Nasopharyngeal Carcinoma In Individuals Research Articles

Effect of machine learning-based integration develops M2 macrophage-activation genes signature on outcomes in nasopharyngeal carcinoma.

e14581 Background: The M2 macrophages are independent prognostic factors in nasopharyngeal carcinoma (NPC). Nevertheless, the clinical significance of M2 macrophages remains largely unexplored. Methods: We applied public single-cell sequencing data (GSE150825) to reconstruct a pseudotime trajectory of macrophage polarization in NPC and analyzed the gene expression patterns along the trajectory. GeneSwitches was used to identify the order of the critical regulatory gene during M2 macrophage activation. A novel computational framework was constructed to screen the M2 macrophage-activation genes (MAGens) for developing MAGens signature by integratively analyzing the transcriptomes data of single-cell, published dataset (GSE102349, N=88) and Fujian NPC dataset (N=188) using 10 machine learning algorithms (101 combinations). Results: Combining single-cell transcriptomics with GeneSwitches analyse, we identified SPP1 as the top switching gene and the order at which the switch takes place for the state of M2 macrophage activation. At the bulk transcriptome level, we found that the high expression of SPP1 had poor prognosis and more infiltration of M2 macrophages. Immunohistochemistry was used to validate the association between the critical regulatory gene expression and M2 macrophages. Then we analyzed the differential expressed genes (DEGs) upregulated by M2 macrophages at the single-cell transcript level. And the NPC transcriptome data was used to identify SPP1-related genes and prognostic genes. Based on the share genes of M2 macrophage DEGs，SPP1-related genes and prognostic genes, we established a five-gene MAGens signature which exhibited highly diagnostic accuracy in predicting progression-free survival in patients with NPC. Conclusions: We explored the role of SPP1 in NPC progression, M2 macrophage polarization and established an MAGens signature related prognostic model for NPC. MAGens signature could serve as a robust and promising tool to improve clinical outcomes for individual NPC patients.

Deep learning for risk prediction in patients with nasopharyngeal carcinoma using multi-parametric MRIs

BackgroundMagnetic resonance images (MRI) is the main diagnostic tool for risk stratification and treatment decision in nasopharyngeal carcinoma (NPC). However, the holistic feature information of multi-parametric MRIs has not been fully exploited by clinicians to accurately evaluate patients. ObjectiveTo help clinicians fully utilize the missed information to regroup patients, we built an end-to-end deep learning model to extract feature information from multi-parametric MRIs for predicting and stratifying the risk scores of NPC patients. MethodsIn this paper, we proposed an end-to-end multi-modality deep survival network (MDSN) to precisely predict the risk of disease progression of NPC patients. Extending from 3D dense net, this proposed MDSN extracted deep representation from multi-parametric MRIs (T1w, T2w, and T1c). Moreover, deep features and clinical stages were integrated through MDSN to more accurately predict the overall risk score (ORS) of individual NPC patient. ResultA total of 1,417 individuals treated between January 2012 and December 2014 were included for training and validating the end-to-end MDSN. Results were then tested in a retrospective cohort of 429 patients included in the same institution. The C-index of the proposed method with or without clinical stages was 0.672 and 0.651 on the test set, respectively, which was higher than the that of the stage grouping (0.610). ConclusionsThe C-index of the model which integrated clinical stages with deep features is 0.062 higher than that of stage grouping alone (0.672 vs 0.610). We conclude that features extracted from multi-parametric MRIs based on MDSN can well assist the clinical stages in regrouping patients.

Plasma Macrophage Migration Inhibitory Factor and CCL3 as Potential Biomarkers for Distinguishing Patients with Nasopharyngeal Carcinoma from High-Risk Individuals Who Have Positive Epstein-Barr Virus Capsid Antigen-Specific IgA

