Back in the day, the Paras were kind of a bit of a pariah in the army. They weren't particularly well liked by the rest of the army. They had an elitist attitude. Understandably so, because training was hard. There are no words I can use at this moment to describe my true feelings. I mean, amongst them, there were civilians. None to do with any dispute with anyone. And a party, a Roman Catholic. But it's hard, Chris, because you know the biggest weapon of these people or the club of which you and I are not members. His diversion tactics keep everybody occupied, keep worried, keep fear. I've got like the Guildford Four and all that sort of stuff and the hunger strikes and everything. One thing I'm sure it will not weaken the resolve of this government to put an end to this type of evil violence. John, how are you good, sir? I am fine, thank you for asking, Chris, and I trust you are the same. Oh, brother, it's absolutely wonderful to meet you. I've got like the Guildford Four and all that sort of stuff and the hunger strikes and everything. My first thought was, look, we've got to have a chat. We had a bit of a tumultuous year last year because the event you alluded to was the, well, is known as the old shop bombing. It's kind of been airbrushed largely from history, but the narration was that it was the reprisal attack for the events known as Bloody Sunday. And it was an attack on a garrison camp, a camp within the garrison old shop. Three weeks after Bloody Sunday, intended to target the particular unit involved. A very famous unit held in a high regard, the Parish Regiment. A regiment that you have great respect for, obviously, being a former Marine. They now work together a hell of a lot. But back in the day, the Paras were kind of a bit of a pariah in the army. They weren't particularly well liked by the rest of the army. They had an elitist attitude. Understandably so, because training was hard. Many people know what happened to Bloody Sunday. Obviously, there's two sides. One side says that they were fired upon and they returned fire.  It had massive repercussions around the world for the Republican cause. And the fact that perhaps some people might say the fact that a reprisal attack was mounted with relative success, so surely afterwards, certainly raised a lot of questions for me. At the time, I was among the shy, my seventh birthday. And all I'd known was being raised within Parish Regiment garrisons, you know, going on different postings. And for me, the Parish Regiment was Superman. You know, he's my dad and my oldest brother. And the events took place three weeks after Bloody Sunday. There was apparently no security. I'm led to believe, and I've been told that the guard room log for that particular day went missing. There was no security. There was apparently no warning, although one of my brothers went to collect my mum's wages and couldn't get access to the building because he was told I had a bomb threat.  As I say, as a child, it didn't it didn't matter.  So it's raised a lot of questions. And being realistic, Chris, it's 51 years later. There's a lot to be said for the fact that it was never it was never addressed during the Bloody Sunday inquiry. Now, if this was purported to be the reprisal attack, there should have been a nod to it. One of my brothers was very vocal in trying to get it addressed. Really get this, you know, wise note you mentioned in this and that was unsuccessful and it really ranked at him over a long period. The Bloody Sunday inquiry went on over 12 years. John, could you enlighten our friends at home? What because we've got youngsters watching that won't know what Bloody Sunday was or people that aren't familiar with the Northern Ireland troubles. Well, the troubles from my understanding go back way, way, way longer than than we acknowledge. It goes back 800 years or so. But recently that the recent period of trouble started in the late 60s. There was tensions between the Protestant loyalist community primarily and the Catholics who in numbers were in favour of Northern Ireland becoming part of Southern Ireland and being reunited to one country. Initially, the British government deployed security there to protect the Catholics from attacks from the Protestants. But as time wore on the animosity moved from by the Catholics from the Protestants who were potentially attacking them to having an issue with the government forces that were allegedly there to protect them. And that's how we know that the troubles became what we now remember. The IRA primarily taking on government forces, Protestants and Catholics fighting between themselves and a real mess for over 30 years and cost a lot of lives, damage a lot of lives and ended with peace talks as these things always do. But it just took everybody a long time to get there. And as we now know, the whole the whole process is probably on a little bit of a shaky ground recently. But yeah, that's that's Bloody Sunday was a civil rights march on it was 31st January 1971. And the Catholic stroke Republican community felt they weren't getting decent housing, they weren't getting job opportunities. And they were basically second class citizens and they organised a civil rights march back turned into a riot and the response from the armed forces was, yeah, it had repercussions. I mean, 14 people at the end of the day were dead. The repercussions, as I said, went around the world, basically increased support for the Republican cause and money and recruitment within Northern Ireland to Republican terrorist organisations. So it was a big own goal really for the British. I'm not denigrating the powers. I mean, you'd have to question why so soon after the Buddy Murphy incident, when one power revolved within another incident, not so well publicised, would you then bring them in as potential peacekeepers if in case things go pear shaped when that's going to obviously rile the Republican people. Just I'm just a synopsis for friends at home. Allegations were from the Republican side of things that the parrots had opened up unnecessarily and shot dead 14 innocent people. Yeah, obviously, obviously the parrots are going to say, no, we saw we were fired upon first to know exactly what happened.  And what I always say is it's war, folks. It's horrible. We got to stop having the wars.  The Catholics still feel that they haven't got justice, which which no doubt they they haven't. The truth is somewhere in the middle, isn't it? Yeah, yeah, yeah, it's often the case. Yeah, it's often the case. But this this for me, this came to light last year. It was the 50th anniversary. And I used to attend the Memorial Services, which were organized by the Parish Regiment Association. And my feeling personally was that it became a military celebration of the Parish Regiment, which, okay, you can understand that, but in the great scheme of things, only one serviceman was killed in the the car bomb. The remainder were five civilian waitresses and a semi-tide gardener. Unfortunately, I knew all the women, some better than others. My mom was was amongst them. And she was a single parent. She left behind three relative young boys plus an older boy that was already enlisted in the Parish Regiment following in our father's footsteps. And I had obviously had big repercussions, which which remain to this day. But attending the Memorial on the 50th year was important because it was I wanted to attend never, never go there again. It was I was going to draw the line under it. I accepted there are a lot of unanswered questions. There's there's not really a Memorial in place. There was a Memorial, an impromptu Memorial made of little concrete stump and a brass plaque, which was made by the other maintenance staff in the camp. So it was never officially given a Memorial and some people have been campaigning for that. So this year was the unveiling of a stone on which a Memorial will be built. That's only now because the land has been sold by the military and is in the hands of residential developers who were told of what happened there. And it was then themselves that said, well, we should commemorate that. We should have a Memorial Gardens and a Super Bowl Memorial. What I wanted to do was nobody that's directly involved was ever allowed to speak. There was just a guy, the next para and smashing fella who was a young Tom at the time and he gives his account of the events of the day. Could you tell us them, John, so people at home know, get a better idea of what we're talking about? Right, as I said before, my brother claims, he's no longer with us now, he claims that he went to the building on the Friday before the bombing on the 22nd of February, that was the following Tuesday to collect mum's wages. She'd been off work. She was experiencing depression because her and my old man had split up about a year or so before. She was old school. So it was a big deal for her. Ironically, a Catholic, very, very staunch Catholic. And he was not allowed to enter the officers mess, which is obviously, you know, where the officers will die when they have a room upstairs, maybe. And he was your dad was a para, was he? Yeah, he was a sergeant of the para. So they wasn't, he wasn't there at the time. He was stationed at the end of his career. He was coming to the end of his 22 years in the Paris. He was old at Arborville, which is the Remy training center, just teaching young recruits. So he wasn't there. Well, my other brother was on a, he was in the Paris, but he was on a, I think it was on a PTI course or something, not far from the camp. So a guy or somebody drove a car bomb into the garrison into the camp where 16 Airborne Brigade were stationed. Part of the car was unchallenged. There were no checkpoints, no fences, no roadblocks. Again, three weeks after Bloody Sunday. He parked the vehicle and presumed he was on a timer and he left, walks back into all shot and got a train back into London.  Unlike the majority of people finding the Republican calls there tend to be Catholics. It was also more interestingly, he wanted a United Island under a socialist government. Now if you're old enough to cast your mind back and I'm not, but I do know history in 1971-72-73 before the IRA or the current or the most recent campaign came to fruition that the big bogeyman was communism. So you have to ask, well, okay, if this guy is put in prison or whatever, whether he was involved in this or not, who benefits? You know, did the British get rid of somebody who might be a thorn in the side? Because he was not a conventional sleeper. He was quite active in union activities in London where he lived and he was an outspoken socialist. I understand. So the pieces don't really, really fit. And again, I didn't serve. I didn't serve in Northern Ireland. Thankfully, I was not committed to the Marine side, but as an issue which wouldn't progress.  