Serum CYFRA 21-1 in patients with invasive bladder cancer and its relevance as a tumor marker during chemotherapy

Molecular diagnostics and biomarkers in cholangiocarcinoma

Regardless of anatomic origin, cholangiocarcinoma is generally an aggressive malignancy with a relatively high case fatality. Surgical resection with curative intent remains the best opportunity to achieve meaningful long-term survival. Most patients present, however, with advanced disease and less than 20% of patients are candidates for surgical resection. Unfortunately, even patients who undergo resection have a 5-year survival that ranges from 20 to 40%. Biomarkers are indicators of normal, pathologic, or biologic responses to an intervention and can range from a characteristic (i.e., blood pressure reading which can detect hypertension) to specific genetic mutations or proteins (i.e., carcinoembryonic antigen level). Novel biomarkers and improved molecular diagnostics represent an attractive opportunity to improve detection as well as to identify novel therapeutic targets for patients with cholangiocarcinoma. We herein review the latest advances in molecular diagnostics and biomarkers related to the early detection and treatment of patients with cholangiocarcinoma.

Liquid biopsy in bladder cancer: State of the art and future perspectives

Bladder cancer is the most common malignancy of the urinary tract. Cystoscopy represents the gold standard in the diagnosis of suspicious bladder lesions. However, the procedure is invasive and burdened by pain, discomfort and infective complications. Cytology, which represents an alternative diagnostic possibility is limited by poor sensitivity. Considering the limitations of both procedures, and the necessity to perform multiple evaluations in patients who are in follow-up for bladder cancer, an improved non-invasive methodology is required in the clinical management of this disease. Liquid biopsy, e.g. the detection of clinical biomarkers in urine, represent a promising novel and non-invasive approach that could overcome those limitations and be integrated into the current clinical practice. The aim of this review is to summarize the state of the art of this approach and the latest novelties regarding detection, prognosis and surveillance of bladder cancer.

Exploring the value of pleural fluid biomarkers for complementary pleural effusion disease examination

OBJECTIVE

Pleural fluid biomarkers are beneficial for the complementary diagnosis of pleural effusion etiologies. This study focuses on the multidimensional evaluation of deep learning to investigate the pleural effusion biomarkers value and the diagnostic utility of combining these markers, in distinguishing pleural effusion etiologies.

METHODS

Pleural effusion were divided into three groups according to the diagnosis and treatment guidelines: malignant pleural effusion (MPE), parapneumonic effusion (PPE), and congestive heart failure (CHF). First, the value of the biomarker was analyzed by a receiver operating characteristic (ROC) curve. Then by utilizing deep learning and entropy weight method (EWM), the clinical value of biomarkers was computed multidimensionally for complementary diagnosis of pleural effusion diseases.

RESULTS

There were significant differences in the six biomarkers, TP, ADA, CEA, CYFRA211, NSE, MNC% (p < 0.05) and no significant differences in three physical characteristics including color, transparency, specific gravity and six other biomarkers such as WBC, PNC%, MTC%, pH level, GLU, LDH (p > 0.05) among the three pleural effusion groups. The comprehensive test of pleural fluid biomarkers based on deep learning is of high accuracy. The clinical value of cytomorphology biomarkers WBC, MNC %, PNC %, MTC % was higher among pleural fluid biomarkers.

CONCLUSION

The clinical value of multi-dimensional analysis of biomarkers by deep learning and entropy weight method is different from the ROC curve analysis. It is suggested that during the clinical examination process, more attention should be paid to the cell morphology biomarkers, but the physical properties of the pleural fluid are less clinical significance.

