Advanced prostate cancer activates coagulation: a controlled study of activation markers of coagulation in ambulatory patients with localized and advanced prostate cancer

Coagulation markers as independent predictors of prostate cancer aggressiveness: a retrospective cohort study

Coagulation system activation is commonly observed in tumor patients, including prostate cancer (PCa), with coagulation markers proposed as potential prognostic indicators for cancer severity. However, the correlation between these markers and clinicopathological features in PCa remains unclear. Thus, this study investigates the association between comprehensive coagulation markers and clinicopathological characteristics in PCa patients. A retrospective evaluation of 162 PCa patients diagnosed and categorized into low-intermediate-risk or high-risk groups based on clinical and pathological features was conducted. Coagulation markers, including fibrinogen (FIB), D-dimer (DD), activated partial thromboplastin time (APTT), prothrombin time (PT), prothrombin activity (PTA), thrombin time (TT), platelet count (PLT), and international normalized ratio (INR), were assessed. Univariate and multivariate logistic regression analyses were performed to determine associations with clinicopathological features. FIB and DD were confirmed as independent factors associated with high-risk PCa. Furthermore, FIB and DD levels showed significant positive correlations with clinical parameters, including PSA levels, ISUP grade, T stage, N stage, and M stage. Our findings suggest that FIB and DD hold promise as independent prognostic biomarkers for risk stratification in PCa. These coagulation markers may aid in assessing PCa severity and guiding personalized treatment strategies.

D-Dimer beyond Diagnosis of Pulmonary Embolism: Its Implication for Long-Term Prognosis in Cardio-Oncology Era

Venous thromboembolism (VTE) is a common comorbidity of cancer, often referred to as cancer-associated thrombosis (CAT). Even though its prevalence has been increasing, its clinical picture has not been thoroughly investigated. In this single-center retrospective observational study, 259 patients who were treated for pulmonary embolism (PE) between January 2015 and December 2020 were available for analysis. The patients were divided by the presence or absence of concomitant malignancy, and those with malignancy (N = 120, 46%) were further classified into active (N = 40, 15%) and inactive groups according to the treatment status of malignancy. In patients with malignancy, PE was more often diagnosed incidentally by computed tomography or D-dimer testing, and the proportion of massive PE was lower. Although D-dimer levels overall decreased after the initiation of anticoagulation therapy, concomitant malignancy was independently associated with higher D-dimer at discharge despite the lower severity of PE at onset. The patients with malignancy had a poor prognosis during post-discharge follow-up. Active malignancy was independently associated with major adverse cardiovascular events (MACE) and major bleeding. D-dimer at discharge was an independent predictor of mortality even after adjustment for malignancy. This study's findings suggest that CAT-PE patients might have hypercoagulable states, which can potentially lead to a poorer prognosis.

Cardiac Biomarkers and Geriatric Assessment in Metastatic Castrate-Resistant Prostate Cancer During Abiraterone Acetate Therapy – A Cardio-Oncology Study

Background

Abiraterone acetate (AA) is a drug used in advanced prostate cancer. However, known clinical factors with predictive and prognostic value are scarce. This study evaluated cardiovascular (CV) factors and geriatric scales as potential markers of superior response during AA therapy.

Methods

This is a prospective observational study. Serum levels of high sensitivity troponin T (hsTnT), D-dimer, NT-proBNP and left ventricle ejection fraction (LVEF) were used for CV evaluation. Questionnaires of G8, VES-13, Activities of Daily Living (ADL), Instrumental Activities of Daily Living (iADL), and Geriatric Depression Scale (GDS) were included in the geriatric screening assessment. All measures were taken before AA initiation. Survival curves and Cox proportional hazard models (univariate and multivariate) were used to determine the predictors for a longer time to treatment failure (TTF).

Results

Forty nine patients were included in the study. Overall median TTF was 7.9 months (95% CI: 5.9-12.4). In univariate analysis, factors associated with inferior TTF were ( P-value < .05): visceral metastases - HR 2.34; 95% CI: 1.24-4.45, history of coronary artery disease - HR 3.02; 95% CI: 1.19-7.66; LVEF < 50% - HR 2.53; 95% CI: 1.03-6.17; P = .041; age-adjusted D-dimer > upper reference limit (URL) - HR 3.53; 95% CI: 1.81-6.85; P < .001; hsTnT > URL - HR 2.17; 95% CI: 1.13-4.16; P = .016; NT-proBNP ≥ 300 pg/mL - HR 2.3; 95% CI: 1.22-4.34; P = .01; G8 score ≤14 points - HR 2.47; 95% CI: 1.29-4.74; P = .007. In multivariate analysis, age-adjusted D-dimer > URL, G8 score ≤ 14 points and visceral metastases remained statistically significant in prediction of inferior TTF. The number of these factors was associated with shorter median TTF: 0-1 factor – 14.1 months; 2 factors – 5.9 months; 3 factors – 2.7 months; P < .001, log-rank).

Conclusions

Age-adjusted D-dimer, and geriatric G8 scores may predict TTF in men with metastatic castration-resistant prostate cancer during AA therapy. These observations require further study in a larger population.

Prognostic value of circulating markers of neutrophil activation, neutrophil extracellular traps, coagulation and fibrinolysis in patients with terminal cancer

Predicting survival accurately in patients with advanced cancer is important in guiding interventions and planning future care. Objective tools are therefore needed. Blood biomarkers are appealing due to their rapid measurement and objective nature. Thrombosis is a common complication in cancer. Recent data indicate that tumor-induced neutrophil extracellular traps (NETs) are pro-thrombotic. We therefore performed a comprehensive investigation of circulating markers of neutrophil activation, NET formation, coagulation and fibrinolysis in 106 patients with terminal cancer. We found that neutrophil activation and NET markers were prognostic in terminal cancer patients. Interestingly, markers of coagulation and fibrinolysis did not have a prognostic value in this patient group, and there were weak or no correlations between these markers and markers of neutrophil activation and NETs. This suggest that NETs are linked to a poor prognosis through pathways independent of coagulation. Additional studies are needed to determine the utility of circulating neutrophil activation and NET markers, alone or in concert with established clinical parameters, as objective and reliable prognostic tools in advanced cancer.