I think it was 50 pounds in a four-core scene. Okay. Well, it's Semtex or something? Or I'd know. No, it doesn't. It doesn't matter. It's only there's people out there who know this this technical stuff better than you and I. We used to measure it in the old days that if it was a fertilizer bomb, like a homemade explosive, you needed quite a lot for, you know, they used to use a lot and it obviously went boom. If it was Semtex, which was kind of industrially great manufactured, it was a small amount. Could really do a lot of damage, but this car just went went up. I'm guessing and your your mother, the other four women were walking past. I believe that they were actually having a cup of coffee in their kind of staff room on the other side of the wall from where the car was parked. I could be wrong, but I know that my mother was identified apparently by a piece of a scalp and a red hair. So the the bomb blast was quite profound. It was her role shot. I know that again, one of my brothers was at school and he heard it from my cut the miles away where he was at school. So a lot of everybody that was shot heard it. And as I say, it was the first bombing on the mainland of that period. Since probably after the Second World War, Edwardian side of the IRA had done a few things, but it was the first mainland bombing, which was even more puzzling to think that there was no it was not recognized. It's now blurred into into history. Did you get to hear of the bomb first and then to hear of of of your mother's death or was it the you know, did someone tell you at the same time? No, basically what happened, I was because of family circumstances, me and me and my two slightly older brothers were quite feral. I would sometimes not go to school, but I came home from school. The house was locked and there was nobody about, which was unusual. There's always somebody about. So I went next door and spent time with my neighbor's kids who were my age. And then my dad came walking down the back garden. I just I just made out his arm with an army uniform on and he talked to my neighbor, a woman, Deborah. And I heard a sobbing. No, it's still no idea what's going on. And the old man just walked into their living room where I was on the floor playing with the kids or whatever with my mates. He said, come on, go with your pack, we're going. So we went next door to our house where me, mum and my brothers were living. And the other brothers turned up. There's a lot of bleary eyes and a lot of mumbling, but nobody actually said anything in those packs and gear and went to my dad's house, which was in an adjacent garrison about 20 miles away. But then I saw the news on the TV as we were all sitting in the living room and I saw where mom worked with fixer cars everywhere. Curtains flapping in the wind. And again, still, I knew that's where she worked, but I didn't, I mean, I was seven, so I didn't know what had no idea what was going on. And it was only, it was only later that the full extent of what happened or the reason why mom was no longer there was the claim clearer. And I mean, you've already gone through a lot because your parents have separated, which is I think anyone that's been through that will know is it's different now back then. It wasn't managed well. Now it's quite normal. People get together and they split up and I'm sure it's not nice for the children. But back then it was sort of a rarity. And when it happened, your world was ripped apart because parents didn't know how to manage it appropriately. It was just we're splitting up. We're following up and you're right. Sorry to interject, Chris. You're right. But from that, from our point of view, with the benefit of, you know, maturity such as I have it, I understand that my dad was the product of a very disadvantage background, you know, the proper gear, Yorkshire villages, you know, borderline workhouse. So he was raised a certain way and he had to survive. And in his mind, he thought he was on a bound to raise his boys to face whatever life could throw it. There's no no room for lovey-dovey stuff.  You've got to be ready. Now that was quite cruel at the time, but as the older I get, I think Jesus Christ, he wasn't wrong. You know, he wasn't wrong. There's some bad stuff out there. But when mum and dad split up and he went to marry a younger woman for us, it was a relief because, you know, the house was going to potentially be a bit more normal, you know, not not. There was a lot of violence in the house that way. If you come from that background as my dad did and you joined the Paris Regiment, he was also a commandosier in the war and the army commandos before they were disbanded and the commando role was given exclusively to the war Marines and he couldn't adjust after the war. He won the Croix de Guerre as well, which was a French medal. And I think we just got to say that the there's still army commandos just for all the people that are leapt off their seats. No, no, of course, the army commandos are obviously doing the command of course and then serve with the Marines to give them support. But in those days, there was like number three army commandos. Yes, I've got you. So, yeah, he didn't settle down after the war. So he did it for the 22 years in the Paris Regiment didn't Suees and Aden and these sort of places. So, but when he but when they split up, we thought it was a new dawn, it was going to have a bit more normality. But obviously that was good. So once once the incident happened an old shop. What I was alluding to is like you've been through a lot for a little lad anyway. And and did you understand that your mum had died? Did you understand at that moment that she's not coming back? Yes. Yes. But, you know, if you've been a, you know, not this was not this in anybody who's, if it's a car crash or a natural disease, then you don't not see a hand any differently, but you know where to where to box it. And you don't go to school with many people whose mothers have died as a result of a car bomb by apparently Irish people who are Irish people like me. They talk like I do.  What does that mean? Why would somebody waiting tables get blown up? It just so it was beyond my comprehension. But I think as I've done an interview before and as I said it, the primary thing was survival. Everything had changed. My brothers were taken away somewhere else. I went to live with my dad and his new wife up north. So it was a complete change of picture. So just everything kicked into survival. Just keeping out of the way, keeping low profile, trying to be invisible, just, you know, because obviously, obviously, but sometimes people that you end up with are not best pleased with you being being there, your service requirements. So you just got to crack on and do the best you can to to bring yourself up. So you're saying your dad's met this married a younger woman and they they you weren't part of their plans. No. Yeah, and I just want to get to I mean, one of my earliest memories, John, is my old man driving us 300 miles from home. First, like our mum just was gone when we come home one day. Then it's like a few days past the old man says, right, getting a car. Or is it? No, it's a mini mini van, right? No windows. I don't know. We're just the kids lying in. Drives 300 miles up to Lincolnshire, which is where my mother had absconded to to be with her mum on the way up. My sister's got this little tape player and she's playing out. I think it was Abba and my sister looks at my dad and says, Dad, this song's about you and mummy and I could see my dad just gripping the steering wheel, right? My sister hasn't. She doesn't know what's going on. I know what's even though I'm the younger one. I I know what's going on. We got 300 miles. My dad, we get out on a pavement. My dad just drops our bags. And bear in mind, I've never seen my dad cry. Also, he's never hugged me, right? He just grabs me. Not my sister's already run inside. She's I'm going to go and see mummy and grandma. You know, she she's I'm just left with my dad on the pavement. I know what's happening. And obviously my dad does and he just he he he grabbed me. He give me a hug. He said, I love you so much, son. And he literally jumped into the driver's seat, drove off and I'm just and he's waving out the window like that. In M days, it was unheard of. He didn't drive 300 miles and then jump in the car and drive 300 back. But this is how horrible that, you know, he just he couldn't he didn't want anyway. He's off there. I'm stood there and my mom comes out. She says, where's your father and you're going to stop for a cup of tea. And that was it to see how like, is it only me and my dad understand the seriousness of this situation? We're never going to see our dad again. He's never how old were you, Chris? Oh, maybe seven, maybe, you know, in your mind, you're never going to see your dad again.  My, my, my, my dear, I want mommy.  You know, that's probably the one of the instance I can say on camera. It's a lot of other stuff that that wasn't so, you know, wasn't so top tier, you can say. And so I'm just thinking of you as this little lad that you're already in this traumatic situation.   Cry yourself to sleep or? Well, no, there was, I mean, this is possibly easier to talk about that you may imagine, Chris, because I thought about it in the last 50 years, really trying to analyze it, how I feel, why I feel that way. Like you've done in a way that you compare your experience to other people, not because because you need to know there are other people that go through stuff. It might not be the same, but you know, you look at them, they survived. You know, I need to find a way to survive this thing with with mom was ironically before she was killed. She gave me a bit of a bit of a hiding. I mean, she was old school.  And but we were very, very Catholic. I say we the house was very Catholic. There was Mother Mary's and Hello Dolly's and all sorts of things over the house over the house everywhere. And mom mom really just went to church and I went to bed all bad and a little bit bruised and I was like, I really hate I wish she was dead. I wish she was dead. And then when it happened on the Tuesday, my mind thought, Jesus Christ, somebody was listening to me. So I had a wish granted. God, that was my fault because it was so outlandish. It wasn't. How are we to come? Where did the car bomb come from? What's the car bomb? So I kind of blame myself. I'm ever thinking how can some of brothers walk down? So when I moved up north and lived with the stepmother and father, I started having nightmares. The stepmother was having her own issues. She was an alcoholic substance of use was an issue and she had mental health issues for which she was sectioned almost as soon as we got there and she would just run in the room if I woke up and just punch me in the face. So then I learned that, okay, I don't want to have nightmares, but I also need to keep it quiet if I do. So and I wasn't the only one getting a bad time there. She had a daughter a couple of years younger than me and there was a newborn baby, which is a product of my dad and this woman. And, you know, it was not it was not exactly the Waltons put that way. So it's yeah, it was it was it was difficult thing.  I looked up to them. I didn't see them for up to a year of time in the early days and we we we ended up growing apart as the years went by and they were trying to survive over 13 and 15 and they were moving about with different people in London and just trying to survive. They couldn't really do anything about my situation. When you look back, John, do you realize now that your reason for let's just call it not not fitting into the training pattern, although I'm sure you had every, you know, everything that all the rest of us have got. Do you realize that that was related to your childhood trauma? It was complicated by a lot of things. Okay. I was I was like way to put it.  