Blood-based protein biomarkers in bladder urothelial tumors

Bladder cancer (BC) is the fifth most common cancer with a high prevalence rate. It is classically classified in two groups, namely non-muscle invasive (NMIBC) and muscle invasive (MIBC). NMIBC accounts for 75% of cases and has a better prognosis than MIBC. However, 30-50% of the NMIBC patients will show recurrences throughout their lives, and about 10-20% of them will progress to MIBC, with frequent metastasis and a reduced survival rate. The diagnosis of bladder cancer is confirmed by direct visualization of the tumour and other mucosal abnormalities with endoscopic excision using cystoscopy and transurethral resection of the bladder (TURBT). An adequate TURBT requires complete resection of all visible tumour with appropriate sampling of the bladder to assess the depth of invasion. However, for many years, researchers have attempted to identify and utilise urinary markers for bladder cancer detection. Voided urine cytology has been the mainstay of urine-based diagnosis of bladder cancer since originally described by Papanicolau and Marshall. Nonetheless, urine cytology has several drawbacks, including a poor sensitivity for low-grade/stage tumours, a lack of interobserver consistency and a variable range of readings (e.g., atypical, atypical-suspicious, non-diagnostic). These shortcomings have inspired the search for more sensitive bladder cancer biomarkers. To bring precision medicine to genitourinary oncology, the analysis of the plasma/serum wide genome and proteome offers promising possibilities.

Diagnostic and Prognostic Potential of Biomarkers CYFRA 21.1, ERCC1, p53, FGFR3 and TATI in Bladder Cancers

The high occurrence of bladder cancer and its tendency to recur in combination with a lifelong surveillance make the treatment of superficial bladder cancer one of the most expensive and time-consuming. Moreover, carcinoma in situ often leads to muscle invasion with an unfavorable prognosis. Currently, invasive methods including cystoscopy and cytology remain a gold standard. The aim of this study was to explore urine-based biomarkers to find the one with the best specificity and sensitivity, which would allow optimizing the treatment plan. In this review, we sum up the current knowledge about Cytokeratin fragments (CYFRA 21.1), Excision Repair Cross-Complementation 1 (ERCC1), Tumour Protein p53 (Tp53), Fibroblast Growth Factor Receptor 3 (FGFR3), Tumor-Associated Trypsin Inhibitor (TATI) and their potential applications in clinical practice.

Development of a novel immunoassay for the simple and fast quantitation of neutrophil gelatinase-associated lipocalin using europium(III) chelate microparticles and magnetic beads

Neutrophil gelatinase-associated lipocalin (NGAL) is a promising biomarker for diagnosing acute kidney injury (AKI). Currently, there are few assays for determining NGAL and they are complex, time-consuming or expensive. We aimed to establish an efficient immunoassay to measure NGAL in human urine simply and rapidly. A novel immunoassay for NGAL determination was established by combining a dissociation-enhanced-free time-resolved fluoroimmunoassay (TRFIA) and immunomagnetic separation. Based on a "sandwich"-type immunoassay format, analytes in samples were captured by a pair of monoclonal antibodies (mAb) in which one mAb was coated in magnetic beads and the other mAb was labeled with europium(III) chelate microparticles (CM-EUs) as "fluorescent reporters". NGAL concentrations were determined in a linear range (10-1500 ng mL^-1) with a limit of detection of 0.32 ng mL^-1. The reproducibility, recovery, and specificity of our TRFIA were acceptable. Our method was compared with that of a chemiluminescence immunoassay (CMIA) using 115 urine samples, and the results showed good correlation (R² = 0.8677). We expect our novel method to be useful for the early diagnosis of AKI.

Diagnostic biomarkers in non-muscle invasive bladder cancer

Successful treatment of non-muscle invasive bladder cancer (NMIBC) relies heavily on our ability to accurately detect disease typically in the presence of hematuria as well as to detect the early recurrent tumors in patients with a history of NMIBC. Unfortunately, the current biomarker landscape for NMIBC is a work in progress. Cystoscopy continues to be the gold standard, but can still miss 10% of tumors. Therefore, physicians frequently use additional tools to aid in the diagnosis of bladder cancer, such as urinary cytology. The urinary cytology is a good option for high-grade disease; however, it is limited by low sensitivity in detecting low-grade disease, as well as variable interpretation among cytopathologists. Thus, the limitations of cystoscopy and urinary cytology have brought to light the need for more robust diagnostic assays. In this non-systematic review, we discuss the performance, potential advantages or disadvantages of these tests, and the future direction of biomarkers in NMIBC.

Evaluation of Cellular Fibronectin Plasma Levels as a Useful Staging Tool in Different Stages of Transitional Cell Carcinoma of the Bladder and Renal Cell Carcinoma

Reliable markers for both renal cell carcinoma (RCC) and transitional cell carcinoma of the bladder (TCC) are lacking.

