level 2 Jake Audinger Future watch bouncy card level to bouncy for the stars. They took a rask bouncy card for the Boston Bruins here Luke Dubois out of 100. There you go Bruins David posture knock The 2001 throwback I think is what they are on a red Sebastian. Ah, oh Vancouver Bo Horvat leader's card Dallin do the Jets have a coach yet? Are they still looking? There's a Bobby or performers Nice Bobby or Got brain point celebrated moments who they get no fear a Riley Klingburg Brady Kachuk Yeah, I know mark. I was so surprised That the sharks clean house Black cocks red Dillon strome at least this laid into the to everything our bonus. He's pretty good Nice a Mike Gartner on the auto.   Yeah, dude. Just make sure you choose something you like What's all about? God bow and Byron celebrated moments for the abs brain point Moving on box number three Bow and Byron celebrated moments for the avalanche True leaders capitals Alex Ovechkin Konechny Guys like it says in chat right there. At least I know it says it in Twitch But personals are full for tonight. They've been full since before we went live today Lightning red brain and point brain point celebrated moments Matt some Dean performances or performers for the Leafs moments Austin Matthews for the Leafs Connor McDavid Red for the Jets Pierre-Luc Dubois Got an Anders Lee nice hit Islanders. That's a sick-looking card there the limited gold. I want to say Is that what it is? Let me see. Let me see One in 144 packs, right? Yeah, nice Anders Lee Just limited auto base limited basically Islanders with a nice one there. I don't carry my cards with me normally The rarest card I have I honestly don't know got a Montreal rookie auto or a future watch auto a Jake Evans to 999 Say get in hella book Yeah, no fear. It's crazy make David's so good. Nice a Ryan Ellis sign of the Times Auto for the Preds Sandin Panarin got Pierre-Luc Dubois Jets on the spectrum FX Bounty card Yeah, two autos for box. There's some pretty good ones in here It's a nice cards tonight ace card missing. I guess Yeah, for sure. No fear Red for the Sabres Rasmus Dallin Yeah, I think I think Matthews deserved it though, but then obviously postseason McDavey just he He willed that team so close to like competing with the abs Jordan Stahl cheerleaders And overall they're just there's no business competing with them dude Be so good Ryan Zingo Alright one more. Good luck everybody for box number three Level three Dylan cousins future watch bounty car nice one Sabres Good stuff level three There's a Matthews bounty card there for the Leafs Roman Yossi future watch Niko Mikola to 999 blues that one snuck up on me. It was with another card and one less base Interesting interesting flames red Sean monoham the rarest card is probably it I forget the product But it's a Tuka Roscoe auto a Nick Felino cheerleaders He's in his Finnish uniform. I have it at home and slab. It's a 9 5 10 Tuka Roscoe auto It's not numbered, but the pop count is like real low on the graded ones Jonathan drew in Plus it's like it's like late 2000s like before Rask was even like a Bruins backup I think got Austin Matthews celebrated moments Lane got that cards and how I bought it off Cheerleaders closed your room. He was like, hey, I'm gonna put this in an almond. I do want to buy it. I was like, yeah I was like looked at it for a second. I was like, yeah All right, see you Ari. Have a good one. We're live seven days a week. Not me personally I won't be here, but yeah, we will be live Or mostly seven days a week Monday, but we won't be live Monday. We're closed, but I read for the lightning Steven Stamcoe's Pavel Dotsuk. Yeah, dude. He was so fun to watch Got a lot for a year moments there for the Rangers high skin and Sydney Crosby true leaders Moments Joe Thornton for the sharks right? Yep sharks Joe Thornton jumbo Joe. I believe there's basketball tomorrow Got a break schedule if you want to check it out. Yep. There's noir prism Lawless basketball even though that in a while. That's awesome. So good basketball breaks tomorrow Copetar Patrick Kane blackhawks red He did right JB. I Don't know I don't want to assume that Joe Thornton retired a Duggy Hamilton son of the time Zotto for the for the Canes Duggy Hamilton and a Peyton Krebson 999 Nights future watch auto You go night solid hit there on the Krebs Mr. Krebs SpongeBob's boss. All right Let's go ahead and do a recap We're of the Krusty Kreb. Hey, what's up Kemper? No, it's a four-day weekend. It's Bobby Bonilla day today Then there's something else on Monday. We have Bobby Bonilla days the more important one. I think we've got Bounty car it's Austin Matthews level three Dylan Cousins for the Sabres Pier Luke Dubois took a rask Level two Jake Ottinger for the stars level one Cal foot for the lightning Kyle Connor autos via Doug Peyton Krebs Doug Hamilton Ryan Ellis Jake Evans Anders Lee Go Shane Bowers Mike Gartner Auto coi vula and patch auto Ian Mitchell Good stuff there. Thanks again, everybody We've got another hockey break up next