You know, I was not composed of good experiences. Most kids have demanding times, but I was I was in all sorts of a mess. I hated the world next dog. I should have gone in the Paris and followed my brothers into the Paris and I was invited up and spent a week with one power and did some training with them. But the Marines was an option to do something that was perceived as testing, but going my own way, do my own thing. And initially I was very fit. I was doing boxing and training and whatever. So the fitness was not a problem. But I didn't expect the level of ill feeling between the Marines and the parents immediately after the Falklands, which obviously is a baited over the last 40 years. But there was there was a lot of rivalry when I got there was not a problem. I mean, the training team initially 180 is my troop. They were hard. We really hard. But nobody really paid much attention to the fact that, you know, I was from a family of Paris. But I've injured messing about another guy who completely trained and he went on to serve with SB. He was very good, but I won't name him for obvious reasons. He was smashing lad, you know, the full ticket, very fit. And we were boxing. He was showing me some improving techniques in boxing. Well, I could box. I wasn't like him and I was showing him a few judo throws and because we're doing it slow, he started pissing about my knee rips and the ligaments and they became detached and a crunch. Now, the initial training team thought I was fit enough to recover and get back into the training team into that troop, but it was it was not going to happen. You appreciate Chris that the training brought ratchets ratchets up and becomes more physically demanding. And once I got back into the troop after about eight weeks, nowhere near it was nowhere near it. And then I started getting motivated.  I was I excelled, but then the attitude started changing. I started feeling alienated and then incredibly. I didn't find this find this out for a couple of years, but one of my brothers phoned up around and part of the training team at Libston from where head wherever it was. He was a color sergeant, one pair. And he claimed I just want to know my brother's getting on and this guy didn't. There's nothing to do with my training team.  He gets a little bit bolder, but you know, he's getting over his injury now and whatever. And it's somehow apparently descended into a will send him up here where he belongs. He should be with the power is not with you. Not waste his time. It got a bit. No handbags, really. And I was down on the bottom field with my troop and running about to do a fireman to carry this random guy came out of the train center. Asked who I was. I put my hand up. He just came over and gave me the hair dryer treatment for five minutes and really go for who the hell's this guy? I don't know him for a box, you know, bar or so.   I was puzzled and then years after a couple years after I came out, I was having a talk with this brother, we were having a couple of drinks. And he told me what happened. I said, are you joking? Did you you phoned up and had an argument with a member of the training team? So do you realize him?  You know, it's just and then it was opened up really because we're spreading. And yeah, John, that's that's a bit. That's harsh, man. You know, that's after the I think this is always a funny one, right? Every time I chat to a para. Particularly on the show. He's always like within five minutes that they bring up the rivalry. And and I say every time all the time I was in the Marines. Right. We we look down on the army that that's just a given in, you know, that that's that's just like a given. But honestly, Royal Marines don't for the seven years I was in they didn't spend their time slagging off to Paris. They just never even mentioned them, mate. Honestly, we work with them in Ireland. They were great. They were aggressive. More more so than us. We we were we you have to keep a rain on Marines. You know, I've told this story before during our Northern Ireland training. We shot the range to pieces. Yeah. You know, you've got to check that they hate but I can imagine back then though after the Falklands having a para phone up your you know, your training team and and possibly change is up a bit. Yeah. Well, yeah, it's just whatever it was. I'm sure you're sure he meant nothing by it. It's yeah, bad luck, mate. When I wasn't like at the end of the day, I was doing a good much of screw things up myself because I could get in a fight in a phone box on me. Oh, I was a night there and a big chip in my shoulder. I think an old credit to the training teams that I met down there. They were great and looking back at first when we parted company. I did some physio and I got fit again and I joined the army. I knew I couldn't do anything as physically demanding as that again because as it turned out, the injury reoccurred several times. It was a blessing. It gave me a really good kick up the arse. I think any training like that in Paris Marines guards testing training teach you a lot about yourself in some ways you learn that you're a bit harder than you thought in some ways you're you're not, you know, you really do find out a lot about yourself good and bad and it probably takes a few years. You might have done the same for us where it's not until you look back with a more mature viewpoint in Christ, you know, I understand that now. That's why that did me good. I didn't appreciate it at the time. For me, what happened to Marines was a massive rejection and massive failure on my part because I always wanted to belong to something that I perceived as worth belonging to. And I was really impressed with Marines and it's to my regret that it didn't pan out. But having said that, had I taken my place as that young man, I don't know what the ramifications would have been because I was not. I was not on the races mentally. I had too many issues, too many things that I was carrying with me. Although I could run, I could carry weight, I could climb up ropes, but as you alluded to there, you know, you need a bit of thought. You need to be able to control yourself to some extent. You need to be able to work things through and I was, you know, I was a bit too reactive. So I think the Marines made a good decision. And it stood me good stead. Yeah, no regrets.  We live in a present, don't we?  Yeah, brilliant time. It was unlike anything I'd ever done. And it was enjoyable. In fact, that's why I moved down to this part of the world because I fell in love with the area. I've always wanted to live down here and now live in the Southwest. So, yeah, you can look back and regret, but I think you're probably somebody who believes that everything does eventually happen for a reason. You don't appreciate it at the time, but it's the universal whatever guarding you towards whatever choice you have to make next or whatever task or challenge you're going to face next. I want to come back about, John, we'll talk about the justice ramifications of what happened to your mum. But you're you told me a story about your your your brother, Carl, was it? A bit of a standoff with the police? We all dealt with what happened to some of them in different ways being different characters. And Carl I've never really got the measure of what he was up to. He was always very angry. He was always probably the most dramatic one out of all of us. He subsequently joined three para and fun enough like like me, the para's of my other two brothers. They did serve in Northern Ireland. Carl in three para apparently the para said, you know, we won't be taking you to Ireland with us. So he had a real being he's bonnet about the whole bloody Sunday inquiry in in regards to it not making any mention of the reprisal attack. And he kept asking questions at the time and this is early nineties when the bloody Sunday inquiry started and he was writing to MPs and newspapers. Why is nobody mentioned what happened to him? These were me, you know, these people that were his lives rendered as a result of this, but nobody was interested. Now you have to look at it and say, well, the bloody Sunday inquiry is a means to an end. It was a peace process. It was part of the peace process ultimately to so that community could see justice being done such as it was. But he was right. Somebody should have tips of wing to the people who died old Sean, giving them some kind of acknowledgement. But his frustration boiled over into an armed siege in a street in Stretton on a railway bridge. I was working in Berlin at the time. 1996. And he was lucky. He he goaded. He wasn't adversaries was the police that turned up. It was an armed response unit and they taught him down.  And they were very calm, though very restrained. He ended up doing a year of prison. But for him, that was that was the beginning of the end because although he was ex power and he was quite a hard lad. He was a gifted artist. He was working in advertising London trendy art places. So of course, after he was released from prison. These same people were a little bit less enamored with working with it because you know, yeah, the usual power type face and a bit of a weathered beaten face. And we ended up having to go to do close security work in Iraq. And again, he stayed in mind meant that they wasn't really suitable. He wasn't sufficiently adjusted to do that.  And two years ago, he was found having drunk drunk himself to death in his own home in in London. And I think that's that was a very late victim of the on shot bombing, if you like, because his life was like mine, David's and Brian's. It was it was just survival. Just get it by not getting trouble. And he had everything going for it. But it all just fell apart. We weren't on terms when he died.  But yeah, he was he was very bothered, very bothered by it. But this isn't yet. This is the on on the unknown tally of conflict, isn't it? Yeah, the people that suffer with a mental health and end up either taking their lives or drinking themselves to death. They don't put these in the statistics today. Today, this memorial was unveiled as part of a drumhead service commemoration with the names of all seven Margaret Gardner, John Hasler, Jill Mansfield, Sherry Muntin, Father Jerob Weston, Joan Lunn, and Thelma Bosley. No, you're right, Chris. And for example, if you take stereotypical example of the person who's been exposed to horrific things in being Afghanistan, Iraq, wherever it be, they come back and they struggle to deal with it. And then it's like a ripple effects. It affects their spouse, wife, their husband, boyfriend, their children. And these effects multiply and affects a lot of different people. And that's why, as you said earlier, you've got to find a way to stop wars and conflicts. Ordinary people don't want it. You know, you can always all these conflicts eventually get resolved by people sitting around the table. Yeah, every time. Yeah, after the bankers and the war mongers have made their money, made their money, mate.  