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Objective Gynaecological cancer surgery is associated with high rates of venous thromboembolism (VTE) despite recommended prophylaxis. We sought to investigate the impact of extended prophylaxis with fixed dose and weight based LMWH in patients undergoing gynaecological cancer surgery. Methods VTE rates were recorded in patients who received LMWH prophylaxis (4500 IU Tinzaparin once daily) for the duration of hospital stay (2006–2012) (n = 610) and were compared with VTE rates in patients who underwent surgery after the introduction of extended prophylaxis (3500/4500 IU Tinzaparin for patients with BMI 40 kg/m2) (2012–2017) (n = 651). Peak (4 h) anti-Xa levels in a subset of patients were also evaluated. Results 73 (5.7%) cases of VTE were recorded during 1 year of follow-up. 20 cases occurred during hospital stay. There was no significant difference in the rate of VTE between the extended prophylaxis cohort and the standard prophylaxis cohort. 23/24 patients who developed VTE in the extended prophylaxis cohort received a fixed (4500 units) dose of Tinzaparin. 63% of patients who received a fixed LMWH dose had peak anti-Xa levels below the target range (0.2–0.4 IU/ml). Peak anti-Xa was lower in patients who subsequently developed VTE compared with those who received either fixed dose (P = 0.041) and weight adjusted Tinzaparin (P = 0.0006). Conclusions Extended prophylaxis with Tinzaparin does not significantly reduce VTE rates in gynaecological cancer patients post surgery. Peak anti-Xa levels may be suboptimal in many patients receiving a fixed LMWH dose. Further studies are required to determine whether weight adjusted doses of Tinzaparin may provide more effective prophylaxis following gynaecological cancer surgery.

INTRODUCTION Ovarian cancer patients are at high risk of thrombosis particularly during chemotherapy treatment however the mechanism is not understood. The aim of this study is to investigate the role of the activated protein C (aPC) pathway in the procoagulant activity observed in ovarian cancer patients undergoing neoadjuvant chemotherapy. PATIENTS AND METHODS Thrombin generation was determined before and after addition of thrombomodulin (TM) in high grade serous ovarian cancer (HGSOC) patients treated with neoadjuvant chemotherapy (n = 29) compared with HGSOC patients who were chemo naive (n = 23) and patients with benign tumours (n = 29). Plasma expression of proteins from the aPC pathway was analysed. mRNA expression was determined in endothelial (EA.hy926) and ovarian (OAW42) cell lines following addition of carboplatin and paclitaxel. RESULTS Lower levels of ETP (p

Cancer cells that transit from primary tumours into the circulatory system are known as circulating tumour cells (CTCs). These cancer cells have unique phenotypic and genotypic characteristics which allow them to survive within the circulation, subsequently extravasate and metastasise. CTCs have emerged as a useful diagnostic tool using “liquid biopsies” to report on the metastatic potential of cancers. However, CTCs by their nature interact with components of the blood circulatory system on a constant basis, influencing both their physical and morphological characteristics as well as metastatic capabilities. These properties and the associated molecular profile may provide critical diagnostic and prognostic capabilities in the clinic. Platelets interact with CTCs within minutes of their dissemination and are crucial in the formation of the initial metastatic niche. Platelets and coagulation proteins also alter the fate of a CTC by influencing EMT, promoting pro-survival signalling and aiding in evading immune cell destruction. CTCs have the capacity to directly hijack immune cells and utilise them to aid in CTC metastatic seeding processes. The disruption of CTC clusters may also offer a strategy for the treatment of advance staged cancers. Therapeutic disruption of these heterotypical interactions as well as direct CTC targeting hold great promise, especially with the advent of new immunotherapies and personalised medicines. Understanding the molecular role that platelets, immune cells and the coagulation cascade play in CTC biology will allow us to identify and characterise the most clinically relevant CTCs from patients. This will subsequently advance the clinical utility of CTCs in cancer diagnosis/prognosis.