Systemic Coagulation Markers Especially Fibrinogen Are Closely Associated with the Aggressiveness of Prostate Cancer in Patients Who Underwent Transrectal Ultrasound-Guided Prostate Biopsy

Objective

It has been well elucidated that multiple types of cancers are at high risk of thrombosis. Several studies have indicated the prognostic value of fibrinogen (Fib) and D-dimer (DD) in prostate cancer (PCa). However, it remains unclear regarding the association of the comprehensive coagulation markers with the clinicopathological features of PCa.

Methods

A total of 423 pathologically diagnosed patients with PCa were consecutively collected and stratified as low-intermediate-risk or high-risk groups. The association of coagulation parameters including Fib, DD, prothrombin (PT), activated partial thromboplastin time (APTT), thrombin time (TT), and antithrombin III (AT-III) with clinicopathological features was determined by univariate and multivariate logistic regression analyses.

Results

The levels of Fib, DD, and PT were significantly higher in the high-risk group (p < 0.001, p < 0.001, and p = 0.043, resp.), while APTT, TT, and AT-III were similar between two groups (p > 0.05, all). Univariate logistic regression analysis demonstrated that Fib, DD, and PT were all positively correlated with high-risk PCa (OR = 2.041, p < 0.001; OR = 1.003, p < 0.001; OR = 1.247, p = 0.044). Nonetheless, after adjusting for PSA, grade, and stage, Fib (T3 vs. T1, OR = 15.202, 95% CI: 1.725-133.959, p = 0.014) but not DD or PT was the unique independent factor associated with high-risk PCa in the multivariate regression analysis.

Conclusions

Our study firstly revealed that Fib but other coagulation markers was independently associated with the severity of PCa, suggesting Fib might be useful in PCa risk stratification beyond PSA, stage, and grade.

Routine coagulation molecules predict nasopharyngeal carcinoma and associated metastases

Introduction: Most patients with malignant solid tumours have abnormal blood coagulation and an abnormal peripheral blood count, but data on nasopharyngeal carcinoma is scare. We hypothesised abnormal coagulation indices and red cell distribution width (RDW) in this group that are linked to the tumour (T), lymph node (N) and metastatic aspects (M) of the patients.Methods: We recruited 740 newly diagnosed patients with nasopharyngeal carcinoma and 238 healthy controls, taking venous blood for prothrombin time, activated partial thromboplastin time (APTT), thrombin time, fibrinogen, fibrin degradation products (FDP), D-dimer, RD), platelets and platelet distribution width (PDW). In the patients, lab indices were analysed according to clinical stage.Results: All indices except thrombin time were significantly different between cases and controls (p < 0.001), and many predicted TNM classifications and early or late stage of the disease. In sensitivity/specificity analysis, the prothrombin time, APTT and PDW gave AUCs >0.7, and in combination gave an AUC of 0.88 (95% CI 0.86-0.91) for nasopharyngeal carcinoma. No index provided an AUC >0.7 for T or N classification, or early v late stage, but APTT, fibrinogen and FDP all gave AUCs ≥0.7 for predicting metastases. Together, these three indices gave an AUC of 0.84 (0.78-0.91).Conclusions: Routine coagulation indices can predict nasopharyngeal carcinoma, with the combination of prothrombin time, APTT and PDW being strongest. The combination of APTT, fibrinogen and FDPs provides a useful score to predict metastases. These indices should be considered in the diagnosis and staging of this disease.

Biomarkers of Cancer-Associated Thromboembolism

Venous thromboembolism is known to be associated with an increase in morbidity and mortality in patients with malignancy. Predictive laboratory biomarkers of venous thromboembolism (VTE) have long been sought after to improve outcomes and help guide clinical decision making. Previously studied biomarkers include C reactive protein (CRP), tissue factor expressing microparticles (TF MP), D-dimer, soluble P-selectin (sP-selectin), plasminogen activator inhibitor 1 (PAI-1), factor VIII, platelet count, and leukocyte counts. This chapter will focus on these possible biomarkers for cancer-associated thrombosis (CAT) with particular emphasis on the pathophysiology behind thrombosis formation as well as data from clinical studies in patients with malignancy. The incorporation of the above biomarkers into risk assessment tools to predict CAT will also be reviewed, as will risk factors for recurrent VTE in patients with malignancy. Further studies are ongoing to develop readily available biomarkers that can be incorporated into future risk assessment models with the goal of reducing morbidity and mortality due to cancer-associated thrombosis.

D-dimer and high-sensitivity C-reactive protein levels to predict venous thromboembolism recurrence after discontinuation of anticoagulation for cancer-associated thrombosis

Background

Optimal duration of anticoagulation for cancer-associated thrombosis (CAT) remains unclear. This study assessed D-dimer (DD) and high-sensitivity C-reactive protein (hs-CRP) levels after the withdrawal of anticoagulation treatment to predict the risk of venous thromboembolism (VTE) recurrence among patients with CAT.

Methods

Prospective, multicentre study to evaluate CAT with ≥3 months of anticoagulation that was subsequently discontinued. Blood samples were taken when patients stopped the anticoagulation and 21 days later to determine the DD and hs-CRP levels. All patients were followed up for 6 months to detect VTE recurrence.

Results

Between 2013 and 2015, 325 patients were evaluated and 114 patients were ultimately enrolled in the study. The mean age was 62 ± 14 years and nearly 40% had metastasis. Ten patients developed VTE recurrence within 6 months (8.8%, 95% confidence interval [CI]: 4.3–15.5%). The DD and hs-CRP levels after 21 days were associated with VTE recurrence. The subdistribution hazard ratios were 9.82 for hs-CRP (95% CI: 19–52) and 5.81 for DD (95% CI: 1.1–31.7).

Conclusions

This study identified that hs-CRP and DD were potential biomarkers of VTE recurrence after discontinuation of anticoagulation in CAT. A risk-adapted strategy could identify low-risk patients who may benefit from discontinuation of anticoagulation.

