 Thanks to the organizers for their kind of invitation to speak. This is a really exciting program. My brief today is actually simpler than the previous speakers. It's the follow-up of patients after surgical treatment for RCC. Before I go on, I would recommend, however, to you a paper by the eminent Murray Brennan published in the Analyst of Surgical on College with the devil's advocate view of why we may not need to actually follow patients. But having said that, my outline today is to summarize some of the North American guidelines, the NCCN guidelines, and the AUA guidelines. And I'll spend two slides talking about the potential role of other markers. Why do we follow patients? 20% to 30% of RCC patients will localize tumors, will experience relapse, with lung mets being the most common sight. The median time is usually one to two years, with most relapses occurring within three years, although all of us have seen patients who do present decades later with a met. Besides those oncologic reasons for follow-up, the functional reasons for follow-up are important, particularly monitoring for renal insufficiency, and most of the presenters in this session have actually touched upon that today. In preparation for this talk, I was actually talking to a patient who happens to be my neighbor, and he insisted that I present his case. He's a 58-year-old man with diabetes and hypertension, creatinine preoperatively 1.3 with the EGFR of 55. In 2010, we took out a Clear Cell RCC PT3B Level 1 thrombus, negative margins from in 2. So how should we follow him? What does the NCCN guidelines tell us about this? They were updated in 2013 in January. They're all category 2B recommendations. LDH was actually removed from lab tests. Follow-up imaging was modified to have pelvic imaging as optional. And again, not again, but importantly, PET scan is not mentioned. So the follow-up is every six months for two years, then annually for five years, H&P, CMP, a post-op scan at two to six months, and then as indicated. The authors make the statements, no single follow-up plan is appropriate for all patients. And individualization based on size, stage, and grade has to be considered. I would submit that this is a moderately successful way at capturing the risk of relapse. What does the AUA say on this subject? Recently, the AUA guidelines were put forward in 2013. This is a very rigorous methodology that was followed. It encompassed a long period of literature survey, 45 pages in length with 27 guideline statements. I recommend not only the paper, but the reference as well as I found them excellent, divided into five different categorization standard, meaning what you should do, because the benefit clearly outweigh the risks, category A or B evidence, recommendations, options, then clinical principles and expert opinions. Do history and physical? I'm not sure I always do this well, but this is what the guidelines say. In terms of laboratory evaluation and contra-distinction to the NCTN guidelines, the AUA does focus on urinary, UA, buon creatinine, and importantly, EGFR, with the other labs considered somewhat at the discretion of the clinician. Importantly, a statement has made monitor renal function for possible referral to nephrology. So in preparation for this talk, I actually called my favorite nephrologist and said, I'm gonna talk to a bunch of cancer people. What should I really say about kidneys and RCC? And these next slides are actually from Sharon Graves. She said, stop talking about serum creatinine. These six patients over here all have the same serum creatinine, but yet they all have different EGFRs that give them a different CKD between one and three. That's highlighted in this next slide where you have patients who are the same age, two different patients, both have the same serum creatinine of 1.5, albumin of four, B1 of 15, when they happen to have a different race and gender with the creatinine clearance of the person on the left of 90 and the creatinine clearance on the right of 33. Threefold difference. Also, of note, I would submit to you that the calculators that we do routinely use are estimates and are sometimes imperfect, especially as kidney function declines. Why is this important? One of the previous commenters also mentioned that the rate of all-cause death increases the GFR declines. So that is summarized in this slide, but in green, I put down something that the nephrologist really wanted us to become aware of or stay aware of, is that at the first sign of proteinuria on post-op urine analysis, particularly microablenuria, please make a referral. What about bone scans? Do them for indications. What about brain meds? In the entire 27 guidelines, this is the one that achieved the quality of standard, meaning you should do this. Patients with acute neurological signs should undergo CNS cross-sectional imaging because meds can be reliably detected and in the modern era, actually very well treated. As for molecular markers, something that's near and dear to my heart, actually the panel does not feel they should be assessed currently because larger prospective trials are needed. They divide patients to two different risk categories, T1 and zero low risk categories and ask for guidelines about those and then the high risk. Abdominal CT or MRI should be done post-operatively after partial nephrectomy, but after radical nephrectomy, abdominal CT, MRI, or ultrasound can be done. In terms of surveillance, abdominal imaging, abdominal imaging either ultrasound, CT, or MRI done yearly for three years after partial nephrectomy for these low risk patients, but do have a consideration. You can have a one centimeter tumor or a 6.9 centimeter tumor, both are T1. That has to be considered along with positive margin grade, aberrant histology, papillary features, et cetera, and don't forget patients with post-op complications. Which patients may forego imaging? And I thought this was particularly relevant in the era of cost containment that we are now in. For these low risk patients, additional dominant imaging is optional if the post-op baseline imaging is negative given the low risk of progression recurrence. Although if one does this, the patients need to be advised that there is a low finite risk of metachronous contralateral tumors. As for chest imaging, chest X-ray is advocated for three years, and then after that, only as clinically indicated, chest CT may lead to false positive leading to potentially invasive further testing. What about the high risk or moderate risk patients, T2 to 4 or TNE and N plus? Four guidelines. Here, a chest, an abdominal and chest scan should be done three to six months post-op in order to have a baseline. And then Q6 month scans, either CT, MRI or ultrasound of the abdomen and chest X-ray for the chest, potentially chest CT for three years, annual imaging for years four and five. What about beyond five years? And that's a real question that is relevant. That's to the discretion of the clinician. Most relapses as come to that earlier occur within three years. Metastases may occur indeed very, very late, but multiple decades later. As far as PET scans go, much like the NCCN guidelines, the panel comes down hard on the side. There's no data to currently support the routine use of PET scanning for such patients, although more relevant recent radio tracers are under studies such as the Chimeric G250 products. Are there other ways of thinking about predicting the risk of recurrence? This is the utility, if you will, of adding cost-effective markers. The GPS Glasgow prognosis scores a combination of C-reactive protein and albumin, CRP greater than 10 or less than 10 and albumin less than 3.5 or greater than 3.5, given a score of zero, one or two. And it actually is an independent predictor of metastases. On the right is a paper that's currently in press, which is an external validation of data from the Glasgow group itself, we validated it, and if patients have a score of two compared to zero, their risk of development of metastases is sevenfold higher. And that's even after controlling for all other variables. For a while I was thinking that maybe I had drunk my own Kool-Aid on C-reactive protein, although there's literally hundreds of papers on this topic from Europe and Asia, there's a positive data from America. And so on the suggestion of Weyland-Shaw fact member at Emory, we sent all our data to the emperor of all nomograms, Michael Katan, and he helped us to construct a post-operative and pre-operative nomogram, which a high C index of 0.89 incorporating pre-up CRP, post-up CRP and M-stage grade age, and it actually covers all histologies. So there may be a future for this. Back to our patient. He's four years out, creatinine of 1.77. He's seen by nephrology as eight scans. He says he pays $1,000 out of pocket each time. And he's irritated and wanted to know why he couldn't have something else done. Emory cost is $8,000 per scan. CRP costs $12. So potentially there's a use for this in terms of tailoring the amount of surveillance we need. Thank you.