During tumor progression and invasion components of extracellular matrix (ECM) are degraded and parts of these different components are detectable in plasma. Cellular fibronectin (cFN) represents a well characterized ECM protein. In contrast to fibronectin in plasma produced by hepatocytes (FN) cFN has a total extra domain sequence and occurs in much smaller amounts in the circulation. The aim of our study was to evaluate cFN as a marker and to determine its possible role in clinical staging of TCC and RCC.

Blood samples were collected from 30 patients before they underwent transurethral resection of the bladder because of newly diagnosed TCC. Additionally samples were collected from 69 patients with RCC before therapy. Sixty patients with non-malignant urological disorders were recruited as control group. Determination of cFN in plasma was performed by using a highly sensitive time-resolved fluorescence immunoassay (TRFIA).

The control group had median cFN plasma levels of 437 ng/ml. Patients suffering from TCC or RCC showed significantly higher cFN levels. In patients with muscle invasive TCC significant higher cFN levels (p < 0.05) could be demonstrated compared to non-muscle invasive TCC. Similar results were found in RCC with significant elevated cFN levels in metastatic RCC (p < 0.005) compared to localized stage of disease. No differences were found concerning tumor grading in both malignancies.

In the face of significant elevated cFN levels in TCC and RCC our data underline the important role of cFN. For future investigations the elevated cFN levels in locally progressed and metastastic disease, indicating a clinically useful tool for preoperative staging and postoperative monitoring, are of high interest.

Diagnostic and therapeutic biomarkers in pancreaticobiliary malignancy

Pancreatic ductal adenocarcinoma (PDAC) and cholangiocarcinoma (CCA) are two malignancies that carry significant morbidity and mortality. The poor prognoses of these cancers are strongly related to lack of effective screening modalities as well as few therapeutic options. In this review, we highlight novel biomarkers that have the potential to be used as diagnostic, prognostic and predictive markers. The focus of this review is biomarkers that can be evaluated on endoscopically-obtained biopsies or brush specimens in the pre-operative setting. We also provide an overview of novel serum based markers in the early diagnosis of both PDAC and CCA. In pancreatic cancer, the emphasis is placed on prognostic and theranostic markers, whereas in CCA the utility of molecular markers in diagnosis and prognosis are highlighted.

CYFRA 21-1: a potential molecular marker for noninvasive differential diagnosis of urothelial carcinoma of bladder

Establishing CYFRA 21-1 detection for noninvasive differential diagnosis of urothelial carcinoma (UC) of bladder would help to improve assessment and follow-up of patients, as well as to improve screening of high-risk groups. The study group comprised of 147 subjects including 72 patients with UC of bladder, 75 controls and 17 follow-up cases. The levels of CYFRA 21-1 in serum, urine and urinary cell lysate were estimated by high sensitivity ELISA. Our results indicate that urinary CYFRA 21-1 provides a high value of overall sensitivity for UC of bladder and is also useful even for detection of low grade tumors that might indicate possible earlier detection and treatment administration.

Circulating CYFRA 21-1 is a Specific Diagnostic and Prognostic Biomarker in Biliary Tract Cancer

BACKGROUND: Biliary tract cancer (BTC) has a poor prognosis, in part related to difficulties in diagnosis. Cytokeratin 19 (CK19) is a constituent of the intermediate filament proteins of epithelial cells. CK19 fragments (CYFRA 21-1) are rarely identified in the blood of healthy individuals. We assessed the utility of CYFRA 21-1 as a diagnostic and prognostic marker of BTC. METHODS: Blood was prospectively collected from patients with benign biliary disease (n = 39), primary sclerosing cholangitis (n = 19), PSC-related cholangiocarcinoma (n = 6) and sporadic BTC (n = 60). CYFRA 21-1 levels were measured in duplicate by ELISA. RESULTS: CYFRA 21-1 (≥ 1.5 ng/mL) had a sensitivity of 56% and specificity of 88%, compared with figures of 79% and 78% for CA 19-9 (≥ 37U/mL). Using a higher cut-off of 3 ng/mL, CYFRA 21-1 had a sensitivity of 30% and specificity of 97%. Combination of CYFRA 21-1 (≥ 1.5 ng/mL) and CA 19-9 (≥ 37 U/mL) resulted in sensitivity and specificity of 45% and 96%. In contrast to CA 19-9, CYFRA 21-1 (≥ 3.0 ng/mL) alone was a strong predictor of prognosis (median survival 2 months vs 10 months, p = 0.001). CONCLUSION: Elevated circulating CYFRA 21-1 is a specific, but less sensitive diagnostic marker than CA 19-9, predicts a poor outcome and may act as a surrogate marker of circulating tumor cells in BTC. Further prospective studies of its utility in assessing operability and response to chemotherapy are needed.

