 So that basically is a summary of the surgical management for patients who present with localized locally advanced and metastatic kidney cancer. Does anyone have any questions, sir? So just to repeat the question for the video, one of the audience members is asking if the quality or the sensitivity of the scans done say here in a major medical center are different from those done out in the community and is there anything that could be done to sort of improve the quality and sensitivity of the scans done in the community to detect disease recurrence earlier with the potential that it may be more curable if it's found earlier? Yeah, you know, it's a good question. The fact is there's really no method for us to tell another doctor how to do their job. And so the fact is in the community we do see some good scans. And so, you know, some places understand why they're doing the test or given a requisition that asks for a CT scan of the admin to be done, for example, in a patient with treated kidney cancer. And so the radiologist knows what to look for and they may protocol it appropriately. So it depends on multiple levels of things that happen up to that point. How much information they're given if they know what it's being done for and then also how they actually do the test. And we do get good scans from the community. I'm not saying we only do the best. That's not the case at all. But we do see a wide variety of quality of scans from the outside. In your particular case, if you haven't heard of problems from when you're getting scans from the outside, then it sounds like it's probably fine. And then when we do scans for follow-up in terms of surveillance, it is a little different than when we're looking at first to assess the tumor in the kidney and how we're going to address it. Actually, that scan arguably uses more radiation as a little more complicated because basically they do almost four different phases, before contrast, early contrast, medium range and then late contrast phase. When we're doing it for follow-up, we don't need all that. And so, you know, again, those are some of the details. And again, most radiologists who, if they're told why it's being done, and of course that depends on who's ordering the test, then they'll know usually how to protocol it appropriately. But again, depending on where these things are, sometimes it's just a one-size-fits-all approach, and then some others are more specific. Is that too complicated of an answer? Pretty long-winded. So the other thing is what we do here, in addition to the radiologist, is we are radiologists doing the test and reading it. And our practice, as urologists here, Dr. Wood, Dr. Matin and I, we all look at the images ourselves as well. So that's also a very important point, not just going simply by the radiology report and what it says, but also physically, in our clinic, we look at the images ourselves just to make sure that this is the case. And it's a team approach, you know? Sometimes they miss things, they're human. Sometimes we miss things. And we rely on the radio, you know, I don't look at the bones. I don't, not great at looking at the liver and the lung. And so I recount on the radiologist to catch those things, but I do know that I'm not likely to miss anything in the lung, in the kidney, excuse me. And so, you know, I think with that, it's a team approach. And what we encounter a lot of times are patients who have scans. And I suspect a lot of times it's just a report that's being read. Because you can easily look at the scan and realize that either there really is no problem or that there was a problem and no one really picked up on it. And we see that all the time. Question? So the question for the audiences, are there genetic markers that can be used to better understand and treat kidney cancer and perhaps improve prognosis? Is there anyone to tackle that? No, I was able to. The short answer is at this point, no. There are some markers that we use to help differentiate the diagnosis itself, so what Dr. Matin mentioned earlier, sometimes it's not very clear on the microscope what type of kidney cancer it is. And then you can do some additional genetic testing to try to tease that out. But in clinical practice, I don't believe we use any specific marker to tell us we should do this type of surgery or that type of surgery at present. The only caveat to that would be that, you know, there are clearly genetic syndromes, like VHL and HLRCC and other syndromes that are associated with specific genetic defects that knowing those genetic defects can put the clinician on, you know, make him aware to look for other potential sequelae associated with that genetic syndrome. Like, for instance, in VHL, they can get vascular tumors of the brain. They can get piochromocytomas. They can get tumors of the pancreas and so forth. And so knowing that your patient has that VHL genetic defect is going to make you much more aware and looking for those other potential side effects that occur as a consequence of the syndrome. Other questions? Sir? So the question, one question from the audience is, you know, in terms of genetic forms of kidney cancer, what's the recommendations regarding, you know, what are the chances of passing it on to your children and how should they be evaluated and so forth? Dr. Matin? Thank you. I'm going to potentially give another long-winded answer, but it's also because I want you to understand. And this is actually a very common misunderstanding, even amongst urologists and physicians, that we think that if we suspect there's something genetic going on, that we can send it to genetics counseling, and that there will be this incredible discovery, that they can look for anything. That's not the case. There are known genetic syndromes, as Chris mentioned, VHL being the predominant one with kidney cancer, and all genetics people can do is look for those specific mutations and conditions. So if I see something that occurs in a family, and I'm worried about a genetic syndrome and we send it to them and they say, no, this is not a case of VHL, it doesn't mean that there's no genetic syndrome. It means there's not one that we can identify because we've only probably identified the most common ones. Although with kidney cancer, then there's the issue of common exposure. Maybe everybody in the family had it because maybe you got exposed to something along the way that predisposed you to it. You don't know. But so that's what I think we need to understand. And what I try to teach our trainees is that it's not this magic that happens when you send someone to genetic counseling. We actually have to suspect what that is. It's not like they reach into this magic box and suddenly they make a great discovery. It has to be a known defect because that's all they can really look for. I don't know if this makes sense or not. So it's not that hard of a science as people make it out to be. There has to be actually a clinical suspicion that backs it up. So having said that, to answer much more specifically, in cases when even we get a negative genetic test, but very recently, actually a physician that I treated, father and son, had it. I suspect the genetic test will be negative because there isn't those other vascular tumors that we tend to see in that genetic syndrome. It doesn't mean there's nothing going on. And so what I tell them is, look, everybody else in your first line descendants, any reason you can find to get an ultrasound of the kidney, after age 25, 30, maybe once a year or every other year, get it done. There may be some issues with insurance coverage. So I don't propose CT scans and things like that for no reason. There's also radiation. Just finding a reason to get an ultrasound done by a primary care doctor every once in a while in those settings is what I recommend. Even though there is no objective evidence that there's anything genetic going on, I did tell you it was going to be long-winded. It was. Just to reiterate the question, the question is about adjuvant therapy. And basically, the question from the audience, is there anything lifestyle changes that can occur that can be done that potentially can decrease the risk of recurrence of cancer? So the short answer, unfortunately, is no. I mean, from my perspective, a lot of the people always say that, do I need to change my diet? Do I need to exercise more and lose weight, et cetera? All those things, they should do, not necessarily because it's going to decrease the risk of cancer occurrence, but because it's healthy and better for them, heart health and cardiovascular health and so forth. From my perspective, although there's no direct evidence, if you've already had kidney cancer, the diet has been cast. And it's hard for me to sort of believe that if you give up steak and don't drink red wine anymore, that it's going to somehow alter that risk of having the cancer come back. So I don't usually typically advocate dramatic changes in lifestyle, aside from the things that I talked about. And that is weight loss and blood pressure control. I'll make sure that the patient stays hydrated and things that I would advocate to anybody in this room, regardless of their status regarding kidney cancer. Do you guys agree? Yes, I mean, the data that Dr. Matin showed in his presentation for patients with early stage kidney cancer, the chance of recurrence is quite low. And then when these patients pass away, most of them don't do that from kidney cancer. Most of them is from heart disease or other issues. So all these things that you mentioned, diet, exercise, stopping, smoking, all this, this is just important for not necessarily cancer health, but also health in general. And we recommend them for our patients just because most of our patients, early stage, are cured already with surgery. But we need to make sure that they live long from the other reasons as well.