To investigate whether HE4 and CA125 could identify endometrioid adenocarcinoma patients who might most benefit from full staging surgery with lymphadenectomy.Sequential patients with a preoperative banked serum and histology of endometrioid adenocarcinoma of endometrium who had undergone surgical staging with lymph node dissection over a 5-year period between 2011 and 2016 were included from a tertiary Gynaecological Cancer Centre, Dublin, Ireland. Preoperative serum HE4 and CA125 were measured using ELISA, with the cut-offs HE4 81 pmol/L and CA125 35 U/ml. Predictive values were estimated using AUC, sensitivity, specificity and odds ratios.9.5% of the cohort had lymph node metastases. A HE4 cut-off of 81 pmol/L yielded a sensitivity of 78.6% and specificity of 53.4% for predicting lymph node metastases. Sensitivity of CA125 at 35 U/ml was 57% and specificity 91.4%. The AUC was 0.66 (0.52-0.80) for HE4 and 0.74 (0.58-0.91) for CA125. Sensitivity was 92.8% and specificity 51.1% when an elevation of either HE4 or CA125 was included, AUC was 0.72 (0.61-0.83), this combination yielded the highest NPV of 98.6%. Sensitivity was 42.9% and specificity 93.8% if both markers were elevated simultaneously, AUC was 0.68 (0.51-0.86). Preoperative clinical predictors of high-grade preoperative histology and radiology had sensitivities of 21.4% and 41.7%, respectively. Patients with a HE4 above 81 pmol/L had an odds ratio of 4.2 (1.12-15.74), p 0.05, of lymph node metastases and CA125 had an odds ratio of 14.2 (4.16-48.31), p 0.001.Serum HE4 and CA125 improved on existing methods for risk stratification of endometrioid carcinomas and warrant further investigation.

Background Gynecologic cancers are associated with high rates of venous thromboembolism (VTE), which is exacerbated by pelvic surgery and chemotherapy. Objectives The aim of this study was to develop and validate a risk score for VTE in patients with gynecologic cancer and to test the predictive ability of the score following addition of procoagulant biomarker data. Patients and methods Clinical and laboratory variables were used to develop a risk score for the prediction of VTE in patients with gynecological cancer (n = 616), which was validated in a separate cohort of patients (n = 406). Endogenous thrombin potential and D‐dimer levels were determined in a subset (n = 290) of patients and used to produce an extended score in the validation cohort. Results Multivariable regression analysis identified BMI >30, hemoglobin

Introduction/Background* Gynaecological cancer surgery carries a high risk of venous thromboembolism (VTE). In the absence of thromboprophylaxis, 34.5% of women with gynaecological cancer develop VTE post operatively compared to 2% in benign gynaecological surgery patients. Lymph node dissection (LND), an integral part of any gynaecological procedure, carries therapeutic benefit in some cancers but also increases the complications of cancer surgery. An association of LND with VTE has been suggested. The aim of this study is to investigate the role of LND and lymph node (LN) metastasis on the incidence of VTE following both open and laparoscopic surgery for gynaecological cancer. Methodology This is a retrospective cohort study analysing data from 1084 patients who underwent gynaecological cancer surgery between 2006-2019 in St James Hospital, Dublin, Ireland (Tertiary referal centre). 1018 patients with complete follow up were included in the study. Patients with previous VTE, history of significant haemorrhage outside of a surgical setting within the last 5 years, familial bleeding diathesis and patients receiving anticoagulant therapy were excluded. Univariate analysis was used to determine the effects of LND and LN metastasis on the rate of VTE 90 days post surgery. Result(s)* Forty three patients developed VTE in 90 days post-surgery (4.3%). VTE rate was significantly higher following open surgery (5.4%) compared with laparoscopic approach (2.3%) (P 10 para-aortic LN removed , 5.9% in patients 5 LN positive for metastasis (P Conclusion* Gynaecological cancer surgery increases VTE risk. The number of paraaortic LN and pelvic LN metastatic status is associated with increased VTE risk and may be useful in predicting VTE post surgery.

INTRODUCTION CA 125, the biomarker in common clinical use for ovarian cancer, is limited by low sensitivity for early disease and high false positives. The aim of this study was to evaluate several candidate biomarkers, alone or in combination, compared with CA 125 in the prediction of malignant/borderline vs benign tumor status in premenopausal and postmenopausal women with pelvic masses. MATERIAL AND METHODS This was a retrospective observational cohort study set in St James's Hospital, a tertiary referral center for gynecological malignancy in Dublin, Ireland. Women undergoing surgery for pelvic masses between 2012 and 2018 were included. Preoperative human epididymis protein 4 (HE4), the Risk of Ovarian Malignancy Algorithm, the Risk of Malignancy Index I and II, D-dimer, and fibrinogen were assessed. Logistic regression models were fitted for each biomarker alone and in combination. Receiver operating characteristics-area under the curve (ROC-AUC) and partial AUCs in the 90%-100% specificity range were determined. RESULTS In all, 89 premenopausal and 185 postmenopausal women were included. In premenopausal women, no biomarker(s) outperformed CA 125 (AUC 0.73; 95% CI 0.63-0.84). In postmenopausal women, HE4 had a partial AUC (pAUC) of 0.71 (95% CI 0.64-0.79) compared with 0.57 (95% CI 0.51-0.69) for CA 125 (p = 0.009). HE4 + D-dimer had an improved pAUC of 0.74 (95% CI 0.68-0.81, p

