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Vang S, Helton ES, Guo Y, Burpee B, Rose E, Easter M, Bollenbecker S, Hirsch MJ, Matthews EL, Jones LI, Howze PH, Rajasekaran V, Denson R, Cochran P, Attah IK, Olson H, Clair G, Melkani G, Krick S, Barnes JW. O-GlcNAc transferase regulates collagen deposition and fibrosis resolution in idiopathic pulmonary fibrosis. Front Immunol 2024; 15:1387197. [PMID: 38665916 PMCID: PMC11043510 DOI: 10.3389/fimmu.2024.1387197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 03/25/2024] [Indexed: 04/28/2024] Open
Abstract
Background Idiopathic pulmonary fibrosis (IPF) is a chronic pulmonary disease that is characterized by an excessive accumulation of extracellular matrix (ECM) proteins (e.g. collagens) in the parenchyma, which ultimately leads to respiratory failure and death. While current therapies exist to slow the progression, no therapies are available to resolve fibrosis. Methods We characterized the O-linked N-Acetylglucosamine (O-GlcNAc) transferase (OGT)/O-GlcNAc axis in IPF using single-cell RNA-sequencing (scRNA-seq) data and human lung sections and isolated fibroblasts from IPF and non-IPF donors. The underlying mechanism(s) of IPF were further investigated using multiple experimental models to modulate collagen expression and accumulation by genetically and pharmacologically targeting OGT. Furthermore, we hone in on the transforming growth factor-beta (TGF-β) effector molecule, Smad3, by co-expressing it with OGT to determine if it is modified and its subsequent effect on Smad3 activation. Results We found that OGT and O-GlcNAc levels are upregulated in patients with IPF compared to non-IPF. We report that the OGT regulates collagen deposition and fibrosis resolution, which is an evolutionarily conserved process demonstrated across multiple species. Co-expression of OGT and Smad3 showed that Smad3 is O-GlcNAc modified. Blocking OGT activity resulted in decreased phosphorylation at Ser-423/425 of Smad3 attenuating the effects of TGF-β1 induced collagen expression/deposition. Conclusion OGT inhibition or knockdown successfully blocked and reversed collagen expression and accumulation, respectively. Smad3 is discovered to be a substrate of OGT and its O-GlcNAc modification(s) directly affects its phosphorylation state. These data identify OGT as a potential target in pulmonary fibrosis resolution, as well as other diseases that might have aberrant ECM/collagen accumulation.
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Affiliation(s)
- Shia Vang
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Eric Scott Helton
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Yiming Guo
- Department of Pathology, Division of Molecular and Cellular Pathology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Bailey Burpee
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Elex Rose
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Molly Easter
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Seth Bollenbecker
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Meghan June Hirsch
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Emma Lea Matthews
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Luke Isaac Jones
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Patrick Henry Howze
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Vasanthi Rajasekaran
- Department of Pathology, Division of Molecular and Cellular Pathology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Rebecca Denson
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Phillip Cochran
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Isaac Kwame Attah
- Biological Science Division, Pacific Northwest National Laboratory, Richland, WA, United States
| | - Heather Olson
- Biological Science Division, Pacific Northwest National Laboratory, Richland, WA, United States
| | - Geremy Clair
- Biological Science Division, Pacific Northwest National Laboratory, Richland, WA, United States
| | - Girish Melkani
- Department of Pathology, Division of Molecular and Cellular Pathology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Stefanie Krick
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Jarrod Wesley Barnes
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
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Schwartzberg BS, Abdelatif OMA, Lewin JM, Bernard JM, Brehm JL, Bu-Ali HM, Cawthorn SJ, Chen-Seeto M, Feldman SM, Govindarajulu S, Jones LI, Juette A, Kavia S, Maganini RO, Pain SJ, Shere MH, Shriver CD, Smith SG, Valencia A, Whitacre EB, Whitney R. Abstract P3-13-03: Multicenter clinical trial of percutaneous laser ablation for early stage primary breast cancer. Results of 49 cases with radiographic and pathological correlation. Cancer Res 2016. [DOI: 10.1158/1538-7445.sabcs15-p3-13-03] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Introduction: Percutaneous laser ablation of early stage primary breast cancer remains investigational. A multicenter, international clinical trial (NCT01478438) was completed to determine feasibility of this technique.
