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Mackman N, Sachetto AT. Commentary: Tissue factor as a potential coagulative/vascular marker in relapsing-remitting multiple sclerosis. Front Immunol 2023; 14:1320179. [PMID: 38106419 PMCID: PMC10722905 DOI: 10.3389/fimmu.2023.1320179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 11/15/2023] [Indexed: 12/19/2023] Open
Affiliation(s)
- Nigel Mackman
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Sachetto AT, Archibald SJ, Bhatia R, Monroe D, Hisada Y, Mackman N. Evaluation of four commercial ELISAs to measure tissue factor in human plasma. Res Pract Thromb Haemost 2023; 7:100133. [PMID: 37275179 PMCID: PMC10233285 DOI: 10.1016/j.rpth.2023.100133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/09/2023] [Accepted: 03/11/2023] [Indexed: 03/30/2023] Open
Abstract
Background Under pathological conditions, tissue factor (TF)-positive extracellular vesicles (EVs) are released into the circulation and activate coagulation. Therefore, it is important to identify methods that accurately quantitate levels of TF in plasma. Enzyme-linked immunosorbent assays (ELISAs) are a fast and simple method to quantitate levels of proteins. However, there are several specific challenges with measuring TF antigen in plasma including its low concentration and the complexity of plasma. Objectives We aimed to evaluate the ability of 4 commercial ELISAs to measure TF in human plasma. Methods We determined the ability of 4 commercial ELISAs (Imubind, Quantikine, Human SimpleStep, and CD142 Human) to detect recombinant human TF (Innovin) (12.5-100 pg/mL), TF-positive EVs isolated from the culture supernatant from a human pancreatic cancer cell line (57 pg/mL), TF in plasma containing low levels of EV TF activity (1.2-2.6 pg/mL) from lipopolysaccharide-stimulated whole blood, and plasma containing high levels of EV TF activity (151-696 pg/mL) from patients with acute leukemia. Results The CD142 Human ELISA could not detect recombinant TF. Imubind and Quantikine but not Human SimpleStep detected recombinant TF spiked into plasma and TF-positive EVs isolated from the culture supernatant of a human pancreatic cancer cell line. Quantikine and Imubind could not detect low levels of TF in plasma from lipopolysaccharide-stimulated whole blood. However, Quantikine but not Imubind detected TF in plasma from acute leukemia patients with high levels of EV TF activity. Conclusion Our results indicate that commercial ELISAs have different abilities to detect TF. Quantikine and Imubind could not detect low levels of TF in plasma, but Quantikine detected TF in plasma with high levels of TF.
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Affiliation(s)
- Ana T.A. Sachetto
- UNC Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Sierra J. Archibald
- UNC Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ravi Bhatia
- Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Dougald Monroe
- UNC Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Yohei Hisada
- UNC Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Nigel Mackman
- UNC Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Tissue factor in cancer-associated thromboembolism: possible mechanisms and clinical applications. Br J Cancer 2022; 127:2099-2107. [PMID: 36097177 PMCID: PMC9467428 DOI: 10.1038/s41416-022-01968-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 08/19/2022] [Accepted: 08/22/2022] [Indexed: 01/29/2023] Open
Abstract
Venous and arterial thromboses, called as cancer-associated thromboembolism (CAT), are common complications in cancer patients that are associated with high mortality. The cell-surface glycoprotein tissue factor (TF) initiates the extrinsic blood coagulation cascade. TF is overexpressed in cancer cells and is a component of extracellular vesicles (EVs). Shedding of TF+EVs from cancer cells followed by association with coagulation factor VII (fVII) can trigger the blood coagulation cascade, followed by cancer-associated venous thromboembolism in some cancer types. Secretion of TF is controlled by multiple mechanisms of TF+EV biogenesis. The procoagulant function of TF is regulated via its conformational change. Thus, multiple steps participate in the elevation of plasma procoagulant activity. Whether cancer cell-derived TF is maximally active in the blood is unclear. Numerous mechanisms other than TF+EVs have been proposed as possible causes of CAT. In this review, we focused on a wide variety of regulatory and shedding mechanisms for TF, including the effect of SARS-CoV-2, to provide a broad overview for its role in CAT. Furthermore, we present the current technical issues in studying the relationship between CAT and TF.