Objective The aim of this study was to examine the clearance of serum human epididymis protein 4 (HE4) in the immediate postoperative period in patients undergoing maximal effort cytoreductive surgery for ovarian carcinoma. Methods The study was performed at a tertiary gynecologic oncology center. The surgery was performed by accredited gynecological oncologists. Results Preoperative and serial postoperative venous blood samples at 4, 8, 24, 48, 72, 96, and 120 hours were taken from 10 sequential patients. Pretreatment HE4 is considered elevated at greater than 70 pmol/L. Human epididymis protein 4 was greater than 70 pmol/L in 7 patients, including all patients with high-grade serous carcinoma. Patients with preoperative elevation of serum HE4 and complete cytoreduction cleared more than 80% of serum HE4 in the first 4 hours and more than 88% within 5 days of surgery. One patient with incomplete cytoreduction of high-grade serous carcinoma had 66% clearance at 4 hours and a plateau thereafter. Conclusions Human epididymis protein 4 derived from ovarian carcinoma had a short half-life of less than 4 hours in the circulation when cytoreductive surgery was complete. Sustained low HE4 following surgery could be a useful indicator of the completeness of cytoreduction. Plateau or rise in serum HE4 could suggest persistent disease. Comparison of values on day 1 and day 4 or 5 might have value in assessing the completeness of cytoreduction.

Highlights • Platelet cancer cell interactions are a key factor in driving the pro-metastatic phenotype. • Platelet cancer cell interactions appear to be mediated by 5 key genes which have established roles in metastasis. • Targeting these mediators of metastasis could improve outcomes for cancer patients., Tumour metastasis accounts for over 90% of cancer related deaths. The platelet is a key blood component, which facilitates efficient metastasis. This study aimed to understand the molecular mechanisms involved in tumour-platelet cell interactions. The interaction between cancer cells and platelets was examined in 15 epithelial cell lines, representing 7 cancer types. Gene expression analysis of EMT-associated and cancer stemness genes was performed by RT-PCR. Whole transcriptome analysis (WTA) was performed using Affymetrix 2.0ST arrays on a platelet co-cultured ovarian model. Platelet adhesion and activation occurred across all tumour types. WTA identified increases in cellular movement, migration, invasion, adhesion, development, differentiation and inflammation genes and decreases in processes associated with cell death and survival following platelet interaction. Increased invasive capacity was also observed in a subset of cell lines. A cross-comparison with a platelet co-cultured mouse model identified 5 common altered genes; PAI-1, PLEK2, CD73, TNC, and SDPR. Platelet cancer cell interactions are a key factor in driving the pro-metastatic phenotype and appear to be mediated by 5 key genes which have established roles in metastasis. Targeting these metastasis mediators could improve cancer patient outcomes.

Introduction/Background Ovarian cancer (OC) is the fifth most common cancer among Irish women with a higher incidence rate than other European countries. OC patients have a good response rate to first line chemotherapy treatment. However, the prognosis for OC following treatment is very poor in the majority of OC patients, especially patients with stage III or IV disease on diagnosis. Patients respond well initially to chemotherapy but go on to develop recurrent chemoresistant disease. Peptidyl arginine deiminase type 4 (PADI4) performs post-translational modification and catalyzes the arginine residue to a citrulline in numerous protein substrates. Citrullination of histones, cytokeratin, antithrombin and fibronectin have been confirmed to be involved in abnormal apoptosis, altered coagulation, and disordered cell proliferation, all of which are main features of primary tumors and metastasis. As PAD enzymes have been shown to be elevated in certain human diseases including autoimmune diseases and cancer, we hypothesized that targeting this enzyme with small molecule inhibitors such as GSK484 and GSK199 could lead to a novel therapeutic strategy. Therefore, we propose to investigate their therapeutic potential in a panel of OC cell lines and ex-vivo explants. Methodology OC cell lines and ex-vivo explants were exposed to various concentrations of PADI4 inhibitors at different time points. PADI4 expression, cell cycle, viability, caspase 3 and 8 activation were measured using immunoblotting, immunohistochemistry and FACS analysis. Results We demonstrated an inhibition of PADI4, changes in cell cycle status, reduction in cell viability and increased caspase 3,and 8. All these changes were concentration dependent. Conclusion Our study observed the role of PADI4 in cell proliferation, apoptosis. These results suggests that PADI4 is involved in cell growth and death. GSK484 and GSK199 presents a promising direction in the search for novel OC treatment strategies. Disclosure Nothing to disclose.

