Tribunal Criminal Tribunal for the Former Yugoslavia

Page 12593

 1                           Thursday, 26 February, 2015

 2                           [Open session]

 3                           [Accused not present]

 4                           --- Upon commencing at 2.30 p.m.

 5             JUDGE DELVOIE:  Good afternoon to everyone in and around the

 6     courtroom.

 7             Madam Registrar, could we have the appearances, please.

 8             THE REGISTRAR:  Good afternoon, Your Honour.  This is case number

 9     IT-04-75-T, the Prosecutor versus Goran Hadzic.

10             JUDGE DELVOIE:  Thank you.

11             May we have the appearances, please, starting with the

12     Prosecution.

13             MR. STRINGER:  Good afternoon, Mr. President, Your Honours.

14     Douglas Stringer, Sarah Clanton, Elizabeth Spelman, Thomas Laugel for the

15     Prosecution.

16             JUDGE DELVOIE:  Thank you.

17             Mr. Zivanovic, for the Defence.

18             MR. ZIVANOVIC:  Good afternoon, Your Honours.  For the Defence of

19     Goran Hadzic, Zoran Zivanovic and Christopher Gosnell, with legal interns

20     with Sara Butkovic and Raila Abas.

21             JUDGE DELVOIE:  Thank you very much.  And we note for the record

22     that Mr. Hadzic is not present and we received the waiver that has been

23     filed.

24             Before we call the expert, Dr. Seute, the Chamber would like to

25     put on the table again whether we should go into private session.  The


Page 12594

 1     Chamber is of the view that yesterday nothing has been revealed that is

 2     not already in the public due to the Defence's decision to make public

 3     the elements of Mr. Hadzic's health condition.  There is no indication

 4     that today's hearing would be any different.

 5             Therefore, there seems to be little or no reason for private

 6     session today, as well as yesterday.

 7             Mr. Zivanovic, would you agree?

 8             MR. ZIVANOVIC:  Yes.  Your Honours, yesterday I just conveyed the

 9     information I've got after consultation with Mr. Hadzic and he didn't

10     change his mind, but it is on you to decide.

11             JUDGE DELVOIE:  Prosecution, anything?

12             MR. STRINGER:  We have no position on that, Mr. President.

13             JUDGE DELVOIE:  Thank you.

14                           [Trial Chamber confers]

15             JUDGE DELVOIE:  Can we go into closed session for a moment,

16     please -- or private session, rather.  Just private session.

17                           [Private session]

18   (redacted)

19   (redacted)

20   (redacted)

21   (redacted)

22   (redacted)

23   (redacted)

24   (redacted)

25   (redacted)

Page 12595

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 6   (redacted)

 7   (redacted)

 8   (redacted)

 9   (redacted)

10                           [Open session]

11             THE REGISTRAR:  We are in open session, Your Honour.

12             JUDGE DELVOIE:  Thank you.

13             The witness, Dr. Seute, may be brought in.

14                           [The witness entered court].

15             JUDGE DELVOIE:  Good afternoon, Doctor.

16             THE WITNESS:  Good afternoon.

17             JUDGE DELVOIE:  Could I please ask you, for the record, to state

18     your name and date of birth.

19             THE WITNESS:  Tatjana Seute, November 15th, 1971.

20             JUDGE DELVOIE:  Thank you.  And your profession?

21             THE WITNESS:  I'm a neuro-oncologist.

22             JUDGE DELVOIE:  Thank you very much.

23             Dr. Seute, you are about to make the solemn declaration by which

24     all witnesses before this Tribunal commit themselves to tell the truth.

25     I must point out to you that by doing so you commit yourself to the --


Page 12596

 1     you expose yourself, sorry, to the penalties of perjury should you give

 2     false or untruthful information to the Tribunal.

 3             So this being said, could I ask you to give the solemn

 4     declaration.  The text of it will be given to you by the usher.

 5             THE WITNESS:  Very well.  I solemnly declare that I will speak

 6     the truth, the whole truth, and nothing but the truth.

 7             JUDGE DELVOIE:  Thank you very much.  Please be seated.

 8             THE WITNESS:  Thank you.

 9                           WITNESS: TATJANA SEUTE

10             JUDGE DELVOIE:  Mr. Stringer.

11             MR. STRINGER:  Thank you, Mr. President.

12                           Examination by Mr. Stringer:

13        Q.   Good afternoon, Dr. Seute.

14        A.   Good afternoon.

15        Q.   My name is Douglas Stringer and I'm an attorney for the

16     Prosecution here at the Tribunal, and I've got some questions about the

17     report that you've prepared on the basis of the Chamber's request.  Do

18     you have the report with you?

19        A.   Um-hm, I have.

20        Q.   In the course of my questions, if there is anything that you

21     don't understand or that you wish me to be clearer on, please don't

22     hesitate to let me know.

23        A.   Okay.

24        Q.   Dr. Seute, your background, as I understand it you're a

25     practicing neuro-oncologist.

Page 12597

 1        A.   Um-hm.

 2        Q.   Which means that, I guess, in layman's terms your job largely

 3     involves treating people, patients who have conditions such as the one

 4     that has been the recent diagnosis for Mr. Goran Hadzic; is that correct?

