Search

Cancer-related venous thromboembolism (VTE) remains a major health problem, accounting for at least 18% of all cases of VTE. Cancer patients with VTE have worse prognosis than those without VTE. Prophylaxis reduces VTE risk, but it is not feasible for all outpatients with cancer due to an increased bleeding risk. The factors involved in the pathogenesis of cancer-related VTE are direct coagulation activation, platelet activation, induction of inflammatory responses, and inhibition of fibrinolysis. Direct coagulation activation can be due to cancer procoagulant (a cysteine protease), microvesicles, or other prothrombotic abnormalities. Risk factors for developing VTE in cancer patients can be divided into four groups: tumor-related risk factors, patient-related risk factors, treatment-related risk factors, and biomarkers. Cancers of the pancreas, kidney, ovary, lung, and stomach have the highest rates of VTE. Patient-related risk factors such as age, obesity, or the presence of medical comorbidities can contribute to VTE. Platinum-based chemotherapies and antiangiogenesis treatments have also been associated with VTE. Biomarkers identified as risk factors include high platelet count, high leukocyte count, P-selectin, prothrombin fragments, D-dimer, and C-reactive protein. Based on the known risk factors, risk assessment models were developed to stratify patients who would benefit from thromboprophylaxis. The Khorana model was the first and is still the most widely used model. Because of its low sensitivity for certain tumor types, four new models have been developed in recent years. In this review, we describe the current knowledge about the pathogenesis and risk factors for cancer-related VTE, hoping to contribute to further research on the still many obscure aspects of this topic.

Venous thromboembolism (VTE) is a major health problem in patients with cancer. Cancer augments thrombosis and causes cancer-associated thrombosis (CAT) and vice versa thrombosis amplifies cancer progression, termed thrombosis-associated cancer (TAC). Risk factors that lead to CAT and TAC include cancer type, chemotherapy, radiotherapy, hormonal therapy, anti-angiogenesis therapy, surgery, or supportive therapy with hematopoietic growth factors. There are some other factors that have an effect on CAT and TAC such as tissue factor, neutrophil extracellular traps (NETs) released in response to cancer, cancer procoagulant, and cytokines. Oncogenes, estrogen hormone, and thyroid hormone with its integrin αvβ3 receptor promote angiogenesis. Lastly, patient-related factors can play a role in development of thrombosis in cancer. Low-molecular-weight heparin and direct oral anticoagulants (DOACs) are used in VTE prophylaxis and treatment rather than vitamin K antagonist. Now, there are new directions for potential management of VTE in patients with cancer such as euthyroid, blockade of thyroid hormone receptor on integrin αvβ3, sulfated non-anticoagulant heparin, inhibition of NETs and stratifying low and high-risk patients with significant bleeding problems with DOACs.

Introduction: It is well known that the tendency toward thrombosis is increased in cancer patients. The increase in cancer procoagulant and tissue factor levels, endothelial damage, and stasis due to compression are among the most accused causes of thrombosis in cancer patients. Hypereosinophilia is a rare condition that causes endothelial damage leading to thrombosis. Case Presentation: We present a 64-year-old male patient with cardiac involvement of hypereosinophilia which developed in the T-cell lymphoma ground resulting in a fatal cardioembolic stroke. Despite normal left ventricular (LV) contractions, almost half of the ventricular volume was full of thrombus in this case. Conclusion: Hypereosinophilia is a rare cause of thrombus formation in the left ventricle in patients with preserved ejection fraction. However, hypereosinophilic cardiac involvement can lead to rapid, progressive, life-threatening complications.