Effect of rosuvastatin on risk markers for venous thromboembolism in cancer

Essentials Statins lower venous thromboembolism risk in general but have not been studied in cancer patients. We completed a randomized trial of rosuvastatin vs. placebo among cancer patients on chemotherapy. Rosuvastatin did not significantly lower prothrombotic biomarkers including D-dimer. The role of statins in venous thrombosis prevention in cancer patients remains unknown.

SUMMARY

Background Statin therapy is associated with lower risk of venous thromboembolism (VTE) but has not been prospectively evaluated in patients with advanced cancer. Objectives We determined if statin administration in this high-risk population reduces the risk of VTE, based on established and emerging biomarkers. Patients/Methods This double-blind, crossover, randomized controlled trial among patients with advanced cancer receiving systemic therapy allocated participants to rosuvastatin 20 mg daily or placebo for 3-4 weeks prior to crossover to the alternative therapy, with a 3-5-week washout. D-dimer, C-reactive protein (CRP), soluble (s)P-selectin, factor VIII (FVIII), thrombin generation and exploratory biomarkers focusing on endogenous thrombin potential, including tissue factor (TF), activated factor IX (FIXa) and activated factor XI (FXIa), were measured at the start and end of both treatment periods. The primary outcome was change in D-dimer with rosuvastatin compared with placebo. Results Of 38 enrolled participants, 24 (63%) completed the study. Rosuvastatin did not cause statistically significant changes in D-dimer levels or any other biomarker. CRP levels decreased by 40%; 4.3 mg L-1 (95% confidence interval, -11.0 to +2.5 mg L-1 ) compared with placebo. In post-hoc analysis, participants who received rosuvastatin initially during their first line of treatment had a 13% decrease in D-dimer. Circulating TF, FIXa and FXIa were detected in 26%, 68% and 71% of cancer patients despite not being found in healthy individuals. Conclusions Rosuvastatin did not cause favorable changes in biomarkers of VTE risk in advanced cancer patients receiving chemotherapy. The role of statin therapy as thromboprophylaxis in the cancer population remains uncertain.

Prognostic value of pretreatment plasma D-dimer levels in patients with diffuse large B cell lymphoma (DLBCL)

BACKGROUND

We assessed the prognostic significance of D-dimer in patients of diffuse large B cell lymphoma (DLBCL).

METHODS

We performed a retrospective study including 254 patients who were newly diagnosed DLBCL. X-tile was used to generate a cutoff value for D-dimer. Both univariate screen by Cox proportional hazard model and multivariable analysis by Cox regression model were used to assess the impact of pretreatment D-dimer levels on the overall survival (OS).

RESULT

According to X-tile, the optimal cut-off value of D-dimer for prediction of survival was set as 1.6 μg/mL, and a D-dimer level ≥ 1.6 μg/mL was significantly associated with poor overall survival (OS) (OS: 31.7 vs. 79.1%, P < 0.001). In multivariable analysis, it was found that a higher D-dimer level was an independent predictor for worse OS (Hazard ratio (HR): 3.594 95% Confidence interval (CI): 2.296-5.267, P < 0.001). In subgroup analysis of International Prognostic Index (IPI), survival of low-risk and intermediate-risk group with a D-dimer level ≥ 1.6 μg/mL were both similar to that of the high-risk group (OS: 31.6 vs. 36.5%, P = 0.957; OS: 38.0 vs. 36.5%, P = 0.758). In addition, among patients treated with surgery, those with higher D-dimer had substantially worse survival than that with lower D-dimer (OS: 27.0 vs. 84.5%, P < 0.001).

CONCLUSION

Pretreatment D-dimer is a simple but effective predictor of survival among patients with DLBCL.

Is Circulating D-Dimer Level a Better Prognostic Indicator than Cea in Resectable Colorectal Cancer? Our Experience on 199 Cases

Purpose

To evaluate the clinical impact of D-dimer (DD) as a tumor marker in patients with colorectal cancer (CRC). The prognostic value of preoperative DD measurement was assessed in relation to carcinoembryonic antigen (CEA) levels.

Methods

DD and CEA levels were measured preoperatively in 199 patients who underwent resection for CRC and the results were analyzed statistically.

Results

The preoperative mean (±SD) levels of DD and CEA were 347.5 (±940.1) ng/mL and 106.4 (±1099.2) ng/mL. The DD level was significantly correlated with the nature of surgery (emergency vs. elective; p=0.002), presence of residual tumor (R1–2 vs R0; p=0.037), and tumor diameter (p<0.001). Conversely, DD was not correlated with tumor grade, pT, pN and M stages, and stage according to the Dukes classification. The 5-year survival rates were 80% and 64% for patients with negative and positive DD values, respectively (p=0.156). CEA was significantly related to all major prognostic factors (resection category, pT, pN and M stages as well as Dukes stage). A significantly worse prognosis was observed for patients with positive CEA levels. Multivariate analysis confirmed CEA as an independent prognostic factor (p=0.005), whilst DD was not (p=0.796).

Conclusions

The possible clinical usefulness of preoperative assessment of DD suggested by previous studies has not been confirmed by our data. CEA was confirmed to be the most reliable and valid indicator of prognosis.

Role of the Coagulation System in Genitourinary Cancers: Review

Tumor progression is associated with aberrant hemostasis, and patients with malignant diseases have an elevated risk of developing thrombosis. A crosstalk among the vascular endothelium, components of the coagulation cascade, and cancer cells transforms the intravascular milieu to a prothrombotic, proinflammatory, and cell-adhesive state. We review the existing evidence on activation of the coagulation system and its implication in genitourinary malignancies and discuss the potential therapeutic benefit of antithrombotic agents. A literature review was performed searching the Medline database and the Cochrane Library for original articles and reviews. A second search identified studies reporting on oncological benefit of anticoagulants in genitourinary cancer. An elevated expression of procoagulatory tissue factor on tumor cells and tumor-derived microparticles seems to stimulate cancer development and progression. Several components of the hemostatic system, including D-dimers, von Willebrand Factor, thrombin, fibrin-/ogen, soluble P-selectin, and prothrombin fragments 1 + 2 were either overexpressed or overactive in genitourinary cancers. Hypercoagulation was in general associated with a poorer prognosis. Experimental models and small trials in humans showed reduced cancer progression after treatment with anticoagulants. Main limitations of these studies were heterogeneous experimental methodology, small patient numbers, and a lack of prospective validation. In conclusion, experimental and clinical evidence suggests procoagulatory activity of genitourinary neoplasms, particularly in prostate, bladder and kidney cancer. This may promote the risk of vascular thrombosis but also metastatic progression. Clinical studies linked elevated biomarkers of hemostasis with poor prognosis in patients with genitourinary cancers. Thus, anticoagulation may have a therapeutic role beyond prevention of thromboembolism.