 5        A.   That's correct.  I diagnose, treat, and guide patients with

 6     glioblastomas.  That's my main job, yeah.

 7        Q.   And you examined Mr. Hadzic on the 11th of February?

 8        A.   Correct.

 9        Q.   And examination occurred closer to where you work at the

10     UMC Utrecht, the hospital out in Utrecht?

11        A.   Correct.

12        Q.   The exam, according to your report, lasted about one and one

13     quarter hours.

14        A.   Um-hm.

15        Q.   And you've indicated in your report, actually, that in relation

16     to one of the questions, you've never been to the Detention Unit --

17        A.   Um-hm.

18        Q.   -- here at the Tribunal.

19        A.   Um-hm.

20        Q.   So you don't know what the conditions are out there in which

21     Mr. Hadzic is currently being detained?

22        A.   Um-hm.  Correct.

23        Q.   I can see some of the papers you've got, and I know from its

24     Scheduling Order, that the Chamber directed that you be provided with

25     papers that have been submitted by the parties; the Prosecution and the

Page 12598

 1     Defence, in regard to sort of the legal question that's currently with

 2     the Chamber, which is to release Mr. Hadzic from the detention unit so he

 3     can go back to Serbia for the next few months until he comes back in May

 4     for his MRI evaluation.

 5        A.   Um-hm.

 6        Q.   Do you understand that that's the main issue that's before the

 7     Chamber today?

 8        A.   Um-hm, I understand.

 9        Q.   When you spoke to Mr. Hadzic, did you discuss with him anything

10     about the conditions, the place where he's proposing to go live in Serbia

11     if he's released?

12        A.   No, no.

13        Q.   Okay.

14        A.   We don't speak about that.

15        Q.   So you don't know anything about where he would go --

16        A.   No.

17        Q.   -- if he was released?

18        A.   No.

19        Q.   Before you examined Mr. Hadzic, you've indicated in your report

20     that you reviewed all of the medical reports, the data, the images that

21     were available to you; correct?

22        A.   Correct.

23        Q.   I think you had at least once conversation with Dr. Falke, whose

24     the chief medical officer here at the --

25        A.   Right.

Page 12599

 1        Q.   -- what we call the DU, the detention unit.  And are you aware

 2     that the Chamber appointed another person to serve in your capacity -

 3     that is, as an independent expert?

 4        A.   I was and I was aware and I also spoke.

 5        Q.   And that's Dr. Cras.

 6        A.   Yeah.

 7        Q.   And as I understand it you spoke to Dr. Cras, maybe just briefly,

 8     but just around the time that each of you submitted your reports?

 9        A.   Right, right.

10        Q.   Have you seen Dr. Cras's report?

11        A.   Yes, I have.

12        Q.   Okay.  And then you're aware, I take it also, that Mr. Hadzic,

13     his treating physician is Dr. Martin Taphoorn.

14        A.   Um-hm.

15        Q.   And he's based with the MCH, the hospital group here in The

16     Hague.  Is that --

17        A.   Yes.

18        Q.   And he is like yourself a neuro-oncologist?

19        A.   Right.

20        Q.   Do you know Dr. Taphoorn?

21        A.   Yes, I know him.

22        Q.   Based on your knowledge of Dr. Taphoorn and your review of the

23     medical file for Mr. Hadzic, can you comment on the quality of the

24     medical care that Mr. Hadzic has received so far in this case?

25        A.   Yes, yes, I can.  The quality of the care Mr. Hadzic received

Page 12600

 1     until now is of very high quality.  It's based on standard treatment

 2     decisions as we know until now in Europe and America and all over the

 3     world.  Imaging is of excellent quality.  Pathological reports are of

 4     excellent quality, and Professor Taphoorn is a highly respected

 5     oncologist in the neurological field.

 6        Q.   And as I understand it Dr. Taphoorn is one of the people who

 7     developed or at least published what we've been referring to as the Stupp

 8     scheme which is sort of the regime of treatment that Mr. Hadzic is now

 9     undergoing?

10        A.   Yeah.  It was a very large trial performed in the early end 1990s

11     to 2000, 2005, a lot of neuro-oncologists put in their patients so that

12     is why we are all there on the list of authors.  Yeah.

13        Q.   Yeah, I saw your name on a number of publications as well,

14     related to treatment of glioblastoma.

15        A.   Um-hm.

16        Q.   Before we actually move to the substance of your findings or your

17     opinion, I did want to direct you to one part of the report and ask for a

18     clarification.

19        A.   Um-hm.

20        Q.   If you could go to page 4, which is the last page of your report,

21     and the last paragraph there, and this is the answer to the question that

22     is in the small Roman numeral (v).

23             You said:

24             "The median survival of patients diagnosed with glioblastoma

25     multiforme varies from 12 to 14 months, however median indicates 50

Page 12601

 1     per cent."

 2             And then the next sentence says:

 3             "The two year survival ranges from 25 to 30 per cent."

 4             So I wanted to ask you if you could clarify the 12 to 14 months

 5     there and whether that is accurate?