Введение. В настоящее время доказана взаимосвязь между онкологическими заболеваниями и тромбозами, установлены причины тромбообразования, обнаружена закономерность неблагоприятного течения заболевания и рецидивирующих тромбозов. Считается, что большинство скрининговых тестов мало чувствительны к гиперкоагуляции и слабо прогнозируют возникновение тромбоэмболических осложнений. Цель исследования: изучить состояние коагуляционного звена гемостаза у больных неходжкинскими лимфомами (НХЛ) с помощью скрининговых и интегрального тестов и дать их сравнительную оценку. Материалы и методы. Обследовано 75 больных с впервые установленными В-клеточными НХЛ (40 пациентов с агрессивными и 35 — с индолентными лимфомами). Свертывающую систему крови оценивали до начала проведения специфической противоопухолевой терапии и после 4–6 курсов полихимиотерапии с помощью данных коагулограммы и интегрального теста «Тромбодинамика». Результаты. На этапе диагностики заболевания отмечено значимое увеличение начальной (Vi) и стационарной (Vs) скоростей роста сгустка и размера сгустка (Cs). У 26 пациентов на ранних стадиях заболевания выявлено повышение Vs и Cs. У 49 больных с генерализованными стадиями НХЛ установлено повышение Vi, Vs, Cs, протромбинового времени по Квику (ПВ), тромбинового времени, уровня растворимых фибрин-мономерных комплексов, укорочение активированного частичного тромбопластинового времени (АЧТВ); из них у 27 (55%) выявлен рост спонтанных сгустков вдали от активатора. При анализе прокоагулянтной активности у пациентов с генерализованными стадиями заболевания обнаружено достоверное повышение Сs, ПВ и укорочение АЧТВ. При достижении ремиссии у 34 (45%) больных НХЛ склонность к гиперкоагуляции сохранялась. Заключение. Полученные результаты свидетельствуют о высокой чувствительности теста «Тромбодинамика» к прокоагулянтным состояниям у больных НХЛ., Introduction. The close interrelation between cancer and thromboses is well proven on today. However usual screening tests are not sensitive to hypercoagulation that limits their use to predict tromboembolic complications. Aim: to study coagulative hemostasis in patients with non-Hodgkin’s lymphomas (NHL) using screening and integral tests in order for their comparison. Materials and methods. We examined 75 patients with fi rst-identifi ed B-cell NHL (40 with aggressive and 35 with indolent lymphomas). Blood coagulation was examined before specific antitumor therapy and after 4–6 courses of polyсhemotherapy using coagulogram and «Тhrombodynamics» test. Results. In the diagnosis of disease the signifi cant increasing of initial clot growth rate (Vi), stationary clot growth rate (Vs) and clot size (Cs) were determined. At early stages of disease 26 patients had increased Vs and Cs. 49 patients with generalized stages of NHL had increased Vi, Vs, Cs, prothrombin time by Quick (PT), thrombin time, level of soluble fi brin-monomer complexes, shortening of activated partial thrombin time (APTT); in 27 of them (55%) growth of spontaneous clot away from the activator was observed. Analysis of procoagulant activity in patients with generalized stages of disease revealed a signifi cant increasing of Cs, PT and shortening of APTT. In 34 (45%) NHL-patients with remission the tendency to hypercoagulation remained. Conclusion. The results obtained indicate a high sensitivity of «Тhrombodynamics» test to procoagulant conditions in patients with NHL., №3(2018) (2018)

Cancer procoagulant (CP), a direct activator of coagulation factor X, is among one of the tumour cell products or activities which may promote fibrin formation and has been suggested to be selectively associated with the malignant phenotype. At present, the most reliable assay for the quantification of CP activity is the three-stage chromogenic assay which utilises the ability of CP to activate factor X. In this assay, the activation of factor X leads to the formation of activated thrombin from prothrombin and the eventual hydrolyses of a thrombin chromogenic substrate which contains a p-nitroaniline leaving group. The complexity of the three-stage chromogenic assay suggests a need for a direct method of assaying CP activity. This study focuses on the design of a fluorogenic substrate that would enable the direct quantification of CP activity. The results of the study show two promising substrates for the determination of CP activity: Boc-PQVR-AMC and PQVR-AMC. Further analysis showed that Boc-PQVR-AMC could be excluded as a potential substrate for CP since it was also cleaved by collagenase.

Proteases are essential for tumour progression and many are over-expressed during this time. The main focus of research was the role of these proteases in degradation of the basement membrane and extracellular matrix (ECM), thereby enabling metastasis to occur. Cancer procoagulant (CP), a protease present in malignant tumours, but not normal tissue, is a known activator of coagulation factor X (FX). The present study investigated the function of CP in cancer progression by focussing on its enzymatic specificity. FX cleavage was confirmed using SDS-PAGE and MALDI-TOF MS and compared to the proteolytic action of CP on ECM proteins, including collagen type IV, laminin and fibronectin. Contrary to previous reports, CP cleaved FX at the conventional activation site (between Arg-52 and Ile-53). Additionally, degradation of FX by CP occurred at a much slower rate than degradation by conventional activators. Complete degradation of the heavy chain of FX was only visible after 24 h, while degradation by RVV was complete after 30 min, supporting postulations that the procoagulant function of CP may be of secondary importance to its role in cancer progression. Of the ECM proteins tested, only fibronectin was cleaved. The substrate specificity of CP was further investigated by screening synthetic peptide substrates using a novel direct CP assay. The results indicate that CP is not essential for either cancer-associated blood coagulation or the degradation of ECM proteins. Rather, they suggest that this protease may be required for the proteolytic activation of membrane receptors.

The aim of the study To analyze human breast cancer cell line MCF-7 and human malignant melanoma cell line WM-115 in order to characterize the cellular expression of CP and to evaluate whether ATO may affect this activity, as well as the viability of the cells. Material and methods The inhibitory effect of arsenic trioxide on the proliferation of MCF-7 and WM-115 cells were measured with MTT test. The activity of cancer procoagulant after ATO exposure was determined by a specific three-stage chromogenic assay. Results ATO decreased the CP activity in a dose- and time-dependent manner in MCF-7 cells with no effect on cell proliferation at the same time. However, it affected the CP activity of WM-115 cells in a different way. Reduction in CP activity was followed by an increase after 48 h incubation. The cells viability results showed dose-and time-correlated response within high arsenic concentrations. Conclusions Arsenic trioxide downregulates the CP expression in human breast cancer and melanoma cells.