Methods: Patients with a single focus of biopsy proven infiltrating ductal carcinoma measuring 20 mm or less by pre-ablation MRI were treated by image-guided percutaneous laser ablation. A laser diode source (805 nominal nanometer wavelength) was used to perform the thermal ablation. Thermal sensors placed at the periphery of the tumor measured achievement of predefined temperature levels, indicating successful ablation. The patients were evaluated by post-ablation mammogram, ultrasound and MRI at 4 weeks post-ablation, after which they underwent surgical excision. Pathology specimens were evaluated by hematoxylin & eosin, CK 8/18, Ki-67 and estrogen receptor staining.
Results: Forty-nine of the 61 enrolled patients (ages 42-77, mean age 64 years) undergoing percutaneous laser ablation have finished protocol analysis and are reported in this series. Ablation was considered complete by the treating physician in all cases. The mean tumor size was 11.3 mm. The mean laser time was 15.7 minutes. There were no serious adverse events. Seven patients (14%) reported mild adverse events (pain, blisters, lump). Post-ablation cell viability was determined by MRI and by changes in CK 8/18, Ki67 and estrogen receptor staining. A post-ablation discordance between MRI and pathology was found in evaluation of 4 patients (8%). Three patients (6%) were considered "false negative" with a post-ablation residual tumor burden of less than 2mm which was not detected by MRI. One patient (2%) had a complete pathologic ablation but positive MRI ("false positive"). One patient (2%) had adjacent residual DCIS, visible in retrospect on the pre-ablation MRI and was considered a screening failure. Eight patients (16%) were found to have residual invasive cancer by both post-ablation MRI and pathologic analysis. Complete ablation was confirmed in 36 patients (73%) when evaluated by both post-ablation MRI and pathologic analysis.
Conclusion: Percutaneous laser ablation holds promise as an alternative to lumpectomy in the treatment of early stage breast cancer. There is a strong correlation (92%) between findings on post-ablation MRI and changes in CK 8/18, Ki67 and estrogen receptor staining in this series. Additional trials are necessary to determine the long-term curative potential of this technique.
Citation Format: Schwartzberg BS, Abdelatif OMA, Lewin JM, Bernard JM, Brehm JL, Bu-Ali HM, Cawthorn SJ, Chen-Seeto M, Feldman SM, Govindarajulu S, Jones LI, Juette A, Kavia S, Maganini RO, Pain SJ, Shere MH, Shriver CD, Smith SG, Valencia A, Whitacre EB, Whitney R. Multicenter clinical trial of percutaneous laser ablation for early stage primary breast cancer. Results of 49 cases with radiographic and pathological correlation. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-13-03.
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Affiliation(s)
- BS Schwartzberg
- Sarah Cannon at Rose Medical Center, Denver, CO; Carondelet St. Joseph's Hospital, Tucson, AZ; Walter Reed National Military Medical Center, Bethesda, MD; Wheaton Franciscan Health System, Wauwatosa, WI; North Bristol NHS Trust - Southmead Hospital, Bristol, United Kingdom; Columbia University Medical Center, NY, NY; Norfolk and Norwich University NHS Trust - Norfolk and Norwich University Hospital, Norwich, United Kingdom; Mid-Essex NHS Trust - Broomfield Hospital, Chelmsford, United Kingdom; Alexian Brothers Health System, Barlett, IL; Breast Center of Southern Arizona, Tuscon, AZ
| | - OMA Abdelatif
- Sarah Cannon at Rose Medical Center, Denver, CO; Carondelet St. Joseph's Hospital, Tucson, AZ; Walter Reed National Military Medical Center, Bethesda, MD; Wheaton Franciscan Health System, Wauwatosa, WI; North Bristol NHS Trust - Southmead Hospital, Bristol, United Kingdom; Columbia University Medical Center, NY, NY; Norfolk and Norwich University NHS Trust - Norfolk and Norwich University Hospital, Norwich, United Kingdom; Mid-Essex NHS Trust - Broomfield Hospital, Chelmsford, United Kingdom; Alexian Brothers Health System, Barlett, IL; Breast Center of Southern Arizona, Tuscon, AZ