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Sachetto ATA, Mackman N. Tissue Factor and COVID-19: An Update. Curr Drug Targets 2022; 23:1573-1577. [PMID: 36165519 DOI: 10.2174/1389450123666220926144432] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 08/21/2022] [Accepted: 08/29/2022] [Indexed: 01/25/2023]
Abstract
The coronavirus 2019 (COVID-19) pandemic is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. Infection with SARS-CoV-2 is associated with acute respiratory distress syndrome, thrombosis and a high rate of mortality. Thrombotic events increase with severity. Tissue factor (TF) expression is increased during viral and bacterial infections. This review summarizes studies that have examined TF expression in response to SARS-CoV-2 infection. SARS-CoV-2 virus and its proteins upregulate TF mRNA, protein and activity in a variety of cells, including bronchial epithelial cells, neutrophils, monocytes, macrophages, endothelial cells and adventitial fibroblasts. COVID-19 patients have increased TF expression in lungs, bronchoalveolar lavage fluid and circulating extracellular vesicles. The increase in TF was associated with coagulation activation markers, thrombosis, inflammatory markers, severity of disease and mortality. Taken together, the studies suggest that TF plays a central role in thrombosis in COVID- 19. TF may be a useful prognostic marker and therapeutic target to reduce thrombosis and inflammation.
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Affiliation(s)
- Ana Teresa Azevedo Sachetto
- Laboratory of Pathophysiology, Butantan Institute, São Paulo, São Paulo, Brazil.,University of São Paulo Medical School, São Paulo, São Paulo, Brazil.,Department of Medicine, UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Nigel Mackman
- Department of Medicine, UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Mackman N, Hisada Y, Archibald SJ. Tissue factor and its procoagulant activity on cancer-associated thromboembolism in pancreatic cancer: Comment by Mackman et al. Cancer Sci 2022; 113:1885-1887. [PMID: 35132733 PMCID: PMC9128168 DOI: 10.1111/cas.15276] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 01/21/2022] [Indexed: 12/01/2022] Open
Abstract
The Quantikine® ELISA detects tissue factor in cell lysates and culture supernatants containing extracellular vesicles from tissue factor-expressing cell lines but does not detect low levels of tissue factor antigen in plasma.
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Affiliation(s)
- Nigel Mackman
- UNC Blood Research CenterDivision of HematologyDepartment of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Yohei Hisada
- UNC Blood Research CenterDivision of HematologyDepartment of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Sierra J. Archibald
- UNC Blood Research CenterDivision of HematologyDepartment of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
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Koizume S, Kobayashi S, Ruf W, Miyagi Y. Authors' reply to the Letter to the Editor: Tissue factor and its procoagulant activity on cancer-associated thromboembolism in pancreatic cancer. Cancer Sci 2022; 113:1888-1890. [PMID: 35332617 PMCID: PMC9128152 DOI: 10.1111/cas.15324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 03/01/2022] [Indexed: 12/28/2022] Open
Abstract
Tissue factor-procoagulant activity (TF-PCA) on cells is modified by multiple molecular mechanisms of encryption and decryption. The risk of thrombosis is higher for patients with a high tissue factor antigen level at registration as this enables patient's blood more PCA-high status before the onset of cancer-associated thromboembolism (CAT). ELISA, including the Quantikine assay with validation as performed in our study, can contribute to more precise prediction of CAT.