Efficacy of transurethral resection of the bladder tumor (TUR-BT) for huge bladder cancer

There are no guidelines regarding whether to perform either a radical transurethral resection of the bladder tumor (TUR-BT) or a total cystectomy after TUR biopsy for huge bladder cancer, and this decision is entrusted to each institution. Of 439 patients in whom TUR-BT was performed from 2005 through 2009, the weight of the total resected volume was > 50 g in 6 patients, and among these 6 patients the following variables were compared: operating time, weight of resected volume, transfusion volume, presence or absence of hydronephrosis, preoperative urinary cytology, serum cytokeratin 19 fragment (CYFRA) level, intraoperative bladder compliance, and histopathological findings. The median age, operating time, weight of resected volume, transfusion volume, and length of follow-up were 72 years, 300 minutes, 88 g, 202 mL, 16 months, respectively. The serum CYFRA level in patients with muscle-invasive cancer (11.8 ng/mL) was higher than that in patients with non-muscle-invasive cancer (5.06 ng/mL). All patients with non-muscle-invasive bladder cancer survived without recurrence. Although the mean length of follow-up was only 16 months (5-59 months), the 1 patient who was followed up for 59 months had no recurrence. In cases of muscle-invasive bladder cancer, all patients, except for a relatively recent patient, have died. In cases without muscle invasion, lymph node metastasis, distal metastasis, or preoperative renal dysfunction accompanied by hydronephrosis, with favorable bladder compliance, we believe that radical TUR-BT should be actively performed to preserve the bladder. A second TUR-BT should be performed in cases of non-muscle-invasive cancer without G3 components to treat the huge bladder cancer.

Serum efficacy biomarkers for oncology

Considerable interest has emerged in serum biomarkers that can be used to evaluate early effects of cancer therapeutics. Such efficacy biomarkers are expected to become valuable both for routine clinical care and for anticancer drug development. Here, we review the literature on serum efficacy biomarkers. We discuss how data using such markers can be interpreted, particularly with regard to the issue of specificity of different markers. An important question is whether biomarker response evaluation is expected to be congruent with evaluation by traditional anatomical methods. We argue that they may not be - biomarkers are expected to provide information with regard to induction of tumor cell death that will not necessarily reflect clinical outcome.

Advanced carcinoma of the prostatic urethra in a patient with marked response to chemotherapy, leading to preservation of the bladder

We performed transurethral resection of the prostate (TUR-P) for a 66-year-old man with benign prostatic hyperplasia. Pathological examination diagnosed poorly differentiated urothelial carcinoma of the urethra with broad prostatic permeation. Random bladder biopsies showed no malignancy, but a second TUR-P revealed urothelial carcinoma in the prostate and bladder neck. Computed tomography (CT) showed lymph node metastases from para-aortic to right/left external iliac and left obturator nodes, so clinical stage T3N2M0 carcinoma of the prostatic urethra was diagnosed. Given the presence of lymph node metastases, neoadjuvant chemotherapy using cisplatin 70 mg/m(2), ifosfamide 1.2 g/m(2) and docetaxel 70 mg/m(2) (PIT) was considered. After chemotherapy, CT showed complete response (CR) of all lymph nodes. Local control in the bladder was considered to be good, so total prostatectomy and retroperitoneal lymph node dissection was selected instead of total cystoprostatectomy. Pathological findings of surgical specimens showed no residual carcinoma in the prostatic urethra or lymph nodes, although prostatic adenocarcinoma was recognized. No recurrences or metastases have been encountered as of 3 years and 5 months since surgery.