 6        A.   Yeah, yeah.  It is accurate.  You know, these numbers come,

 7     actually, from the Stupp trial, you know, this treatment, regimen

 8     Mr. Hadzic is receiving right now, is undergoing, is based on the Stupp

 9     trial.  There were lots of patients in this trial, and if you look at the

10     survival rates of these patients, you will get to a median survival close

11     to 14 months.  But if you -- because that's why I also took into account,

12     I said from these numbers are based on trials and based on personal

13     experience from our own hospital, because I run the biggest clinic in

14     Holland.  We have the largest amount of patients.  Then you have to be --

15     no, you can have the number of 13.7 months.  I took the number of 12 to

16     14 months because if you look at the at the whole of Holland, that will

17     be the median survival.  But to be very clear, for the patient in front

18     of you, especially in this early phase of his disease, nothing is to be

19     said about these 12 to 14 months.

20        Q.   Okay.  And I bring this to your attention because I think, again,

21     for those of us who are not physicians or experts in your field,

22     Dr. Cras --

23        A.   Um-hm.

24        Q.   -- in his second report actually says that at present

25     Mr. Hadzic's survival can be estimated in the range of 12 to 24 months.

Page 12602

 1        A.   Yeah.

 2        Q.   -- depending on the success of radio and chemo.  So perhaps you

 3     can explain what is the -- what's behind the different ranges --

 4        A.   Yeah.

 5        Q.   -- that we're seeing here.

 6        A.   Yeah, I think that what's behind if you look at the 12 to 14

 7     months, that's -- that's the number that came out of the trial.  All

 8     sorts of patients are in there, like, all the patients in bad physical

 9     condition even before starting, before diagnosed with the glioblastoma.

10     There are patients who underwent surgery, like resection of the tumour.

11     There are patients who didn't undergo surgery.  There are patients with

12     very large tumours in very eloquent sections of the brain.  There are

13     patients with very small tumours.  All with the same diagnosis.  So a

14     very large scale of different sorts of patients.  So if you look at the

15     case, the patient as Mr. Hadzic, there is also in Dr. Cras's report,

16     there are some elements that could be judged as beneficial prognostic

17     factors like his relatively young age, although this disease is a disease

18     of young people; his good physical condition; and then on the other hand,

19     there are some factors that -- that are negatively -- negative prognostic

20     factors like the multi- -- the fact that the tumour is in different parts

21     of the brain so that a resection was not possible.  If you add up all of

22     these factors, then you can make little bit -- you can try -- let me

23     clarify that.  You can try to make little bit of a broad view.  And then

24     also Professor Taphoorn and Professor Cras think that it might be

25     somewhere between 12 to 24 months.

Page 12603

 1             Personally, I think that in this part of his -- this stage of his

 2     disease, it's extremely difficult to say anything about his future.

 3        Q.   Okay.  When you examined Mr. Hadzic on the 11th of February, you

 4     indicated that although you did not perform any neuropsychological tests,

 5     you stated that he did appear to have no cognitive dysfunction?

 6        A.   Correct.

 7        Q.   Dr. Cras indicated in his report that he found Mr. Hadzic to be

 8     well-oriented, to express himself clearly --

 9        A.   Yeah.

10        Q.   -- and that he tested normally on the Montreal Cognitive Exam.

11        A.   Um-hm.

12        Q.   My question is whether Dr. Cras's findings and observations are

13     generally consistent with your own on that?

14        A.   Yes, yes, they are generally consistent.  I thought Mr. Hadzic

15     was very clear minded.  He answered my questions through the interpreter

16     very quickly.  Didn't need allot of time to think.  Was orientated in

17     time, space, and person.  But -- well, as stated, I didn't do a real

18     large battery of neuropsychological tests because that would take me

19     like --

20        Q.   Yes?

21        A.   -- hours to do that and I would have to involve my

22     neuropsychologist and didn't go to that effort because I didn't think

23     that it was necessary at that time.

24        Q.   And then getting to really the main point that you've been asked

25     to address, if I could direct you to page 2 of your report.  Actually,

Page 12604

 1     we're going to look at a couple of questions.  And this is question

 2     number 2.  And your -- here you're asked whether Mr. Hadzic will have the

 3     capacity to physically attend and participate in trial proceedings for a

 4     period of four months either during or after treatment.  And then in your

 5     answer that follows, you state that in your opinion he would not be able

 6     to participate for four months during treatment or during episodes with

 7     serious side effects.

 8        A.   Um-hm.

 9        Q.   And before I come back to the question, if we could just turn the

10     page and go to question 4, which also relates to the same issue.  This

11     was if Mr. Hadzic is incapable of physically attending proceedings at the

12     Tribunal, would he have the capacity to participate via video conference

13     link set up in the UN Detention Unit.  Now, as one of the people who was

14     involved in suggesting questions, I think we might have done a better job

15     for you in distinguishing between "attending" or what maybe I'll use

16     today as "being present at" versus "participation," and so I would like

17     to distinguish between those if I may in the questions that follow.

18             Because in your answer to this question that we've just read,

19     you -- first of all, you indicate or you refer to your previous answer,

20     and then you express concern about the burden of intensive questioning

21     and also the length of the proceedings, that being several months.