Most cancer cells trigger thrombin generation (TG) to various extent. In the present study, we dissected the mechanisms responsible for the procoagulant activity of pancreatic adenocarcinoma cells (BXPC3), a highly thrombogenic cancer type, and breast cancer cells (MCF7), a less thombogenic tumor type. TG of normal plasma was assessed by the Thrombinoscope (CAT®) in the presence or absence of cancer cells. TG was also assessed in plasma depleted of clotting factors, in plasma spiked with tissue factor (TF) and/or procoagulant phospholipids, in plasma spiked with an anti-TF monoclonal antibody or with corn trypsin inhibitor (CTI). The presence of alternatively spliced TF (asTF), TF activity (TFa) and cancer procoagulant (CP) levels were determined. TFa and asTF were highly expressed by BXPC3 cells, compared to MCF7 cells, while CP levels were higher in MCF7 cells. BXPC3 cells had a stronger effect on TG than MCF7 cells. Accordingly, anti-TF had more inhibitory activity on TG triggered by BXPC3 cells while CTI had more pronounced inhibitory effect on TG triggered by MCF7 cells. TG enhancement by both BXPC3 and MCF7 cells was mediated by FVII and intrinsic tenase while FXII and FXI were also important for MCF7 cells. The induction of TG by BXPC3 cells was mainly driven by the TF pathway while TG generation triggered by MCF7 cells was also driven by FXII activation. Therefore, hypercoagulability results from a combination of the inherent procoagulant properties of cancer cell-associated TF as well as of procoagulant phospholipids in the plasma microenvironment.

Cancer cells and coagulation system are strictly connected. General prothrombotic mechanisms are related both to the host response to cancer and to the procoagulant activity of cancer cells (Fig. 4.1). Host-related factors include the acute-phase reaction, paraprotein production, inflammation, necrosis, and hemodynamic disorders. Malignant cells can activate blood coagulation in several ways. They can produce: procoagulant factors as tissue factor (TF) and cancer procoagulant factor (CP), which are the most powerful procoagulant observed; microparticles (MP); inflammatory cytokines such as tumor necrosis factor (TNF) and interleukin-1 (IL-1); pro-angiogenic factors as vascular endothelial growth factor (VEGF), which promote both endothelial prothrombotic alterations and angiogenesis. VEGF is an indirect procoagulant that increases microvascular permeability, reprograms gene expression, and promotes the survival of endothelial cells; the resulting increased vascular density plays a key role in the pathophysiology of many cancers. The same procoagulant factors contribute to tumor progression. Also platelets, endothelial cells, and neutrophils of host cells are stimulated to express procoagulant activity. Thus, thromboembolism frequently complicates the course of malignancy and can be the first symptom of cancer [1, 2].

Intracranial hemorrhage (ICH) is a catastrophic complication in patients with acute myeloid leukemia (AML). AML cells, especially in the acute promyelocytic leukemia subtype, may release microparticles (MPs), tissue factor (TF), and cancer procoagulant (CP) to promote coagulopathy. Hyperfibrinolysis is also triggered via release of annexin II, t-PA, u-PA, and u-PAR. Various inflammatory cytokines from cancer cells, such as IL-1β and TNF-α, activate endothelial cells and promote leukostasis. This condition may increase the ICH risk and lead to poor clinical outcomes. Here, we present a case under a unique situation with acute ICH detected prior to the diagnosis of AML. The patient initially presented with two episodes of syncope. Rapidly progressive ICH was noted in follow-up computed tomography (CT) scans. Therefore, we highlight that AML should be among the differential diagnoses of the etiologies of ICH. Early diagnosis and timely intervention are very important for AML patients.

Hypercoagulable states are common disorders with high risk of thrombosis associated with cardiovascular and malignant diseases. The pathogenesis of hypercoagulability is multifactorial. The basic physiological mechanism is the imbalance between anticoagulant activities and procoagulant activities in hemostatic system. In this review, we discuss the correlation between apoptosis and thrombogenesis in hypercoagulable states. Some cell-associated cofactors in coagulation system, including phosphatidylserine, tissue factor, thrombomodulin and cancer procoagulant, are regulated during apoptosis of various cell types. Vascular endothelial cells may act as one of the most important aspects affecting the balance of anticoagulant and procoagulant activities. When endothelial cells are activated or induced to undergo apoptosis by a number of physiological factors, such as inflammatory cytokines and bacterial lipopolysaccharide, the procoagulant activities of endothelial cells are enhanced. Other cell types such as apoptotic vascular smooth muscle cells, monocytes and macrophages may also contribute to the pathogenesis in atherosclerosis. Apoptotic tumor cells, which express high level of procoagulant activities, may act as a direct trigger for coagulation activation.

