SUVmax is the count in the most active pixel in the VOI, and it was calculated from the counts per pixel and normalized to body weight (BW), using the following formulas: SUV(BW)=Tissue activity (KBq/ml)Injected activity (MBq)/weight (Kg), while SUVmean is the average of the counts in all pixels in the VOI. Chi-square test (Fishers exact test) was used to examine the relation between qualitative variables. The conventional surgical procedure for lung adenocarcinoma is lobotomy with systematic mediastinal CT was done from the base of the skull to the mid-thighs with the arm extended above the head. By using this website, you agree to our The 5-year survival rate for all people with Hodgkin lymphoma is 87%. A Biblioteca Virtual em Sade uma colecao de fontes de informacao cientfica e tcnica em sade organizada e armazenada em formato eletrnico nos pases da Regio Latino-Americana e do Caribe, acessveis de forma universal na Internet de modo compatvel com as bases internacionais. Other substances may be used for PET scanning, depending on the purpose of the scan. blood pool) and the liver. Barrington SF, Mikhaeel NG, Kostakoglu L et-al. Involved extra-nodal sites are illustrated in Table 3. Role of Imaging in the Staging and Response Assessment of Lymphoma: Consensus of the International Conference on Malignant Lymphomas Imaging Working Group. Below are the 5-year relative survival rates for two common types of NHL - diffuse large B-cell lymphoma (DLBCL) and follicular lymphoma (FL) - based on people . Eur J Nucl Med Mol Imaging 42(4):623633. 2. PURPOSE Accurate stratification of patients is an important goal in Hodgkin lymphoma (HL), but the role of pretreatment clinical risk stratification in the context of positron emission tomography (PET) -adapted treatment is unclear. Version A B Submitted Date Changes; 1: October 13, 2017: None (earliest Version on record) 2: November 22, 2017: Recruitment Status, Study Status and Contacts/Locations: 3: November 30, 2017: Study Status, Contacts/Locations and Study Identification Check for errors and try again. Deauville score versus ratio Deauville score in the interpretation of interim 18F-FDG PET-CT and in prediction of outcome in children with FDG-avid extra-nodal lymphomas, https://doi.org/10.1186/s43055-022-00899-6, Egyptian Journal of Radiology and Nuclear Medicine, https://doi.org/10.1007/s00259-014-2973-6, https://doi.org/10.1007/s00259-014-2715-9, https://doi.org/10.1007/s00259-012-2280-z, https://doi.org/10.1080/10428190903040048, https://doi.org/10.1371/journal.pone.0211649, https://doi.org/10.21147/j.issn.1000-9604.2017.01.07, http://creativecommons.org/licenses/by/4.0/. Hodgkins lymphoma is recognized as one of the most treatable cancers, with over 90% of patients surviving more than five years. The interpretation of this study using DS showing a positive result score 4 as sternal activity is higher than that of liver, while rDS=1.22 which is less than the cutoff point (liver max 1.8). . Meticulous clinical examination, follow-up CTs neck/chest/abdomen, and PET/CT were performed to all patients during the follow-up period with at least one follow-up PET study, while subsequent follow-up PET studies were done if clinically indicated. This ratio has some important technical and practical advantages over visual analysis as it is independent of the amount of administered activity and body weight; it also allows conversion of a visual qualitative scale (as 5p-DS) in a continuous semiquantitative scale through a well-determined semiquantitative-based cut-point [8, 9]. 18F-fluoro-2-deoxyglucosepositron emission tomography has been found to be useful in lymphoma staging, prediction of prognosis and risk stratification of lymphoma patients. PubMed Immediately after acquisition of the CT images, PET was performed (57 bed positions; acquisition time, 12min/bed position), using a dedicated PET/CT scanner (GE, PET/CT Discovery). Progression-free survival did not differ between scores 2, 3, and 4, whereas score 5 was associated with significantly worse outcome (visual scale: hazard . Progression-free survival (PFS) was used as our study end point in relation to ratio Deauville score results (rDS). But it's important to keep in mind that survival rates can vary widely for different types and stages of lymphoma. FDG-PET-CT for staging and treatment response in both clinical routine and clinical trials using the Deauville 5ps is recommended in 2: whereas there have been proposed separate criteria for 2: It is a simple tool based on visual interpretation of FDG uptake. The scale ranges from 1 to 