The YouTube fireworks motivates us to grow. What is it? It's when you go to your YouTube dashboard, refresh your page, and see this. Those fireworks are displayed only when you get number one of 10 in your latest 10 videos, as reported by YouTube, you're competing against yourself. But what's really cool is it shows you relative to the time your video is uploaded compared to the other videos in the same timeframe, how you're doing. So I got this fireworks because Google deletes accounts for inactivity, was got 285 views in its first 18 hours and 52 minutes, which is much more than the previous one, which only had 267 views in its first 18 hours and 52 minutes. And the other cool thing to look at is these views, impressions, click-through rate, and average view duration, all of which are number one or in the top part of my videos. You can go to analytics to see all the others. Here in the bottom right corner, you see that this is my latest one. I go to the previous one. So that one only had a normal one minute and 27 second watch view duration compared to my latest video, which had almost two minutes, which was on the upper end of the spectrum. So you can use these tools guys to see which videos are doing better for your audience and you should make more of the ones that are doing better. Here's one that only had a low 2.3% impressions click-through rate, which means the thumbnail wasn't as attractive and compared to the first two, which had a 4% and a 5.3% impressions click-through rate. So all of these tips will help you grow faster if you just pay attention to your analytics. Here's one more new tip. You see this research tab? This research tab is new. If you click it in your YouTube analytics and go to your viewers searches, look, you, now this will be different for your channel, but for my channel or our channel, Freedom Central, we are found by people searching for unboxing, unboxing videos, how to upload movies on YouTube without copyright. That's a surprising one. I don't think I have any videos on our channel about this topic, but somehow we're ranking high in that search and photopia, I believe. We have quite a few photopia videos and tutorials. We also have lots of unboxing videos and so that's why we're ranking high. What do you rank high Freedom Family? Tell me down there in the comments below. I'd love to know. Let's share with each other and help each other grow together as a family because that is the spirit of freedom. We are the Freedom Family. So let's learn about this research tab. There's also a very cool thing called content gaps. So if I click learn more and so can you, you'll come to this article and where they talk about the tab and here is the concept of a content gap which is YouTube telling you when viewers can't find enough quality search results on YouTube for a specific search. You can use content gaps as inspiration to create content that doesn't exist or could be improved. That's key because YouTube is basically telling you we don't have enough information about this topic. Do you want to help fill the content gap? If so, we will drive organic search to your videos to fill if you fill that content gap. So I encourage you to check that out. Now I don't have any content gaps in my report here. And I'm assuming that's because these search terms are well-served. There are many videos about them. But if we do something else like, I don't know, purple donkeys which don't exist. So maybe that'll be a content gap. Okay, I'm not seeing any content gap report. So I'm not actually sure how that is presented as content gaps. But if you have a content gap visible in yours, send us a screenshot down there in the comments below. We'd love to see it. So yes, we have the research tab. We have these historical comparisons to all of your videos, your at least your latest 10 videos which is an important way to measure which thumbnails and content are good for your audience. Like this one is all normal. There's no upper area of performance for this video. And I have a few of them like that where, oh, this one's even below average. So the YouTube culture and trends nobody was interested in. Or maybe it was my picture of Daenerys in the thumbnail that drove people away. Oh, come on, it's a cute baby. I don't think that was it. So you can study these results and help you make informed decisions about your own channel to grow faster. All right, one other thing I wanted to mention to you, the video I made yesterday about Google deletes your account, I featured a short clip of the Dune 2 trailer, part two trailer. And I got a copyright, not a strike, but a copyright match which means it doesn't have any negative impact on my channel, but it does prevent me from monetizing my video. And I'll show you the content clip. It's only like 40 seconds here, and here it is. And I better not show it because this video will probably get a content copyright match if I do. The whole point is the owners of this clip had decided to set the content ID match policy to be very tight. So