Shall I read out the names of the people that were killed just out of respect? So we've got the Reverend Father Jerry E. Weston and MBE. We've got your mother, Thelma Bosley, Margaret Grant, John Hasler, Joan Lund, Jill Mansfield. I think that's Cherry Muntin. Rest in peace. Thank you. Thank you. Yeah, I knew. I knew all the girls. Definitely. I would have known John Hasler, the gardener. But I used to go to work with my mum and as a 6 year old kid and you'd climb around their knees and they'd cover your lipstick and Did the IRA accept the blame for this? The responsibility for this, John? Apparently the official IRA. Admitted responsibility. There was the provisional IRA, the official IRA. Now, if you can imagine all the people are watching this back in the day, the troubles were just reemerging, if you will. And the IRA had different splinter groups and different people with different agendas within that Republican organization. They were buying for supremacy, if you like. Again, older people have a similar background to you and I who have been in the forces and served in Northern Ireland in the early days. In services, we'll no doubt know that there were things that went on behind the scenes and deals struck and lines of communication. That might not surprise people, but this that conflict and that situation is no different. Do you want to enlighten us? Because I can tell you a few things I've had just just through doing this job. So, for example, Good Friday agreement. Why did suddenly people that would never sign up to a peace deal suddenly sign up? Apparently because they were getting and they was getting stuff out of it, John. Yes. No. There's a there's always a payback. Yeah, not not that we don't wish and pray for peace because that's that you know, it's that's that's the way it's got to be for the for the children and the next generations. But what and also I mean that there's a film 50 dead men walking. I believe it's called. It's about the it's about the informants that were controlled in in the province. So these are the informants for the British forces government police. But you know, the secret services basically. And there's an interesting bit. So you've got handlers and then you've got the informants. Does this make sense? Yeah, the handlers we've had Bernie on the show. Bernie's former Royal Marine. He's he's been a handler. He was a handler in Afghanistan and you know, you manage local people. The assets assets. Exactly. I believe in 50 dead men walking from what I remember at the end. After all these shenanigans going on through the film and near death experiences and people, you know, if you say one wrong word as an informant or as a handler it triggers suspicion it can trigger suspicion. You can prematurely set off an event that screws up like mumps worth of intelligence work or to the other side of the fence mumps were for planning for a you know, for a bomb event or something like that. And at the end of that shouldn't laugh, but this is the irony of the world. It it turns out that they're all being controlled by London. The part the Pyro. I mean, I mean, yes, I'm not saying that. I'm nothing would surprise me. Chris, nothing would surprise you. Let's be honest. The more you uncover the further you go down rabbit holes and it doesn't matter what topic you look at which shapes policy or whatever or outcomes that there are a few grubby fingers in a few grubby places. Some might say that there were unofficial rules if you like that that came to fruition so far as the British side and the Republican side agreed that, for example, certain people were out of bounds off limits as targets perhaps loyalty. Of course, that was not the case when a certain person was dispatched by means of a bomb on a on a boat in a lake in Northern Ireland. And can I just chip in there and say, have you had the latest on that? The late the latest buzz? What about the potentials or the suspicions of? Well, if it is an adjoining boarding school, it was the I don't know if we're being a bit naughty saying this, but I think it it's common knowledge. It's public knowledge. So a certain person was, you know, fiddling with people that he shouldn't have been. There we go for you know, repeatedly through and it it makes you question who put the bomb on that boat. Was it London or or indeed? Yeah, absolutely. I mean, it was it's funny, Chris. Sorry to interject, but I won't go into the story. If you don't mind, I won't go into the stories that were related to me over the years by my proximity to people that had served there and, you know, friends and you know, whatever. But some things went on that were not really stuff that you see in the news. That's not withstanding. We all know that the Republican side committed some awful atrocities. I mean, we've been talking about one. So as you said, was a was a very messy and horrific thing, but it's also full of treachery and double dealing. And, you know, we will give this version of events to our side and when in fact that version of events isn't the reality. And I think people know this now. They're not willing to just go through the books in your classroom and this is what happened and you know, more and more questions are being raised. But the Irish troubles, the problems, whatever you want to call it was very complex, very complex. There are lots of different sides. There was the religious aspect, the English, we look at the troubles as being the last 40, 50 years with the Irish because they have a history of storytelling. They pass that, you know, their culture is a big thing to them. They have a different version that their their issues go back way long, the hundreds of years with lots of pretty unpleasant events, which they still remember vividly. It's a strange one, Chris, as all conflicts are. There's there's very little positive to take out of these things at the end of the day. Yeah, there's so many things need looking into, don't they? For example, who who supplies all the drugs in Ireland, you know, into the north? There was a certain person that doesn't he he's no longer with us. So I won't say his name, but let's just say he was at the table for the Good Friday Agreement that allegedly when we were in Belfast, he was the, you know, the guy bringing it all into the into the country.  Absolutely. Wherever that's power from selling stuff or power from being in power. Let's talk about the John. How does it feel to you that this incident has kind of it's been like what steam rolled into the past, can we say? Yeah, very much so, very much so. I mean, me and a well, I know I've been campaigning from up for an appropriate memorial to be on the site. Now, I've been involved with some other people with to that regard because the sites now been redeveloped. It's quite a nice housing estate and the developers Granges are going to build a memorial garden in the middle of this state at the location with a memorial, obviously a monument to be decided. Now, ironically, my brother who died a couple of years ago, when he stopped doing the close protection work and he put his feet back on the ground, he ended up being a telescopic forklift driver. He wasn't telescopic. The forklift was and he he worked on the site as it was being built and he brought this attempt to the attention of developers and said, look, do you know what happened here, guys? And they said, well, no need to explain.  And he said, well, look, you know, this was a there was a car bomb left here and these people died. And they said, well, as such earlier, they said, well, we'll have to commemorate that. Now, my interest was having this removed from a celebration of all things military. Old shots got that pretty well covered. You know, there are statues everywhere. It's a garrison town. And I thought, wouldn't it be good to turn this around and say, well, there's people going to be making their homes here. You know, it's a new community. Have it as a memorial by all means, but let's look to it for something better. You know, a monument to the mistakes of the past, what we were doing wrong in the past, a memorial to better things to come, educate our kids better. You know, and any future memorial should be a coming together. No bands, no bugles, no speeches from dignitaries with big feathers in their hats and all that. They were totally unrelated to that. Oh, no, John, John, sorry, I just want to chip in because we had a very good chap on a podcast recently, Paul Cardin, and he really went under the surface with the whole Falklands conflict and he unearthed so much stuff that the public don't know to the point of, you know, criminality basically. And I think it's everyone's duty, especially veterans to if you find out something, you know, we should all be against war. It's not it's nonsense. It's nonsense. It's the same twisted manipulation of young naive go getting young people used to be predominantly young men, but I hope people understand what I'm saying. It's just it's the same like twisted plot that they bring out every single time. There's a bogeyman over there. You've got to go and get them.  And then and then there's the peace thing when everyone's made them their money. So yeah, Paul, Paul done a great job. I mean, for example, just give people an example in his book, which is called Return to Bomb Alley. He highlights 80 percent of the Falklands is owned by a private corporation, not the Falkland Islanders.  Chile had a peace deal on the table that conveniently Margaret Thatcher overlooked. Can we disregard, you know, yeah, yeah, didn't didn't collect didn't announce publicly that they disregarded, but you're somebody who's made made an adult career, if you like, of realizing these things of going against your initial upbringing and going to war and training within a good unit to go to war. What you're alluding to, I think, is that there's a great raft of dispossessed people, young, take the UK, you know, your depressed towns, your dysfunctional families. And if you look at it for society like Britain, if we want to get the best out of these kids, you know, youngsters as we once were, is this the best we can do? We can train you. We can put you in a uniform. I know we can send you off overseas wherever it is, and it's no different from the First World War from, you know, to do these things which profit massive companies. And we'll tell you it's for this and it's for freedom and it's for it very rarely is, it very rarely is. And, you know, again, removing the war aspect, is this the best any society can do? Can't we imagine training kids up, educating them, giving them technical skills, practical skills? They're right. Go over, let's develop parts of the world. Don't convert them to your religion or ram that down their throats. Just helpful, this is how we, this is how we construct things in our part of the world. This will last for a long time. This is water irrigation. This is whatever. I did little bits of that in the Royal Engineers in Kenya in a later career. It was really fulfilling. It was really good. You actually mix with the people. Samburu tries people, you know, ordinary people and see how they live and you interact with them. You don't shoot anybody. You know, and it, it's just a shame that that's the best we can do, you know, that's, but one thing I will, this is kind of their field, Chris, but a couple of years ago, I was watching the remembrance service. And I'll just say, John, that's the point that Paul makes. When you talked about a statue in a monument, it Paul just highlights how on Remembrance Sunday up at the cenotaph. You get all these politicians, for example, that turn up the very people that sent our youngsters off to die.  And then you get this Remembrance Sunday where Tony Blair steps up to present a reef. The exact same guy that sent these people to their deaths so he could get rich. Okay. I actually believe he's sort of in a way a victim. I think he just got in way over his head. I think because of his own past, he was being blackmailed by the by, you know, the club, right? And rather than just hold his hand up and say, yeah, look, I got my winky out in a men's toilet once. I'm sorry. He, you know, he took us to to war, John, you know, and yeah, we're very good. Aren't we? The glorious dead.  