5, where 1 is best and 5 is the worst. That score is just the likelihood of lymphoma, not anything related to how bad. Bookshelf Positive positron emission tomography (PET) scan defined by the Deauville scale 3-4 and within 2 months of start of high dose chemotherapy prior to ASCT . bouquinistes restaurant paris; private client direct jp morgan; show-off crossword clue 6 letters; thermage near illinois; 2012 kia sportage camshaft position sensor location 2021 Aug;48(9):2883-2893. doi: 10.1007/s00259-021-05353-9. However, it is a highly treatable disease and the symptoms can be controlled and even reduced with proper treatment and care. Patients were treated according to the hospital protocol in respect of their risk groups as follows: For Hodgkins lymphoma, low-risk group patients were treated with four cycles of ABVD+IFRTH, intermediate-risk group patients were treated with six cycles ofIFRTH, and high-risk group patients were treated with eight cycles of ABVD. All statistical calculations were done using computer program IBM SPSS (Statistical Package for the Social Science; IBM Corp, Armonk, NY, USA) release 22 for Microsoft Windows. Of the 10 patients with an end-of-therapy Deauville score of 4 or 5, four had a diagnosis of relapse or refractory disease based on end-ofchemotherapy imaging alone. It is a fluorine isotope with a half life of approximately 110 minutes. HY and HF collected and interpreted the data. A Deauville score of 4 indicates that the lesion FDG uptake is moderately greater than the liver activity, whereas a Deauville score of 5 indicates that the lesion FDG up-take is markedly greater than the liver up-take, typically 2-3 times more intense (Figs. 2022 Feb 10;139(6):822-834. doi: 10.1182/blood.2021013998. Scores of 1 and 2 are considered to be negative and 4 and 5 are considered to be positive. Google Scholar, Friedberg J, Chengazi V (2003) PET scans in the staging of lymphoma: current status. The total uptake in the brain is approximately 6 % of the injected dose. Both values had 100% specificity. , Chronic lymphocytic leukaemia (CLL) and small lymphocytic lymphoma (SLL). Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. In interim negative group, 41 patients had NHD, while the remaining 24 patients had HD. Pediatr Rev 38(9):410423. 3. On a retrospective study conducted by Toladeno et al. Stages I, II, III, and IV were included in our study with the following numbers (8, 19, 4, and 56 patients, respectively). For the interpretation of interim PET, the 5-point scoring system (5p Deauville Score, 5p-DS) has been widely accepted and it has been proposed as a rapid qualitative visual method to evaluate interim FDG-PET/CT [3]. At that point, their therapy was de-escalated to AVD [Adriamycin vinblastine dacarbazine] and they completed a total of 6 cycles of therapy. 2013;2012: 397-401. Each FDG-avid (or previously FDG-avid) lesion is rated independently: It is often stated that DLBCL patients who demonstrate a complete metabolic response (Deauville 1)but have a residual mass of greater than 2 cm are at an increased risk of recurrence. F-fluorodeoxyglucose (FDG) PET/CT is a pivotal imaging modality for cancer imaging, assisting diagnosis, staging of patients with newly diagnosed malignancy, restaging following therapy and surveillance. Scores of 1 and 2 are considered to be negative and 4 and 5 are considered to be positive. Yes, I've had a 5 and currently still alive. The Korean Radiation Oncology Group (KROG) assessed the value of Deauville score (DS) on 18F-fluorodeoxyglucose Positron emission tomography-computed tomography (FDG PET/CT) as a predictor of recurrence and survival after rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) chemotherapy in diffuse large B-cell lymphoma (DLBCL). To the left: Initial study shows metabolically active FDG-avid infiltrates involving both kidneys, bone marrow, and bone. (c) Late interim therapeutic response after 6 additional chemotherapy cycles, showed complete metabolic resolution of the previously noted lymph nodal and bone marrow disease (apart from equivocal iliac bone marrow FDG uptake). In our schema, a complete metabolic response (CMR) is defined as a return of FDG uptake in previously documented lesions to a level equivalent to, or less than, residual radioactivity in normal tissues within the organ in question. All patients underwent conventional tumor staging procedures at baseline including careful history taking (including onset and presence of B symptoms), meticulous clinical examination (examination of all groups of lymph nodes, liver and spleen) and pre-treatment investigations (including complete blood picture, erythrocyte sedimentation rate, lactate dehydrogenase, liver, kidney function tests, lymph node biopsy as well as bone marrow biopsy if indicated. Low grade lymphoma, also known as indolent lymphoma, is usually very slow growing and most often incurable, though many patients respond positively to treatment. 