Introduction NSCLC progression is often associated with VTE. Activation of factor X is an important step in blood coagulation activation in cancer patients. PZ)/ZPI contribute to direct factor Xa inhibition, and ZPI - attenuates factors IXa and XIa activity. The role of the PZ/ZPI in NSCLC is obscure. The aim of the study was to localize ZPI and PZ in NSCLC tissue in relation to factors X, IX and XI, as well as indicators of blood coagulation activation: prothrombin fragment F1 + 2 (F1 + 2) and fibrin. Material & Methods Immunohistochemical studies were performed on surgical NSCLC specimens employing antibodies against ZPI, PZ, coagulation factors X, IX, XI, as well as fibrinogen, F1 + 2 and fibrin. A semiquantitative analysis (acc. to immunoreactive score-IRS) was conducted. Results Medium expression of ZPI(IRS = 6.5), together with weak expression of PZ(IRS = 4), was observed in cancer cells. Strong or medium staining for factors IX, X, and XI(IRS = 8–9) was revealed in cancer cells. Fibrinogen(IRS = 10) and fibrin(IRS = 8) were demonstrated in tumor stroma and cancer cells. F1 + 2(IRS = 10) was localized in NSCLC cells. Endothelial cells (ECs) and tumor infiltrating macrophages (TAMs) were characterized by a positive staining for ZPI and PZ. Conclusions ZPI and PZ expression in NSCLC cells, ECs and TAMs may suggest a role for PZ/ZPI in the anticoagulant mechanisms at the tumor site. The presence of F1 + 2 and fibrin, along with a disproportional expression of ZPI and PZ, might point to impaired function of the coagulation inhibitory system in NSCLC tissue.

Introduction Several hemostatic system components, including factor X (FX), contribute to cancer progression. The Protein Z (PZ)/protein Z-dependent protease inhibitor (ZPI) complex directly inhibits factor Xa proteolytic activity. The aim of this study was to determine the antigenic distribution of ZPI and PZ, in relation to FX, as well as indicators of blood coagulation activation (F1+2 and fibrin) in human colon cancer tissue. Materials & methods Studies were performed on human colon cancer fragments. Immunohistochemical (IHC) ABC procedures and double staining method employed polyclonal antibodies against PZ, FX, F1+2 and monoclonal antibodies against ZPI and fibrin. In-situ hybridization (ISH) methods employed biotin-labeled 25-nucleotide single-stranded DNA probes directed to either FX, PZ or ZPI mRNAs. Results Expression of FX, PZ and ZPI in association with colon cancer cells was observed by IHC. Moreover, the presence of both F1+2 and fibrin in association with colon cancer cells was found, which indicates that blood coagulation activation proceeds extravascularly at the tumor site. Furthermore, expression of FX and PZ was visualized in association with endothelial cells. In turn, colon cancer-associated macrophages were characterized by FX , PZ and ZPI presence. The double staining studies revealed strong FX/PZ, FX/ZPI, as well as PZ/ZPI co-localization on colon cancer cells. ISH studies revealed the presence of FX mRNA, PZ mRNA and ZPI mRNA in colon cancer cells indicating induced synthesis of these proteins. Conclusions The localization of PZ/ZPI and FX in colon cancer cells indicates that PZ/ZPI may contribute to anticoagulant events at the tumor site. Strong co-localization of PZ/ZPI and FX in cancer cells, and the presence of the mRNAs encoding the proteins, suggests their role in the tumor's biology. However, the presence of F1+2 and fibrin at the colon cancer site also suggests that the regulation of FXa by the PZ/ZPI complex at this site is incomplete.

All trans-retinoic acid (ATRA) induces apoptosis and/or differentiation in solid tumors, including breast cancer, and has become a therapeutic tool in this disease. In human promyelocytic leukemia ATRA reduces the expression of cellular procoagulant activities (PCA), i.e. tissue factor (TF) and cancer procoagulant (CP). There are no studies on the effects of ATRA on the PCA of solid tumors, i.e. breast cancer cells. We analyzed different human breast cancer cell lines in order to: 1. characterize the expression of TF and CP; 2. evaluate whether these activities are affected by ATRA; and 3. verify whether a reduction in tumor cell procoagulants may occur in association to apoptosis and growth inhibition induced by ATRA. Two estrogen receptor positive (ER-positive; i.e. MCF7 and ZR75.1) and one estrogen receptor negative (ER-negative; i.e. MDA.MB.231) cell lines were included into the study. The results show that ATRA affected TF in a dose-dependent fashion only in ER-positive cell lines. In particular, at 1 uM ATRA, TF significantly (p < 0.05) decreased by 57%, 44% in MCF7, ZR75.1 cells, respectively. Differently the results show that ATRA dose-dependently affected CP expression in all three cell lines. Specifically, at 1 uM ATRA, CP significantly decreased by 44%, 50% and 25% in MCF7, ZR75.1, and MDA.MB.231. Only in ER-positive cell lines, there was a dose-dependent inhibition of cell growth that became statistically significant at 1 uM ATRA, which was associated to a slight but significant increase in the percentage of apoptotic cells. In conclusion, this study demonstrates for the first time that ATRA downregulates the expression of TF and CP in breast cancer cells. Due to the pivotal role of coagulation activation in tumor progression, the capacity of ATRA to affect also tumor procoagulants, in parallel to cell apoptosis, open new perspectives in tumor therapy.