Proteomic assays for the detection of urothelial cancer

Bladder cancer is one of the most expensive cancers from diagnosis to death of the patient due to life-long surveillance involving upper tract imaging, urinary cytology, and cystoscopy. Cytology has been historically used in conjunction with cystoscopy to help detect disease that may be missed by routine cystoscopy (e.g., carcinoma in situ and upper tract disease). Urine cytology is highly cytopathologist dependent and has reasonable sensitivity for detecting high grade disease. However, its sensitivity drops precipitously with regard to well-differentiated low grade cancers. Intensive investigations have been undertaken using proteomics to find an alternative to cystoscopy and cytology. Urine proteomic markers currently evaluated critically in the literature include bladder tumor antigen, nuclear matrix protein 22, BLCA-4, hyaluronic acid, hyaluronidase, cytokeratin 8, cytokeratin 18, cytokeratin 19, tissue polypeptide antigen, and tissue polypeptide-specific antigen. Markers used as alternatives to cystoscopy must be accurate with high sensitivity and specificity, cost effective for life-long surveillance, and minimally invasive to minimize the burden to the patient. To date, no proteomic marker has been developed that can replace cystoscopy for the detection of bladder cancer. However, several urinary markers appear to have higher sensitivity albeit lower specificity than cytology and can be used to supplement cystoscopy. Some of those markers are herein described in this chapter. By defining and characterizing the current state of the art in protein based markers, we are poised to evaluate and benchmark newly discovered protein biomarkers that will be isolated through new proteomics based investigations of urine.

Molecular markers for detection, surveillance and prognostication of bladder cancer

Many markers for the detection of bladder cancers have been tested and almost all urinary markers reported are better than cytology with regard to sensitivity, but they score lower in specificity. Currently molecular and genetic changes play an important role in the discovery of new molecular markers for detection, prognostication and surveillance. The purpose of this review is to highlight the most important urinary molecular biomarker developments that have been studied and reported recently. In the current review we have summarized the most recent and relevant published reports on molecular urinary markers. The results of this review show that the first generation of urinary markers did not add much to urinary cytology. The current generation of markers is better, but additional clinical trials are needed. Our knowledge of molecular pathways in bladder cancer is growing and new methods of marker development emerge, but the perfect marker is still to be found. Currently, there are not clinically usable molecular markers that can guide us in diagnosis or surveillance, nor guide us in lowering the frequency of urethrocystoscopy in bladder cancer.

Mesothelin-related predictive and prognostic factors in malignant mesothelioma: a nested case-control study

Soluble mesothelin-related protein (SMRP) in serum is potentially a sensitive marker of malignant mesothelioma (MM) diagnosis and progression, and may be useful as screening marker. Mesothelin expression in tumors is regarded as a sensitive marker for diagnosis and disease progression, and is a candidate prognostic marker. Levels of SMRP, CA125 and CYFRA 21-1 in pre-diagnostic (1-30 years) serum samples from 47 mesothelioma cases and 141 matched controls were analysed. Mesothelin expression in tumors was assessed. The association between biomarker level and mesothelioma risk and survival was analysed, adjusting for asbestos exposure. Survival related to tumor mesothelin expression, age, sex, histological type, location, asbestos exposure and pre-clinical SMRP was analysed. There was no significant association between biomarker levels and mesothelioma risk when analysed as continuous variables or as tertiles. Biomarker levels <10, 10-19 and >or=20 years before diagnosis were not significantly associated to mesothelioma risk. Mesothelin expressed in >50% of tumor cells was seen in 36 of 47 (77%) tumors. Mesothelin expression in <50% of tumor cells was a significant negative prognostic marker in all cases of malignant mesothelioma (median survival=6 months vs. 12 months, hazard ratio (HR)=2.49, 95%CI 1.17-5.27), and also when only epithelial mesothelioma was analysed (median=6 months vs. 14 months, HR=2.36, 95%CI 1.07-5.22). When adjusted for age and gender, the prognosis was still dismal, but non-significant (HR=1.85, 95%CI 0.85-4.05). High age (>65 years) was an independent negative prognostic factor that was related to both mesothelin expression and asbestos exposure. Mesothelioma of the epithelial type of the peritoneum had a significantly longer survival than epithelial type in pleura and was also related to mesothelin expression.

Urinary markers in bladder cancer

OBJECTIVES

Many markers for the detection of bladder cancers have been tested. Almost all urinary markers reported are better than cytology with regard to sensitivity, but they score lower in specificity. The purpose of this review is to highlight the most important urinary biomarkers studied and reported recently.

METHODS

Literature on bladder cancer markers has been reviewed regularly in the last few years. In the current review we have tried to summarise the most recent literature of urinary markers.