| | - JM Lewin
- Sarah Cannon at Rose Medical Center, Denver, CO; Carondelet St. Joseph's Hospital, Tucson, AZ; Walter Reed National Military Medical Center, Bethesda, MD; Wheaton Franciscan Health System, Wauwatosa, WI; North Bristol NHS Trust - Southmead Hospital, Bristol, United Kingdom; Columbia University Medical Center, NY, NY; Norfolk and Norwich University NHS Trust - Norfolk and Norwich University Hospital, Norwich, United Kingdom; Mid-Essex NHS Trust - Broomfield Hospital, Chelmsford, United Kingdom; Alexian Brothers Health System, Barlett, IL; Breast Center of Southern Arizona, Tuscon, AZ
| | - JM Bernard
- Sarah Cannon at Rose Medical Center, Denver, CO; Carondelet St. Joseph's Hospital, Tucson, AZ; Walter Reed National Military Medical Center, Bethesda, MD; Wheaton Franciscan Health System, Wauwatosa, WI; North Bristol NHS Trust - Southmead Hospital, Bristol, United Kingdom; Columbia University Medical Center, NY, NY; Norfolk and Norwich University NHS Trust - Norfolk and Norwich University Hospital, Norwich, United Kingdom; Mid-Essex NHS Trust - Broomfield Hospital, Chelmsford, United Kingdom; Alexian Brothers Health System, Barlett, IL; Breast Center of Southern Arizona, Tuscon, AZ
| | - JL Brehm
- Sarah Cannon at Rose Medical Center, Denver, CO; Carondelet St. Joseph's Hospital, Tucson, AZ; Walter Reed National Military Medical Center, Bethesda, MD; Wheaton Franciscan Health System, Wauwatosa, WI; North Bristol NHS Trust - Southmead Hospital, Bristol, United Kingdom; Columbia University Medical Center, NY, NY; Norfolk and Norwich University NHS Trust - Norfolk and Norwich University Hospital, Norwich, United Kingdom; Mid-Essex NHS Trust - Broomfield Hospital, Chelmsford, United Kingdom; Alexian Brothers Health System, Barlett, IL; Breast Center of Southern Arizona, Tuscon, AZ
| | - HM Bu-Ali
- Sarah Cannon at Rose Medical Center, Denver, CO; Carondelet St. Joseph's Hospital, Tucson, AZ; Walter Reed National Military Medical Center, Bethesda, MD; Wheaton Franciscan Health System, Wauwatosa, WI; North Bristol NHS Trust - Southmead Hospital, Bristol, United Kingdom; Columbia University Medical Center, NY, NY; Norfolk and Norwich University NHS Trust - Norfolk and Norwich University Hospital, Norwich, United Kingdom; Mid-Essex NHS Trust - Broomfield Hospital, Chelmsford, United Kingdom; Alexian Brothers Health System, Barlett, IL; Breast Center of Southern Arizona, Tuscon, AZ
| | - SJ Cawthorn
- Sarah Cannon at Rose Medical Center, Denver, CO; Carondelet St. Joseph's Hospital, Tucson, AZ; Walter Reed National Military Medical Center, Bethesda, MD; Wheaton Franciscan Health System, Wauwatosa, WI; North Bristol NHS Trust - Southmead Hospital, Bristol, United Kingdom; Columbia University Medical Center, NY, NY; Norfolk and Norwich University NHS Trust - Norfolk and Norwich University Hospital, Norwich, United Kingdom; Mid-Essex NHS Trust - Broomfield Hospital, Chelmsford, United Kingdom; Alexian Brothers Health System, Barlett, IL; Breast Center of Southern Arizona, Tuscon, AZ
| | - M Chen-Seeto
- Sarah Cannon at Rose Medical Center, Denver, CO; Carondelet St. Joseph's Hospital, Tucson, AZ; Walter Reed National Military Medical Center, Bethesda, MD; Wheaton Franciscan Health System, Wauwatosa, WI; North Bristol NHS Trust - Southmead Hospital, Bristol, United Kingdom; Columbia University Medical Center, NY, NY; Norfolk and Norwich University NHS Trust - Norfolk and Norwich University Hospital, Norwich, United Kingdom; Mid-Essex NHS Trust - Broomfield Hospital, Chelmsford, United Kingdom; Alexian Brothers Health System, Barlett, IL; Breast Center of Southern Arizona, Tuscon, AZ
| | - SM Feldman