Fibrinogen and D-dimer levels in prostate cancer: Preliminary results

BACKGROUND

Prostate cancer is one of the most common malignancy in men. The main risk factors for coagulation activation and thrombosis are malignancy and older age. The thrombosis risk may be associated with increased level of coagulation markers such as fibrinogen and D-dimer. The aim of this study is evaluate the relationship between coagulation markers and prostate cancer.

METHODS

This prospective study includes the patients who underwent transrectal ultrasound guided prostate biopsy and prostate surgery was performed between January 2015 and January 2016. Plasma prostate specific antigen (PSA), free PSA (fPSA), percentage fPSA, D-dimer and fibrinogen levels were measured before the procedures. The patients were divided into two groups according to the pathology results. The patients with benign prostate hyperplasia were in group 1 and the patients with prostate cancer were in group 2.

RESULTS

There were 76 patients in the current study. There were 53 patients in group 1 and 23 patients in group 2. The mean age of the patients, PSA, fPSA, fibrinogen and D-dimer levels was 65.33 ± 7.47 years, 8.21 ± 4.59, 1.41 ± 0.74 ng/ml, 309.75 ± 80.46 mg/dl, 0.42 ± 0.39 ug/ml in group 1. In group 2; the mean age of the patients, PSA, fPSA, fibrinogen and D-dimer levels was 66.08 ± 6.7 years, 145.69 ± 509.35, 7.32 ± 15 ng/ml, 312.16 ± 69.48 mg/dl, 1.09 ± 2.11 ug/ml. The prostate biopsy and transurethral surgery were performed in 64(%84.21) and 12(%15.79) patients.

CONCLUSION

The present study demonstrated that plasma D-dimer level was higher in patients with prostate cancer. Further studies that include large number of patients are needed to define the relationship between prostate cancer and coagulation disorder.

Role of coagulation factors in urological malignancy: A prospective, controlled study on prostate, renal and bladder cancer

OBJECTIVES

To study the behavior of specific coagulation factors in different types of non-metastatic urological cancers, and to identify their possible role as diagnostic and prognostic markers.

METHODS

This was a prospective controlled study, which included three cancer patient groups and a control group of healthy individuals. The cancer subgroups consisted of renal (n = 44), prostate (n = 56) and bladder cancer (n = 47). We excluded patients receiving anticoagulant therapy, or with significant comorbidity. In all patients, certain coagulation parameters were measured (prothrombin time, international normalized ratio, partial thromboplastin time, D-dimers, fibrinogen, F1 + 2, thrombin-antithrombin complex). Statistical analysis was carried out to explore the association of hemostasis markers with tumor-nodes-metastasis stage, Gleason score, transitional cell carcinoma grade, Fuhrman grade and prostate-specific antigen.

RESULTS

Our final sample consisted in 58 control patients and 147 patients with urological cancer. We found specific patterns of increased coagulation factors in the different cancers that were statistically significant. Renal cancer showed increased levels of D-dimers, partial thromboplastin time and fibrinogen. D-dimers and fibrinogen were increased in prostate cancer; whereas in bladder cancer, only fibrinogen was elevated. Correlations were found between certain factors and tumor stage and grading, with D-dimers being independently associated with higher tumor grade. Thrombin-antithrombin complex was associated with Gleason score. Furthermore, D-dimers, fibrinogen and F1 + 2 were associated with higher tumor stages (II-IV).

CONCLUSIONS

The coagulation pathway seems to be activated in urological malignancies. Specific panels of coagulation factors might play a role as screening or prognostic tools in earlier stages of renal, prostate and bladder cancer. Further research should also focus on their role in the association of cancer with thromboembolic events.

Increased coagulation activity and genetic polymorphisms in the F5, F10 and EPCR genes are associated with breast cancer: a case-control study

Background

The procoagulant state in cancer increases the thrombotic risk, but also supports tumor progression. To investigate the molecular mechanisms controlling cancer and hemostasis, we conducted a case-control study of genotypic and phenotypic variables of the tissue factor (TF) pathway of coagulation in breast cancer.

Methods

366 breast cancer patients and 307 controls were genotyped for SNPs (n = 41) in the F2, F3 (TF), F5, F7, F10, TFPI and EPCR genes, and assayed for plasma coagulation markers (thrombin generation, activated protein C (APC) resistance, D-dimer, antithrombin, protein C, protein S, and TF pathway inhibitor (TFPI)). Associations with breast cancer were evaluated using logistic regression to obtain odds ratios (ORs) and 95% confidence intervals (CIs), or the chi-square test.

Results

Four SNPs in F5 (rs12120605, rs6427202, rs9332542 and rs6427199), one in F10 (rs3093261), and one in EPCR (rs2069948) were associated with breast cancer. EPCR rs2069948 was associated with estrogen receptor (ER) and progesterone receptor (PR) positivity, while the SNPs in F5 appeared to follow hormone receptor negative and triple negative patients. The prothrombotic polymorphisms factor V Leiden (rs6025) and prothrombin G20210A (rs1799963) were not associated with breast cancer. High APC resistance was associated with breast cancer in both factor V Leiden non-carriers (OR 6.5, 95% CI 4.1-10.4) and carriers (OR 38.3, 95% CI 6.2-236.6). The thrombin parameters short lag times (OR 5.8, 95% CI 3.7-9.2), short times to peak thrombin (OR 7.1, 95% CI 4.4-11.3), and high thrombin peak (OR 6.1, 95% CI 3.9-9.5) predicted presence of breast cancer, and high D-dimer also associated with breast cancer (OR 2.0, 95% CI 1.3-3.3). Among the coagulation inhibitors, low levels of antithrombin associated with breast cancer (OR 5.7, 95% CI 3.6-9.0). The increased coagulability was not explained by the breast cancer associated SNPs, and was unaffected by ER, PR and triple negative status.

