Follicular Dendritic Cell Secreted Protein (FDCSP), also known as FDC-SP or C4orf7, is a small, secreted protein critical for immune regulation and disease pathogenesis. It is primarily expressed in follicular dendritic cells (FDCs) within lymphoid tissues and plays a role in B-cell interactions, antibody responses, and tumor metastasis. Below is a detailed analysis of its molecular characteristics, tissue expression, functional roles, and research applications.
FDCSP demonstrates tissue-specific expression, with high levels observed in:
Binding to Activated B Cells: FDCSP binds specifically to B-lymphoma cells (e.g., BJAB) but not T-lymphoma cells (e.g., Jurkat). Binding is enhanced by T-dependent activation signals (e.g., anti-CD40 + IL-4).
IgA Regulation: Overexpression in mice reduces IgA levels in serum, saliva, and bronchoalveolar lavage fluid (BALF), while deficiency elevates IgA, leading to IgA nephropathy (IgAN) in males.
Cancer Cell Migration: Promotes migration and invasion of B-lymphoma cells, suggesting a role in lymphoma progression.
HPV+ Head and Neck Squamous Carcinoma (HNSC): High FDCSP expression correlates with favorable prognosis, increased T follicular helper cells (TFHs), and CXCL13 chemokine signaling.
Chemokine Pathways: Regulates T cell responses and immune cell recruitment via CXCL13.
TNF-α Induction: Expression in FDC-like cell lines is upregulated by TNF-α, linking FDCSP to inflammatory signals.
Experimental Uses:
Transgenic Models: Mice with FDCSP overexpression or knockout have been used to study IgAN and GC formation.
FDCSP (Follicular Dendritic Cell Secreted Protein) is a novel secreted protein expressed by follicular dendritic cells (FDCs) in the human immune system. It is a small secreted protein with a unique structure, containing a conserved N-terminal charged region adjacent to the leader peptide . FDCSP gene is located on chromosome 4q13, notably positioned adjacent to clusters of proline-rich salivary peptides and C-X-C chemokines . The protein has a highly restricted tissue distribution, primarily expressed in tonsil tissue and gingival epithelium .
Functionally, FDCSP appears to act as a secreted mediator specifically targeting B cells, as evidenced by its ability to bind to the surface of B lymphoma cells but not T lymphoma cells . This binding affinity is significantly enhanced when B cells are activated with T-dependent activation signals such as anti-CD40 plus IL-4 . This suggests that FDCSP plays a role in modulating B cell responses during immune reactions, particularly within germinal centers where B cell maturation and affinity maturation occur.
FDCSP expression demonstrates a highly specific regulation pattern in human tissues. The protein is primarily expressed by activated follicular dendritic cells from tonsils and TNF-α-activated FDC-like cell lines . Importantly, it is not expressed by B cell lines, primary germinal center B cells, or anti-CD40 plus IL-4-activated B cells, indicating a cell-type specific regulation mechanism .
Within the germinal center microenvironment, FDCSP is highly expressed in the light zone, consistent with expression by follicular dendritic cells . This spatial regulation suggests its involvement in germinal center reactions where B cells undergo selection and maturation. Additionally, FDCSP expression can be induced in leukocyte-infiltrated tonsil crypts and by leukocytes activated with LPS or Staphylococcus aureus Cowan strain 1, indicating that its expression can also be triggered by innate immunity signals .
In pathological contexts, FDCSP demonstrates differential expression patterns. It is more abundant in head and neck squamous carcinoma (HNSC) tissue than in normal tissue, and significantly more abundant in HPV-positive HNSC compared to HPV-negative HNSC . This suggests that viral infection status may influence FDCSP expression in tumor microenvironments.
Several experimental approaches are employed to detect and quantify FDCSP in human samples:
Quantitative PCR (qPCR): This method is used to measure FDCSP expression levels in tissue samples. For instance, researchers have used qPCR to detect FDCSP expression in HNSC tissues collected from Nanfang Hospital .
Transcriptome Analysis: FDCSP expression can be analyzed using transcriptome data from databases such as The Cancer Genome Atlas (TCGA) and Gene Expression Omnibus (GEO) . This approach enables large-scale analysis of expression patterns across different samples and conditions.
Bioinformatic Tools: Tools like TIMER2.0 and BioGPS web tool are utilized to analyze FDCSP expression across different tissues and to examine correlations with other parameters .