Introduction/Background The use of nanomaterial-based therapeutic systems is rapidly growing and covering several biomedical applications such as detection, diagnosis and treatment. Recently, nanodiamonds (NDs) have been demonstrated to have great potential as a multimodal imaging/therapy platform. NDs are attractive for use in drug delivery because of their rich surface chemistry. NDs enhance the ability of the drug to cross the cell membrane, increase intracellular drug delivery to the cancer cells, improve treatment efficacy, and decrease toxicity to normal cells or tissues. Docetaxel (DTX) ‘a chemotherapeutic agent’ has very low neurotoxic effect to the cancer patients. Therefore, we hypothesized that targeting HER-3 positive ovarian cancer (OC) ex-vivo explants by loading NDs with DTX would improve drug targeting and delivery. Thus, we aimed to investigate the efficacy of ND-conjugated DTX on OC ex-vivo explants. Methodology Bare, uncoated NDs were PEGylated and functionalized with DTX (NDs/DTX) and conjugated with anti- HER-3 antibody. Dynamic Light Scattering (DLS) was used to measure the hydrodynamic diameter of individual NDs dispersed in solutions (NDs,ND/DTX/HER-3). Ex-vivo explants from OC patients were exposed to various concentrations of ND/DTX, ND/DTX/HER-3 and DTX for over 24 hour‘s incubation. Cytotoxicity was examined by measuring cell viability changes, caspase 3 and caspase 8 activation and the molecular cell stress variation was investigated by examining the activation of transcription factor-2 (ATF-2). Results Significant alterations of the examined biological markers were detected in OC ex-vivo explants. As expected no nuclear translocation of ATF-2 was observed in the nuclei of untreated explants. Interestingly, the ex-vivo explants showed greater responses to NDs/DTX/HER-3 versus ND/DTX and DTX alone. Conclusion Our study demonstrates that NDs loaded with DTX exert significant inhibitory activities on OC explants. Thus, the proposed drug delivery system of ND-conjugated chemotherapy represents a promising, biocompatible strategy for targeting and enhancing chemotherapy efficacy and safety. Disclosure Nothing to disclose.

Introduction/Background Endometrial cancer (EC) is the most common gynaecological malignancy. The mainstay of treatment is surgical resection. Currently, there are no sensitive and specific biomarkers for EC. Human Epididymis protein 4 (HE4) shows promise as a diagnostic and prognostic marker. We investigated the sensitivity of preoperative serum HE4 for predicting high-risk EC. Methodology 206 patients were recruited from the DISCOVARY bioresource between 2011 and 2016. Demographic and tumour characteristics were recorded. Preoperative serum HE4 and CA125 was measured using Fujirebio Diagnostic ELISA Kits, with the cut-off points of HE4 70 pmol/L and CA125 35 U/ml. ELISA results were correlated with clinicopathological details. Statistical analysis was performed using SPSS. Results The cohort comprised of endometrioid adenocarcinomas (n=167) representing over 80% of the malignant cohort, carcinosarcoma (MMMT) (n=14), serous (n=17), mixed (n=6), mucinous (n=1) and clear cell (n=1). Using a cut-off of 70 pmol/L, serum HE4 had a sensitivity of 75.9% for predicting >50% myometrial invasion, more than twice the sensitivity of CA125 for >50% myometrial invasion (27.8%). Specificities were similar at 93.6% for HE4 and 95.1% for CA125. HE4 was more sensitive for predicting the presence of LVSI in EC (71%), compared to CA125 (34%). HE4 had a sensitivity of 89.6% and specificity of 46.2% for predicting lymphadenopathy, compared to a sensitivity of 46% and a specificity of 90.7% with CA125. Conclusion HE4 showed a high sensitivity for predicting the presence of high ­risk prognostic factors. Clinically, HE4 may have a role in supplementing transvaginal ultrasound in EC diagnosis. Furthermore, preoperative HE4 may supplement imaging studies when stratifying EC patients as high­ or low­ risk, enabling personalisation of surgical management, and improved outcomes. Further work is needed on establishing relevant cut-offs for high-risk cohorts. Disclosure ELISA kits were supplied by Fujirebio Diagnostics.