Introduction Microparticles (MP) can be elevated in cancer and thromboembolic disease. We hypothesized a role for MP in the hypercoagulable state in breast cancer patients using endocrine therapy, in whom both cancer and the use of endocrine therapy are independent risk factors for the development of thrombosis. Design and methods Plasma samples were collected from 40 breast cancer patients using endocrine therapy (20 patients without metastases receiving adjuvant therapy and 20 patients with metastatic disease treated in a palliative setting) and from 20 female healthy controls. The endocrine therapy used was either an anti-estrogen or an aromatase inhibitor. Numbers and cellular origin of MP subsets were analyzed by flowcytometry. MP-associated procoagulant activity was measured using a thrombin generation assay using conditions that allow analysis of MP induced thrombin generation. Results Breast cancer patients using endocrine therapy had higher levels of MP positive for Annexin V (median 10000 vs 6500 × 10E6/l), P-selectin (330 vs 200 × 10E6/l), tissue factor (33 vs 15 × 10E6/l), and of MP derived from platelets (CD41) and leukocytes (CD45). Thrombin generation in plasma was dependent on the presence of MP and thrombin generation performed after addition of isolated MP to normal plasma showed a higher endogenous thrombin potential (1105 vs 1029 nM.min) in breast cancer patients. No differences were observed in MP levels and thrombin generation parameters between the metastatic and adjuvant group. Conclusion Breast cancer patients using endocrine therapy have an increased MP number and a higher MP-dependent thrombin generation, irrespective of the presence of metastatic disease. Altered MP subset characteristics in these patients, especially the higher number of (activated) platelet derived MP and leukocyte derived MP, may in part explain a heightened procoagulant state in breast cancer patients using endocrine therapy.

Activation of the coagulation system in malignancy enables tumor spreading and is thus associated with poor prognosis for the patient. In this study, we analyzed the in vitro mechanisms by which two human metastatic melanoma cell lines, MV3 and WM9, transform the vascular endothelium into a prothrombotic activated state. We show that both melanoma cell lines activate prothrombin due to tissue factor (TF) expression by showing that thrombin generation was blocked with a TF-neutralizing antibody and TF-siRNA. In addition, using the cysteine protease inhibitor E-64, we excluded the formerly described cancer procoagulant (CP) as a major factor contributing to thrombin generation. Furthermore, we describe a direct thrombin-independent response of endothelial cells (ECs) to MV3-derived supernatant as measured by rapid release of VWF. We also show that two clinically approved LMWHs, tinzaparin and enoxaparin, are effective inhibitors of thrombin generation and thrombin activity in plasma. Furthermore, our data indicate a protective effect of heparins on EC activation as shown by reduced VWF release in response to MV3 supernatant. These promising effects of heparins on the melanoma-induced thrombotic conditions justify further clinical investigations in the field of oncology.

Additional carboxylation of glutamic acid by vitamin K-dependent gamma-carboxylase is a common posttranslational modification of many proteins, including some of blood clotting factors. Vitamin K-antagonists, such as warfarin, are often included in the therapy of malignant disease, decreasing the blood coagulation potential. Cancer procoagulant, a direct blood coagulation factor X activator from malignant tissue, is considered as a vitamin K-dependent protein, so it could serve as one of possible targets for the therapy with warfarin. However, there is still no experimental data demonstrating directly the presence of gamma-carboxyglutamic acid (Gla) in a cancer procoagulant molecule. The presence of Gla in cancer procoagulant isolated from human amnion-chorion membranes and from human malignant melanoma WM 115 cell line was analyzed directly, using specific anti-Gla monoclonal antibodies. There was no detectable amount of Gla in cancer procoagulant isolated from fetal or malignant tissue. Cancer procoagulant from human tissues does not contain Gla-rich domain. The finding indicates that cancer procoagulant is rather a poor target for warfarin therapy of malignant disease.

In this introductory chapter a story has been reviewed concerning the evolution of the concept of "cancer and thrombosis", since its first description by Armand Trousseau in 1865. From scattered reports on experimental material (tumor extracts) or on animal models of tumor/metastasis growth, through the progress of cell biology and experimental pharmacology, during the last 20 years interest has moved to clinical questions, such as: how to prevent and treat thrombosis, a frequent complication of both solid and hematologic malignancies? Has an occult cancer to be suspected in the majority of cases of idiopathic deep vein thrombosis? Do we need to prevent pharmacologically the occurrence of chemotherapy-associated thrombosis? Do anticoagulants have an impact on the natural history of some tumors? Why antiangiogenetic agents may be associated to a thrombotic risk? Presently, a continuous cross-talk between clinical results and experimental data is required to provide answers to these questions, taking advantage of a multidisciplinary approach to this old but still partially mysterious issue.

Bleeding and thrombosis are major risk factors for early death in patients with acute leukemia; chemotherapy increases the likelihood of both of these complications. Patients with acute leukemia often present with a hypercoagulable state or with evidence for chronic disseminated intravascular coagulation, even in the absence of active thrombosis and/or bleeding. Leukemic cell procoagulant properties, cytotoxic therapies, and concomitant infections are major determinants of clotting activation in acute leukemia. Clinical manifestations range from localized venous or arterial thrombosis to diffuse life-threatening bleeding. All-trans retinoic acid has greatly improved the management of acute promyelocytic leukemia, but has not significantly changed the rate of early hemorrhagic deaths and may actually promote thrombosis. Randomized, controlled trials of different prophylactic regimens to prevent thrombosis and/or bleeding in acute leukemia are urgently needed, particularly in patients with acute promyelocytic leukemia. Anticoagulant therapy is a unique challenge in patients with acute leukemia, who are at high risk for hemorrhage. Although no guidelines are available for prophylaxis or treatment of thrombosis, extrapolation can be made from existing guidelines for management of patients with other malignancies prolonged periods of treatment-induced thrombocytopenia in patients with acute leukemia, however, require a more judicious application of standard anticoagulant approaches. Use of the newer anticoagulants will require careful assessment of hemorrhagic risk in this group of high risk patients but may be justified under special circumstances.