PCR-based cDNA Subtraction: This technique has been used to identify FDCSP as a gene specifically expressed in primary FDCs isolated from human tonsils .
Immunohistochemistry: Although not explicitly mentioned in the provided references, immunohistochemical staining would be a standard method to visualize FDCSP protein expression in tissue sections.
FDCSP expression demonstrates significant correlations with immune cell infiltration patterns in human tumors, particularly in head and neck squamous carcinoma (HNSC). These correlations differ based on HPV status, revealing a complex relationship between FDCSP expression and the tumor immune microenvironment.
In HPV-positive HNSC, FDCSP expression shows strong positive correlations with multiple immune cell types:
T follicular helper cells (TFHs): R = 0.599
Regulatory T cells (Tregs): R = 0.511
B memory cells: R = 0.428
Macrophage M1 cells: R = 0.394
CD4+ memory resting cells: R = 0.374
T gamma delta cells: R = 0.285
B naive cells: R = 0.282
Resting dendritic cells: R = 0.25
In HPV-negative HNSC, the correlations are more limited, with FDCSP showing significant positive correlation primarily with B memory cells (R = 0.287) .
The CIBERSORT algorithm, which calculates scores of 21 immune cells based on single-cell sequencing models, has been instrumental in quantifying these correlations . Notably, despite FDCSP being secreted by follicular dendritic cells, no correlation was found between FDCSP expression and dendritic cell score, which may be because the CIBERSORT algorithm excludes the FDC immune cell score .
These findings suggest that FDCSP may play different immunomodulatory roles in HPV-positive versus HPV-negative HNSC, with a more pronounced effect on T follicular helper cells in HPV-positive tumors.
FDCSP has emerged as a potential prognostic biomarker in HPV-positive head and neck squamous carcinoma (HNSC) based on several significant findings:
Expression Level Correlation with Survival: Higher expression of FDCSP is associated with favorable prognosis in HNSC patients . This correlation is particularly pronounced in HPV-positive HNSC cases.
Immune Correlation: In HPV-positive HNSC, FDCSP expression is strongly correlated with T follicular helper cell (TFH) infiltration. Patients with higher FDCSP levels and higher TFH infiltration demonstrate significantly better prognosis compared to those with lower TFH infiltration .
Association with TP53 Mutation Status: FDCSP expression is associated with TP53 mutation status in HPV-positive HNSC, providing an additional layer of prognostic information .
Chemokine Pathway Connection: The function of FDCSP is closely connected to chemokine pathways, particularly with C-X-C motif chemokine ligand 13 (CXCL13) . This association may explain its immunomodulatory effects and prognostic value.
These findings collectively suggest that FDCSP serves as a chemokine-associated prognostic biomarker in HPV-positive HNSC, potentially through its interactions with TFHs and influence on the tumor immune microenvironment. The improved prognosis associated with higher FDCSP expression may be linked to enhanced immune surveillance and response against tumor cells, particularly in the context of HPV-driven carcinogenesis.
Researching FDCSP function in human immune responses presents several methodological challenges that researchers must navigate:
Addressing these challenges requires multidisciplinary approaches combining molecular biology techniques, immunological assays, bioinformatics, and proper experimental design principles to elucidate the complex functions of FDCSP in human immune responses.
Reconciling contradictory findings about FDCSP's role across different human pathologies requires several methodological approaches:
Context-Dependent Analysis: FDCSP function appears highly context-dependent, as evidenced by its differential relationship with immune cells in HPV-positive versus HPV-negative HNSC . Researchers should explicitly define and compare specific pathological contexts rather than generalizing across conditions.
Systematic Meta-Analysis: Implementing systematic reviews and meta-analyses that aggregate data across multiple studies can help identify patterns that explain apparent contradictions. This approach should include rigorous evaluation of study quality using standardized tools.
Stratification by Molecular Subtypes: Contradictions may arise from molecular heterogeneity within disease categories. For instance, FDCSP's association with prognosis in HNSC differs by HPV status and TP53 mutation status . Stratifying analyses by relevant molecular markers can resolve seemingly contradictory results.
Methodological Standardization: Variations in experimental techniques can produce contradictory results. Standardizing methods for FDCSP detection and quantification across studies would enhance comparability.