any instance of that trailer will flag it and all revenue gets redirected to that rights holder, which I think is pretty unfair, but I have not clicked dispute because to be honest, I'm not building this channel for making money. I'm building this channel to teach you guys how to make money. And so the money we do make is kind of just reinvested back into our business to help you grow. But if you're building a channel to make money, you should be disputing fair use claims like this so that hopefully you can get them reinstated or the monetization reinstated. But as I said, it has no negative impact to the channel. Unless it was a copyright strike, then the video would have been taken down and that means I only get three strikes in a 90 day period. So do you. Everybody gets only three strikes before their channel gets terminated. So you definitely want to dispute any takedowns which create copyright strikes. All right, what other tips can I give you? So on the earned page, we have something where I'm saying, where YouTube is telling me I have an action required where I need to confirm your personal information. Otherwise I will not get paid by YouTube. Check your earn tab periodically. Make sure there are no notices like this because you don't see them anywhere else. Like on the dashboard homepage, there is no notice about my ad sense. Ooh, I love these fireworks. Yes. I can watch those all day. We do have an active community guideline strike warning, but this has been there for years. This is when we created a video showing you how to download your videos to your hard drive for a backup. And that got a community guideline strike because downloading YouTube videos, we showed many ways, the legitimate ways and the ones where you use a third party tool because we were advertising how to download videos using a third party tool which is not, according to YouTube terms of service, we got a community guideline strike. I was really surprised about that. I challenged it, but YouTube upheld it. However, when you get your very first community guideline strike, it's not a strike. It's really just a warning, which is right here. The problem is that warning never goes away. Strikes go away after 90 days. This warning is here forever to remind me forever that I better not be a bad boy and talk about how to download YouTube videos without using the official, or in ways other than the official YouTube tools for downloading videos.  That's how you officially download YouTube videos or you use Google takeout. Google takeout is a tool that lets you download anything from your channel, not just your YouTube channel, but your Gmail, your photos, any content you've uploaded to any Google service, you can take it out, download it for your own backup using Google takeout. But that's not the point of this video, so we won't go into that topic. Just wanted to point out the legitimate ways to download YouTube videos from YouTube. All right, guys. And yeah, I think those are some good tips. One last tip I wanted to share with you is if you do get a copyright match, which again doesn't harm your channel, YouTube does have the option to trim.  This trim out segment will really delete it from your video and remove the copyright claim. So if it's music, you can even mute the song. So the video doesn't get trimmed, only the music gets removed from your audio and your spoken words remain, even if you're speaking on top of the music, it's pretty cool tech, where it can just remove the musical piece from the audio stream. Anyway, my point is I can click trim segment and YouTube would automatically delete this 42nd section from my video and then the monetization would be restored, I don't have to click dispute, but of course someone watching my video would then miss that section and it would look strange to someone watching the video. It'd look like something's been deleted because it was, but it's a cool tool that helps you remove copyright claims that you cannot remove any other way. So you don't have to delete the video, re-upload it, lose all your views and comments, whoa. That is an alarm telling me I have a meeting in four minutes, I better wrap this up. So yeah, use the trim feature to help you maintain monetization for your videos that have copyright matches. All right, Freedom Family, I hope the YouTube fireworks also motivates you as it does me, what else motivates you to grow? Tell me down there in the comments below so we can all help each other grow together as a family. Let's get into a little bit of a bigger George here, shall we? So as my final words, I went to the gym today, did you? I feel so good, I did my bench press, my squats, I did my warmup, which was a six minute high speed walk at a 12.5% incline at 6.6 kilometers per second speed on the treadmill. It's mouthful, but it was very good and painful. Don't like those warmups, but they get my blood going. I did abs, where I did a lot of crunches on the bench, keeping my legs straight, kind of like this, going up to be like a match book, an L shape. Those are tough, especially when you go down slowly. And yeah, what else did I do? I did, I mentioned the squats, I did dips. I like the dips, they help build the triceps, triceps. Like your biceps are common where you would just go like this, but your triceps, most people don't do, so I do the dips where I go like this behind me to lift my body up, and that's very effective. And yeah, what else did I do? I did the overhead press like this with the dumbbells, one in each hand, and I think that's it. Yeah, yeah.  