PurposeThe purpose of this study was to identify novel plasma biomarkers for distinguishing nasopharyngeal carcinoma (NPC) patients from healthy individuals who have positive Epstein-Barr virus (EBV) viral capsid antigen (VCA-IgA).Materials and MethodsOne hundred seventy-four plasma cytokines were analyzed by a Cytokine Array in eight healthy individuals with positive EBV VCA-IgA and eight patients with NPC. Real-time polymerase chain reaction, Western blotting, enzyme-linked immunosorbent assay (ELISA), and immunohistochemistry were employed to detect the expression levels of macrophage migration inhibitory factor (MIF) and CC chemokine ligand 3 (CCL3) in NPC cell lines and tumor tissues. Plasma MIF and CCL3 were measured by ELISA in 138 NPC patients, 127 EBV VCA-IgA negative (VN) and 100 EBV VCA-IgA positive healthy donors (VP). Plasma EBV VCA-IgA was determined by immunoenzymatic techniques.ResultsThirty-four of the 174 cytokines varied significantly between the VP and NPC group. Plasma MIF and CCL3 were significantly elevated in NPC patients compared with VN and VP. Combination of MIF and CCL3 could be used for the differential diagnosis of NPC from VN cohort (area under the curve [AUC], 0.913; sensitivity, 90.00%; specificity, 80.30%), and combination of MIF, CCL3, and VCA-IgA could be used for the differential diagnosis of NPC from VP cohort (AUC, 0.920; sensitivity, 90.00%; specificity, 84.00%), from (VN+VP) cohort (AUC, 0.961; sensitivity, 90.00%; specificity, 92.00%). Overexpressions of MIF and CCL3 were observed in NPC plasma, NPC cell lines and NPC tissues.ConclusionPlasma MIF, CCL3, and VCA-IgA combination significantly improves the diagnostic specificity of NPC in high-risk individuals.

A GWAS Meta-analysis and Replication Study Identifies a Novel Locus within CLPTM1L/TERT Associated with Nasopharyngeal Carcinoma in Individuals of Chinese Ancestry.

Genetic loci within the major histocompatibility complex (MHC) have been associated with nasopharyngeal carcinoma (NPC), an Epstein-Barr virus (EBV)-associated cancer, in several GWAS. Results outside this region have varied. We conducted a meta-analysis of four NPC GWAS among Chinese individuals (2,152 cases; 3,740 controls). Forty-three noteworthy findings outside the MHC region were identified and targeted for replication in a pooled analysis of four independent case-control studies across three regions in Asia (4,716 cases; 5,379 controls). A meta-analysis that combined results from the initial GWA and replication studies was performed. In the combined meta-analysis, rs31489, located within the CLPTM1L/TERT region on chromosome 5p15.33, was strongly associated with NPC (OR = 0.81; P value 6.3 × 10(-13)). Our results also provide support for associations reported from published NPC GWAS-rs6774494 (P = 1.5 × 10(-12); located in the MECOM gene region), rs9510787 (P = 5.0 × 10(-10); located in the TNFRSF19 gene region), and rs1412829/rs4977756/rs1063192 (P = 2.8 × 10(-8), P = 7.0 × 10(-7), and P = 8.4 × 10(-7), respectively; located in the CDKN2A/B gene region). We have identified a novel association between genetic variation in the CLPTM1L/TERT region and NPC. Supporting our finding, rs31489 and other SNPs in this region have been reported to be associated with multiple cancer sites, candidate-based studies have reported associations between polymorphisms in this region and NPC, the TERT gene has been shown to be important for telomere maintenance and has been reported to be overexpressed in NPC, and an EBV protein expressed in NPC (LMP1) has been reported to modulate TERT expression/telomerase activity. Our finding suggests that factors involved in telomere length maintenance are involved in NPC pathogenesis.

Immunogenetics of nasopharyngeal carcinoma

Nasopharyngeal carcinoma (NPC) is a complex multifactorial disorder involving both genetic and environmental factors. Genetic predisposition linked to the immune system has been associated with various tumors. This involves genetic diversity of the genes encoding the molecules of the immune response such as inflammation and anti-tumor surveillance. In this work, we examined the impact of the immunogenetic diversity on the risk of the NPC in different populations studied. These data show that the interindividual variability of the genetic regulation of immune processes increases the risk of NPC in individuals previously predisposed due to other risk factors (genetic / environmental). This synthesis, in addition to the predictive aspects, could provide innovative research for the development of new therapeutic approaches.