Multi-omics Integration: Integrating data from genomics, transcriptomics, proteomics, and functional studies can provide a more comprehensive view of FDCSP's role. For example, correlating FDCSP genetic variations with expression levels and functional outcomes could explain discrepancies.
Temporal Dynamics Consideration: FDCSP's effects may vary over disease progression stages. Longitudinal studies that track FDCSP expression and function over time would help clarify these temporal relationships.
Experimental Design Optimization: Applying rigorous experimental design principles as outlined in human factors experimental design references is essential. This includes appropriate statistical power calculations, randomization, blinding, and control selection.
By implementing these approaches, researchers can develop more nuanced models of FDCSP function that account for contextual factors and reconcile apparently contradictory findings across different human pathologies.
Several bioinformatic approaches have proven effective for analyzing FDCSP expression in large datasets, particularly in cancer research contexts:
Transcriptome Analysis Platforms: Utilizing established databases such as The Cancer Genome Atlas (TCGA) and Gene Expression Omnibus (GEO) provides access to large-scale transcriptomic data across multiple cancer types and normal tissues . These platforms enable comprehensive analysis of FDCSP expression patterns across different biological contexts.
Immune Infiltration Algorithms: The CIBERSORT algorithm has been successfully employed to calculate immune cell infiltration in tumors based on gene expression data . This approach allows researchers to correlate FDCSP expression with specific immune cell populations, revealing functional relationships in the tumor microenvironment.
Tissue-Specific Expression Analysis: Tools like BioGPS web tool have been used to identify FDCSP expression across different human tissues, enabling researchers to characterize its tissue specificity . When analyzing FDCSP expression, filtering for expression levels above a defined threshold (e.g., >2 cell types) can help focus on biologically significant patterns.
Correlation Analysis with Clinical Parameters: Statistical approaches correlating FDCSP expression with clinical parameters such as survival, tumor stage, and treatment response provide insights into its prognostic value. The TIMER2.0 database has been used to map immune infiltration in relation to FDCSP expression .
Stratified Analysis by Disease Subtype: Stratifying analyses by relevant disease parameters (e.g., HPV status in HNSC) is critical for revealing context-specific relationships . This approach prevents masking of significant associations that may exist only in specific disease subtypes.
Pathway Enrichment Analysis: Analyzing pathways associated with FDCSP expression can reveal functional mechanisms. Research has identified connections between FDCSP and chemokine pathways, particularly with CXCL13 .
Mutation Correlation Analysis: Correlating FDCSP expression with mutation status of key genes (e.g., TP53) can provide insights into genetic interactions that influence its expression and function .
When implementing these approaches, researchers should be mindful of proper experimental design principles, including adequate sample sizes, appropriate statistical methods, and validation across independent datasets to ensure robust and reproducible findings .
Several experimental models offer distinct advantages for investigating FDCSP function in human disease, particularly in cancer and immunological disorders:
Primary Cell Cultures:
Follicular Dendritic Cells: Isolated from human tonsils, these primary cultures represent the natural source of FDCSP . While challenging to maintain, they provide the most physiologically relevant system for studying FDCSP production and regulation.
B Lymphocytes: Given FDCSP's specific binding to B cells, particularly activated B cells , primary B lymphocyte cultures serve as valuable models for studying FDCSP's effects on target cells.
Cell Line Models:
FDC-like Cell Lines: TNF-α-activated FDC-like cell lines have been shown to express FDCSP and can serve as more accessible alternatives to primary FDCs for mechanistic studies.
B Lymphoma Cell Lines: These have been used to demonstrate FDCSP's binding specificity and can be employed for high-throughput screening of FDCSP interactions.
Ex Vivo Tissue Models:
Tonsil Explant Cultures: Since tonsil tissue shows high FDCSP expression , explant cultures can maintain the complex cellular architecture where FDCSP naturally functions.
Tumor Tissue Explants: For studying FDCSP in cancer contexts, particularly HNSC, fresh tumor explants can preserve the tumor microenvironment and immune cell interactions.
In Vivo Models:
Patient-Derived Xenografts (PDXs): These models maintain tumor heterogeneity and can be stratified by FDCSP expression levels to study its impact on tumor progression.
Humanized Mouse Models: These can recapitulate human immune system components, allowing for study of FDCSP in a complex immune environment.