He was so proud when his son passed out in that smart unit and then he gets sent off to one of these illegal conflicts and he don't come back and that father's got to live with it. It's with this, what I was going to say to Chris may not, it may resonate with the other ex-forces people that might be watching this. And I don't mean this in any disrespect to anybody, but the thought occurred to me because when I was watching, it was probably about seven years ago. I was watching the remembrance at the Senator. Now, just before that, they'd been a big expose on the Panama papers and about people avoiding tax and one of the main allegedly one of the main people was the head of our then rule family evading trillions of pounds over a given period. So I thought in my mind, I was watching a member of the Royal Family lay a wreath on the Sunets off and in the background was rows of very smart looking soldiers, made of female Navy, whatever. And then front row was a line of veterans in wheelchairs, some quite young. So some clearly from recent conflicts Iraq, Afghanistan with legs missing arms missing. And I thought, I bet that a lot of those guys have got those prosthetic limbs because of the efforts of say people like you that do these fun runs to assist and raise money. But I think that wouldn't be needed if the person laying the wreath had been honourable about the contributions they're supposed to make to the state that are there to unfortunately facilitate what these people need. They could of course facilitate the removal of the need for these guys to go to these places and girls. But I just thought the whole thing was so hypocritical. Forgive me. I would say that obviously you do you do talk about the spirituality dimensions and all this sort of thing. I think you're a lot above a lot of people that may watch your podcast. And I get it. I mean, I'm sure people do, but it takes a lot to move up that and move up that scale and not be diverted by the you know, the nonsense around you. But yeah, I mean, unless you find something spiritual or something to believe in something to aspire to that's beyond the crap that's offered, you know, like not not being so quick to blame the people that's telling you your enemies, be immigrants, boat people, people of different colours, people of different cultures. You know, when you when it really boils down to it. You know, we've all got a common enemy. These these same people put in the streets, but it's all crisp because you know the biggest weapon that these people or the club of which we are you and I are not members is diversion tactics. Keep everybody occupied. Keep them worried. Keep them in fear. The thing is, Chris, I mean, we're also actually think that in order to remove ourselves from this or to improve the situation, we then are trained to become adversarial. We've got to bring this down. We've got to fight those who have been an insurrection. Apparently we don't. I mean, if if people educate themselves of the fact that the laws we live under are bogus, they're bogus. And then there's lots of things again, confusion, common law, natural law, this, that, the other, but most societies originally lived under common law, which is do no harm.  You know, they're very, very small list of rules. The law that we live under in the UK and I'm only just educate myself this is apparently based on maritime law, hence you stand in the dock. You have a birth certificate and it's kind of a a bastardization of like legal is not the same as law. Legal is these acts that are passed in Parliament. They have no validity and the only reason they have control over us is because we submit to it. And even the police apparently the police work for a corporation which is registered in the city of London or or wherever. And when they write you to find you or they do whatever they do, it's an exchange between two corporations, the corporation, which is the police in reality and the corporation's been invented when you're born, which is why they apparently address you in capital letters. Yeah, to call it legal fiction.  I mean, yeah, but a woman was on a podcast explaining she's an Irish lady, Dolores Delores Carhill. That's the one. That's the one. And she put it over very simply and just said, look, it does take it does take courage and individuals can't do on their own. But when enough people realize and just say, well, thanks for that, but we're not. I don't recognize your law. Yeah, it does. It does take it does take some some balls, but the whole thing's been a big scan for years. And we're so used to it by all the pants on the wigs and the cloaks and the Lord and all this. It's so it's all distraction. It's all distraction. Yeah, it's like these parking fines. They come through the door. You just put return to sender. Well, hang on.   What? What? Sorry, what? What? How have I hurt anybody? How have I stolen anything from anyone? Who did I? You know, who did I do over? I believe it was absolutely no one. So do you know what? You can you can take your letter and you can you can shove it where the sun don't shine. But the bottom line is, Chris, again, going back to this real law date for the common law, everybody's great equal. No, no, no one person has demeaning over others to, you know, according to this to tell people what or not what not or what to do. As long as you're doing no harm, you don't intend any harmony on you can go about your lawful business, but all these increasing barriers to movement, to freedom. It's it's piecemeal drip drip. And then one day people get away come fuck, I'm not allowed to go there. I can't go and trip over there. What happened? John, one I could chat to you all the all evening. So honestly, it's it's it's great to find a is it kindred spirit? Is that the right expression? Hopefully, yes. And I appreciate you. Johnson's some very kind stuff about the podcast earlier folks very much enjoying it. And that's that's a result we're going for. Have you found your peace? I'm getting there. I'm getting there because I know that the the I know what I'm capable of doing what I'm not. For example, I can't relationships and stuff are difficult for me because I prefer to be on my own now. I've got a dog. I've got friends and stuff. So I'm happy with that and you've got to cut your cloth to suit. So yeah, I'm as happy as the next man and like you working to find a better place to be mentally and spiritually. Excellent. You know what they say about women? You can't live with them.  Nice talk to Chris. Best of luck. Brilliant, mate. Just stay on the line so I can thank you properly. Friends at home. Massive thank you to to to John. Whoa, what a what? What is it?   Folks, if you can support the podcast, I'd really appreciate it. If you can chuck us a like for this video, hit the subscribe button if you haven't already and click the notification bell. If I could ask you to support us, please on Patreon for one 99 a month or become a YouTube member. It's just one 99 a month. That's all from me. So another thank you to John. Massive love to you all and see you soon.


Pymation's Powerpuff Girls YTP by Kite Antonio. What is going on? Is that Mojo Jojo? Oh, something to ride. There's an emergency at the mayor's office. Oh, Bubbles. Think something about a pickle jar again. I swear I'm gonna strangle him. I will stab you. We gotta go. Come on. Bubbles up with their faces. Oh, they got a Spoonerman. That smells like South Park. Yo. He's escaping. Where do you think he went? I think Bubbles is broken. Mojo Jojo. Overkill. Nice. Wait. If the mayor's dead, who's gonna call us for emergencies? That is true. Bro, why were they fighting? What? This was insane. What is up, YouTube? Realistic Gaming here. And today we're gonna watch some Powerpuff Girls videos. And they might just contain some chemical eggs in them. So let's go ahead and begin with Corey Clayton, Powerpuff Girls parody.  I just want the perfect little girls. Is that so much to ask? This is so weird. God. Fine. I'll make them myself. Let's see. Sugar. Yeah. Yeah, we'll put some sugar in here because they're nice and sweet.  Some spice. Make them spicy. Yeah, to get that little kick. You know? That little kick. And what else? Oh, of course. Everything nice. Because little girls are just... They're so nice. Yeah. Yeah, be perfect. It's gonna mix that together and... Oh, no. Oh, God. Oh. Ah, f**k me. Chemical eggs. What I put it right there. It should be locked away in the basement. Oh, that was a lot of chemical eggs. Oh, my God. What is wrong with you guys? Oh. Look at your faces.   Oh, my God. Your hands. Well... You have no fingers. Come on, Harry. How are you gonna be able to write with no fingers? Oh, my God. Well, this is a failed experiment. I'm gonna have to put you down. Oh, no. Huh. Flight. They're bulletproof. Invulnerability. Say. You guys could be superheroes. Does that sound good? You guys wanna be superheroes? Yeah. I don't know where I am. Or who I am. Bro. They look so monstrous. It's not even cool. I think I lost the coppers. Stop right there, criminals gum.  We are the Powerpuff Girls. Where's the bubbles going? They're going to stop you. Yeah, how are you gonna do that? Oh, my God. The bubbles are floating away like a bubble. Just ripped his jaw open. Girls. I'm home. You've been doing such a good job lately. I figured, hey, why not reward them with a pet? I got a chimp. Oh, no. His name's Mojo. Oh, my God. Oh, God. Girls, help. He's eating my feet. You motherf***er. Dude, they're liking their own little land. They're a lot of land.  Look, Professor, I drew. Oh, my goodness. Professor's being attacked. Let's get him, girls. Six months later. Well, he's been a grueling six months. Oh. But Professor is looking better than ever. Where's Buttercup on the floor? Welcome home, Professor. You look like Vatna. I was wondering, could you just hand me that syringe of potassium? I just want to see it. Oh, I don't think. Oh, Professor, we don't know what you're saying.  I don't think that's a good idea. Look at Professor's hands. Yeah, he's just like us. Yay! This is twisted. Epic Patreon Shadow 2. Serious, the skeptic. Right, Sean McDonnell, you're the pop-up girls can't go to kindergarten. Oh, not the baby animals. What's wrong with this guy? Ow. Thus, the power pop-girls were coveyed using their ultra- Wait, wait.  Yeah, pretty much. I mean, dude, that's pretty irresponsible.  Well, look, I learned my lesson. I mean, I don't keep it up there anymore. Okay, well, man, I'm finding it real hard to find some sort of justification to allow your kids to be enrolled here at Okie-Pokie Theater Garden. Gunshots in the background, everything. You were drinking a little when you made these children? Yeah, I mean, yeah, a little bit. That's pretty questionable. Why? That's how most people are made. Yeah, and it's just kind of odd that a single guy would just want to voluntarily become a single parent of three little girls, so he just makes them in his laboratory in a spare time. I mean, that's just weird to say the least. That does sound pretty weird. Look, and they're not documented. They don't have birth certificates. I'm sorry. We can't enroll them. What? Mostly due to their unorthodox conception. But... Oh. Hey. Hey, f**k you. Hey. Whoa. I took four vague ingredients, threw them in a spaghetti pot, and little girls came out and started skewing the crime race. I understand. Do your kids save the world?  Excuse me. There is nothing but an intermediary for garbage. Garbage. Garbage. Garbage.   All right. I'll enroll them. And once again, the day is saved. Thanks, too. Professor Eutonia. God. You sh**. I actually pulled the trigger. I said I didn't enroll them.  That's a good turn. All right. Well, there we have it. Some powerful girls videos. I probably won't see them the same anymore after watching these. And thank you for watching, and I'll see you guys in the next one.