Conclusions

A procoagulant phenotype was found in the breast cancer patients. Novel associations with SNPs in F5, F10 and EPCR to breast cancer susceptibility were demonstrated, and the SNPs in F5 were confined to hormone receptor negative and triple negative patients. The study supports the importance of developing new therapeutic strategies targeting coagulation processes in cancer.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2407-14-845) contains supplementary material, which is available to authorized users.

Thromboelastography identifies hypercoagulablilty and predicts thromboembolic complications in patients with prostate cancer

Cancer patients are at higher risk for thromboembolism compared to the normal population. This may be related to tumour burden and/or enhanced by systemic therapy. While there is ample evidence regarding venous thromboembolism, systematic studies investigating arterial thrombotic events are scarce. Conventional coagulation tests have limited capacity in evaluating the coagulability or the need for anticoagulant prophylaxis. In this pilot study, we investigated whether assessment of global haemostasis using thromboelastography (TEG) and quantification of plasma pro-coagulant microparticles can help determine the risk of adverse thrombotic events in patients with prostate cancer (PCa). Thirty two patients were recruited a priori into three groups: 11 men on 'watchful waiting' following recurrent disease after definitive treatment (Group A); 10 patients with metastatic disease on Androgen deprivation therapy (ADT) (Group B); and 11 with castration resistant cancer (Group C) and followed up over a period of 12months. These patients were compared to a control group composed of 8 men with negative prostate biopsy. Whole blood TEG and plasma tissue factor-carrying microparticles (TF-MPs) in addition to basic coagulation testing, plasma fibrinogen and d-dimer were performed. 22/32 (68.8%) of the patients demonstrated hypercoagulable TEG traces. Hypercoagulability was marked in group B compared to the control. Plasma MPs were significantly elevated in patients compared to the controls with significant increase in group B. All other coagulation tests were normal. Seven of the 22 hypercoagulable patients (31.8%) developed one or more thromboembolic events over 12months follow up period. The data in this pilot study show that PCa patients are hypercoagulable, particularly those with advanced disease on ADT and that this hypercoagulability can be identified by TEG. While this needs to be verified in a larger study, the data indicate TEG may aid in thrombosis risk stratification and determining the subsequent need for anticoagulant prophylaxis in PCa patients.

Biomolecular markers of cancer-associated thromboembolism

Venous thromboembolism (VTE; deep venous thrombosis and pulmonary embolism) is associated with a poor prognosis in most malignancies and is a major cause of death among cancer patients. Universal anticoagulation for primary thromboprophylaxis in the outpatient setting is precluded by potential bleeding complications, especially without sufficient evidence that all patients would benefit from such prophylaxis. Therefore, appropriately targeting cancer patients for thromboprophylaxis is key to reducing morbidity and perhaps mortality. Predictive biomarkers could aid in identifying patients at high risk for VTE. Possible biomarkers for VTE include C-reactive protein, platelet and leukocyte counts, D-dimer and prothrombin fragment 1+2, procoagulant factor VIII, tissue factor, and soluble P-selectin. Evidence is emerging to support the use of risk assessment models in selecting appropriate candidates for primary thromboprophylaxis in the cancer setting. Further studies are needed to optimize these models and determine utility in reducing morbidity and mortality from cancer-associated thromboembolism.

Pretherapeutic laboratory findings, extent of metastasis and choice of treatment as prognostic markers in ocular melanoma- a single centre experience

BACKGROUND

Uveal melanoma is the most common intraocular neoplasm with a high tendency to metastasize predominantly to the liver. Prognostic parameters for progression and overall survival are not well defined. The aim of this study was to assess the value of pretherapeutic serum levels of C-reactive protein (CRP), lactate dehydrogenase, albumin and fibrinogen in patients with uveal melanoma and to evaluate their significance as prognostic parameters for survival.

METHODS

Forty-nine patients with metastatic uveal melanoma treated between 2000 and 2010 were retrospectively analysed. The potential influence of levels of CRP, lactate dehydrogenase, fibrinogen and albumin as well as other commonly known prognostic variables on progression-free and overall survival were investigated.

RESULTS

Patients' age and treatment with systemic chemotherapy were the only variables to show significant influences on progression-free and overall survival in a univariate analysis. Multivariate analysis confirmed the influence of these variables on progression-free survival, presence of metastasis, pretherapeutic CRP levels and treatment with systemic chemotherapy were associated with overall survival.

CONCLUSION

In this patient cohort elevated pretherapeutic CRP and extent of metastasis are independent prognostic factors for decreased overall survival, whereas treatment with systemic chemotherapy showed a significant association with improved overall survival.

Increases in quantitative D-dimer levels correlate with progressive disease better than circulating tumor cell counts in patients with refractory prostate cancer

Changes in quantitative D-dimer levels, circulating tumor cell (CTC) counts, and prostate-specific antigen (PSA) levels were measured in 28 patients with refractory castration-resistant prostate cancer to assess their concordance during the course of therapy and their relationship with risk of progressive disease. A significant correlation was identified between changes in PSA and both CTC counts and D-dimer levels (r = 0.67 and 0.58, respectively; P < .001). In addition, there was a significant correlation between changes in CTC count and D-dimer level (r = 0.62; P < .001). A significantly stronger concordance between these biomarkers was noted for increasing values (sensitivity, 72%-77.8%) compared with decreasing values (specificity, 43.8%-71.4%). Notably, increases in PSA and D-dimer levels, not CTC counts, were associated with increased risks for progressive disease (P < .024). Increases in quantitative D-dimer levels correlate with progressive disease better than CTC counts in patients with refractory prostate cancer.

D-dimer and prothrombin fragment 1 + 2 predict venous thromboembolism in patients with cancer: results from the Vienna Cancer and Thrombosis Study

PURPOSE

Venous thromboembolism (VTE) is a well-recognized complication of cancer. Laboratory parameters might be useful to assess the VTE risk in patients with cancer. The aim of this study was to investigate D-dimer and prothrombin fragment 1 + 2 (F 1 + 2), which reflect activation of blood coagulation and fibrinolysis, for prediction of cancer-associated VTE.