- Sarah Cannon at Rose Medical Center, Denver, CO; Carondelet St. Joseph's Hospital, Tucson, AZ; Walter Reed National Military Medical Center, Bethesda, MD; Wheaton Franciscan Health System, Wauwatosa, WI; North Bristol NHS Trust - Southmead Hospital, Bristol, United Kingdom; Columbia University Medical Center, NY, NY; Norfolk and Norwich University NHS Trust - Norfolk and Norwich University Hospital, Norwich, United Kingdom; Mid-Essex NHS Trust - Broomfield Hospital, Chelmsford, United Kingdom; Alexian Brothers Health System, Barlett, IL; Breast Center of Southern Arizona, Tuscon, AZ
| | - S Govindarajulu
- Sarah Cannon at Rose Medical Center, Denver, CO; Carondelet St. Joseph's Hospital, Tucson, AZ; Walter Reed National Military Medical Center, Bethesda, MD; Wheaton Franciscan Health System, Wauwatosa, WI; North Bristol NHS Trust - Southmead Hospital, Bristol, United Kingdom; Columbia University Medical Center, NY, NY; Norfolk and Norwich University NHS Trust - Norfolk and Norwich University Hospital, Norwich, United Kingdom; Mid-Essex NHS Trust - Broomfield Hospital, Chelmsford, United Kingdom; Alexian Brothers Health System, Barlett, IL; Breast Center of Southern Arizona, Tuscon, AZ
| | - LI Jones
- Sarah Cannon at Rose Medical Center, Denver, CO; Carondelet St. Joseph's Hospital, Tucson, AZ; Walter Reed National Military Medical Center, Bethesda, MD; Wheaton Franciscan Health System, Wauwatosa, WI; North Bristol NHS Trust - Southmead Hospital, Bristol, United Kingdom; Columbia University Medical Center, NY, NY; Norfolk and Norwich University NHS Trust - Norfolk and Norwich University Hospital, Norwich, United Kingdom; Mid-Essex NHS Trust - Broomfield Hospital, Chelmsford, United Kingdom; Alexian Brothers Health System, Barlett, IL; Breast Center of Southern Arizona, Tuscon, AZ
| | - A Juette
- Sarah Cannon at Rose Medical Center, Denver, CO; Carondelet St. Joseph's Hospital, Tucson, AZ; Walter Reed National Military Medical Center, Bethesda, MD; Wheaton Franciscan Health System, Wauwatosa, WI; North Bristol NHS Trust - Southmead Hospital, Bristol, United Kingdom; Columbia University Medical Center, NY, NY; Norfolk and Norwich University NHS Trust - Norfolk and Norwich University Hospital, Norwich, United Kingdom; Mid-Essex NHS Trust - Broomfield Hospital, Chelmsford, United Kingdom; Alexian Brothers Health System, Barlett, IL; Breast Center of Southern Arizona, Tuscon, AZ
| | - S Kavia
- Sarah Cannon at Rose Medical Center, Denver, CO; Carondelet St. Joseph's Hospital, Tucson, AZ; Walter Reed National Military Medical Center, Bethesda, MD; Wheaton Franciscan Health System, Wauwatosa, WI; North Bristol NHS Trust - Southmead Hospital, Bristol, United Kingdom; Columbia University Medical Center, NY, NY; Norfolk and Norwich University NHS Trust - Norfolk and Norwich University Hospital, Norwich, United Kingdom; Mid-Essex NHS Trust - Broomfield Hospital, Chelmsford, United Kingdom; Alexian Brothers Health System, Barlett, IL; Breast Center of Southern Arizona, Tuscon, AZ
| | - RO Maganini
- Sarah Cannon at Rose Medical Center, Denver, CO; Carondelet St. Joseph's Hospital, Tucson, AZ; Walter Reed National Military Medical Center, Bethesda, MD; Wheaton Franciscan Health System, Wauwatosa, WI; North Bristol NHS Trust - Southmead Hospital, Bristol, United Kingdom; Columbia University Medical Center, NY, NY; Norfolk and Norwich University NHS Trust - Norfolk and Norwich University Hospital, Norwich, United Kingdom; Mid-Essex NHS Trust - Broomfield Hospital, Chelmsford, United Kingdom; Alexian Brothers Health System, Barlett, IL; Breast Center of Southern Arizona, Tuscon, AZ
| | - SJ Pain
- Sarah Cannon at Rose Medical Center, Denver, CO; Carondelet St. Joseph's Hospital, Tucson, AZ; Walter Reed National Military Medical Center, Bethesda, MD; Wheaton Franciscan Health System, Wauwatosa, WI; North Bristol NHS Trust - Southmead Hospital, Bristol, United Kingdom; Columbia University Medical Center, NY, NY; Norfolk and Norwich University NHS Trust - Norfolk and Norwich University Hospital, Norwich, United Kingdom; Mid-Essex NHS Trust - Broomfield Hospital, Chelmsford, United Kingdom; Alexian Brothers Health System, Barlett, IL; Breast Center of Southern Arizona, Tuscon, AZ