Evaluation of plasma Epstein‐Barr virus DNA load to distinguish nasopharyngeal carcinoma patients from healthy high‐risk populations in Southern China

The utility of circulating Epstein-Barr Virus (EBV) DNA as a tumor marker for nasopharyngeal carcinoma (NPC) detection suggests that it might improve the diagnostic performance of anti-EBV antibody markers in NPC screening. In this study, the authors evaluated whether circulating EBV DNA load is capable of distinguishing NPC patients from high-risk individuals who have positive anti-EBV antibodies. In a population-based NPC screening trial in Sihui City and Zhongshan City, Guangdong Province, China, the authors previously identified 862 high-risk participants with 2 screening markers, immunoglobulin A (IgA) antibodies to EBV capsid antigen (VCA/IgA) and nuclear antigen-1 (EBNA1/IgA). In the current study, real-time polymerase chain reaction was used to measure the baseline plasma EBV DNA load among 825 participants (97%). Follow-up was extended to the end of 2011 to evaluate the diagnostic and predictive values of plasma EBV DNA load. By using 0 copies/mL as the cutoff value, plasma EBV DNA had a sensitivity of 86.8% (33 of 38 patients) for NPC detected within the first year of follow-up, yielding a positive predictive value of 30% (33 of 110 participants) and a negative predictive value of 99.3% (696 of 701 participants). The patients who had early stage NPC had lower sensitivity (81.5%; 22 of 27 patients) than those who had advanced NPC (100%; 11 of 11 patients). For the 14 patients who had NPC detected after 1 year of follow-up, only 50% (7 of 14 patients) tested positive for EBV DNA at baseline. The plasma EBV DNA load may improve the accuracy of diagnosing NPC in high-risk individuals, but it appears to have limited value in screening patients who have early stage NPC and predicting NPC development.

Nasopharyngeal carcinoma incidence and mortality in China in 2009

Nasopharyngeal carcinoma (NPC) is rare globally but common in China and exhibits a distinct ethnic and geographic distribution. In 2009, the National Central Cancer Registry in China provided real-time surveillance information on NPC. Individual NPC cases were retrieved from the national database based on the ICD-10 topography code C11. The crude incidence and mortality of NPC were calculated by sex and location (urban/rural). China's population in 1982 and Segi's world population structures were used to determine age-standardized rates. In regions covered by the cancer registries in 2009, the crude incidence of NPC was 3.61/100,000 (5.08/100,000 in males and 2.10/100,000 in females; 4.19/100,000 in urban areas and 2.42/100,000 in rural areas). Age-standardized incidences by Chinese population (ASIC) and Segi's world population (ASIW) were 2.05/100,000 and 2.54/100,000, respectively. The crude mortality of NPC was 1.99/100,000 (2.82/100,000 in males and 1.14/100,000 in females; 2.30/100,000 in urban areas and 1.37/100,000 in rural areas). The age-standardized mortalities by Chinese population (ASMC) and world population (ASMW) were 1.04/100,000 and 1.35/100,000, respectively. The incidence and mortality of NPC were higher in males than in females and higher in urban areas than in rural areas. Both age-specific incidence and mortality were relatively low in persons younger than 30 years old, but these rates dramatically increased. Incidence peaked in the 60-64 age group and mortality peaked in the over 85 age group. Primary and secondary prevention, such as lifestyle changes and early detection, should be carried out in males and females older than 30 years of age.

A Study on the Correlation of HLA-DPA1 and-DPB1 Polymorphisms With Nasopharyngeal Carcinoma in the Southern Chinese Han Population

Objective To study the correlation of HLA-DPA1 and-DPB1 polymorphisms with nasopharyngeal carcinoma (NPC) in the southern Chinese Han population.Methods From February to July 2012,a total of 74 patients who diagnosed as NPC by pathological examination in Guangxi Wuzhou Red Cross Hospital and Shenzhen Armed Police Hospital were included in this study as study group.And during the same period,a total of 160 healthy donors who were selected by computer randomly in Shenzhen blood center were included in this study as control group (The study protocol was approved by the Ethical Review Board of Investigation in Human Being of our hospital).Both the study group and control group were from southern Chinese Han.All the samples were subjected to sequencing-based typing (PCR-SBT) at exon 2 of HLA-DPA1 and-DPB1 genes in both directions.The allelic frequencies of HLA-DPA1 and-DPB1 loci for the NPC patients were compared with control group by x2 test,the P value and relative risk (RR) value were calculated according to the Wolf method.Results A total of 4 HLA-DPA1 alleles (DPA1 * 01:03,02:01,02:02 and 04:01) were identified in both study group and control group.As for the highly polymorphic HLA-DPB1 locus,14 HLA-DPB1 alleles in the NPC patient group and 18 DPB1 alleles in the healthy controls were identified.The allele frequencies for both HLA-DPA1 and-DPB1 loci showed no significant differences between study group and control group (x2＜3.84,P＞0.05).Conclusions The present study implied that the polymorphisms of HLA-DPA1 and-DPB1 showed no independent association with NPC in the southern Chinese Han individuals. Key words: human leukocyte antigens; HLA-DP; allelic polymorphisms; sequencing based typing; nasopharyngeal carcinoma