PATIENTS AND METHODS

In a prospective, observational, cohort study of 821 patients with newly diagnosed cancer or progression of disease who did not recently receive chemotherapy, radiotherapy, or surgery were enrolled and followed for a median of 501 days (interquartile range, 255 to 731 days). The malignancies in these patients were as follows: breast (n = 132), lung (n = 119), stomach (n = 35), lower gastrointestinal tract (n = 106), pancreas (n = 46), kidney (n = 22), and prostate (n = 101) cancers; high-grade glioma (n = 102); malignant lymphoma (n = 94); multiple myeloma (n = 17); and other tumor types (n = 47). The study end point was occurrence of objectively confirmed symptomatic or fatal VTE.

RESULTS

VTE occurred in 62 patients (7.6%). The cutoff level for elevated D-dimer and elevated F 1 + 2 was set at the 75th percentile of the total study population. In multivariable analysis that included elevated D-dimer, elevated F 1 + 2, age, sex, surgery, chemotherapy, and radiotherapy, the hazard ratios (HRs) of VTE in patients with elevated D-dimer (HR, 1.8; 95% CI, 1.0 to 3.2; P = .048) and elevated F 1 + 2 (HR, 2.0; 95% CI, 1.2 to 3.6; P = .015) were statistically significantly increased. The cumulative probability of developing VTE after 6 months was highest in patients with both elevated D-dimer and elevated F 1 + 2 (15.2%) compared with patients with nonelevated D-dimer and nonelevated F 1 + 2 (5.0%; P < .001).

CONCLUSION

High D-dimer and F 1 + 2 levels independently predict occurrence of VTE in patients with cancer.

Evaluation of platelet function and lack of response to epinephrine in pregnant women

Previous studies in healthy subjects have demonstrated a lack of response of platelets to epinephrine at a rate of 16-40% on an aggregometer. An association between the increased procoagulant factors during pregnancy and venous thromboembolism is known, and it has also been shown that prolactin levels increase platelet aggregation. We evaluated whether platelet functions in pregnant women and also assessed the lack of response to epinephrine during this period. We compared 27 healthy and volunteering pregnant women with 26 similar control subjects. Platelet functions were assessed with an aggregometer and a Platelet Function Analyzer (PFA-100). Less than 40% response to epinephrine on the aggregometer was defined as an impaired epinephrine response. The aggregation response of epinephrine was normal in 25 of the 27 pregnant women, while two of them showed a late-rising response. Eight of the 26 subject control group (30.8%) showed an impaired response to epinephrine. When we compared the 25 pregnant and 18 control subjects with normal aggregation responses, the maximum aggregation responses to ADP and epinephrine, and the Col/Epi and Col/ADP cartridge closure time values were significantly lower in pregnant women. There were no difference between second and third trimesters as regards platelet function parameters. The fact that no impaired response to epinephrine was detected in pregnant women while a 30% rate was observed in non-pregnant women indicates that the platelet malfunction caused by a disorder in the Gi protein and intracellular mechanisms is bypassed during pregnancy thanks to some physiological changes.

Cancer-associated thrombosis

There is strong evidence linking venous thromboembolic events and malignancy. Laboratory markers of coagulation activation such as thrombin-antithrombin complex or prothrombin fragments 1+2 support the premise that malignancy is a hypercoagulable state. Inflammatory cytokines (e.g. tumor necrosis factor and interferon-gamma), coagulation proteins (e.g. tissue factor and factor VIII), and procoagulant microparticles may be elevated in patients with malignancy. However, the molecular basis for cancer associated thrombosis remains unknown and the relative contribution of chemotherapeutics, tumor cells, endothelium, and circulating procoagulants in promoting thrombus formation continues to be investigated.

Ten-year survival and cardiovascular mortality in patients with advanced prostate cancer primarily treated by intramuscular polyestradiol phosphate or orchiectomy

BACKGROUND

The aim of the study was to evaluate overall and prostate cancer (PCa) specific survival with special attention to cardiovascular (CV) mortality in patients primarily treated by parenteral polyestradiol phosphate (PEP) 240 mg/month or with orchiectomy (OE), taking into account the effect of pretreatment diseases and medication, and later PCa therapies.

METHODS

The present Finnprostate 6 study (10-year follow-up) consisted of 244 patients with locally advanced PCa (T3-4 M0) and 200 patients with metastatic PCa (T1-4 M1). Patients were randomized to OE or PEP therapy. The T3-4 M0 and T1-4 M1 patients were analyzed separately.

RESULTS

There was no difference in overall or PCa specific survival between the primary therapy groups in T3-4 M0 or T1-4 M1 patients. In the T3-4 M0 patients the primary treatment (PEP vs. OE) was statistically significantly associated with a risk of CV deaths (P = 0.001). Such an association was not found in the T1-4 M1 patients.

CONCLUSIONS

The primary PEP and OE therapies are equal in terms of overall and PCa specific survival in patients with T3-4 M0 or T1-4 M1 disease. In T3-4 M0 patients PEP increases the risk of CV deaths compared to OE but not in T1-4 M1 patients.

Prothrombotic effect of prostasomes of metastatic cell and seminal origin

BACKGROUND

Prostasomes are secretory granules produced by the glandular epithelial cells of the prostate. Seminal prostasomes contain high amounts of Tissue Factor (TF) but no studies of TF on malignant cell prostasomes have been made. Here we compare the expression, phosphorylation, and function of TF on prostasomes of different origin.

METHODS

TF was detected on prostasomes isolated from seminal fluid and human prostate cancer cell lines (PC-3, DU145, and LNCaP) using FACS and enzyme immunoassay (EIA). Incubation of prostasomes with radioactive ATP under conditions favoring protein kinase A activity led to phosphorylation of TF as detected by immunoprecipitation and SDS-PAGE. The prothrombotic effect of prostasomes was investigated in whole blood and recalcified plasma. Blocking experiments were performed using anti-TF antibodies and corn trypsin inhibitor.