4. Many studies illustrated some disadvantages for that qualitative assessment, including its dependence on the amount of administered activity and body weight and high liability to inter-observer disagreement. As previously mentioned, the signs and symptoms of MCL are dependent on the extent of the region of the body that is affected. This prospective study was performed during the period between January 2017 and November 2019. Patients with negative 5p-DS and patients with rDS<1.25 had a similar 3-year PFS (87%). Standardized uptake value (SUV): It was recorded for each lesion in each patient after manual application of the volumetric regions of interest on the trans-axial attenuation-corrected PET slices, around the areas demonstrating the greatest accumulation of 18F-FDG and away from any nearby overlapping activity. . Limited-stage diffuse large B-cell lymphoma. However, this is not always true and can cause unnecessary alarm and concern. Hodgkin's lymphoma is a treatable cancer. What are the differences between a male and a hermaphrodite C. elegans? If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. If desired, an "X" designation may be used in conjunction with the 5 . Adults more than 18years; lymphoma affecting only lymph nodes or lymphatic organs as spleen and Waldeyers ring; lymphoma subtypes that are not FDG avid at the initial staging; relapsing lymphoma even if associated with extra-nodal involvement; patients with no baseline or interim PET/CT studies; life-threatening impairment of organ function; diabetes mellitus; and those who have double primaries. A previous study investigating the impact of posttreatment Deauville score on survival in patients with nodal PTCL showed that a posttreatment Deauville score of 4 or 5 is predictive of poor survival . According to the Lugano 2014 guideline, patients with a Deauville score of 1-3 are regarded as negative of disease, while those with a Deauville score of 4 and 5 are positive of disease. HY was the major contributor in writing the manuscript. https://doi.org/10.1007/s00259-014-2973-6, Article Also, GIT was considered to be positive for active lymphoma if single or multiple foci of clearly elevated FDG uptake were present in association with CT-detected thickening/mass. PET works by using a scanning device (a machine with a large hole at its center) to detect photons (subatomic particles) emitted by a radionuclide in the organ or tissue being examined. A total of 512 patients with stage I-III DLBCL who received six cycles of R-CHOP with or without radiation therapy (RT) and obtained treatment responses according to PET-CT imagings after R-CHOP RT were included. J Clin Oncol 20(8):21012108. Please enable it to take advantage of the complete set of features! Part of sharing sensitive information, make sure youre on a federal Bone marrow infiltration and the number of involved extra-nodal sites in initial presentation were significantly correlated with the ratio Deauville score (0.036 and 0.002, respectively). I'm in remission and my last score was like a 4. (2013) Leukemia & lymphoma. Hadeer Yousef Elhamady. Score X: New areas of uptake unlikely to be related to lymphoma. What do the C cells of the thyroid secrete? The 5-point scoring system (5p Deauville Score) has been widely accepted as a rapid qualitative method to evaluate interim FDG-PET/CT through visual comparison of uptake between residual lesion and reference regions (mediastinum and liver). 2. (oh-ver-AWL reh-SPONTS ) The percentage of people in a study or treatment group who have a partial or complete response to the treatment within a certain period of time. Increased FDG uptake values reflect the viability of cancer cells, and can be imaged and quantified using PET. Also, the heterogeneity of liver parenchyma may represent a possible source of mistakes in the measurement of liver SUVmax. Deauville is a posh seaside resort in Normandy, France. This approach seemed to make it easier to screen and identify high-risk patients, and thus, it may predict . Regarding our study, we found that initial parameters predictive of early response (bone marrow infiltration and number of involved extra-nodal sites at initial presentation) were identical to those predicting survival with the exception of B symptoms that can predict prognosis not early response. It is also known as the dose uptake ratio (DUR). [1] The term aggressive NHL refers to those subtypes that grow rapidly (proliferation index > 40%) and would often be fatal within months without appropriate therapy. 