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Affiliation(s)
- Shiro Koizume
- Molecular Pathology and Genetics DivisionKanagawa Cancer Center Research InstituteKanagawaJapan
- Pathology DivisionKanagawa Cancer CenterKanagawaJapan
| | - Satoshi Kobayashi
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology DivisionKanagawa Cancer CenterKanagawaJapan
| | - Wolfram Ruf
- Center for Thrombosis and HemostasisJohannes Gutenberg University Medical CenterMainzGermany
| | - Yohei Miyagi
- Molecular Pathology and Genetics DivisionKanagawa Cancer Center Research InstituteKanagawaJapan
- Pathology DivisionKanagawa Cancer CenterKanagawaJapan
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Hisada Y, Mackman N. Tissue Factor and Extracellular Vesicles: Activation of Coagulation and Impact on Survival in Cancer. Cancers (Basel) 2021; 13:cancers13153839. [PMID: 34359742 PMCID: PMC8345123 DOI: 10.3390/cancers13153839] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/24/2021] [Accepted: 07/27/2021] [Indexed: 12/17/2022] Open
Abstract
Simple Summary The tissue factor (TF)-factor VIIa complex is the major physiological initiator of blood coagulation. Tumors express TF and release TF-positive extracellular vesicles (EVs) into the circulation, and this is associated with the activation of coagulation. Circulating levels of EVTF activity may be a useful biomarker to identify patients at risk for thrombosis. Tumor TF and TF-positive EVs are also associated with reduced survival. Abstract Tissue factor (TF) is a transmembrane glycoprotein that functions as a receptor for FVII/FVIIa and initiates the extrinsic coagulation pathway. Tumors and cancer cells express TF that can be released in the form of TF positive (TF+) extracellular vesicles (EVs). In this review, we summarize the studies of tumor TF and TF + EVs, and their association with activation of coagulation and survival in cancer patients. We also summarize the role of tumor-derived TF + EVs in venous thrombosis in mouse models. Levels of tumor TF and TF + EVs are associated with venous thromboembolism in pancreatic cancer patients. In addition, levels of EVTF activity are associated with disseminated intravascular coagulation in cancer patients. Furthermore, tumor-derived TF + EVs enhance venous thrombosis in mice. Tumor TF and TF + EVs are also associated with worse survival in cancer patients, particularly in pancreatic cancer patients. These studies indicate that EVTF activity could be used as a biomarker to identify pancreatic cancer patients at risk for venous thrombosis and cancer patients at risk for disseminated intravascular coagulation. EVTF activity may also be a useful prognostic biomarker in cancer patients.
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Hisada Y, Mackman N. Measurement of tissue factor activity in extracellular vesicles from human plasma samples. Res Pract Thromb Haemost 2019; 3:44-48. [PMID: 30656275 PMCID: PMC6332748 DOI: 10.1002/rth2.12165] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 10/13/2018] [Indexed: 11/11/2022] Open
Abstract
Tissue factor (TF) is the cellular receptor for plasma factor (F) VII/FVIIa and triggers blood coagulation. Extracellular vesicles (EVs) are small membrane vesicles that are released from activated cells and tumor cells. Different cell types, including activated monocytes and tumors cells release TF-positive EVs into the circulation. We developed an assay to measure levels of TF activity in EVs isolated from human plasma samples. We and others have used this assay to demonstrate increased levels of EV TF activity in a variety of diseases associated with thrombosis, including cancer. These studies suggest that EV TF can be used as a biomarker of thrombotic risk. The strength of this laboratory assay is that it is relatively sensitive and specific. However, the limitations of the assay are that it is labor intensive and the coefficient of variation is too high for it to be used as a clinical assay.