RESULTS

TF was expressed on all tested prostasome preparations with lowest values found for seminal ones. Prostasomal TF was the main endogenous substrate for prostasomal protein kinase A. All tested prostasome preparations greatly enhanced the rate of clot formation in a dose-dependent fashion, that is, the clotting capability of prostasomes seemed to be related to the extent of their expression of TF. In addition, the density of the clot varied between different prostasome preparations. When incubated in whole blood, prostasomes were found to associate to WBC thereby inducing them to express and release TF.

CONCLUSIONS

These data show that TF is overexpressed and also subjected to phosphorylation by malignant cell prostasomes. This suggests major roles for prostasomes in thrombotic events that occur in some advanced cases of prostate cancer.

Single-shot antithrombin in human pancreas-kidney transplantation: reduction of reperfusion pancreatitis and prevention of graft thrombosis*

Reperfusion pancreatitis and graft thrombosis often induce early graft loss in simultaneous pancreas-kidney (SPK) transplantation. Antithrombin (AT) is a coagulatory inhibitor with pleiotropic activities that reduces experimental ischemia/reperfusion injury. This study retrospectively analyses prophylactic high-dose AT application in patients with first SPK. In an university transplantation center, 53 consecutive patients with SPK were studied without randomization. In one group, 3000 IU of AT was given intravenously before pancreatic reperfusion (AT, n = 24). Patients receiving standard therapy including postoperative AT supplementation (controls, n = 29) served as controls. Daily blood sampling was performed as a part of the clinical routine during four postoperative days. There were no differences in demographic and laboratory parameters [donor/recipient age, ischemia time, perfusion solution, body weight, mismatches] between both groups. Baseline creatinine values were lower in the control group versus AT group (P < 0.05). Coagulatory parameters and bleeding incidence were not influenced by AT, while incidence of graft thrombosis was reduced (control: 7/29; AT: 4/24; relative reduction of risk: -33%; P < 0.05). Single-shot AT application during SPK modulated serum lipase activity on postoperative days 2 and 3, and minimized risk for graft thromboses without increasing perioperative bleeding. This new concept should deserve testing in a prospective clinical trial.

PAR1-mediated NFkappaB activation promotes survival of prostate cancer cells through a Bcl-xL-dependent mechanism

We have previously reported that protease-activated receptor 1 (PAR1 or thrombin receptor) is over-expressed in metastatic prostate cancer cell lines compared to prostate epithelial cells. In this study, we examined 1,074 prostate biopsies by tissue microarray analysis and demonstrated that PAR1 expression is significantly increased in prostate cancer compared to normal prostate epithelial cells and benign prostatic hyperplasia. We hypothesized that PAR1 activation contributed to prostate cancer cell progression. We demonstrated that stimulation of PAR1 by thrombin or thrombin receptor activating peptide (TRAP6), in androgen-independent DU145 and PC-3 cells resulted in increased DNA binding activity of the NFkappaB p65 subunit. IL-6 and IL-8 levels were also elevated in conditioned media by at least two-fold within 4-6 h of PAR1 activation. This induction of cytokine production was abrogated by pretreatment of cells with the NFkappaB inhibitor caffeic acid phorbol ester. The p38 and ERK1/2 MAPK signaling cascades were also activated by PAR1 stimulation, whereas the SAPK/JNK pathway was unaffected. Inhibition of p38 and ERK1/2 by SB-203589 and PD-098059, respectively, did not abrogate NFkappaB activity, suggesting an independent induction of NFkappaB by PAR1 stimulation. Furthermore, TUNEL assay showed that activation of PAR1 attenuated docetaxel induced apoptosis through the upregulation of the Bcl-2 family protein Bcl-xL. Akt activation was not observed, suggesting that drug resistance induced by PAR1 was independent of PI3K signaling pathway. Because thrombin and PAR1 are over-expressed in prostate cancer patients, targeting the inhibition of their interaction may attenuate NFkappaB signaling transduction resulting in decreased drug resistance and subsequent survival of prostate cancer cells.

Coagulopathy, following medical therapy, for carcinoma of the prostate

Cancer of the prostate can be associated with coagulopathy characterized as primary fibrinolysis or diffuse intravascular coagulopathy (DIC) with secondary fibrinolysis. These complications are usually associated with surgical manipulation of the prostate or with advanced metastatic disease. This report describes a patient with DIC and fibrinolysis following medical management of advanced prostate cancer with gonadotropin-releasing hormone leuprolide, while receiving the androgen receptor blocking agent flutamide. This report suggests that release of procoagulant material from prostatic carcinoma may be so rapid following hormonal management that consumptive coagulopathy with fibrinolysis can follow. Shortened Abstract: Medical management with gonadotropin releasing hormone allowed the expression of consumptive coagulopathy in patients with metastatic prostate cancer.

Circulating D-dimer levels are better predictors of overall survival and disease progression than carcinoembryonic antigen levels in patients with metastatic colorectal carcinoma

BACKGROUND

Fibrin formation is required for tumor angiogenesis, metastasis, and invasion. D-dimer, a fibrin degradation product, is produced when crosslinked fibrin is degraded by plasmin. The current study prospectively examined D-dimer levels in patients with metastatic colorectal carcinoma treated in a Phase II randomized trial comparing bevacizumab (Avastin, Genentech, South San Francisco, CA) plus 5-fluorouracil/leucovorin (5-FU/LV) with 5-FU/LV alone.

METHODS

At least one circulating D-dimer level was evaluable in 98 of the 104 previously untreated patients with metastatic colorectal carcinoma in the current trial. Plasma D-dimer levels were determined using a quantitative immunoassay kit at enrollment, before each treatment, and at the time of trial completion or disease progression.