Well, it's it's a pleasure to be here and to be speaking to you and I think to to the point that was brought up by Dr Abel I think it's it's truth really is wonderful to be here because a lot of our patients our families inspire us to do and to Care for and so it also gives motivation to try to move the feel for it. So thanks for being here and It is again a privilege to be speaking to you today So it what I'd like to do first and foremost is I always find it's you know cases and all of us have cases all of You are Demonstrations of the successes and some of the challenges in the management kidney cancer But to talk about a case that highlights metastasectomy and we'll talk a little bit about that And we'll sort of go and do a little bit of a deeper dive Into the various sites of disease that kidney cancer can spread to and what the resections entails and what are some of The important characteristics. So this is a patient no identifiers from a patient standpoint 60-year-old that I managed to believe about five years ago But a 11-cent arenal mass suspicious for a kidney cancer lymph nodes were slightly enlarged and concerning Two small spots in the lungs which were not very clear whether they represented metastasis and a bone metastasis in fact of an L3 So lumbar spine which had not been symptomatic up until that point But as we'll discuss was fairly advanced in terms of its potential compression and risk of fracturing Patient really was an excellent performance status and remains in that way Sorry good question. So ECOG performance status is a way we we ultimately Identify the type of performance or physical shape the patient is when we consider treatment considerations whether I'd be surgery or other Correct exactly zero means Performance that's really very fit and in excellent shape For some reason wants to go backwards okay So this is the patient's imaging studies I think we've gone through several of these this morning So you can see here the mass which is suspicious of a cancer you see some lymph nodes as well there are slightly enlarge back here and This again were the spots in the lungs They were not very large really less than a centimeter and as most of us clinically sort of say is anything less than centimeter He's really equivocal and not very clear whether it's a metastasis or not And this is the the area of the bone that you can see here quite large Again patient had not been symptomatic from a neurological standpoint, but there was significant concern in that regard And really the question is what do you offer that patient? Well, there's multiple treatments as we discussed and it was highlighted I think the care at most of our centers is multidisciplinary I think surgeons medical oncologists radiation oncologists We really bring a little bit to the table all together and I think we need to personalize the treatment of every single patient So that's what typically happens in most major centers And I think again I emphasize that has clearly been shown to offer the best outcomes ultimately for patients So really the question is would this patient be offered up for in treatment with medical therapy? We had a great talk on some of these systemic therapies Radiation or really a surgery the right way to go So really this was a case we discussed multidisciplinary and it really was felt the lung lesions were not very clear The bone area was significant concern that it could progress And in fact what we decided to do is do a combined surgical resection of the primary and the bone with Discussion with our some of our surgical oncologists in the neurosurgical program So patient underwent a cytoreductive so removal of the kidney is setting a metastatic kidney cancer So that's what we refer to a cytoreductin infractomy All right lymph node dissection removal of those lymph nodes, which I showed you and then removal of that Bony segment subsequent to which the patient had radiation to the specific areas of the bone as well Discussion point afterwards, and I know will be discussed as whether there's a role of giving medical therapy afterwards these patients So the pathology in fact showed this was kidney cancer Fairly aggressive type firm and grade grade clearly being a factor Which tells you how aggressive ultimately the cancer is the margins were clean Which is what this SM means? Lymph nodes were all positive that we were sected and the bone area clearly was a metastasis as well So what is the evidence to support this approach? Well, let's discuss that a little bit in detail. So as dr. Wood mentioned what is metastasectomy? So let's start with defining that so that is the surgical removal of cancerous growths that have spread beyond the Original tumor site to other sites of the body So as we were discussing earlier in some of the talks a meta analysis is when you basically take all the data That's out there of high quality and you really look at it in detail and say well Is there any really good conclusions? We can make whether something has a benefit So this is a study that was published several years ago From the group of the Mayo Clinic. They looked at over 2267 patients who underwent metastasectomy and really try to identify whether first of all if you completely remove it Versus incomplete remove it doesn't make a difference. Well I know intuitively that makes sense if you remove all of it. You think you would do better Well, they came to that conclusion and how much of a benefit was there? Well, fairly significant difference when you look at overall survival differences between complete versus incomplete recession You see 36.5 months versus 8.4 months So bottom line if you can completely remove it you do better So it's important again highlighting the point when you have your care make sure the people that are caring for you have Expertise know ultimately that they've done it before and also they can discuss with you with some of the morbidity Making complications associated with that recession could be So this is a what's we refer to as a forest plot Which is a very fancy statistical way of saying well when you put all the data together and these are the individual studies The bottom line is there's a favorable prognosis associated with the complete resection and that's that base that two number means essentially Two times greater. I guess Chance of cure essentially So this is another study that was published. This is a comprehensive review. It was published looking at Knowledge overall in terms of local treatments for metastasis and trying to come up with some conclusions What what conclusions they come up with? Well same thing they came to the conclusion if you can completely remove it you do better So I sort of hit that point So this is just a good summary of and it'll be sort of really the discussion points We're going to sort of have the next 20 to 25 minutes is where where does kidney cancer go to when you consider surgical resection? Well, the lungs are the most common sites so lung resections for metastasectomy is the most common And this is the overall survival associated with metastasectomy specifically for long So long the most common bone is a very common area liver as well Pancreas lymph nodes abdomen and then thyroid and head neck area and you clearly see certain areas for like for example Pancreas I really have a very favorable prognosis in terms of how patients do This is an interesting study that was published Last year and really it was done as a study in Europe It really they tried to look at sub types of kidney cancer So obviously today we know more than just histology meaning is it kidney cancer is at a clear cell or is it a non-clear cell? We actually know what kind of molecular profile meaning what kind of genes these specific tumors are expressing So this group looked specifically at the clear cell type of metastasic Neustatic kidney cancers and found there are really four different clones of cells based on their genetic profile and I mentioned this just because this is a way of looking at the genes that are being expressed and what they Ultimately are involving in terms of how cancer progresses and they in fact showed in a subsequent study that Depending on what subtype of a clear cell kidney cancer you had When you had a metastasectomy you actually did better with certain sub types So that's some of the innovative type of research and I think Information we're now getting from genetics and from molecular profiling We now know in addition to the subtype of kidney cancer based on the genetic profile How you may do with with a complete resection of a metastasis? I Would say because some some colleagues have asked that's not really being used widespread clinically But it is clearly where research is going in the future in terms of how ultimately we determine which patients should undergo surgery So this is a paper that was published from Memorial Sloan Kettering in New York of 138 patients with Metastatic kidney cancer undergoing a single site metastasectomy meaning they only had one site Which cancer had spread to and what did they find they found the patients in terms of recurrence free and cancer-specific survival actually Did fairly better than expected 84% of patients at five years had a cancer-specific survive So something more encouraging that we would typically associate with it and what were factors that associate with how patients did? Large tumors and sarcomatoid histology sarcomatoid histology is a subtype of kidney cancer Which is very aggressive in its pattern of behavior not only locally meaning in the abdomen also in its pattern of spread to other areas So those are the factors that were associated with how patients did Another question that they answered is no evidence that if you had metastasis when you were diagnosed with kidney cancer You did any worse than if you developed a metastasis afterwards and underwent this type of surgical approach So that was also an insightful type of conclusion or point that was brought up by this specific study And this is the survival curve so ultimately if you look at cancer-specific survival And I'll tell you what that ultimately means is if you look at survival specific to that cancer not meaning Not looking at whether someone had a heart attack or another cause of death You see that again patients did better than would be expected with about at five to six years 75 patients were cancer-specific. I had a were cancer-free in that regard in terms of being alive following that resection So this study specifically looked at well, you know, it's important You know that we clearly discuss prognosis in terms how you do from a cancer standpoint But an important discussion point for patients is we'll talk to me a little bit about the morbidity meaning what kind of side effects Am I going to have from this treatment that have lies not only to surgery but medical therapy You want to know what you're sort of looking into what you can expect in terms of how likely you're going to recover from an operation So this study looked at a national database of kidney cancer patients looked at over a period of about 10 years and Found in the 1,100 patients that were looked at major Complications were were found in about 25 to 27 percent of patients And it found in fact certain sites of resections did worse in terms of rates of complications like liver resections For example, we're one of the areas where you had a two and a half times higher risk of having a complication So these are also very important discussion points when you're discussing it as a clinician or as a clinical care team with patients In terms of what you can expect with the treatment What were the most common complications things like transfusions respiratory complications those are really the most common ones things like wound infections things like Like cardiac were really fairly low about a 5% incidence of having those things And that's also an important discussion point is today when we care for patients And I'm sure many who had surgery Patients are really very carefully scrutinized and evaluated by medical teams and cardiologists to really make sure you're in the best of shape When you're having an operation particularly if you have some medical condition So let's now talk about the individual sites of metastasis and how patients do with resection So lung metastasectomy, and I'm going from a chronological from the highest frequency of of sites of metastasis and resection to the lowest So again lung being the most frequent site that cancer can go to and where patients have had experience in terms of metastasectomy What do we know and I highlight this is just this is a spot of metastasis or highly suspected It would in fact was biopsy proven to represent that So this is a paper that was published from the group in China They looked at a good looking at prognosis prognostic factors of patients with metastatic kidney cancer who had lung metastasectomy So again, we'd like to talk about Survival rates again, and I think it was a good point