Despite the development of highly effective treatment strategies for acute promyelocytic leukaemia around 10% of patients die in the presentation period as a consequence of the associated bleeding diathesis. The cause of the coagulopathy is complex resulting from a combination of tissue factor (TF) and cancer procoagulant (CP) induced disseminated intravascular coagulation, exaggerated fibrinolysis due predominantly to enhanced expression of annexin II on APL blast cell membranes and blast cell production of cytokines. All-trans retinoic acid (ATRA) has revolutionised the treatment of APL. When combined with chemotherapy long term survival rates of up to 80% can be achieved. Commencement of ATRA induces APL blast cell differentiation and is associated with a rapid resolution of the bleeding tendency through a combination of effects which include up regulation of thrombomodulin and down regulation of TF and CP production and cell surface expression of annexin II.

The effect of preimmunisation with cancer procoagulant (CP) on the growth of Walker 256 carcinosarcoma cells in Wistar Lew/Han/IMP rats in vivo has been analysed. One group of rats was immunised with CP purified from human amnion-chorion membranes. The rest of the animals (control groups) were injected with 0.9% NaCl in Freund's adjuvant or were not immunised at all. When the presence of polyclonal anti-CP antibody was detected in CP-immunised rats' serum, all (CP-immunised and control) animals were injected i.p. with 4.8 x 10(5) Walker 256 cells per rat. After 5 days ascitic fluid was collected and viable cells were counted. The complete lack of viable Walker 256 carcinosarcoma cells in 24% of the CP-immunised rats was observed. However, the viable neoplastic cells were present in all control (NaCl-injected and nonimmunised) animals. It seems possible that CP plays an important role in tumour progression, so immunisation with CP can reduce the risk of development of malignant disease.

Die venöse Thromboembolie (VTE) ist die zweithäufigste Todesursache bei Tumorpatienten und ist Zeichen einer verschlechterten Prognose. Insbesondere bei Patienten mit idiopathischer VTE findet sich in etwa 10% eine zugrunde liegende Tumorerkrankung. Dennoch ist derzeit die Effektivität einer extensiven Tumorsuche bei diesen Patienten nicht belegt. Zahlreiche plasmatische und zelluläre Faktoren sind an der Genese der Hyperkoagulabilität bei Malignomen beteiligt, z.B. Cancer-Prokoagulant und eine Gerinnungsaktivierung im Sinne einer akuten Phase-Reaktion. Operative Eingriffe bei Tumorpatienten gehen mit einem erhöhten Thromboembolierisiko einher, so dass eine intensivere und längere Thromboseprophylaxe nötig werden kann. Auch bei konservativ behandelten Patienten ist ein aktives Malignom mit einem erhöhten Thromboserisiko assoziiert. Tumorpatienten haben unter einer Standard-Thrombosebehandlung mit Vitamin K-Antagonisten (VKA) eine signifikant höhere Versagerrate und vermehrt Rezidiv-VTE. Niedermolekulares Heparin ist in der längerfristigen Sekundärprophylaxe der VTE signifikant wirksamer als VKA. Daher gibt es die Empfehlung niedermolekulares Heparin bei Tumorpatienten für die ersten 3–6 Monate der Sekundärprophylaxe zu verwenden. Erste Hinweise, dass niedermolekulares Heparin bei Tumorpatienten in nicht metastasiertem Stadium zu einer verbesserten Gesamtprognose führen kann, müssen durch weitere Studien belegt werden.

Venous thromboembolism (VTE) is a well-recognized problem in malignancy. Patients with cancer who have VTE have a worse prognosis than other patients with cancer. Hypercoagulability in patients with cancer is related to malignancy itself and its treatment. These patients have multiple risk factors for thromboembolism, such as being immobilized, having central venous catheters, and receiving chemoradiation therapy. Cancer procoagulant, tissue factor, factor VIII, and thrombin have important roles in causing cancer-associated thromboembolism. Tumors require neovascularization for delivering oxygen and other nutrients. Therefore, angiogenesis facilitates tumor growth, invasion, and metastasis. New blood vessels formed by angiogenesis are thrombogenic. Hypercoagulability and tumor growth are closely related. Vascular endothelial growth factor (VEGF) is a proangiogenic factor that may also cause VTE in patients with cancer. The relationship between cancer, angiogenesis, VEGF, and thrombosis is reviewed herein. Studies are ongoing to enhance our understanding of this complex interaction.