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Affiliation(s)
- Yohei Hisada
- Division of Hematology and Oncology, Thrombosis and Hemostasis ProgramDepartment of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth Carolina
| | - Nigel Mackman
- Division of Hematology and Oncology, Thrombosis and Hemostasis ProgramDepartment of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth Carolina
- Department of Pathology and Laboratory MedicineUniversity of North Carolina at Chapel HillChapel HillNorth Carolina
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Coagulation biomarkers and prediction of venous thromboembolism and survival in small cell lung cancer: A sub-study of RASTEN - A randomized trial with low molecular weight heparin. PLoS One 2018; 13:e0207387. [PMID: 30412630 PMCID: PMC6226210 DOI: 10.1371/journal.pone.0207387] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 10/26/2018] [Indexed: 12/21/2022] Open
Abstract
Coagulation activation and venous thromboembolism (VTE) are hallmarks of cancer; however, there is an unmet need of improved biomarkers for individualized anticoagulant treatment. The present sub-study of the RASTEN trial was designed to explore the role of coagulation biomarkers in predicting VTE risk and outcome in a homogenous cancer patient population. RASTEN is a multicenter, randomized phase-3 trial investigating the survival effect of low molecular weight heparin enoxaparin when added to standard treatment in newly diagnosed small cell lung cancer (SCLC) patients. Plasma collected at baseline, during treatment, and at follow-up was used in this ad hoc sub-study (N = 242). Systemic coagulation was assessed using four assays reflecting various facets of the coagulation system: Total tissue factor (TF); extracellular vesicle associated TF (EV-TF); procoagulant phospholipids (PPL); and thrombin generation (TG). We found small variations of biomarker levels between baseline, during treatment and at follow-up, and appeared independent on low molecular weight heparin treatment. Overall, none of the measured biomarkers at any time-point did significantly associate with VTE incidence, although increased total TF at baseline showed significant association in control patients not receiving low molecular weight heparin (P = 0.03). Increased TG-Peak was significantly associated with decreased overall survival (OS; P = 0.03), especially in patients with extensive disease. Low baseline EV-TF predicted a worse survival in the low molecular weight heparin as compared with the control group (HR 1.42; 95% CI 1.04–1.95; P = 0.03; P for interaction = 0.12). We conclude that the value of the analyzed coagulation biomarkers for the prediction of VTE risk was very limited in SCLC patients. The associations between TG-Peak and EV-TF with patient survival and response to low molecular weight heparin therapy, respectively, warrant further studies on the role of coagulation activation in SCLC aggressiveness.
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Schreiber K, Breen K, Parmar K, Rand JH, Wu XX, Hunt BJ. The effect of hydroxychloroquine on haemostasis, complement, inflammation and angiogenesis in patients with antiphospholipid antibodies. Rheumatology (Oxford) 2017; 57:120-124. [PMID: 29045759 DOI: 10.1093/rheumatology/kex378] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Indexed: 11/13/2022] Open
Abstract
Objectives HCQ has been described as having a beneficial effect in patients with APS but its mechanism of action is unclear. We hypothesized that HCQ may have effects on subnormal angiogenesis, inflammation and haemostatic biomarkers seen in APS. The aim of our study was to assess laboratory markers [annexin A5 (AnxA5) anticoagulant activity, tissue factor (TF) levels, thromboelastography (TEG), CRP, Bb, C3a and VEGF] in HCQ-naïve patients with aPL at baseline and after commencing HCQ. Methods Twenty-two patients with aPL [20 female, 2 male, median age 55 (range 18-70) years] had blood taken pre- and 3 months after starting HCQ 200 mg daily. Results Soluble TF levels were significantly reduced comparing baseline and 3 months after HCQ commencement [401.8 (152.8) vs 300.9 (108) pg/ml (P = 0.010)]. No significant changes were found in the following [reported as pre- and post-HCQ commencement, mean (s.d.)]: AnxA5 anticoagulant ratio [187.1 (29.5) vs 193 (31) (P = 0.157)], anti-domain1 β2 glycoprotein1 IgG activity [1.8 (2) vs 1.2 (1.4) μg/ml (P = 0.105)], complement C3a-des-Arg [147.8 (84.5) vs 154.4 (88.1) ng/ml (P = 0.905)], complement Bb [1.3 (0.7) vs 1.1 (0.7) μg/ml (P = 0.422)], VEGF [68.8 (40) vs 59.4 (19.6) pg/ml (P = 0.454)] and CRP [7 (3.5) vs 7 (3.9) μg/ml (P = 0.917)]. TEG results including TEG reaction time, achievement of clot firmness, TEG maximum amplitude and TEG percentage lysis 30 and 60 min after maximum amplitude showed no significant difference. Conclusion HCQ significantly reduced soluble TF levels in patients with aPL. No significant change was observed in AnxA5 activity, anti-domain 1 IgG activity, TEG, CRP, complement Bb and C3a-des-Arg, and VEGF. Further studies of a larger patient cohort are needed.