Oh, I did the lower back. I did the deadlifts, so you kind of go up like that. Oh, it's, my camera's not focused now. Come on, focus, please focus. I'm blurred, okay. Well, this is a blurry way to end the video, but since we're at the end, it's okay. Cameras, come on camera, it doesn't want to refocus. Nope, not refocusing, okay. I am George, CEO, blurry CEO, and founder of Freedom, for Freedom, and there's a lot of noise going on in the background, sorry about that. The neighbors downstairs are drilling holes in their ceiling and floors and whatever else they're doing. I don't even know. I am the CEO and founder of Freedom, and you are the Freedom family. We all help each other grow together as a family. I'm George, and you've been watching Who You Dreaming But Love, here. Click that I to partner with Freedom and join the Freedom family so we can all grow together. You get many perks like position music. You also get epidemic sound, a lot of other access to royalty-free videos, sponsorships, and many things to help you grow. Just click the links down there in the description below to get involved in our community, our forums, our Discord chat servers, meet our graphics team, meet our community team, all of that on Discord and the forums. What are you waiting for? Get started. And we will grow together as a family because this is the Freedom family. You are part of it, we are all part of it, and we're all growing together. To get more, George, click that big F that will subscribe you to Freedom Central, home of the George show. And PewDiePie gave one of you, Freedom family, a big shout out. Click that video to see the shout out and to see our new 3D sets for you. And click that video to see what YouTube recommends you watch next.


So, I know that by now, we're all not surprised whenever Donald Trump jokes about consolidating power, whether that be him postponing the election, or, you know, running until 2050, or remaining in power until 2050, because he does this, like, all the time, but it still should never be acceptable. Like, as little as I care about norms, the one norm that we should all care about universally is the norm of democracy and respecting democracy, because democracies, they can't function, they can't survive unless there is a buy-in among the populace. So, once we all check out of democracy and we believe that authoritarianism is an acceptable option, that's what it actually does become an acceptable option, because these types of regimes, democratic regimes, they don't exist, they can't survive if there's no legitimacy to them. But Donald Trump is joking once again about maybe running for president in 2024. Take a look.  So funny, so funny. We're all laughing hysterically. Now, again, he's trying to trigger the libs and troll, right? That's the excuse anyway. But it's not so funny when this president just recently floated postponing the election, because of fraud due to mail-in voting. It's not so funny when he is deploying secret police to kidnap people on the streets of Portland, Oregon. It's not so funny when he is expanding executive power. Now, this isn't due to Donald Trump, but as we continue to allow the executive branch to grow with the amount of power that it has, it's not funny to see the sitting president joke about running for a third term and just brazenly disregarding the Constitution. Like, this is not something that we should ever allow to be normalized, right? But the fact that this is a joke to them and they're okay with it, it's a dangerous sign, because even if Donald Trump might not be the one to become a dictator in the United States, even if he wants to be one, what this does is this kind of gets right-wingers who are already susceptible to this type of demagoguery and authoritarianism to be a little bit more open-minded about the prospect of having a permanent president, as long as it's one that they like.  