Cancer procoagulant (CP) is a cysteine protease produced by fetal and malignant tissues, activating in vitro blood coagulation factor X. It has been demonstrated that CP is able to stimulate blood platelet adhesion to fibrinogen and collagen. The pro-adhesive properties of CP could play an important role in metastatic spread of cancer as well as in primary tumor growth. Effects of anti-CP antibody on the growth of MCF-7 breast cancer cells and on the cells adhesion to vitronectin have been analyzed in vitro. Addition of polyclonal anti-CP antibody to MCF-7 cell culture resulted in 16-18% (P < 0.001) decrease in the cells viability as compared with the control (other antibody or no antibody in the culture). Preincubation of MCF-7 cells with anti-CP antibody reduced the cells adhesion to vitronectin. Further addition of purified CP (0.5-8 microg/ml) to the MCF-7 cells preincubated with anti-CP antibody resulted in complete recovery of adhesive properties of the cells. However, when high concentration (16 microg/ml) of CP was added to the sample, only partial recovery of the adhesive properties by the cells was observed. Results of the experiments support the hypothesis that CP is involved in the growth of cancer cells, but its pro-coagulative properties are of secondary importance. One of the possible mechanisms of the interactions between CP and malignant cell could be the regulation of the cell adhesion processes.

Thrombosis and disseminated intravascular coagulation (DIC) are common complications in cancer. Patients with malignancy have a prothrombotic state due to the ability of almost all type of cancer cells to activate the coagulation system. However, none of the haemostatic markers of coagulation has any predictive value for the occurrence of the thrombotic events in one individual patient. The pathogenesis of the prothrombotic state in cancer is complex and, probably, multifactorial. Prothrombotic factors in malignancy include the tumour production of procoagulants (i.e., tissue factor (TF) and cancer procoagulant (CP)) and inflammatory cytokines, and the interaction between tumour cells and blood (i.e., monocytes/macrophages, platelets) and endothelial cells. Other mechanisms of thrombus promotion include some general responses of the host to the tumour (i.e., acute phase, inflammation, angiogenesis), decreased levels of inhibitors of coagulation, and impaired fibrinolysis. In addition, the prothrombotic tendency of cancer patients is enhanced by anticancer therapy, such as surgery, chemotherapy, hormone therapy and radiotherapy, by indwelling central venous catheter, and by haemodinamic compromise (i.e., stasis). However, not all of the mechanisms allowing the prothrombotic state of cancer are entirely understood. Therefore, it is presently difficult to rank the relative weight of these multiple interactions on the basis of the well-recognised clinical evidences of enhanced thrombotic episodes in patients with cancer. In this review we attempt to describe the current proposed mechanisms for the pathogenesis of the prothrombotic state in cancer patient. A better understanding of these mechanisms could help clinicians in the developments of more targeted treatment to prevent thromboembolic complications in cancer patient.

Life-threatening bleeding, which remains a challenging complication of acute leukaemia, is particularly characteristic of the subtype, acute promyelocytic leukaemia (APL). The clinical picture and laboratory abnormalities are most compatible with the diagnosis of disseminated intravascular coagulation (DIC). Evidence for diffuse activation of the coagulation system, hyperfibrinolysis and systemic elaboration of non-specific protease activity can usually be demonstrated and occurs most commonly during induction chaemotherapy. While both host- and tumour-associated mechanisms can be implicated in the pathogenesis of the coagulopathy, leukaemic cell properties appear to be the proximate cause of activation of the haemostatic mechanisms. In this chapter we summarize the current state of knowledge of the pathogenesis of the coagulopathy of APL and the therapeutic approaches that have proved most useful for the management of this complication. Special attention is devoted to the use of all-traps-retinoic acid (ATRA), which has revolutionized the treatment of APL and markedly ameliorated the APL-related coagulopathy.

Since the observations of Trousseau, not only has the association of cancer and thrombosis been widely recognized but its pathogenesis is now better understood. Attention to the tumor cell as an important source of procoagulants has also contributed to our knowledge of this problem. Tumor cells express tissue factor (TF) and a cancer procoagulant (CP). TF is dormant in the living cell. However, it is activated during apoptosis of the cell, initiating the coagulation cascade and leading to thrombin generation. Because increased apoptosis occurs during treatment with chemotherapeutic agents, hormones, radiation, and hematopoietic growth factors, as well as when there is rapid tumor proliferation, the thrombosis risk is heightened accordingly. These developments have obvious basic and clinical implications.

Risk factors for cancer-related ischemic stroke are difficult to discern from the traditional risk factors for atheroembolic disorders. Certain hematologic and oncologic malignancies predispose to ischemic stroke. However, contributing pathophysiologic mechanisms are complex, and they cannot often be directly identified as specific causes of a thrombotic event. Generally speaking, interactions between the cellular phase and the plasma phase of coagulation are heightened in malignancy patients. Tissue factor and other procoagulant initiators of thrombosis predominate in certain solid tumor subtypes. Specific malignant hematologic disorders, such as polycythemia vera, essential thrombocythemia, Waldenstrom macroglobulinemia, and subtypes of acute leukemia, are perhaps best characterized as causes of a hypercoagulable state. Solid tumor treatments entail effects of radiation and specific chemotherapy agents that may pose a prothrombotic risk. This review focuses on the pathophysiology of ischemic stroke in malignancy with emphasis on underlying prothrombotic states and the management of these patients.