RESULTS

At trial enrollment, 86 of 104 patients (88%) had elevated D-dimer levels (> 20 ng/mL), and 86 of 102 patients (84%) had elevated carcinoembryonic antigen (CEA) levels (> 3 ng/mL). Baseline D-dimer levels were correlated with the following baseline characteristics: CEA (Pearson coefficient, 0.31; P = 0.002), albumin levels (Pearson coefficient, -0.32; P = 0.002), tumor burden (Pearson coefficient, 0.30; P = 0.003), and number of metastatic sites (Pearson coefficient, 0.21; P = 0.04). At the time of progression, plasma D-dimer levels reached a maximum postbaseline value in 51 of 61 patients (84%), whereas the CEA level was at its maximum postbaseline value in 39 of 55 patients (71%). Baseline D-dimer levels were a strong predictor of overall survival on univariate analysis (P = 0.008) and multivariate analysis (P = 0.03). Overall, treatment with bevacizumab (5 mg/kg) and baseline D-dimer levels were the only predictors of overall survival (P < 0.05).

CONCLUSIONS

The current study indicates that fibrin remodeling is an important prognostic feature in metastatic colorectal carcinoma. D-dimer levels should be incorporated into prognostic models, and D-dimer may represent a useful biomarker for patients treated with antiangiogenic agents.

Mechanism of the stimulatory effect of 6-aminohexanoic acid on plasminogen activation by streptokinase or tissue plasminogen activator: The role of chloride

Studies were conducted on the mechanism of the stimulatory effect of 6-aminohexanoic acid (6-AH) during the in vitro activation of human glutamic plasminogen (Glu-Plg) by streptokinase or by tissue plasminogen activator (t-PA) and the possible role of the addition of physiological concentrations of NaCl to the buffer solution. Enhancement by 6-AH was investigated by measuring the rate of plasmin generation using chromogenic substrate H-D-glu-phe-lys-pNA (S-2403). Control studies using plasmin showed that the addition of 6-AH at concentrations below 20 mM did not significantly affect the initial rate of the amidolytic activity of plasmin with or without the addition of NaCl to 0.05 M Tris buffer (pH 7.4). On the other hand, addition of NaCl to the buffer slowed down the initial rate of activation of Glu-Plg by streptokinase or by t-PA while increasing the percent enhancement by 6-AH when compared with the controls. The ratios of the initial rates of plasmin generation in the presence or in the absence of 6-AH were plotted against the inverse of the volume fraction of Glu-Plg, streptokinase or t-PA after serial dilutions. The results showed that when the activation reactions were performed in 50 mM of Tris buffer (pH 7.4), the enhancements by 6-AH were related to its interaction with streptokinase or t-PA, while using the same Tris buffer containing 0.6 % NaCl, the enhancements by 6-AH were related to its interaction with both Glu-Plg and streptokinase or t-PA. However, upon increasing the NaCl to 0.9%, the results showed that the enhancements by 6-AH of the activation of Glu-Plg by streptokinase or t-PA were related to its interaction with Glu-Plg. The results suggested that changes in the concentrations of NaCl play a regulatory role during the activation process.

Marburg I polymorphism of factor VII--activating protease: a prominent risk predictor of carotid stenosis

BACKGROUND

Atherothrombosis is a main pathomechanism in the evolution of vessel stenosis and is counteracted by endogenous fibrinolysis. Recently, the plasmatic serine protease "factor seven-activating protease" (FSAP) was recognized as a potent activator of prourokinase in vitro. The Marburg I polymorphism of FSAP impairs this potential and may thus facilitate arterial thrombosis.

METHODS AND RESULTS

This analysis of the Bruneck Study involved 810 men and women aged 40 to 79 years. The ultrasound-based atherosclerosis progression model (5-year follow-up) permits differentiation between early atherogenesis and the advanced stenotic stages of carotid artery disease. The FSAP Marburg I polymorphism was found in 37 subjects (carriage rate 4.4%). Individuals with this genetic variant showed a prominently reduced in vitro capacity to activate prourokinase. No relation was found to exist between the Marburg I polymorphism and early atherogenesis. In contrast, it emerged as a strong and independent risk predictor of incident/progressive carotid stenosis (multivariate odds ratio [95%CI], 6.6 [1.6 to 27.7]). This finding equally applied to subjects with and without co-segregation of the Marburg II polymorphism. The risk profile of advanced atherogenesis further includes cigarette smoking, high lipoprotein(a), the factor V Leiden mutation, low antithrombin III, high fibrinogen, and diabetes.

CONCLUSIONS

In concert with other genetic and acquired conditions known to interfere with coagulation or fibrinolysis, the Marburg I polymorphism of FSAP, which attenuates its capacity to activate prourokinase, is a significant risk predictor for the evolution and progression of carotid stenosis.

Plasma levels of D-dimer and soluble fibrin polymer in patients with hepatocellular carcinoma: a possible predictor of tumor thrombosis

INTRODUCTION

Fibrin formation and removal occurs continuously during the development of malignancy. Moreover, plasma D-dimer is indicative of ongoing fibrinolysis, and soluble fibrin polymer (Thrombus precursor protein, TpP) represents thrombogenic activity. We evaluated the relationship between the levels of plasma D-dimer and TpP and tumor thrombosis in patients with hepatocellular carcinoma (HCC), and examined these markers as possible predictors of tumor thrombus in the portal or the hepatic vein.

MATERIALS AND METHODS

Plasma levels of D-dimer and TpP were measured in 66 HCC patients (38 without tumor thrombosis, 28 with tumor thrombosis) and 29 healthy controls, by enzyme immunoassay using an Asserachrom D-Di kit (Diagnostica Stago, France) and a TpP kit (American Biogenetic Sciences, USA).

RESULTS

The plasma levels of D-dimer and TpP in HCC patients were found to be significantly higher than those in healthy controls, and these values were also significantly higher in patients with tumor thrombosis than those without tumor thrombosis. Positive D-dimer (>367 ng/ml) correlated weakly with the presence of tumor thrombosis, whereas positive TpP (>5.4 microg/ml) correlated strongly with the presence of tumor thrombosis. By multivariant logistic analysis, positive TpP level was found to be a significant predictor of the presence of tumor thrombosis. In contrast, positive D-dimer level was not found to be a significant predictor for predicting tumor thrombosis.

CONCLUSIONS

Increased D-dimer and TpP levels in HCC may suggest that fibrinolysis and coagulation occur continuously during tumor progression. This study shows that a positive TpP level is a predictor of tumor thrombosis in HCC, which suggests that TpP may be useful for identifying tumor thrombus in the portal and hepatic veins.