3D Organoid Models:
Lymphoid Organoids: These can mimic germinal center organization where FDCSP naturally functions in B cell responses.
Cancer Organoids: Particularly for HNSC, organoids can incorporate both tumor and immune components for studying FDCSP's role in the tumor microenvironment.
Computational Models:
Systems Biology Approaches: Integrating experimental data into computational models can help predict FDCSP's broader impacts on immune networks and disease pathways.
When analyzing FDCSP expression in relation to patient outcomes, several statistical approaches are recommended to ensure robust and clinically meaningful results:
Survival Analysis Techniques:
Kaplan-Meier Analysis: This non-parametric method is effective for visualizing survival differences between patient groups stratified by FDCSP expression levels (high vs. low) . It provides a clear graphical representation of survival probabilities over time.
Cox Proportional Hazards Regression: This multivariate approach allows researchers to assess FDCSP's prognostic value while controlling for confounding factors such as age, stage, and other clinical variables.
Log-rank Test: This statistical test should be used to determine whether observed differences in survival curves between FDCSP expression groups are statistically significant.
Expression Threshold Determination:
ROC Curve Analysis: To determine optimal cutoff values for "high" versus "low" FDCSP expression, Receiver Operating Characteristic curves can identify thresholds with the best sensitivity and specificity for predicting outcomes.
Percentile-based Stratification: As seen in the research, samples can be divided into high expression (≥50%) and low expression (<50%) groups based on FDCSP levels for correlation analysis with immune cell scores .
Correlation Analyses:
Pearson or Spearman Correlation: These methods quantify the strength and direction of association between FDCSP expression and continuous variables such as immune cell infiltration scores .
Significant correlation filtering: Applying thresholds (e.g., p < 0.05 and |R| > 0.2) helps focus on biologically meaningful correlations .
Group Comparison Methods:
Student's t-test/Mann-Whitney U test: For comparing FDCSP expression between two groups (e.g., HPV+ vs. HPV- HNSC) .
ANOVA/Kruskal-Wallis test: For comparing FDCSP expression across multiple groups.
Post-hoc tests: When significant differences are identified, appropriate post-hoc tests should be selected based on whether comparisons are planned or unplanned, as detailed in experimental design references .
Multivariate Analysis Approaches:
Multiple Regression Models: These assess the independent contribution of FDCSP to outcomes while accounting for other variables.
Machine Learning Algorithms: For complex datasets, machine learning approaches can identify non-linear relationships between FDCSP expression, other biomarkers, and patient outcomes.
Stratified Analysis by Disease Subtype:
Validation Approaches:
Cross-validation: To assess the robustness of findings and avoid overfitting.
Independent cohort validation: Findings should be verified across multiple independent patient cohorts when available.
When implementing these statistical approaches, researchers should adhere to rigorous experimental design principles, including appropriate sample size determination, careful consideration of multiple testing corrections, and transparent reporting of all statistical methods and results .
When investigating FDCSP expression and function, implementing appropriate experimental controls is crucial for generating valid and interpretable results. Based on the literature and experimental design principles, the following controls are recommended:
Expression Analysis Controls:
Tissue Type Controls: Include both tissues known to express FDCSP (e.g., tonsil tissue, gingival epithelium) and those with minimal expression as positive and negative controls, respectively.
Cell Type Controls: When analyzing cells, include FDCs as positive controls and B cell lines or primary germinal center B cells as negative controls, as they do not express FDCSP .
Reference Gene Controls: For qPCR analysis, carefully selected housekeeping genes that remain stable across experimental conditions should be used for normalization.
Technical Replicates: Include multiple technical replicates for each sample to account for measurement variability.
Functional Study Controls:
Binding Specificity Controls: When studying FDCSP binding to cells, include both B lymphoma cells (expected to bind) and T lymphoma cells (expected not to bind) as positive and negative controls .
Activation State Controls: Include both resting and activated B cells (e.g., with anti-CD40 plus IL-4) to demonstrate differential binding based on activation status .
Recombinant Protein Controls: Use structurally similar but functionally distinct proteins as negative controls for binding and functional assays.
Antibody Specificity Controls: For FDCSP detection, include isotype controls and pre-adsorption controls to confirm antibody specificity.
Genetic Manipulation Controls:
Empty Vector Controls: When overexpressing FDCSP, include cells transfected with empty vectors to control for transfection effects.