RESULTS

The results of this review show that the first-generation urinary markers did not add much to urinary cytology. The current generation of markers is promising but larger clinical trails are needed. The future of marker development is bright with new techniques emerging, but the perfect marker is still to be found.

CONCLUSION

Currently, no single marker can yet guide us in surveillance and lower the frequency of urethrocystoscopy.

Urinary CYFRA 21.1 is not a useful marker for the detection of recurrences in the follow-up of superficial bladder cancer

OBJECTIVES

The objective of this prospective study is to establish an appropriate cutoff value of urinary CYFRA 21.1 assay and to assess its utility combined with voided cytology and/or haemoglobin dipstick in the follow-up of patients with superficial bladder cancer.

METHODS

From December 2000 to November 2003, 446 patients in follow-up for superficial bladder cancer (Ta-T1) after transurethral resection of the bladder (TURB) were included in a prospective study. Voided urine specimens were collected 7-14 d before cystoscopy and/or TURB for CYFRA 21.1 (one sample), haemoglobin dipstick (one sample), and cytology (three samples). All samples were processed for CYFRA 21.1 and haemoglobin dipstick according to manufacturer instructions. A control group (n=185) was obtained from patients in follow-up after transurethral resection of superficial disease (without recurrences within the following 6 mo). There were 125 recurrent transitional tumours detected by cystoscopy (34 TaG1; 53 TaG2/T1G1-2; 23 Ta-1G3/Tis, and 15 T2-4). Receiver operator characteristic (ROC) curves were constructed and cutoff values were chosen. Sensitivity, specificity, PPV (positive predictive value), NPV (negative predictive value), and their 95% confidence intervals were calculated.

RESULTS

ROC curve analysis based on the previously reported cutoff value of 4ng/ml for CYFRA 21.1 demonstrated a sensitivity and specificity of 43% and 68%, respectively. At a cutoff value of 1.5ng/ml, sensitivity was 73.8% with a low specificity (41%). Further lowering of the cutoff point below 1.5ng/ml did not demonstrate a significant increase in sensitivity. Therefore, this value was chosen as the most sensitive CYFRA 21.1 cutoff point during the rest of the study. Specificity increased when all the patients treated with pelvic radiotherapy or with UTI, urethral catheterisation, and intravesical instillations within 3 previous months were not included in our analysis. CYFRA 21.1 plus cytology and the combination of CYFRA 21.1, cytology, and haemoglobin dipstick demonstrated the highest overall sensitivities, and detected 91.3% of Ta-1G3 tumours and 93.3% of T2-4 tumours. However, there were one muscle-invasive tumour, two T1G3/Tis, three T1G2, and nine T1G1 neoplasms with negative combination of cytology and CYFRA 21.1 (1,5ng/ml). All these tumours were smaller than 2cm in size; most were single tumours. Nevertheless, there were 16 tumours larger than 0.5cm (0.5-2cm), and multiple neoplasms were endoscopically detected in 14 patients. Similar results were obtained through the combination of CYFRA 21.1 (cutoff: 1.5ng/ml), cytology, and haemoglobin dipstick.

CONCLUSIONS

In our experience the low sensitivity of urinary CYFRA 21.1, even using lower cutoff values and/or a combination with cytology and/or haemoglobin dipstick, makes its application not very useful as a surveillance tool for superficial bladder carcinoma.

Rapid diagnosis and follow up of bladder cancer patients using urinary high molecular weight cytokeratins

We have developed an office-based dot-EIA for the detection of a urinary high molecular weight cytokeratin (CK). Immunohistochemical staining and western blot based on CK1K10 monoclonal antibody were used to identify the CK. Urine of 192 patients with different types, grades, and stages of bladder tumor and 72 controls were evaluated using dot-EIA. An intense and diffuse cytoplasmic reaction was shown in bladder squamous cell carcinoma. The target epitope was identified in urine at 65, 56, and 40-kDa. The CK purified from urine showed single polypeptide at 65-kDa using SDS-PAGE and single peak at 7.4 min using capillary zone electrophoresis. The dot-EIA detected the CK with high sensitivity (97%) and specificity (94%). The CK was not detected in urine of bladder cancer patients showing response to radiotherapy. The sensitive and specific office-based detection of urinary cytokeratin would be helpful in rapid diagnosis and follow up of bladder carcinoma.