Functional polymorphism in the 5′-UTR of CR2 is associated with susceptibility to nasopharyngeal carcinoma

Epstein-Barr virus (EBV)-associated nasopharyngeal carcinoma (NPC) is a squamous cell cancer endemic in Southern China and Southeast Asia. It has been shown that inflammatory and immune responses during EBV infection contribute to the development of NPC. The complement receptor 2 (CR2) gene plays central roles during inflammatory and immune responses and, therefore, is a good candidate susceptibility gene for NPC. We performed PCR-based sequencing to identify multiple single-nucleotide polymorphisms (SNPs) within the exon regions of the CR2 gene in a Cantonese population. Two SNPs were screened in 528 NPC patients and 408 normal individuals to perform a case-control study matched according to age, gender and residence. Furthermore, we cloned the entire 5′-UTR and entire CR2 promoter into a luciferase report system and compared the luciferase activities between the different allelic constructs. A SNP in the 5′-UTR of CR2 (24 T/C, rs3813946) showed a significant association (P<0.01) with NPC in the Cantonese population studied. The subjects were categorized into 2 age groups: group 1, age ≤45 years and group 2, age >45 years. In group 1, the allelic frequencies of 24 T/C in the patients were significantly different from those of the controls (P=0.0034). The odds ratio (OR=1.81) also indicated a higher risk of NPC in individuals who carried the minor allele C. All constructs exerted allelic differences on luciferase activities, but only the susceptible allele +24C construct showed increased activity. Our findings implicate CR2 as a susceptibility gene for NPC and suggest that enhanced CR2 expression may be involved in the oncogenesis and development of NPC.

Early detection of nasopharyngeal carcinoma by plasma Epstein‐Barr virus DNA analysis in a surveillance program

Nasopharyngeal carcinoma (NPC) is prevalent in Southeast Asia. Over the last decade, plasma Epstein-Barr virus (EBV) DNA has been developed as a tumor marker for NPC. In this study, the authors investigated whether plasma EBV DNA analysis is useful for NPC surveillance. In total, 1318 volunteers ages 40 to 60 years were prospectively recruited. Plasma EBV DNA and serology for viral capsid antigen immunoglobulin A (IgA) were measured. Participants who had detectable plasma EBV DNA or positive IgA serology underwent nasal endoscopic examination and a follow-up plasma EBV DNA analysis in approximately 2 weeks. All participants were followed for 2 years to record the development of NPC. Three individuals with NPC were identified at enrolment. All of them were positive for EBV DNA and remained positive in follow-up analysis. Only 1 of those patients was positive for EBV serology. In 1 patient who had NPC with a small tumor confined to the mucosa, the tumor was not detectable on endoscopic examination. Because of a 2-fold increase in plasma EBV DNA on the follow-up analysis, that patient underwent magnetic resonance imaging, which revealed the tumor. Among the participants who did not have NPC but had initially positive plasma EBV DNA results, approximately 66% had negative EBV DNA results after a median of 2 weeks. Plasma EBV DNA analysis proved useful for detecting early NPC in individuals without a clinical suspicion of NPC. Repeating the test in those who had initially positive results differentiated those with NPC from those who had false-positive results. Cancer 2013. © 2013 American Cancer Society.