22        A.   Um-hm.

23        Q.   So, Dr. Seute, if I could ask you, first of all, perhaps you

24     could describe or indicate for us when you were responding here, what was

25     in your mind when you were thinking of "participation"?

Page 12605

 1        A.   In my mind, as a medical doctor, I was thinking of

 2     "participating" being here in the trial room, being aware of what was

 3     said in the trial room, and being able to answer questions as I am now.

 4     That was my perception of participating in the trial.

 5        Q.   Okay.  Now setting aside participation, those three things that

 6     you've just described - as being present, his listening, and his

 7     answering questions - setting that aside and focusing strictly on his

 8     capacity or ability to be present which is the first one -- maybe the

 9     first two, to be present and to follow the proceedings, let's say that

10     that's what means -- that's sort of how we will define being present.

11     He's physically present in the courtroom, he'd be sitting over there on

12     that back bench, or even being in his room at the detention unit watching

13     the proceedings live on a video screen, even perhaps with the ability to

14     direct or to contact his lawyers here in the courtroom in realtime.

15             So if that's how we define being present, taking that aside, and

16     I guess I'm going to digress for a quick second to talk about the

17     treatment regime now that he's going to be undergoing for the coming

18     months.  And as I understand it, he's going to be looking at least two

19     more 28-day cycles, each of which involves five days where he's actually

20     taking the chemotherapy --

21        A.   Correct.

22        Q.   -- drug, and that's followed by a 23-day period of recovery.

23        A.   Yeah.

24        Q.   That is how one cycle runs.

25        A.   Yes, correct.

Page 12606

 1        Q.   In your report you said that if Mr. Hadzic's blood counts will

 2     improve it may be possible for him to attend and participate in a hearing

 3     for a limited time per day.  Setting aside again participation in

 4     answering of questions, are you saying that during, say, the 23-day

 5     periods of recovery, it may be possible for Mr. Hadzic to attend as we've

 6     defined it either by being present in the courtroom or following from the

 7     UN Detention Unit?

 8        A.   Um-hm.

 9        Q.   Obviously depending upon how he's affected by the side effects?

10        A.   Yeah.  Well, that's a crucial thing you are mentioning there.  I

11     think depending on whether or not he will experience side effects, I can

12     only then -- let me rephrase:  If you know how he will react to this

13     chemo regimen, then you can make a medical fair judgement about whether

14     he will be able to be present.  We know now that from his first treatment

15     phase with the combination of chemotherapy and radiotherapy that he has a

16     serious blood count drop.  That's a serious side effect.  The counts he

17     had are not life threatening be if they go down more, they are.  They are

18     a serious threat to his life.

19             Now this new phase or this second phase of treatment is the same

20     chemotherapy and it's indeed five days, but it's a much higher dose.  So

21     he will pulse -- he will get a lot of chemotherapy at once and especially

22     the first cycle, you will not know what's going to happen afterwards.  At

23     this point, I'm not informed also about his blood counts right now.  So

24     I'm not even sure as far as I know right now, whether he will be able to

25     start these cycles.

Page 12607

 1             But let's assume he will.  Then I think you can make a fair

 2     judgement during the first 23 days of rest how this will affect him, how

 3     this will affect his blood counts, and then you can judge whether he can

 4     be present.  If his blood counts stay at normal level, if he doesn't

 5     experience nausea and vomiting, if he doesn't experience extreme fatigue,

 6     then he can be present here.  Yes.

 7        Q.   Okay.

 8        A.   And if I may make --

 9        Q.   Please.

10        A.   -- just one more adjustment to that.  I can imagine that you

11     think, well, the five days of chemotherapy are the worst, but the phase

12     afterwards, the recovery phase, that's when the patients experience the

13     side effects.  Mostly not during the five days of taking the medication.

14     The blood counts are lowest at day 21, that's when I assume

15     Professor Taphoorn will also do a blood count.  And then at day 28,

16     that's when I assume he will decide whether the second cycle will take

17     place, assuming the first one will take place.

18        Q.   So, really, the possibilities in terms of Mr. Hadzic's ability to

19     be present, aren't necessarily linked to whether he's taking his chemo on

20     a given day or not?

21        A.   Yeah.

22        Q.   It's linked to more how he's feeling and what his blood count is?

23        A.   Yeah, yeah.

24        Q.   Okay.  Now in terms of -- I don't know how much or how little you

25     know about what a trial day is here or how the schedule runs.  One

Page 12608

 1     question on that:  If -- would the possibility of Mr. Hadzic's ability to

 2     be present, would it be increased if the Chamber -- the Trial Chamber and

 3     the judges showed flexibility in scheduling shorter trial days, for

 4     example, of a few hours, or having the trial take place at times of the

 5     day that are better suited to Mr. Hadzic's schedule?  I saw in one of the

 6     reports that he's got some insomnia but he's sleeping more during the

 7     day.  So would flexibility on those lines also contribute to his ability

 8     to be present?