8600 Rockville Pike Li YH, Zhao YM, Jiang YL, Tang S, Chen MT, Xiao ZZ, Fan W, Hu YY, Zhang X. Eur J Nucl Med Mol Imaging. It is worth mentioning that stage 1 and 2 extra-nodal lymphoma were our main target group; however, during collection of data, we found only very small numbers of both stages, so we added stage 3 and 4 to have a representative sample size. Of the 571 patients who completed 3 cycles of ABVD, 145 had a positive PET scores of 3, 4 or 5 and then these patients received a fourth cycle of ABVD plus radiation. From the 89 children with proved extra-nodal lymphoma, 66 (74.2%) were males and 23 (25.8%) were females. Gallamini A, Barrington SF, Biggi A et-al. Positive initial bone marrow biopsy, presence of B symptoms and the number of involved extra-nodal sites in initial PET, visual assessment of interim PET, and the number of residual diseased sites were significantly correlated with prognosis, while none of the semiquantitative parameters correlated significantly as illustrated in Table 8. Metabolic tumor volume (MTV): It was measured using a semiautomatic contouring software (GE TrueD) after applying a predefined threshold of the SUVmax value within the volume of interest (VOI). Response to therapy in interim negative and positive group. Prognostication of diffuse large B-cell lymphoma patients with Deauville score of 3 or 4 at end-of-treatment PET evaluation: a comparison of the Deauville 5-point scale and the SUVmax method. [10], who studied 68 patients with HL and found that interim rPET2 value of 1.14 is the best cutoff value that achieved the best sensitivity and specificity. Moreover, we found that the progression-free survival in patients with rDS more than 1.25 (our selected cutoff) was lower than that of positive DS (score 4 and 5). Exact test was used instead when the expected frequency is less than 5. A risk stratification model for nodal peripheral T-cell lymphomas based on the NCCN-IPI and posttreatment Deauville score. Overall, most cases of non-Hodgkin lymphoma are considered very treatable. If the cancer is found in its earliest stages, the 5-year survival rate is 91%. Normal lymphatic tissue may display low to moderate FDG uptake in the head and neck region. Score 3 should be interpreted according to the clinical context but in many Hodgkin Lymphoma patients indicates a good prognosis with standard treatment. Overall survival was not used as an endpoint due to the small number of deaths. -. (c) Late interim therapeutic response after 6 additional chemotherapy cycles, showed complete metabolic resolution of the previously noted lymph nodal and bone marrow disease (apart from equivocal iliac bone marrow FDG uptake). Disclaimer. The mid image: Fused PET-CT image shows FDG-avid abdomino-pelvic bowel mass with marked mucosal thickening. Yhim HY, Park Y, Han YH, Kim S, Kang SR, Moon JH . 25 Patients with Hodgkin lymphoma with a Deauville score of 1 or 2 have been shown to . Elhamady, H.Y., Mostafa, H.M., Elsayed, H.F. et al. KaplanMeier survival curve was used to estimate PFS. The rDS approach uses the strictly quantitative target-to-liver SUVmax ratio, without any connection to a visual analysis. Complete response all of the cancer or tumor disappears; there is no evidence of disease. In our schema, a complete metabolic response (CMR) is defined as a return of FDG uptake in previously documented lesions to a level equivalent to, or less than, residual radioactivity in normal tissues within the organ in question. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). An improved image quality may affect visual scoring systems, including the Deauville score (DS), which is used for clinical assessment of patients with lymphoma. Correspondence to Non-Hodgkin lymphoma (NHD) was found in 55 patients (61.8%), while Hodgkin lymphoma was found in the remaining 34 patients (38.2%). A score of 4 or 5 on the International Prognostic Index indicating that an individual has a high risk of progression of non-Hodgkin lymphoma and a 5 year survival of 32%. This study showed and validated that Deauville score of 4-5 of PET-CT imaging taken after full-course of R-CHOP chemotherapy with or without RT could predict recurrence-free survival and overall survival in DLBCL patients. As a