A miR-151 binding site polymorphism in the 3′-untranslated region of the cyclin E1 gene associated with nasopharyngeal carcinoma

Genetic alterations in nasopharyngeal carcinoma (NPC) have been reported in previous works. However, it remains unclear whether polymorphisms within the miRNA-target binding sites are associated with individual NPC risk. In this study, new experimental and computational approaches were developed to assess the polymorphism frequency distribution within the miRNA sites in NPC patients, and to explore its association with NPC risk. We focused on 220 single-nucleotide polymorphisms (SNPs) in the 3′-untranslated regions (3′UTRs) of 32 genes carrying putative miRNA-binding sites by specialized algorithms. A total of 9 candidate genes were selected for further investigation, which were reportedly overexpressed in NPC, including EGFR, COX2, CCNE1, hTERT, MMP2, MMP9, NF-κB VEGF, and WNT3. SNPs in 3′UTRs were genotyped by direct polymerase chain reaction sequencing of the genomic DNA of 24 cases and 24 controls. Then, EGFR rs884225, CCNE1 rs3218073, and MMP2 rs7201 were screened with large samples. Based on the analysis of a series of 167 NPC cases and 171 controls from Guangdong Province, statistically significant associations were found between NPC risk and variant genotypes of CCNE1 rs3218073 for TC+TT (OR=1.585; 95% CI=1.023–2.458; P=0.046) and for T-allele (OR=1.464; 95% CI=1.012–2.118; P=0.042). In addition, a significant association among rs3218073 genotype TC (OR=1.959, P=0.043), T-allele (OR=2.123, P=0.006), and primary tumor (T3–T4) was retrieved. Genotype TC (OR=1.959, P=0.043) and T-allele (OR=2.123, P=0.006) of rs3218073 were correlated with increased risk of higher NPC stage (III to IV). In support of the postulation that the 3′UTR SNP directly affected miRNA-binding site, luciferase reporter assay indicated that CCNE1 was a direct target of miR-151, and the rs3218073 T>C change resulted in altered regulation of CCNE1 expression. By contrast, no statistically significant association with NPC risk was found for MMP2 rs7201 and EGFR rs884225 polymorphisms (P>0.05). In conclusion, our data demonstrate that CCNE1 rs3218073 polymorphism located at miRNA-151 binding site is associated with NPC susceptibility and is correlated with NPC stage. These results suggest that CCNE1 rs3218073 polymorphism can be exploited as a novel biomarker for future NPC diagnosis and prognosis.

Gender-specific associations between MICA-STR and nasopharyngeal carcinoma in a southern Chinese Han population

Previous studies have identified several HLA-B specificities that are associated with nasopharyngeal carcinoma (NPC) in populations of Chinese descent, in particular HLA-B35, -B38, -B46, and -B58. Perhaps except for HLA-B46, other associations cannot be simply accounted for by the linkage disequilibrium between HLA-A and B loci. The human major histocompatibility complex (MHC) class I chain-related gene A (MICA) maps 46 kb centromeric to HLA-B and is highly polymorphic; it encodes a stress-inducible protein which functions as a ligand for the NKG2D/DAP10 complex to activate natural killer (NK) cells, gammadelta T cells, and CD8(+) T cells. We postulated MICA gene as a susceptibility factor for nasopharyngeal carcinoma, an Epstein-Barr virus-associated malignancy. In this study, 218 unrelated patients newly diagnosed with NPC and 196 randomly selected healthy controls from southern China mainland were analyzed for the short tandem repeat polymorphism of exon 5 of MICA gene (MICA-STR) and MICA gene deletion, using fluorescent polymerase chain reaction-gene scanning (PCR/size-sequencing) and polymerase chain reaction-sequence-specific priming (PCR/SSP) technology. MICA*A9 was present at significantly increased frequency in the patient group (P (C)=0.0001002, OR=2.528, 95% CI=1.636-3.907), whereas the frequency of MICA*A5.1 was significantly decreased (P (C)=0.006, OR=0.594, 95% CI=0.437-0.806). Gender-based stratification revealed a significant increase of MICA*A9 frequency (P (C)=0.000072, OR=3.255, 95% CI=1.855-5.709) and a significant decrease of MICA*A5.1 frequency (P (C)=0.000737, OR=0.486, 95% CI=0.337-0.702) in male patients with NPC (N=166), compared with male normal controls (N=120). A significant interaction between MICA*A9 and gender was observed ([see text]=41.58, P=0.0001). Statistics also revealed heterogeneity of effects among MICA*A5.1/MICA*A9-bearing phenotypes and a dose-dependent effect of MICA*A5.1 and MICA*A9 on NPC risk in male subgroup. This constitutes the first demonstration of a gender-specific association between MICA-STR polymorphism and NPC, which could largely be attributable to the underlying gender-related mechanisms that modulate MICA gene expression. The results provide strong supporting evidence suggesting that MICA*A9 may be a genetic risk factor for NPC in male individuals in this population. The potential interaction between MICA and other non-HLA host factors and environmental exposures remains to be further studied.