| | - MH Shere
- Sarah Cannon at Rose Medical Center, Denver, CO; Carondelet St. Joseph's Hospital, Tucson, AZ; Walter Reed National Military Medical Center, Bethesda, MD; Wheaton Franciscan Health System, Wauwatosa, WI; North Bristol NHS Trust - Southmead Hospital, Bristol, United Kingdom; Columbia University Medical Center, NY, NY; Norfolk and Norwich University NHS Trust - Norfolk and Norwich University Hospital, Norwich, United Kingdom; Mid-Essex NHS Trust - Broomfield Hospital, Chelmsford, United Kingdom; Alexian Brothers Health System, Barlett, IL; Breast Center of Southern Arizona, Tuscon, AZ
| | - CD Shriver
- Sarah Cannon at Rose Medical Center, Denver, CO; Carondelet St. Joseph's Hospital, Tucson, AZ; Walter Reed National Military Medical Center, Bethesda, MD; Wheaton Franciscan Health System, Wauwatosa, WI; North Bristol NHS Trust - Southmead Hospital, Bristol, United Kingdom; Columbia University Medical Center, NY, NY; Norfolk and Norwich University NHS Trust - Norfolk and Norwich University Hospital, Norwich, United Kingdom; Mid-Essex NHS Trust - Broomfield Hospital, Chelmsford, United Kingdom; Alexian Brothers Health System, Barlett, IL; Breast Center of Southern Arizona, Tuscon, AZ
| | - SG Smith
- Sarah Cannon at Rose Medical Center, Denver, CO; Carondelet St. Joseph's Hospital, Tucson, AZ; Walter Reed National Military Medical Center, Bethesda, MD; Wheaton Franciscan Health System, Wauwatosa, WI; North Bristol NHS Trust - Southmead Hospital, Bristol, United Kingdom; Columbia University Medical Center, NY, NY; Norfolk and Norwich University NHS Trust - Norfolk and Norwich University Hospital, Norwich, United Kingdom; Mid-Essex NHS Trust - Broomfield Hospital, Chelmsford, United Kingdom; Alexian Brothers Health System, Barlett, IL; Breast Center of Southern Arizona, Tuscon, AZ
| | - A Valencia
- Sarah Cannon at Rose Medical Center, Denver, CO; Carondelet St. Joseph's Hospital, Tucson, AZ; Walter Reed National Military Medical Center, Bethesda, MD; Wheaton Franciscan Health System, Wauwatosa, WI; North Bristol NHS Trust - Southmead Hospital, Bristol, United Kingdom; Columbia University Medical Center, NY, NY; Norfolk and Norwich University NHS Trust - Norfolk and Norwich University Hospital, Norwich, United Kingdom; Mid-Essex NHS Trust - Broomfield Hospital, Chelmsford, United Kingdom; Alexian Brothers Health System, Barlett, IL; Breast Center of Southern Arizona, Tuscon, AZ
| | - EB Whitacre
- Sarah Cannon at Rose Medical Center, Denver, CO; Carondelet St. Joseph's Hospital, Tucson, AZ; Walter Reed National Military Medical Center, Bethesda, MD; Wheaton Franciscan Health System, Wauwatosa, WI; North Bristol NHS Trust - Southmead Hospital, Bristol, United Kingdom; Columbia University Medical Center, NY, NY; Norfolk and Norwich University NHS Trust - Norfolk and Norwich University Hospital, Norwich, United Kingdom; Mid-Essex NHS Trust - Broomfield Hospital, Chelmsford, United Kingdom; Alexian Brothers Health System, Barlett, IL; Breast Center of Southern Arizona, Tuscon, AZ
| | - R Whitney
- Sarah Cannon at Rose Medical Center, Denver, CO; Carondelet St. Joseph's Hospital, Tucson, AZ; Walter Reed National Military Medical Center, Bethesda, MD; Wheaton Franciscan Health System, Wauwatosa, WI; North Bristol NHS Trust - Southmead Hospital, Bristol, United Kingdom; Columbia University Medical Center, NY, NY; Norfolk and Norwich University NHS Trust - Norfolk and Norwich University Hospital, Norwich, United Kingdom; Mid-Essex NHS Trust - Broomfield Hospital, Chelmsford, United Kingdom; Alexian Brothers Health System, Barlett, IL; Breast Center of Southern Arizona, Tuscon, AZ
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