Almost all types of cancer are associated with an activation of coagulation. However, elevation of haemostatic markers of coagulation does not predict venous thrombosis. Multiple and interdependent processes between the tumour and the patient induce a hypercoagulable state. Tumour procoagulant activity, host inflammatory responses and extrinsic factors are involved. Tumour cells express the procoagulants, tissue factor and cancer procoagulant. They also release inflammatory cytokines and vascular endothelial growth factor, substances that enhance procoagulant activity and angiogenesis. Tumour-induced coagulation is intrinsically involved with tumour growth, angiogenesis and metastasis.

Tumours are capable of activating blood coagulation through the expression of procoagulant molecules such as tissue factor, cancer procoagulant and hepsin. Initiation of the clotting cascade results in the generation of the activated serine proteases factor VIIa, factor Xa and thrombin. These proteases act via protease-activated receptors and tissue factor to alter gene expression, thereby modulating tumour cell growth, invasion, metastasis and angiogenesis.

Thrombosis is a frequent complication of cancer, so it follows that the presence of a tumour confers a prothrombotic state. Indeed, in patients with cancer, each of the three components of Virchow's triad that predispose for thrombus formation have abnormalities, thus fulfilling the requirement for a prothrombotic or hypercoagulable state. The many signs and symptoms of the prothrombotic state in cancer range from asymptomatic basic abnormal coagulation tests to massive clinical thromboembolism, when the patient may be gravely ill. Many procoagulant factors, such as tissue factor and cancer procoagulant, are secreted by or are expressed at the cell surface of many tumours. Platelet turnover and activity are also increased. Damaged endothelium and abnormalities of blood flow in cancer also seem to play a part, as does abnormal tumour angiogenesis. Some studies have even suggested that these abnormalities may be related to long-term prognosis and treatment. We briefly describe the various clinical manifestations of thrombosis in cancer and discuss the evidence for the existence of a prothrombotic or hypercoagulable state associated with this disease. Further work is needed to examine the mechanisms leading to the prothrombotic state in cancer, the potential prognostic and treatment implications, and the possible value of quantifying indices of hypercoagulability in clinical practice.

The effects of cancer procoagulant (CP), cysteine protease (EC 3.4.22.26), on the pig blood platelet secretory process and platelet aggregation have been studied. The response of platelets to CP was compared with the response of these cells to thrombin. The obtained results show that blood platelets treated with CP (0.5, 1, 2.5, and 5 microg/ml, 2-30 min, 37 degrees C) released adenine nucleotides (P0.05) and proteins (P0.05). The secretion of compounds from blood platelets after incubation with CP does not correlate with the release of platelet lactic dehydrogenase activity (marker of cell lysis) into the extracellular medium. In comparison with thrombin action, CP stimulates secretory process to a smaller extent than thrombin alone. In the presence of CP, the thrombin action is suppressed (P0.05). We noticed that CP does not induce platelet aggregation.

Thrombosis and disseminated intravascular coagulation are common complications of cancer. Specific conditions associated with cancer such as stasis due to immobilization or blood flow obstruction, surgery, infections, endothelium damage due to chemotherapeutic agents and abnormalities of blood coagulation contribute to the hypercoagulable and thrombophilic state of cancer patients. This procoagulant state in cancer arises mostly from the capacity of tumor cells to express and release procoagulant activities (cancer procoagulant and tissue factor). Decreased levels of inhibitors of coagulation, impaired fibrinolysis, the presence of antiphospholipid antibodies and an acquired activated protein C resistance contribute to the hypercoagulable state. The activation of coagulation is also implicated in tumor proliferation through interactions of coagulation with inflammation and increased tissue factor pathway inhibitor. Laboratory diagnosis of the thrombophilic state include (1) elevation of clotting factors, fibrinogen/fibrin degradation products, hyperfibrinogenemia and thrombocytosis and (2) elevation of specific markers of activation of coagulation: fibrinopeptide A, fragment 1 + 2, thrombin-antithrombin complexes and D-dimers. However, none of the tests has any predictive value for the occurrence of thrombotic events in one individual patient. In patients with venous thromboembolism a noninvasive screening for occult cancer is able to detect a relatively high incidence of hidden cancer and the search for thrombophilia seems important in patients without known cancer.

Cancer procoagulant, cysteine proteinase (CP; EC 3.4.22.26) activates factor X and functions in the absence of factor VII. CP may also change the platelet function. It induces an increase of platelet adhesion to collagen and fibrinogen. Using wortmannin--the inhibitor of phosphoinositide 3-kinase (PI 3-K)--we studied the role of this enzyme in the action of cancer procoagulant on blood platelet adhesion in vitro. Wortmannin (25, 50 and 100 nM, 30 min, 37 degrees C) caused a reduction of platelet adhesion to fibrinogen (P0.01) when blood platelets were stimulated by both 0.2 U/ml thrombin (IC(50)approximately 75 nM) and by 1 microM ADP (IC(50)approximately 60 nM). We observed that after CP treatment the adhesion of thrombin-activated and ADP-stimulated platelets to fibrinogen was augmented. The potentiated by CP adhesion of activated platelets to fibrinogen was reduced after preincubation of platelets with wortmannin (50 nM, 30 min, 37 degrees C). We conclude that in adhesion of platelets to fibrinogen stimulated by CP PI 3-K take place.