Gynaecological cancers are associated with high rates of VTE varying from 6% in endometrial cancer to up to 43% in clear cell cancer of the ovary. The risk of VTE is particularly high following gynaecological cancer surgery where VTE occurs in 6–7% of patients despite LMWH prophylaxis. The presence of a gynaecological malignancy increases the rate of post-operative VTE fourfold compared with patients with benign disease. The risk of VTE persists beyond hospital stay hence guidelines recommend extended prophylaxis (28 days) with LMWH for patients undergoing pelvic abdominal surgery for cancer. Gynaecological cancer surgery has evolved with increasing use of Minimally Invasive Surgery (MIS) and improvements in post-operative care with associated shorter hospital stay. The aim of this review is to evaluate on the risk of venous thromboembolism following gynaecological cancer surgery and the role of extended thromboprophylaxis in the era of MIS. The risk of VTE following MIS for cancer is low and more data is required to justify the use of extended prophylaxis. VTE risk varies depending on tumour, patient, and treatment factors. Individual risk assessment is required to optimise prophylaxis in these patients. Barriers to the use of extended prophylaxis include concerns regarding bleeding risk and physician perception that the risk of VTE is low particularly following laparoscopy. The introduction of new oral anticoagulants may play a role in post-operative prophylaxis in the future however data is lacking in gynaecological cancer patients.

Ovarian cancer is the seventh most common cancer in women and the most frequent cause of gynaecological malignancy-related mortality in women. Currently, no standardized reliable screening test exists. MicroRNA profiling has allowed the identification of signatures associated with diagnosis, prognosis and response to treatment of human tumours. The aim of this study was to determine if a microRNA signature could distinguish between malignant and benign ovarian disease. A training set of 5 serous ovarian carcinomas and 5 benign serous cystadenomas were selected for the initial experiments. The validation set included 20 serous ovarian carcinomas and 20 benign serous cystadenomas. The serum/plasma focus microRNA Exiqon panel was used for the training set. For the validation set a pick and mix Exiqon panel, which focuses on microRNAs of interest was used. A panel of 4 microRNAs (let-7i-5p, miR-122, miR-152-5p and miR-25-3p) was significantly down regulated in cancer patients. These microRNAs target WNT signalling, AKT/mTOR and TLR-4/MyD88, which have previously been found to play a role in ovarian carcinogenesis and chemoresistance. let-7i-5p, miR-122, miR-152-5p and miR-25-3p could act as diagnostic biomarkers in ovarian cancer.

Introduction Gynaecological cancer is associated with some of the highest rates of venous thromboembolism (VTE) with some subtypes of ovarian cancer associated with rates as high as 20%. VTE prophylaxis is an important part of post-operative management in gynaecological cancer patient care. Despite the evidence base and guidelines recommending extended VTE prophylaxis for patients undergoing major cancer surgery, adherence to best practice guidelines has been found to be low. Aim The aim of this study is to assess gynaecological oncologist’s awareness of the guidelines surrounding VTE prophylaxis for post-operative gynaecological cancer patients and to determine the type and duration of VTE prophylaxis implemented by gynaecological oncologists. Materials and Methods The study used the European Society Gynaecology Oncology (ESGO) membership as the population studied. ESGO is a multidisciplinary, non-profit association, founded in 1983. ESGO consisit of more than 1800 professional of different specialities dealing with gynaecological oncology. The e mail address of 650 member were avilable on the ESGO website. We send a Survey Monkey link to the questionnaire by email to a total of 650 ESGO member whose email addresses were obtained from the ESGO directory. 205 e mails returned back as the email used was invalied, only 445 e mail successfully delivered. The survey remained open for 44 days. Results were analysed on Survey Monkey. Results A 59.3% of respondents said that they decided upon appropriate VTE prophylaxis for a patient according to national/international best practice guidelines. A further 39.4% respondents said that they made their choice based upon clinical judgement. 59.8% of respondents said that they begin VTE prophylaxis pre-operatively for the high risk patients. 6.1% said that they begin prophylaxis in the operating theatre, 18.9% begin prophylaxis 6 hours post-operatively and 9.1% begin prophylaxis 12 hours post-operatively. The remaining respondents said that they begin VTE more than 24 hours post operatively 44.7% said that they prescribe VTE prophylaxis for 4 weeks. A further 15.9% said that they prescribe VTE prophylaxis for 6 weeks and 4.75% for longer than 6 weeks. Conclusions In conclusion, the adherence to current guidelines for VTE prophylaxis in the peri-operative period for gynaecological oncology patients is still poor. Awareness needs to be raised in order to decrease the morbidity/mortality of VTE in this high risk group of patients. The adoption of multidiscplinary approach to manage gynaecological cancer patients, which includes the involvment of thrombosis specialist, may reduce post operative VTE rates and improve cancer care.