 9        A.   Yes, I think that would -- that would be helpful, although it's

10     very hard to -- to predict now how he will react and what adjustments

11     have to be made.  If I may speak from my experience, with, like -- I've

12     seen like over 900 patients now who received this treatment and I all

13     guided them myself.  I've now got staff doing that with me.  Then, I have

14     patients who are in good condition, good physical health, even do some

15     working chores during this chemotherapy; on the other hand, there are

16     other patients, also young and physically well-fit patients, who really

17     need hours of extra sleep during the day.  It's really not possible up

18     front to predict how it's going to be for him.  But both scenarios and

19     everything between that are possible.

20        Q.   Okay.  One last question.  And given what you've said earlier

21     about the prognosis --

22        A.   Um-hm.

23        Q.   -- and also given that his condition and his treatment programme,

24     as I understand it, will be re-evaluated in the early part of May --

25        A.   Yeah.


Page 12609

 1        Q.   -- would it be correct to say that Mr. Hadzic's ability to be

 2     present in trial proceedings will diminish over time just in a -- as a

 3     general rule?

 4        A.   That's very hard to say now.  As in a general rule, yes, because

 5     he has a progressive disease and the treatment is aimed to slow it down,

 6     to stop it at best.  And as you can read in my report, sometimes we're

 7     very successful.  That means that we also have long survivals, also

 8     patients who didn't have a resection.  But it's a small group, very

 9     small.  Most people benefit from this treatment, of course, otherwise we

10     wouldn't give it, but in time -- and it's really not possible to say at

11     this point in time in what time, but in time he will diminish.  He will

12     develop neurological dysfunction, he will develop cognitive dysfunction,

13     that is a matter of time, but just the amount of time we have can't be

14     predicted right now, yeah.

15        Q.   Thank you, Dr. Seute.

16        A.   You're welcome.

17             JUDGE DELVOIE:  Mr. Gosnell.

18             MR. GOSNELL:  Yeah.  Thank you, Mr. President.  Good afternoon.

19                           Examination by Mr. Gosnell:

20        Q.   And good afternoon, Dr. Seute.  My name is Christopher Gosnell.

21     I'm here for Mr. Hadzic.  You say in your report in answer to question

22     4(b)(ii) -- well, actually, it's just 4 -- 4(b) -- well, in any event,

23     it's on page 3, you say:

24             "The expected consequences of the radiotherapy and the

25     chemotherapy are low blood count, fatigue, nausea, vomiting, rare.  On

Page 12610

 1     the mid-long cognitive dysfunction, ranging from mild problems with

 2     concentration to serious amnesia."

 3             Are you -- and I'm interested in the expression mid- --

 4        A.   Yeah.

 5        Q.   -- long cognitive dysfunction.  Is there a distinction in your

 6     mind between mid-long dysfunction and some shorter dysfunction?

 7        A.   Yes, definitely.  As I -- it's hard to explain like without

 8     starting lecturing, but radiotherapy -- I'm referring here to the side

 9     effects that radiotherapy can give to a person.  The radiotherapy

10     Mr. Hadzic underwent is aimed, of course, at the areas in the brain where

11     the tumour is -- where the tumour locations are, because there are

12     multiple locations.  When you -- when the radiotherapist makes his plan,

13     he will aim the radiotherapy, as I said, at the tumour locations, but

14     also healthy neurons, healthy brain cells will be involved in this

15     radiotherapy scheme.  This will not affect you directly.  You will not

16     notice that.  When you're receiving the radiotherapy, you will be --

17     patients can complain of fatigue, but they will not suffer from

18     concentration loss directly.

19             Within a time, and that's where the mid-long is kind of fake, and

20     I can't be more specific about it, but the mid-long is then months to

21     years, the healthy neurons, the healthy brain cells that receive

22     radiotherapy will diminish in function, and then you can start

23     experiencing concentration loss.  And if it's a serious case, you can

24     have serious amnesia.

25        Q.   But is it common that you have glioblastoma patients --

Page 12611

 1     glioblastoma multiform, while they are undergoing their chemotherapy, who

 2     present no apparent cognitive dysfunctions but who nevertheless complain

 3     and in reality have significant deficits in terms of more complicated

 4     sustained intellectual tasks?

 5        A.   Do you mean during treatment or afterwards?

 6        Q.   During treatment.

 7        A.   In my experience, most patients do complain in some -- to some

 8     extent of cognitive dysfunction.  Although, I must say again there is a

 9     very wide range of how that affects them in life.  I also have a quite

10     some patients, quite some percentage of patients who continue doing their

11     job, also highly educated patients, and continue being fully active in

12     social and working life.  Very different -- very difficult to say

13     something in general about it because it's also because, like I said

14     before, patients with brain tumours have cancer but they also have a

15     neurological disease very much dependent on where the tumour is located

16     in the brain.

17        Q.   Okay.  Let me put it a different way:  Would it be unusual for

18     you or would you consider it unlikely if a patient were to tell you that

19     they have significant difficulties maintaining a train of thought or

20     maintaining concentration over a one- or a two hour time-period, but when

21     you see them you see no apparent cognitive dysfunction?

22        A.   And the question is whether that would be unusual?  I'm not --

23        Q.   Whether that would be something that you would suspect that what

24     they were telling you wasn't true or that they didn't, in fact, have such

25     difficulties maintaining a train of thought or concentrating for one hour

Page 12612

 1     or two hours?