In fact, we all remember when they freaked out when Obama said that if he were to theoretically run for a third term, he would win because he thinks he's a good president. Now, he was making a point about how it's important for presidents to step down and respect the Constitution, but they saw that as a threat to democracy. They were hypersensitive to the prospect of anyone staying in power past what the Constitution allows. And now look at them with Donald Trump. They freaked out about all of the executive orders that Obama was signing when he wasn't actually signing that much, comparatively speaking. And now Trump signs lots of executive orders and they don't care about that. You know, even if conservatives are supposed to want to uphold traditions, we've seen them go further and further to the right to where now they're openly flirting with not just fascism, but authoritarianism with Donald Trump. And you had one supporter infamously admit back in what, 2018, 2019, that she never thought she would want a dictator. But if there was ever going to be a dictator in the United States, she'd want it to be Donald Trump. And that might just seem like one outlier. Sure, it is anecdotal evidence, but you have to understand that this large to the right, it doesn't just signify an ideological shift for Republicans. You can only go so far right on policy to where enacting that agenda requires authoritarianism. It requires a decline in democracy. And that's what we're seeing like Donald Trump got the Republican Party's feet wet with regard to authoritarianism. He's testing the waters. You know, it's trolling right now. But in spite of whether or not he's being serious or not, they don't seem too mad about the prospect of him becoming a dictator. Now, again, I don't think that Republicans in a vacuum support authoritarianism, but what this proves to us or at least signals to us is that they're open to the idea if it's a dictator that they want, if it's someone who's on their team. And the problem with this is, again, for democracies to be able to function, you should reject. Like you should have a population instinctively reject the prospect of authoritarianism and even be so touchy where they won't accept jokes about it because that's how bad they think that would be, right?  Like, it's not fun. Like, I know that we oftentimes talk about the decline of democracy in America, but to actually live in an authoritarian regime is a very different thing. Like, ask any Tunisian who lived under the dictatorship of Ben Ali how fun that was for them to where they actually had to be fearful of their own relatives that maybe they were working for the government and were selling them out if they espoused any anti-government rhetoric. Like, it's not fun and I'm not saying that even if we were to become a dictatorship, it would immediately get that bad. But sometimes when you take one path, it's really difficult to reverse that momentum and get on a different path. So now before it's too late, we have to be very clear about rejecting authoritarianism, especially when we have a sitting president currently warming people up to the prospect of a dictator because this dictatorship would be a fascistic dictatorship. Now, again, this is all like, this is not something that's guaranteed. I'm not saying that Donald Trump is going to be a dictator even though I know he wants to be a dictator. But just the mere fact that right now Republicans are open to it and they're not outraged with Donald Trump saying I might run for a third term because they chalk it up to him joking. Right now, you know, it's something we can all kind of brush aside. But in 10 years from now, 20 years from now, what will be the sentiment towards dictatorship if things continue on the same path? So that's why I say we have to take these things very seriously. It's not just trolling or triggering libs. Like democracy requires a buy-in to function because if it doesn't have people accepting democracy, then that regime fails. And all democracies have a shelf life. They're not just going to last forever because we have an old democracy. Democracy is a project that is ongoing, right? I would argue that we're not even a full consolidated democracy. Like women didn't have the right to vote. Black people were slaves at the founding of our democracy. So democracy itself is a project and a healthy society always continues on that path towards consolidating democracy, making it more vibrant and healthy and with everything that we've seen from Republicans with voter suppression and attempt to sabotage the USPS ahead of an election where we're expected to see a record number of people vote by mail and have a president openly joking about running for a third term. This is a bad sign of what's to come. Hit the subscribe button, okay? And whatever you do, folks, do not hit the notification bell either. Life treats me so unfairly.


Nanomaterials have seen a tremendous increase in use for novel cancer therapies due to their unique compositions and properties with researchers utilizing them to enhance photothermal therapies and target the effect on tumor tissue through optical absorption of near-infrared light. New uses for nanomaterials in targeted cancer therapy are coming to light and the efficacy of photothermal therapy has increased dramatically. This work reviews some of the current applications of nanomaterials to enhance photothermal therapy as photothermal absorbers, drug delivery vehicles, photoimmunological agents, and theranostic tools. This article was authored by Austin C. V. Dowdy, Ashley R. Hoover, Eli Violaton, and others.