SummaryRecent data has shown that hormone therapy (HT) increases the risk of cardiovascular and thromboembolic disease, particularly in users of oral HT. Phytoestrogens are popular alternatives to oestrogen therapy; however, their effects on cardiovascular risk are unknown. We investigated the effect of the phytoestrogen, genistein on the expression of genes and proteins from the haemostatic system in the liver in an ovariectomised rat model. Fifty-nine virgin female Sprague-Dawley rats were fed with soy-free chow supplemented with 17β estradiol (E2) (daily uptake 0.19 or 0.75 mg/kg body weight), or genistein (daily up-take 6 or 60 mg/kg body weight), for three months and compared to soy-free control rats. Gene expression of prothrombin, factor VII, fibrinogen alpha and fibrinogen beta was increased with E2 and genistein compared to the soy-free control group (p

SummaryHormone therapy (HT) increases the risk of cardiovascular and thromboembolic disease in post-menopausal women. Recent studies have suggested that prothrombotic mechanisms are likely to be involved. Transdermal HT avoids the first-pass effect of oestrogen in the liver and may have a less marked effect on the haemostatic system than equivalent oral preparations. The majority of studies have compared HT preparations that have different formulations as well as routes of administration. We investigated changes in the haemostatic system in post-menopausal women using two pharmacologically similar HT preparations, which differed only in their route of administration. Three hundred forty-four healthy post-menopausal women were randomised to six months treatment with either a transdermal matrix patch containing 25 µg 17 β -estradiol/125 µg norethisterone acetate (NETA) applied every 3–4 days, or an equivalent oral preparation (estradiol 1mg and NETA 0.5 mg given once daily). Oral treatment significantly reduced fibrinogen (p

Background Gynaecological cancers are associated with high rates of venous thromboembolism (VTE). Studies on ambulatory cancer patients do not support thromboprophylaxis during chemotherapy. Approximately 6–7% of gynaecological cancer patients suffer a postoperative VTE despite Low Molecular Weight Heparin prophylaxis (LMWH). Large cancer studies have shown that Calibrated Automated Thrombogram (CAT) and Microparticles (MP) assays may be useful in predicting VTE but data on gynaecological cancer patients is scarce. Objective Our objective was to identify whether the CAT assay and MP functional assays have potential as biomarkers predictive of VTE in gynaecological cancer patients. Patients and methods Gynaecological cancer patients were investigated before surgery (n = 146) and at 5, 14 and 42 days post-surgery (n = 78). Fourteen additional patients were investigated before chemotherapy and after 3 and 6 cycles of therapy. Thrombin generation was measured before and after addition of thrombomodulin. Results Patients with clear cell cancer (CCC) of the ovary and patients with endometrial cancer had higher ETP and peak thrombin compared with patients with benign disease. Patients who developed VTE (n = 8) following surgery had enhanced thrombin generation prior to surgery which persisted during the post-operative period despite LMWH prophylaxis. Both neoadjuvant and adjuvant chemotherapy showed increased thrombin generation following addition of thrombomodulin. There were no differences in MP levels during the study. Conclusions CAT assay shows potential as a promising biomarker for the prediction of VTE in gynaecological cancer patients. The identification of high risk patients combined with individualised LMWH prophylaxis might reduce VTE in this high risk group.