that was brought up by an earlier speaker is It's you have to be very careful when you say there's a one-year three-year five-year overall survival Those are numbers they don't necessarily mean how you're going to do any time a patient asks me that I sort of take A step back and say look I don't necessarily can tell you what you're you're going to likely be in One two three five or ten years. I can give you numbers, but those are numbers It doesn't say those curves are you know They span a certain thing and they don't really represent everybody in this room or potentially who has kidney cancer So you have to spend a little time and really be significantly Educated as well as clinicians have to have to really discuss that in a little bit of detail So what were the factors that were associated with patients that did worse with a lung metastasectomy? Well, if your lymph nodes were involved you did worse if you had incomplete recession like we're discussing earlier You did worse if you had multiple sites of spread within the lungs. You clearly had a less favorable prognosis And so those are important factors for your clinician and for patients who have Lung metastasis or considering this to sort of be aware of and Again, this is a little somewhat busy slide But again, it really is to heighten again the fat various factors that are associated with how patients do and again To emphasize the point that you really need to take these individual prognostic factors or factors that predict how patients are going to do into account This is another study that was published This is a study from Japan and it looked at Interestingly enough surgical resection of pulmonary metastasis in a cohort of about 85 patients And what they found is the five-year overall survival rate for the group of patients was about 59 percent and complete resection again was achieved in 93 percent of patients So surgeons did a pretty good job ensuring they had resected most of the disease and the factors that predicted again How patients did were the size of the tumor the histology meaning if it was a clear cell patients in fact did better and having a complete resection And again, this highlights the point that clear cell timidly in this group of patients was a very favorable Prognostic factor versus other types of histologies of a kidney cancer This is a study that was published from Germany actually it was somewhat I wouldn't say this is streamlined treatment to lung metastasectomy They in fact not only resected it but they use laser technology to ablate the area resection So when they did the resection they use a laser technique to resect it and they were in fact very aggressive They didn't only resect patients with single-sided disease But potentially some patients who had several sites of metastasis in the lungs and I would take pause and say that is not standard approach But they sort of did this in Germany and it sort of gives a little bit of insight of how patients did. What did they find? They found that patients had a complete resection again did better and it was achieved in about 88 percent of patients even if they had several lung metastasis in the lungs and In fact the factors that predicted how patients did were a complete resection and number of sites of metastasis in the lungs So I would tell you clinically I Take a little caution when I look at data like this because if you have multiple sites of metastasis Particularly if it's in both lungs or you have other sites of disease Those are likely patients that you know it would be discussed as a multidisciplinary type approach But probably would get some form of medical therapy first before you went on to do surgery and Again, this was to show that if you had one site of disease you did better But you see in this study they did up to 20 resections in some of these patients Which again, I wouldn't say that would be a standard approach that most of us would sort of advocate for Let's go on to bone metastasis This is the picture I showed you earlier again with a fairly large bulky metastasis Which is at high risk of compression or or or causing some neurological deficits in patients So this is a paper that's a couple of years old But it was published from the group from Boston Orthopedics department in terms of doing bone metastasectomies and they found in fact in the 183 patients Which is a large group of patients that were treated 48 percent of patients under one metastasectomy and then 30 percent of patients under one some sort of Kurtage meaning excision of the inside of the of the lesion and essentially the other 22 percent of patients didn't in fact have a Resection they under want to stabilization So an area was felt to be at high risk of a fracture and the orthopedic surgeons just stabilized it And really the point of this is is there a difference between resecting it versus stabilizing it? So they looked at this and in fact found that if you had a resection of the bone metastasis You did better versus if you had any of these other two different types of approaches Again, this is sort of shown in these Survival curves where again if you have a complete resection with negative margins You clearly do better But really if whether it was a interletal cartage versus a stabilization really was no difference So it's a really either you get a resection complete resection versus other and so those are important discussion points And this is another thing whether they achieve negative margins, which was confirmed with pathology. You clearly did better as well This is a paper that was published as a collaboration Looking at bone metastasectomy treated in two places in Germany and in China They treated 114 patients the overall survival was about 9.6 months So clearly you're seeing that bone metastasectomy for example is not as favorable as we were discussing earlier with lung metastasectomy The factors that were associated with survival on multivirid analysis were whether patients had received some sort of medical therapy at some point Either before or after surgery Whether patients had a resection whether patients were put on some forms of what I call bisphosphonate therapies Which are a way of really boosting and making sure you give Reduce the risk of bone fractures by increasing bone health and favorable predictors of overall survival were those factors in fact and the resection of bone metastasis in combination with medical therapy In fact was shown to have a dramatic improvement in survival with that 31 Close to 32 months survived versus eight months People and you know and we spent some time discussing whenever you look at clinical studies, and I think that's an important point I definitely spend time and I'm sure my colleagues do the same as You have to be very careful when you sort of come to conclusions say well if I have surgeon to get treatment I do better than that if I had treatment alone Well, there's also a certain degree of selection that happens there meaning we're going to get more aggressive therapy Well, it's patients typically like we're discussing about performance status who are very fit patients who are very you know are seeking a very aggressive approach for example and Also patients potentially who are being treated at centers where they have the ability to give multi-disciplinary care So there's any time you see a study there may be some factors which may be influencing the data as well So just always take that into account whenever you look at some clinical studies and Again when you look at that patients who have bone metastasis which you see in the blue curve did better with whether they had Single sites so bone metastasis only versus if they had multiple sites of disease versus if they are in fact had the bone Metastasis left in place and again if combination therapy meaning if you had medical therapy plus resection They also did better How about hepatic and pancreatic metastasis ectomy? So this is again a CT scan showing the kidneys left in place here the patient in fact had The right kidney removed previously and you see this area right here Which in fact is a pancreas metastasis that the patient developed So what's the data in terms of these area of of metastasis and having surgical resection? So this is a 12-year follow-up study so patients were followed over a 12-year period who have liver metastasis And this is a paper that was published From the Mayo Clinic and over a period of about 11 years the median number of liver metastasis were two And the median fall up of the patients was about 26 months So a little bit more than two years and they found that most of the patients had in fact received some form of systemic treatment So medical therapy in addition to surgery alone And they found that overall the five-year survival rate was actually about 60% and there were patients that survived at 142 months was the median survival Factors which are associated with not benefiting from surgery again a higher grade more aggressive histology of the cancer and Having other sites of metastasis at that time And this is sort of putting the data together the survival rates again You see there is whenever you look at clinical studies there can be a quite Significant variation in terms of what a reported Survival rates and how patients are doing so that's also very important when you look at that or you have a discussion with your clinician To understand there is variability and experiences and how patients do and this is a paper specifically looking at isolated pancreatic metastasis if you may remember one of the first slides I showed was pancreatic metastasis in itself or somewhat favorable location for it for Metastasis of kidney cancer in terms of either medical therapy or surgical resection So this is a study of a 276 patients 28 percent of patients were treated with not only either surgery or radiotherapy So either form of a local treatment and 256 patients received some form of systemic therapy again in addition to this type of local treatment The median survival the patients had was about 58 percent at five years and Factors that were associated with overall survival was whether they patients in fact had some form of local treatment on Multi-variant analysis so multi-variant analysis is you all are probably aware is when you take all the factors together And you're sort of controlling for potential things of which may be skewing the data. What are their all bottom line? What are the factors are really impacting how patients do? So whether you had previous kidney removal of the memorial Sloan Kettering and IMDC prognostic Factors, which is just basically ways that we've developed to understand how patients are going to do based on certain characteristics either of their tumor or using blood tests to sort of know a little bit more about their cancer and And whether patients in fact had local treatments either again in the form of radiation or in the form of surgery and Again bottom line that was shown in this study Local therapy makes a difference when you have metastasis the pancreas and you clearly see that these two curves are clearly very different So this is a topic that my colleague a dr. Karam will be discussing in the next few minutes But so I sort of will sort of skim through this fairly quickly But what happens when when the cancer goes locally meaning in the abdomen either to lymph nodes? As seen here, and how do patients ultimately do does it make sense ultimately to go after it surgically for example? so this is a paper that was pleased to collaborate with my friends in Texas and We looked at this and really found that the most common site of metastasis of the lymph nodes specifically in terms of what in the abdomen has the cancer spread to are the Interadural cable region which means between the vena cava in the order and I'll sort of going back