 2        A.   I don't understand the question.  Whether I expect them to -- to

 3     have that or to not to have that or?

 4        Q.   Well, I'm asking you whether you would find that unusual or

 5     outside of the bounds of what would be expected for someone with a

 6     glioblastoma while undergoing the chemotherapy?

 7        A.   Well, again, it would depend on the location of the tumour.  If

 8     you got a tumour in the frontal lobes, I would really be surprised if

 9     there would be no -- if a patient would tell me, "I've got no problems

10     with maintaining thought" or "maintaining concentration over hours."  If

11     the tumour is in the occipital lobe, which is in the back of the head,

12     that could probably be the case, yeah.

13        Q.   But in either way it would be quite possible or even probable in

14     either of those cases that the person would complain exclusively about

15     their ability to concentrate over a long period, digest information over

16     that long period, engage in executive function over a long period,

17     maintain short-term memory over a long period.  Those wouldn't be

18     unusual?

19        A.   No, that wouldn't be unusual.  In our hospital, if patients

20     complained of that and there is a -- we have different neurological

21     psychological tasks we perform on this patient, I would order a full

22     neuropsychological exam to also examine the range of how long somebody

23     can maintain concentration.  You can just examine that.  Yeah.

24        Q.   Now in answer to question (a)(ii), you say:

25             "In my opinion, Mr. Hadzic will not be able to participate in

Page 12613

 1     trial proceedings for four months during treatment and/or during episodes

 2     with serious side effects like low blood counts," and then you go on.

 3             And it was read by my learned friend opposite, so I won't repeat

 4     it except for the sentence after that where you say:

 5             "The near and median term future is very uncertain for him.  His

 6     physical and neurological condition can change rapidly over time."

 7             Now, when you say "rapidly," do you mean to say that his

 8     condition could change from day-to-day to a significant degree?

 9        A.   Yes, that is possible.  But if I may explain a little bit how

10     that can happen.  At this time -- at this point of time, we -- or I are

11     sort of clueless about in how the treatment is affecting Mr. Hadzic,

12     how -- if the tumour is responding to it.

13             THE INTERPRETER:  The speakers are kindly asked to make pauses

14     between question and answer for the purpose of interpretation.  Thank

15     you.

16             MR. GOSNELL:

17        Q.   I think you can proceed, Dr. Seute.

18        A.   Oh, okay.  So -- where were we.  Oh, the rapidly -- rapidly

19     change in his functioning.  So at this time we don't know whether the

20     treatment is effective.  If we go to a worse-case scenario, then the

21     treatment is not effective and tumour is growing inside his brain.  You

22     might say, well, we will notice that from the outside.  He will have

23     cognitive dysfunction or he will have neurological deficient or he will

24     have another seizure.  That doesn't have to happen.  Mostly it doesn't

25     even happen.  Mostly what we notice is when the -- a tumour cell grows

Page 12614

 1     notice brain, then the healthy neurons will start swelling in the brain

 2     and brain edema will develop.  That develops really rapidly and that's

 3     why patients can deteriorate in days.  It's not the tumour growth itself

 4     that will be notable.

 5        Q.   And in answer to my learned friend, you described that the

 6     consequences or side effects of the Temozolomide treatment can be felt --

 7     in fact, is characteristically felt during the rest period, and that

 8     includes low blood platelets.

 9        A.   Um-hm.

10        Q.   Now, I don't know whether you've seen the medical report of the

11     18th of February, 2015, but the indication in that report is that:

12             "The chemotherapy has had to be postponed due to a negative

13     effect on the bone marrow leaving him with a serious platelet deficiency.

14     He has shown a small recovery.  The platelet numbers are increasing."

15             Now as I understand it, the platelets were low enough that the

16     chemotherapy was terminated on the 21st of January.  So that means, as I

17     understand it, that the platelets levels have been below the minimum

18     between the 21st of January and the date of this report, the 18th of

19     February.  Now, is that a negative prognostic indicator about his ability

20     to successfully undergo the rest of the chemotherapy and --

21        A.   Well --

22        Q.   -- and can his anticipated life expectancy?

23        A.   That's hard to answer right now because if his -- if his

24     platelets go up within a week, then I assume that Professor Taphoorn will

25     continue giving him chemotherapy.  And then, of course, you have to be

Page 12615

 1     really careful with, like, the dosage of the chemotherapy because you

 2     know Mr. Hadzic is prone to develop low platelets, have bone marrow

 3     suppression.  But it's not necessarily that the -- that the next cycles

 4     will fail, you know.  This can be a temporarily problem, and we've seen

 5     that patients are sometimes able to succeed six cycles of chemotherapy

 6     also with having these platelet drops in the first period.  That is

 7     because this is a different regimen.  You know, his first treatment was

 8     totally different -- different regimen with daily chemotherapy combined

 9     with radiotherapy.

10        Q.   But this would be an example of what you were describing earlier;

11     namely, the platelet levels decreasing at some period after the

12     administration --

13        A.   Yeah.

14        Q.   -- or ingestion of the drug and having that effect continue for a

15     considerable period.  And in fact, here it seems it has spanned almost

16     the entire recovery period of the first cycle.