Scrambled siRNA Controls: For knockdown experiments, use non-targeting siRNA sequences with similar chemical properties.
Wild-type Controls: Include unmanipulated cells to assess baseline expression and function.
Disease Model Controls:
Normal Tissue Controls: When studying FDCSP in disease contexts like HNSC, include matched normal tissues from the same patients when possible .
Disease Subtype Controls: Include controls for relevant disease parameters (e.g., HPV+ and HPV- samples in HNSC studies) .
Treatment Status Controls: Account for prior treatments that might affect FDCSP expression or the immune microenvironment.
Statistical and Experimental Design Controls:
Validation Controls:
Orthogonal Method Validation: Confirm findings using independent methodological approaches (e.g., validating RNA-seq data with qPCR).
Independent Cohort Validation: Verify findings in separate patient cohorts or experimental models.
Implementing these controls within a well-designed experimental framework as outlined in human factors experimental design references will enhance the reliability and reproducibility of FDCSP research findings.
Several promising research directions could facilitate the translation of FDCSP findings into clinical applications:
Biomarker Development and Validation:
Prognostic Stratification: Further validation of FDCSP as a prognostic biomarker in larger, prospective cohorts of HPV-positive HNSC patients . This would require standardized measurement protocols and established cutoff values.
Multi-marker Panels: Investigating FDCSP in combination with other biomarkers, particularly those related to immune infiltration like TFH markers, could enhance prognostic accuracy and clinical utility.
Liquid Biopsy Development: Determining whether secreted FDCSP can be reliably detected in blood or other body fluids would greatly enhance its clinical applicability.
Immunotherapy Response Prediction:
Immunotherapy Efficacy Correlation: Given FDCSP's association with immune infiltration, particularly TFHs , studies investigating its value in predicting response to immune checkpoint inhibitors in HNSC and other cancers are warranted.
Companion Diagnostic Development: Development of FDCSP-based assays that could serve as companion diagnostics for immunotherapy selection.
Therapeutic Target Exploration:
Recombinant FDCSP Therapy: Investigating whether recombinant FDCSP administration could enhance anti-tumor immune responses, particularly by promoting TFH activity in tumors.
B Cell Modulation: Given FDCSP's binding to B cells , exploring its potential to modulate B cell activity for therapeutic purposes in cancer or autoimmune diseases.
Small Molecule Development: Identifying small molecules that can mimic or enhance FDCSP function could lead to novel immunomodulatory therapeutics.
Mechanistic Studies for Therapeutic Insights:
Receptor Identification: Identifying the specific receptor(s) for FDCSP on B cells would provide new therapeutic targets and enhance understanding of its mechanism of action.
Signaling Pathway Elucidation: Detailed characterization of signaling pathways activated by FDCSP binding could reveal additional intervention points.
Structure-Function Analysis: Determining which domains of FDCSP are critical for its binding and functional activities could guide the development of optimized therapeutic derivatives.
Translational Model Development:
Patient-Derived Organoids: Developing HNSC organoid models that recapitulate FDCSP expression patterns and immune cell interactions would facilitate personalized therapy testing.
Humanized Mouse Models: Refined models incorporating human immune components could better predict clinical responses to FDCSP-targeting interventions.
Clinical Trial Design:
Biomarker-Stratified Trials: Designing clinical trials that stratify patients based on FDCSP expression levels to test whether this improves treatment selection.
Combination Therapy Approaches: Investigating whether targeting FDCSP or its pathway could enhance response to existing therapies, particularly immunotherapies.
These research directions would benefit from collaborative efforts between basic scientists, bioinformaticians, and clinicians, with careful attention to experimental design principles to ensure that findings are robust and reproducible. The ultimate goal would be to leverage FDCSP biology to improve patient stratification, treatment selection, and development of novel therapeutic approaches, particularly in HPV-positive HNSC where its prognostic significance has been established .
Advances in single-cell analysis technologies offer transformative opportunities to elucidate FDCSP's role in human immune responses with unprecedented resolution:
Cellular Source Heterogeneity Characterization:
Single-Cell RNA Sequencing (scRNA-seq): This technology can reveal heterogeneity among FDCSP-producing follicular dendritic cells, potentially identifying distinct FDC subpopulations with varying FDCSP expression levels and functional properties.