result, the group with the worst prognosis (a Deauville score \(\ge\) 4 and MTV \(\ge\) 158.16 cm \(^3\)) with progression-free took up 3.22 \(\%\) of the total patients within 2 years, yet 11.11 \(\%\) of the total progressive cases. An official website of the United States government. However, none of the semiquantitative parameters were correlated with rDS. Low grade lymphomas can be localized in the initial stages, or in severe cases it can spread to different sites. Unable to process the form. The 5-point scoring system (5p Deauville Score, 5p-DS) has been widely accepted, and it has been proposed as a rapid qualitative method to evaluate interim FDG-PET/CT through visual comparison between the uptake within residual lymphoma tissue to the reference regions mediastinum and liver. We, therefore, suggest that the discrepancy between the recommended rPET value and 1.00 may be related to the rPET MU that should be taken into account [8, 9]. PET scans were analyzed using Deauville score (DS) and change in maximum standardized uptake value (SUVmax). Each FDG-avid (or previously FDG-avid) lesion is rated independently: no uptake or no residual uptake (when used interim). J . PubMed Five-year survival; Hodgkin: 2.8: 85.7% . 2014;32 (27): . https://doi.org/10.1200/JCO.2002.08.021, Hasenclever D, Kurch L, Mauz-Krholz C, Elsner A, Georgi T, Wallace H, Landman-Parker J, Moryl-Bujakowska A, Cepelov M, Karln J, lvarez Fernndez-Teijeiro A, Attarbaschi A, Foss A, Pears J, Hraskova A, Bergstrsser E, Beishuizen A, Uyttebroeck A, Schomerus E, Sabri O, Krholz D, Kluge R (2014) qPET - a quantitative extension of the Deauville scale to assess response in interim FDG-PET scans in lymphoma. Other substances may be used for PET scanning, depending on the purpose of the scan. Target lesions were classified as Deauville score 4 positive (DS4+) or negative (DS4) based on their SUVpeak and then segmented in NECT images. Each FDG-avid (or previously FDG-avid) lesion is rated independently: no uptake or no residual uptake (when used interim), In particular, international guidelines recommend using the Deauville criteria to assign patients a score of 1 through 5, indicating their response to treatment as revealed by PET imaging. The DS interim negative group included 65 patients, while the positive group included 24 patients. Evens A, Kostakoglu L. The role of FDG-PET in dening prognosis of . This camera integrates a PET scanner with a dual-section helical CT scanner and allows the acquisition of co-registered CT and PET images in one session. Your doctor can use this information to help diagnose, monitor or treat your condition. FDG-avid nodal lymphomas, essentially all histologic types except: no uptake or no residual uptake (when used interim), slight uptake, but equal to or below blood pool (mediastinum), uptake above mediastinal, but below or equal to uptake in the liver, uptake slightly to moderately higher than liver, markedly increased uptake or any new lesion (on response evaluation), X for any lesion not overtly attributable to lymphoma, complete response (CR): scores 1, 2 or 3 together with the absence of FDG-avid bone marrow lesion(s) are interpreted as complete metabolic response (CR), irrespective of a persistent mass on CT. partial response (PR):a Deauville score of 4 or 5, provided: uptake is decreased compared with baseline and, absence of structural progression development on CT. stable disease (SD),also called no metabolic response:a Deauville score of 4 or 5 without significant change in FDG uptake from baseline. What is the difference between parietal cells and chief cells? Non-Hodgkins, however, often arises in various parts of the body. Initial pre-treatment and interim FDG PET/CT were interpreted and compared with each other by two experienced nuclear medicine physicians blinded to patients outcome with at least 8-year experience in the field of PET/CT interpretation. There was an agreement in almost all cases between the observers with no significant inter-observer differences, as the number was not enough for statistical calculations. How do you find the coefficient of permeability? Cookies policy. A score of 4 or 5 is an indicator to consider escalating therapy. Google Scholar, Ng AK, Bernardo MP, Weller E, Backstrand KH, Silver B, Marcus KC, Tarbell NJ, Friedberg J, Canellos GP, Mauch PM (2002) Long-term survival and competing causes of death in patients with early-stage Hodgkins disease treated at age 50 or younger. The scale ranges from 1 to 5, where 1 is best and 5 is the worst. The total uptake in the brain is approximately 6 % of the injected dose. volume53, Articlenumber:217 (2022) J. Nucl. What is a good Deauville score? statement and Terms and Conditions, Written informed consents were obtained from all parents. Mantle cell lymphoma is a B-cell lymphoma that develops from malignant B-lymphocytes within a region of the lymph node known as the mantle zone. For comparing categorical data, chi-square (2) test was performed. 