17        A.   Yeah.

18        Q.   Is that correct?

19        A.   That's correct.

20        Q.   Now, I'd like to just ask you a couple of questions, and I'm not

21     going to enlighten you about the specific details about what goes on in a

22     trial here.  But I would like to ask you about a more generic example

23     that may be more familiar to you and to consider someone who is, for

24     example, taking a seminar at the Utrecht University, and this seminar

25     requires them to participate for a two-hour period and do, let's say, 200

Page 12616

 1     pages of reading per class.  And you have a person who comes to you with

 2     glioblastoma and they are taking the chemotherapy, and they say, "Doctor,

 3     I feel generally all right, but I cannot maintain my concentration

 4     sufficiently to do all of these readings and to be able to follow the

 5     class and occasionally to intervene."

 6             Now, can I first of all ask you would that be an unusual set

 7     of -- or description or self-reporting by the person of how they are able

 8     to function under these circumstances, and assume that the person has the

 9     profile of Mr. Hadzic?

10        A.   No, that would not be unusual.

11        Q.   Now, let's say the professor in the class decided that they

12     didn't want to take the person's word for that, and they came to you and

13     they said, "Dr. Seute, I don't believe that what this person is saying is

14     true" or "maybe I believe what they are saying is true, but I'd

15     nonetheless like to double-check and see precisely what is their

16     performance level in relation to this seminar."

17             Now, first of all, is there a test that you could or would

18     administer to try to give some kind of a score or a measure in relation

19     to that task?  Is that possible, medically?

20        A.   Yes, that's possible medically.  Actually, you could perform,

21     again as I stated, a neuropsychological examination.  That's an

22     examination of a couple of hours, at least in our university hospital,

23     and then you can address these issues.

24        Q.   The Montreal Cognitive Assessment would be totally inappropriate

25     for that; correct?

Page 12617

 1        A.   Yes.

 2        Q.   Now you also say in your report that -- and it's in respect of

 3     the questions I was asking you earlier about variability.  And if this

 4     student came to you and said I am having this problem, how long would the

 5     tests -- or let's not say the student.  Let's say the professor.  How

 6     long would the test take to perform in order to achieve some kind of a

 7     score about this person's capacities?

 8        A.   You mean how long would a neuropsychological examination take?

 9        Q.   Yes.

10        A.   Three to four hours.

11        Q.   And then is it possible that the person's capacities are varying

12     from day-to-day?

13        A.   Yes, but well trained neuropsychologists take all that kind of

14     information into account.  Before making a report about the cognitive

15     function, you also have to take into account the pre-illness level of a

16     patient, and they are really trained to do that.  Yeah.

17        Q.   So it would certainly be possible for someone one day to have a

18     certain level of mid- to long cognitive capacity which changes over the

19     course of several days?

20        A.   Yes, of course.  That's also the case with healthy persons.  If

21     you're tired, your capacity to concentrate diminish.  If for patients

22     with neurological illness, irrespective of whether it's a tumour or a

23     haemorrhage, this fluctuates through the day.  Yeah.  That's why I said

24     it's very hard to predict for the long-term how it's going to be.  Yeah.

25        Q.   And it's very difficult to measure over an extended period

Page 12618

 1     because it could change; isn't that right?

 2        A.   Yes, that's right.  And it's very hard at this time to predict or

 3     to even say something about Mr. Hadzic because we don't even know, you

 4     know, what his status is at this moment.

 5        Q.   Now, I'd just like to ask you a few questions about prognosis.

 6        A.   Um-hm.

 7        Q.   And you've confirmed today what you said in your report, that the

 8     median survival is 12 to 14 months.  Is the starting point for that

 9     median the beginning of radiotherapy?

10        A.   No, the starting point is the -- they had two different trials,

11     because these are again trial numbers, trial figures.  The starting point

12     is the day the diagnosis was made by the pathologist, so the day of

13     surgery, the day of biopsy.  That's the starting date.

14        Q.   And you talked a little bit about progression in response to some

15     questions by my learned friend.  Do you know the median time to

16     progression for students -- patients with glioblastoma, multiform?

17        A.   Depends if you go to general, for the general population, so all

18     sorts of patients are involved in this -- in this illness, so the older

19     patients, the younger patients, then the median time to progression is

20     around six months.

21        Q.   And I think that the Stupp report that you referred to as a

22     landmark, the median time to progression in that study where the median

23     age was 56, the median time to progression was seven months; is that

24     right?

25        A.   That's correct.

Page 12619

 1        Q.   And would you agree that progression is usually, not always, but

 2     usually associated with a steep decline in physical and cognitive

 3     condition?

 4        A.   I think it's too harsh to say "usually," and that is because in

 5     my experience, and I know that's also the way Professor Taphoorn works,

 6     we perform quite a lot of MRI scans once we started.  Every three months

 7     we look at these patients.  A lot of times we see progression on the scan

 8     before patients will experience complaints from that progression.  And of

 9     course from -- taken from the point of the landmark study of Stupp,

10     that's 2005, you know, a lot of -- fortunately, a lot of progress has

11     been made, and we start second-line treatments, experimental treatments.