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Affiliation(s)
- Karen Schreiber
- Thrombosis & Haemophilia Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Department of Rheumatology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Karen Breen
- Thrombosis & Haemophilia Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Kiran Parmar
- Thrombosis & Haemophilia Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jacob H Rand
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, Cornell University, New York, NY, USA
| | - Xiao-Xuan Wu
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, Cornell University, New York, NY, USA
| | - Beverley J Hunt
- Thrombosis & Haemophilia Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK.,King's College London, London, UK
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Cohen JG, Prendergast E, Geddings JE, Walts AE, Agadjanian H, Hisada Y, Karlan BY, Mackman N, Walsh CS. Evaluation of venous thrombosis and tissue factor in epithelial ovarian cancer. Gynecol Oncol 2017; 146:146-152. [PMID: 28501328 DOI: 10.1016/j.ygyno.2017.04.021] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 04/25/2017] [Accepted: 04/27/2017] [Indexed: 01/27/2023]
Abstract
OBJECTIVE Ovarian clear cell carcinoma (OCCC) and high grade serous ovarian cancer (HGSOC) are associated with the highest risk of VTE among patients with epithelial ovarian cancer (EOC). Tissue factor (TF) is a transmembrane glycoprotein which can trigger thrombosis. We sought to evaluate if there is an association between VTE and tumor expression of tissue factor (TF), plasma TF, and microvesicle TF (MV TF) activity in this high-risk population. METHODS We performed a case-control study of OCCC and HGSOC patients with and without VTE. 105 patients who underwent surgery at a tertiary care center between January 1995 and October 2013 were included. Plasma TF was measured with an enzyme-linked immunosorbent assay. A TF-dependent Factor Xa generation assay was used to measure MV TF activity. Immunohistochemical (IHC) analysis was performed to evaluate tumor expression of TF. RESULTS 35 women with OCCC or HGSOC diagnosed with VTE within 9months of surgery were included in the case group. Those with VTE had a worse OS, p<0.0001, with a greater than three-fold increase in risk of death, HR 3.33 (CI 1.75-6.35). There was no significant difference in median plasma TF level or MV TF activity level between patients with and without VTE. OCCC patients had greater expression of TF in their tumors than patients with HGSOC, p<0.0001. CONCLUSIONS TFMV activity and plasma TF level were not predictive of VTE in this patient population. Given the extensive expression of TF in OCCC tumors, it is unlikely IHC expression will be useful in risk stratification for VTE in this population.
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Affiliation(s)
- Joshua G Cohen
- Division of Gynecologic Oncology, University of California, Los Angeles, 200 Medical Plaza, Suite 220, Los Angeles, CA 90095, USA
| | - Emily Prendergast
- Division of Gynecologic Oncology, Cedars-Sinai Medical Center, 8635 West 3rd Street, Suite 280W, Los Angeles, CA 90048, USA
| | - Julia E Geddings
- Division of Hematology/Oncology, University of North Carolina, Chapel Hill, 2312 MBRB, 111 Mason Farm Rd, CB#7126, Chapel Hill, NC 27599, USA
| | - Ann E Walts
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, USA
| | - Hasmik Agadjanian
- Division of Gynecologic Oncology, Cedars-Sinai Medical Center, 8635 West 3rd Street, Suite 280W, Los Angeles, CA 90048, USA
| | - Yohei Hisada
- Division of Hematology/Oncology, University of North Carolina, Chapel Hill, 2312 MBRB, 111 Mason Farm Rd, CB#7126, Chapel Hill, NC 27599, USA; K.G. Jebsen TREC, The Faculty of Health Sciences, UiT- The Arctic University of Tromsø, 9037 Tromsø, Norway
| | - Beth Y Karlan
- Division of Gynecologic Oncology, Cedars-Sinai Medical Center, 8635 West 3rd Street, Suite 280W, Los Angeles, CA 90048, USA
| | - Nigel Mackman
- Division of Hematology/Oncology, University of North Carolina, Chapel Hill, 2312 MBRB, 111 Mason Farm Rd, CB#7126, Chapel Hill, NC 27599, USA; K.G. Jebsen TREC, The Faculty of Health Sciences, UiT- The Arctic University of Tromsø, 9037 Tromsø, Norway
| | - Christine S Walsh
- Division of Gynecologic Oncology, Cedars-Sinai Medical Center, 8635 West 3rd Street, Suite 280W, Los Angeles, CA 90048, USA.
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