there that basically means in this specific area between these these blood vessels and At a follow-up Really of close to I believe it was two years It was found that about 52 percent of patients develop a subsequent recurrence So about half of patients will recur once again after that that initial resection and the time to recurrence was close to 10 months on Multivariant analysis like we're discussing earlier the factors which were predictive of how patients did ultimately Was whether or not you had a short time from when you develop the recurrence So typically if you have a recurrent a short interval between when the recurrence happens that that is usually a worse Prognostic factor which you need to take into account. So if it comes back early less favorable in terms of how patients could do and that was in fact the factor that was most predictive of progression and What we're able to do is really pinpoint a little bit more Where were these typical lymph nodes in terms of where the cancer had spread to and this is for a left-sided tumors? So if you had a kidney cancer in your left kidney or right-sided tumors So in this kidney where the spread the kidney cancer was spread to and those are helpful for clinicians to sort of be aware of because When you're discussing going in there removing lymph nodes if you know there's a higher risk that other lymph nodes could be involved They may sort of affect how you do the surgery or what lymph nodes ultimately you'd be removing So this is a paper Again from the from our colleagues at at md. Anderson by dr. Wood and karam They looked at 100 patients 102 patients treated over a period of about 15 years And they found that uh metastasis progression was observed in about again slightly more than half of the patients And on multivariate analysis again taking other factors the nodal status meaning if the lymph nodes were involved And the diameter of the lymph nodes were the factors that predicted how patients ultimately did And these are some of these survival curves again highlighting whether uh, you had a recurrence that happened early You did worse whether the lymph nodes were positive Atomic surgery you did worse and also this is an important curve, which apologize. I know it's a little small The site where the cancer recurred meaning if it was lymph nodes You see that patients did slightly worse than for example if the cancer had to come back in the adrenal gland The adrenal done being as was discussed earlier is that little gland that sits right on top of the kidney So adrenal is a is a more favorable location for these cancer to spread to How about brain metastasis, you know when when when this cancer spreads to the brain people say well Is there nothing that could potentially be done? Well, that's not the case Clearly there are treatments that are available and we'll discuss those uh right now So this is a paper that was published from the group from uh, memorial Sloan Kettering And they looked at doing brain metastasectomy and 50 patients treated over a 20-year period So you see the clearly that's a very large period of time very selected patient of population Some patients with brain metastasis typically today would be treated with radiation for example versus surgery The primary was dissected in most of these patients And the median survival of patients was about 31 months Mortality following surgery was found and happened in about 10 percent So clearly something very important for for patients families and and clinicians to discuss is In this series, which was again several years ago. This was published close to 20 years ago There's about a 10 mortality risk associated with the operation itself And uh following surgery uh close to half the patients in fact receive radiation treatment And the reported one two three and five year overall survival and again understanding that these are Very general type numbers are such that about five years overall survival is about 8.5 percent Favourable predictors were whether the site of metastasis, you say what on earth is supertentorial metastasis means If this was in the higher brain patients typically did worse Patients who had left-sided versus right-sided tumors did worse not really sure how to explain that other than to say Maybe that was just also maybe some statistical type reasons why that was But also if you had symptoms neurological symptoms before surgery you typically did worse as well How about the head and neck? So I've had patients over the years who for example had developed a thyroid metastasis of kidney cancer And actually when you look at it that is probably one of the more straightforward sites of surgical resection for our colleagues in the head Neck service to sort of operate on And patients in fact interestingly enough Concurrents meaning presence of thyroid and pancreas metastasis was present about a quarter of patients With thyroid adrenal concurrent metastasis and about 13 percent of patients the five year overall survival rate was about 46 percent And about 28 percent of patients develop a subsequent local recurrence in lymph nodes or other in the general head neck area Again on on looking at all factors. What predicts how patients do well aid was a factor patients who had involvement of adjacent cervical lymph nodes for example did typically worse And predictors of how patients or which patients are most likely to recur was Invasion of these lymph nodes or how long ago the patient had the thyroid ectomy So short interval typically did worse versus if you had a long interval for example So I we were discussing a little bit earlier. Well, is there a role to give medical therapy before you do these types of surgeries? Well, that's a very good question Our counterparts again in texas at md. Anderson have looked at this in a retrospective fashion So looking at their data of patients they had treated and they found in 22 patients treated across three centers md. Anderson dina farber and the clement clinic Metastasectomy was found In the retroperitone meaning in the abdomen in the lungs so multiple areas of sites of cancer And about 50 patients had a recurrence at a fall of close to Three and a half years and the median fall up of about 109 weeks 21 patients were alive and one was deceased from kidney cancer So these are you see in these retrospective studies typically patients get a host of different type of medical therapy either before or afterwards And this is another paper that looked at this This is a paper that was published in a european journal and they looked at patients I got medical therapy before surgery again Same type of question and the problem proceeding with with surgery after you got medical therapy was quite good So sometimes patients ask well if I get medical therapy might burning my bridges that I may not have surgery afterwards Well, this study would tell you not most of these patients in fact were able to have surgery The median survival of these patients when the edge of therapy was about 67 months And the probably to achieve a complete local therapy and discontinued targeted therapy was about 73 percent of patients So what does that mean? So probability that you get resected and you're off the treatments afterwards So fairly good chance that you're going to be able to sort of get off the therapies in this in this experience right here This is a fancy way of showing data where patients like out medical therapy You want to bottom line the the masses sort of shrink Well, most of them in fact did when you look at percentage of shrinkage that you see here And that's sort of what's representing you clearly see one here in which in fact grew during medical therapy And that's what as a clinician as a patient you need to watch out for is clearly if the medical treatment's not doing it You need to recess whether you need to change treatments or maybe you need to consider surgery at that point in time How about giving adjuvant meaning giving treatment after you do the metastasectomy? Well, there definitely is this is an active area of research and I think there's a lot of interest like dr Haas has mentioned earlier. I think the combinations particularly patients who are at risk Of recurring is something which we actively are looking at and I think clinical trials is definitely going to be the way of looking at this So this is a paper that was published from south korea of 33 patients Who were treated following a complete resection and got some form of target therapy and again Same thing as we were discussing before if you had an incomplete resection, you did worse And again bottom line is it makes a difference if you're going to have surgery It's important that your surgeon yourself have a clear discussion of the goals of treatment The likelihood of a resection being complete and sort of be able to sort of know and understand that The factors that predict how patients did were again complete resection whether they got medical therapy This imdc risk group which again is a way we look at cancer having more aggressive histology and having multiple sites of disease And this is shown here again Complete resection sort of makes a dramatic difference there. So this is one of my last studies I'm going to sort of discuss with is this a study that was published looking at target therapy So again medical treatments falling complete resection only 19 patients had immediate post-operative treatment And immediate post-operative treatment was associated with a better survival But again, you need to be very careful. These are retrospective studies selected patients So it sort of guides us about potential of combination treatments, but it's not a definitive meaning It's you can't make over conclusion that this clearly is the way that we need to treat patients or Or that these are the right treatments that we need to be giving patients And again, this is sort of to show you here if you didn't have a complete removal If you had a complete removal and to get treatment, you clearly see the relapse rate was much much higher versus If you had a complete removal and got medical therapy, you clearly see the relapse rate was 20 versus about 80 So in conclusions, the most common sites of metastasis of kidney cancer as we sort of went in a chronological order are the lungs, the bone, liver, pancreas The retroperiod in the brain and the head and neck Complete surgical resection is really the primitive The essential component of how you're treated if you're going to have this type of treatment And I definitely think some of these knee adjuvant and adjuvant trials are very promising Particularly these adjuvant trials following metastasectomy and there's two that were mentioned earlier Keynote five six four emotion zero one zero May help us under understand the combinations of whether checkpoint these immune modulators may be of the important in these treatments And I think this is a a slide I like to always include because there's many factors when you're considering treatment and in particular aggressive surgery patient factors disease factors likelihood of complications with surgery and then site specific meaning Lung bone and brain like we're discussing clearly know how patients are and there's a difference in prognosis depending on those sites Lastly, this is a nice summer slide in terms of the treatments and different types based on the location and just a brief just Mention of I think a mentor from any of us dr. Swanson who's part of the kca for many years And dedicate a lot of his career to the to the really focusing on metastasectomy and the treatment of kidney cancer And I just want to Definitely know that his his legacy is one that we definitely all sort of are striving for To try to make an impact on the treatment of kidney cancer particular aggressive kidney cancer So thank you very much for your time