0049-3848/$ see front matter D 2005 Elsevier Ltd. All rights reserv doi:10.1016/j.thromres.2005.03.016 Abbreviations: LMWH, low molecular weight heparin; TAT, thrombi * Corresponding author. Tel.: +353 1 453 1888; fax: +353 1 453 161 E-mail address: lnorris@tcd.ie (L.A. Norris). factors for venous thrombosis may lead to a disturbance of haemostatic balance culminating in enhanced thrombin and fibrin production predisposing to a thrombotic event. Heparin prophylaxis has been successfully used in the prevention of deep vein thrombosis in pregnancy for many years. Low molecular heparins (LMWHs), which have increased bioavailability and longer duration of effect than standard heparin, are becoming increasingly popular for use in prophylaxis of venous thromboembolism during pregnancy [3]. In the non-pregnant population, monitoring of LMWH therapy is not required; however, we and others have shown that the pharmacokinetics of LMWH are affected by pregnancy. [4,5] Compared with the non-pregnant population, higher doses are required to maintain adequate anti-Xa levels, particularly as pregnancy Thrombosis Research (2006) 117, 283—290

SummaryLow molecular weight heparin (LMWH) is used increasingly for prophylaxis and treatment of venous thromboembolism during pregnancy. However, the prophylactic dose for patients at moderate risk varies between centers, and the recommended LMWH dose for the non pregnant patient is frequently used in pregnant women. The aim of this study was to investigate the effects of pregnancy on the pharmacokinetics of anti-Xa levels during moderate risk thromboprophylaxis with the LMWH, tinzaparin. In 24 pregnant women, one of three doses of tinzaparin (50, 75 or 100 IU/kg) were given according to the treating physician’s assessment of their risk profile. Four-hour peak anti-Xa levels were measured throughout pregnancy and 24-hour profiles were measured at 28 and 36 weeks gestation. Doses were adjusted when peak anti-Xa levels fell below 0.1 IU/ml and, in some cases, when levels at 10 and 18 hours post injection were undetectable (

brin-degradation products in the uteroplacental circulation of pregnancies complicated by preeclampsia [9], suggesting an activation of both the

Background Vitamin E supplementation is associated with a reduced risk of developing atherosclerotic events; probably because it inhibits low-density lipoprotein (LDL) oxidation, an initial step in atherosclerosis. Metal ion-dependent LDL oxidation is a commonly used method to estimate oxidizability of LDL, but the effect of antioxidant supplementation on the levels of autoantibodies to oxidised LDL (ox-LDL), an in vivo indicator of LDL oxidation, is unknown. Design This double-blind, placebo-controlled study investigated the susceptibility of LDL to copper induced oxidation and malondialdehyde (MDA) derivatized-LDL (MDA-LDL) in hyperlipidaemic patients on supplements of vitamin E. The vitamin E group (n = 20) took vitamin E 100 IU daily and the dose was doubled at six-weekly intervals to 1600 IU daily. The control group (n = 17) received placebo in the same fashion. Blood samples were obtained at baseline and each subsequent visit to measure vitamin E status and oxidation of LDL. Results A significant increase in both α-tocopherol levels and the lengths of lag phase was seen in the vitamin E group after first week of supplementation (100 IU day−1). This continued to rise in a dose-dependent fashion with a doubling of the lag phase on 1600 IU daily. However, the titre of antibodies to MDA-LDL was not altered. Conclusions The results suggest that although regarded as an in vivo marker of LDL oxidation, antibodies to MDA-LDL may not be a suitable measure to evaluate the effect of short-term antioxidant supplementation. The failure of autoantibody titres to fall despite reduced oxidizability of LDL may possibly be attributable to a long half-life of the antibody or, once initiated, a continuous immunological response to ox-LDL contained in atherosclerotic lesions of the arterial wall.