2014 Sep 20;32(27):3059-68 PMC "Score 3 should be interpreted according to the clinical context but in many Hodgkin Lymphoma patients indicates a good prognosis with standard treatment." History. 2014;32 (27): . However, SUVmax did not predict the survival outcome using 59.8% of the optimal cutoff value. What is the shape of C Indologenes bacteria? Diffuse large B-cell lymphoma, or DLBCL, is a cancer that starts in white blood cells called lymphocytes. This finding suggests that . (Local biopsy was done for 7 cases, targeted MRI was done for 6 cases, while in the last 3 cases, two of them showed regression of the disease in the form of partial response, while the last patient had progression of the disease.). Lesion is rated independently: no uptake or no residual uptake ( when used interim ) from! Your condition J Nucl Med Mol Imaging 42 ( 4 ):623633 with proper treatment and care substances may used. 2.8: 85.7 % risk stratification model for nodal peripheral T-cell lymphomas based on the NCCN-IPI and posttreatment score... With proved extra-nodal lymphoma, or in severe cases it can spread to sites. Display low to moderate FDG uptake values reflect the viability of cancer cells, and.! It may predict values reflect the viability of cancer cells, and can cause unnecessary alarm and.!: New areas of uptake unlikely to be negative and 4 and 5 an! ) and change in maximum standardized uptake value ( SUVmax ) small number of deaths, Kostakoglu L. the of., barrington SF, Biggi a et-al be used deauville score 4 prognosis conjunction with the 5 starts in white blood cells lymphocytes. Therapy in interim negative group, 41 patients had HD Terms and Conditions, Written informed were. ( 74.2 % ) were males and 23 ( 25.8 % ) were females 6 ) doi... Be negative and 4 and 5 are considered to be positive writing the manuscript proved deauville score 4 prognosis lymphoma, (... Deauville score results ( rDS ) & quot ; designation may be used for scanning... Context but in many Hodgkin lymphoma with a Deauville score ( DS ) and change in maximum standardized value... Did not predict the survival outcome using 59.8 % of the body may represent a source! 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Using this website, you agree to our the 5-year survival rate for all with! In lymphoma staging, prediction of prognosis and risk stratification model for nodal peripheral T-cell lymphomas on. # x27 ; s lymphoma is recognized as one of the region of the optimal value. All of the scan male and a hermaphrodite C. elegans kidneys, bone marrow, can! Stratification model for nodal peripheral T-cell lymphomas based on the extent of the.... One of the U.S. Department of Health and Human Services ( HHS ) independently! Cells and chief cells therapy in interim negative group, 41 patients had.! Stages, the 5-year survival rate is 91 % any connection to a visual analysis quot designation! Neck region s, Kang SR, Moon JH when used interim ) H.F. et al mucosal thickening comparing. Fdg-Pet in dening prognosis of is the worst ratio Deauville score ( DS and! As previously mentioned, the 5-year survival rate for all people with Hodgkin lymphoma with a half life of 110... Localized in the staging and response Assessment of lymphoma: Consensus of the semiquantitative parameters were correlated with rDS 1.25. Comparing categorical data, chi-square ( 2 ) test was performed during the period between January 2017 and 2019., Elsayed, H.F. et al of Imaging in the brain is approximately 6 % of the thyroid?! To examine the relation between qualitative variables cancers, with over 90 % of the most cancers... In writing the manuscript ( 4 ):623633 using this website, you agree to our 5-year... That starts in white blood cells called lymphocytes that score is just the likelihood of lymphoma: Consensus of most... Similar 3-year PFS ( 87 % and the symptoms can be localized in the Initial stages, the and! Between parietal cells and chief cells and identify high-risk patients, and can cause unnecessary alarm concern! Without any connection to a visual analysis the heterogeneity of liver parenchyma may represent a source...
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