12             So I would say regularly we see that patients decline after --

13     physically after progression of disease, yeah.

14        Q.   And cognitively?

15        A.   Depending on the -- on the location of the tumour.

16        Q.   It's not unusual that there is a decline in cognitive and

17     physical condition around the --

18        A.   No.

19        Q.   -- time of progression; is that right?

20        A.   That's right.

21             MR. GOSNELL:  Thank you, Mr. President.  Those are my questions.

22             JUDGE DELVOIE:  Thank you, Mr. Gosnell.

23                           Questioned by the Court:

24             JUDGE DELVOIE:  Dr. Seute, I have a few questions as well, and

25     they might appear to you as repetitive but that is probably because we


Page 12620

 1     need a little bit more time to understand all these things that we are

 2     not used to handle.

 3             In your report, you have indicated that Mr. Hadzic will not be

 4     able to participate in trial proceedings during treatment and/or during

 5     episodes with serious side effects like low blood counts.

 6        A.   Um-hm.

 7             JUDGE DELVOIE:  There are two elements here.  During treatment,

 8     on the one hand; and on the other hand, during episodes with serious side

 9     effects like low blood counts.  Am I correct in reading this as serious

10     side effects, like low blood counts, can occur during the treatment days

11     but they could also occur or continue during nontreatment days; is that

12     correct?

13        A.   Yes, that's correct.  And then I specifically refer to the blood

14     count.  They drop after the therapy is given.

15             JUDGE DELVOIE:  Yes.  Yesterday Dr. Cras told us that in general

16     the side effects other than the blood count are related to the time of

17     administration of the drug, so they occur shortly after administration

18     but would probably last throughout the day.  Would you agree with that

19     assessment?

20        A.   I would agree with that assessment if you refer to the nausea and

21     vomiting.  Vomiting is very rare with this kind of chemotherapy.

22     However, the fatigue, which is explained by bone marrow suppression, you

23     know, your body has to work hard to keep up your blood count, that

24     patients experience that, well, yes, during treatment, but mostly after

25     the treatment, and that's an experience that's not in the books.

Page 12621

 1             JUDGE DELVOIE:  Yes.  I would come back now to that, to the blood

 2     count.  And with regard to that problem, Dr. Cras explained to us

 3     yesterday that this side effect does not have an influence on the

 4     patient's physical status.  The reduction of blood platelets, he told us,

 5     and reduction of white blood cells leads to an increased tendency to

 6     bleed and increased tendency to have an infection.

 7        A.   Yes, that's correct.

 8             JUDGE DELVOIE:  You would agree?

 9        A.   Yes, that's correct.  However -- you know, let me explain

10     differently:  The fact that if I have a low blood count, you wouldn't see

11     anything from the outside.  If I were to fall, I wouldn't bleed to death.

12     Nothing would happen.  However, there's another mechanism there.  Your

13     bone marrow production, your blood cell production we all have, is making

14     all of hours.  And that's -- that's not what I'm thinking, that's not a

15     hypothesis, that's what's going on in your body.  Chemotherapy is

16     directed to dividing cells.  Tumour growth is dividing cells.  It's

17     nothing more, nothing else.  Chemotherapy will go and try to address all

18     cells in your body that are dividing.  Well, as mature persons, of

19     course, most organs don't have dividing cells any more, but the bone

20     marrow, so that's where the blood cells are generated, has constantly

21     dividing cells and your chemotherapy is trying to diminish that.  So the

22     production is going up anyway, and that's what the fatigue causes.  Not

23     the fact that the blood platelets are low, no, but the bone marrow

24     production has to go up.

25             However, the fatigue, if I may elaborate a little bit on that.


Page 12622

 1     It's, as I stated before, it's very much based on individuals.  I mean,

 2     some person doesn't experience fatigue at all or only to a very, very

 3     small amount.  Other persons have to rest for several hours during the

 4     day.

 5             JUDGE DELVOIE:  Thank you very much.

 6             If there are no further questions from the parties, Dr. Seute,

 7     thank you very much for coming to The Hague to assist the Tribunal.  You

 8     are now released as a witness and the court usher will escort you out of

 9     the court.  Thank you very much.

10             THE WITNESS:  Thank you.

11                           [The witness withdrew]

12             JUDGE DELVOIE:  Before we adjourn, the Chamber would like to put

13     a few questions to the Defence with regard of their request for

14     provisional release.

15             First question is this:  Who will serve as Mr. Hadzic's doctor in

16     Novi Sad eventually?  You should indicate -- one moment, please.

17                           [Trial Chamber and legal officer confer]

18             JUDGE DELVOIE:  Perhaps it's a good idea, indeed, to go into

19     closed session now -- private.  Private session will be sufficient.

20     Thank you.

21                            [Private session]

22   (redacted)

23   (redacted)

24   (redacted)

25   (redacted)

Page 12623











11 Pages 12623-12625 redacted. Private session.
















Page 12626

 1   (redacted)

 2   (redacted)

 3   (redacted)

 4   (redacted)

 5   (redacted)

 6                           --- Whereupon the hearing sine die at 3.40 p.m.