The Significance of the Expression of CyclinD1 and Ki67 Antigen in Nasopharyngeal Carcinoma

This study was conducted to detect the expression of cyclinD1 and Ki67 in nasopharyngeal carcinoma (NPC) and their correlation with the biological and prognosis. 56 cases of biopsy specimens of NPC which had been embedded with paraffin in 1996 in our hospital were collected and immunostained with cyclinD1 and Ki67 monoclonal antibodies by means of the streptavidin peroxides method. The patients were followed up periodically, and then their biological behaviors and prognosis were statistically analyzed. The percentage of cyclinD1 and Ki67 positive cells in the NPC specimens ranged from 0–54% and 0–31% respectively. The staining was nuclear. Of the 56 cases, 30 cases (56.6%) highly expressed cyclinD1 or Ki67 HPI and 26 cases (46.4%) lowly expressed cyclinD1, while only 16cases (28.6%) showed Ki67 HPI and 40 cases (71.4%) showed Ki67 LPI. Patients who lowly expressed cyclinD1 or highly expressed Ki67 had a higher radiosensitivity and a better prognosis. Based on these findings, cyclinD1 and Ki67 immunohistochemical staining is considered to be useful, not only as an independent factor of radiosensitivity and prognosis respectively, but also as a means of determining the optimum treatment for each individual patient NPC.

Linear epitopes of the replication-activator protein of Epstein-Barr virus recognised by specific serum IgG in nasopharyngeal carcinoma.

The linear antigenic epitopes of the Epstein-Barr virus replication activator protein (ZEBRA), recognised by specific serum IgG in nasopharyngeal carcinoma (NPC), were determined. This was achieved by synthesizing the entire amino acid sequence of ZEBRA as a set of 29, 22-residue peptides with an overlap of 14 amino acids. The ZEBRA peptides were tested in enzyme-linked immunosorbent assay (ELISA) for IgG binding in sera from 37 selected NPC patients who had IgG antibodies to the native ZEBRA protein. The most immunogenic epitope was peptide 1 at the amino-terminal end with 36 of the sera reactive against it. Further analysis of peptide 1, using the multipin peptide-scanning technique, defined a 10-amino-acid sequence FTPDPYQVPF, which was strongly bound by IgG. Two other regions of ZEBRA were also identified as immunodominant IgG epitopes, namely peptide 11 (amino acids 82-103) and peptide 19/20 (amino acids 146-175) with 8-13 of the NPC sera reactive against the peptides. The number of peptides reactive with individual NPC serum varies from 1 to 6 or more and there is some correlation between a greater number of peptide (at least 4) bound and a higher (at least 1:40) titre of serum IgA to viral capsid antigen. The immunodominant ZEBRA peptide 1 could be utilised in IgG ELISA for the detection of NPC.

Factors affecting serum IgA antibody to Epstein-Barr viral capsid antigens in nasopharyngeal carcinoma

Irrespective of the ethnic origin of the patient, nasopharyngeal carcinoma (NPC), appears to stimulate the production of IgA antibodies against VCA. These antibodies are detected at high frequency and titres in sera from NPC patients but only rarely from control subjects. A majority of relapse-free survivors tested 1-12 years after radiotherapy (RT) sustain a detectable level of IgA anti-VCA. Serum titres of IgA anti-VCA remain relatively unchaged in individual NPC patients after RT, regardless of the disease evolution. These antibodies were detected in serum from one individual 9 months before NPC and the titre rose concomitantly with its clinical onset. Titres of IgA anti-VCA in multiple serum specimens from individual NPC patients, and in sera from different NPC patients, do not correlate with titres of IgG anti-VCA or with Serum IgA. It thus seems possible that the IgA anti-VCA in the sera of NPC patients might be largely derived near NPC. Apparently healthy individuals showing detectable IgA anti-VCA tend to aggregate in families of NPC patients. The distribution of siblings of these families who have the IgA anti-VCA reaction shows the binomial distribution expected for an autosomal recessive trait, implying the involvement of an autosomal recessive gene in the IgA anti-VCA response.