Spatial Transcriptomics: These methods can map FDCSP expression within tissue microenvironments while preserving spatial context, crucial for understanding its role in germinal center organization and function.
Target Cell Response Profiling:
scRNA-seq of B Cell Populations: Given FDCSP's binding to B cells , single-cell analysis of B cells exposed to FDCSP can identify responsive subpopulations and characterize transcriptional changes at single-cell resolution.
Cellular Indexing of Transcriptomes and Epitopes by Sequencing (CITE-seq): This technique combines surface protein and transcriptome analysis, allowing researchers to correlate FDCSP binding with receptor expression and downstream transcriptional responses.
Tumor Microenvironment Characterization:
Multi-parameter Analysis: The strong correlation between FDCSP and immune cell infiltration in HPV+ HNSC can be more comprehensively examined using techniques that simultaneously measure multiple parameters at single-cell resolution.
Single-Cell TCR/BCR Sequencing: When combined with transcriptome analysis, this approach can reveal whether FDCSP influences the clonal expansion of specific T and B cell populations within tumors.
Receptor Identification and Signaling Analysis:
Mass Cytometry (CyTOF): This technique can detect multiple signaling events simultaneously at single-cell resolution, helping to decipher signaling pathways activated by FDCSP in B cells.
Proximity Ligation Assays: At the single-cell level, these can identify protein-protein interactions, potentially revealing FDCSP binding partners and receptors.
Dynamic Response Monitoring:
Live-Cell Imaging Combined with Reporter Systems: These approaches can track real-time responses to FDCSP at the single-cell level, capturing dynamic processes that might be missed in static analyses.
Cellular Barcoding: This technique can trace cellular lineages in response to FDCSP, revealing its effects on B cell differentiation and fate decisions.
Clinical Translation Enhancement:
Single-Cell Analysis of Patient Samples: Applying these technologies to patient samples can establish correlations between FDCSP expression, single-cell immune profiles, and clinical outcomes.
Pharmacogenomic Profiling: Single-cell approaches can predict and monitor responses to therapies targeting FDCSP or its pathways at unprecedented resolution.
Computational Integration:
Advanced Trajectory Analysis: Algorithms that infer cellular differentiation trajectories from single-cell data can reveal how FDCSP influences B cell maturation pathways.
Multimodal Data Integration: Combining single-cell transcriptomics, proteomics, and epigenomics can provide a comprehensive view of FDCSP's effects across multiple molecular levels.
These single-cell approaches, when integrated with proper experimental design principles , have the potential to resolve current contradictions in FDCSP research and reveal new therapeutic opportunities by characterizing its functions at unprecedented resolution. The identification of specific cell populations and molecular mechanisms influenced by FDCSP could lead to more targeted intervention strategies in cancer immunotherapy and other immune-related diseases.
Follicular Dendritic Cell Secreted Protein (FDCSP) is a small, secreted protein primarily expressed in follicular dendritic cells. These cells are crucial components of the immune system, particularly within the lymphoid tissues. FDCSP plays a significant role in regulating antibody responses and has been implicated in cancer cell migration and invasion.
The FDCSP gene, also known as C4orf7, is located on chromosome 4. The protein encoded by this gene consists of 91 amino acids and has a molecular mass of approximately 10.4 kDa . The human recombinant form of FDCSP is produced in E. coli and is fused to a 23 amino acid His-tag at the N-terminus, which aids in its purification through chromatographic techniques .
FDCSP specifically binds to activated B cells, which are essential for the adaptive immune response. By interacting with these cells, FDCSP helps regulate the generation of antibodies . This regulatory function is vital for maintaining a balanced immune response and preventing overactivation, which could lead to autoimmune disorders.
In addition to its role in the immune system, FDCSP has been found to contribute to tumor metastases. It promotes cancer cell migration and invasion, facilitating the spread of cancer cells to other parts of the body . This dual role in both immune regulation and cancer progression makes FDCSP a protein of significant interest in medical research.
Given its involvement in both immune responses and cancer metastasis, FDCSP is being studied as a potential diagnostic and prognostic biomarker. Its expression levels could provide valuable insights into the state of the immune system and the progression of certain cancers . Furthermore, targeting FDCSP could offer new therapeutic strategies for treating autoimmune diseases and preventing cancer metastasis.