The identified main causes of inherited thrombophilia are deficiencies of antithrombin, protein C and protein S, activated protein C (APC) resistance and the factor V Leiden mutation, mutant factor II, and inherited hyperhomocysteinemia. In women from symptomatic families these defects may be associated with an increased risk of venous thrombosis in pregnancy and recurrent fetal loss. Inherited thrombophilia is common and appears to be a multigene disorder. The thrombotic risk would seem to be greatest in women with antithrombin deficiency and more than one thrombophilia defect. The abnormalities that are now recognized represent only part of the genetic predisposition to thrombosis. In assessing thrombotic risk in pregnancy, acquired risk factors as well as genetic predisposition should be considered. Increasing age, obesity, immobility, and delivery by cesarean section are major risk factors. Pregnancy should be planned, and each patient should be managed on an individual basis. In pregnancy, heparin is the anticoagulant of choice, and as far as possible, treatment with warfarin should be avoided because of the risks to the fetus. When patients are on long-term treatment with warfarin, pregnancy should be avoided, and warfarin should be discontinued prior to embarking on a pregnancy or as soon as pregnancy is suspected and before 6 weeks' gestation. In women from symptomatic families with antithrombin deficiency, adjusted dose heparin throughout pregnancy is recommended and warfarin for at least 3 months post partum. In protein C and protein S deficiency, factor V Leiden, or mutant factor II, treatment can be based on personal and family history. Thromboprophylaxis in late pregnancy and post partum should be considered. Fetal loss may be increased in women with inherited thrombophilia. The risk appears greatest in women with antithrombin deficiency and women with more than one thrombophilia defect. A number of reports have claimed that prophylactic treatment with heparin during pregnancy has resulted in successful pregnancy in women with recurrent fetal death and inherited thrombophilia.

Objective: Altered production of nitric oxide by the vascular endothelium may influence the pathogenesis of preeclampsia. The aim of this study was to measure circulating levels of nitric oxide metabolites (nitrites) in the uteroplacental, fetoplacental, and peripheral circulation of preeclamptic pregnancies compared with normotensive controls. Methods: Fifteen women with preeclampsia were compared with 16 women with normotensive pregnancies. At cesarean, blood samples were taken from the uterine vein draining the placental site, the umbilical vein, and the antecubital vein after delivery of the baby but before delivery of the placenta. Plasma nitrites were measured using the Greiss reaction after conversion of plasma nitrates to nitrites using nitrate reductase. Results: Nitric oxide metabolites were higher in the uteroplacental (P < .01), fetoplacental (P < .001), and peripheral (P < .02) circulations in samples from preeclamptic pregnancies compared with control pregnancies. In samples from the fetoplacental circulation only, nitric oxide metabolite levels were negatively correlated with gestational age (r = −.489, P < .01) and birth weight (r = −.544, P < .004). Nitric oxide metabolite levels were not significantly correlated with blood pressure, placental weight, or maternal age. Conclusion: In established preeclampsia, production of nitric oxide was higher in the uteroplacental, fetoplacental, and peripheral circulation than in normotensive pregnancies. This increase may be part of a compensatory mechanism to offset the pathologic effects of preeclampsia.

Objectives Venous thromboembolism (VTE) remains a leading cause of maternal mortality. An effective predictive test would be very clinically important. Measurements of Calibrated Automated Thrombogram (CAT) parameters in the presence and absence of thrombomodulin have been correlated with risk of recurrent VTE. D-Dimers and soluble P-selectin are markers of thrombosis. We aimed to evaluate the CAT assay, D-Dimers and P-selectin as potential predictive tools for thrombosis in pregnancy. Methods The SCOPE (Screening for Pregnancy Endpoints) study is a prospective, multicentre cohort study of nulliparous women with the primary aim of developing screening tests to predict pre-eclampsia, small for gestational age infants and spontaneous preterm birth. Twenty patients with documented VTE in pregnancy or postpartum and 61 controls were identified from the SCOPE cohort (total of 5000 pregnant women). The control group was matched for age, gestation, BMI and ethnicity. CAT assay with and without presence of thrombomodulin was performed on citrated plasma collected at 15 weeks gestation, prior to any thrombotic event. Normalised thrombomodulin sensitivity ratios (n-TMsr) were calculated. D-dimers and P-selectin were also measured by ELISA. Results There were no significant difference in ETP, peak thrombin, lagtime , time to peak, n-TMsr, D-dimer or P-selectin levels between patients who subsequently developed VTE compared with those who remained thrombosis free. Standardisation of CAT assay is needed to ensure it is a clinically effective predictive tool. Conclusions CAT assay, D-dimer and P-selectin levels are not useful as predictors of VTE in a low risk population of primigravida screened at 15 weeks. Disclosures S.K. Ismail: None. L. Norris: None. A. Khashan: None. N. Simpson: None. G. Dekker: None. J. Myers: None. L. McCowan: None. L. Kenny: None. J.R. Higgins: None.

OBJECTIVE: Our purpose was to determine the hemostatic changes in the uteroplacental and peripheral circulations in normotensive and pre-eclamptic pregnancies. STUDY DESIGN: This prospective, observational study involved 2 patient groups. Group 1 consisted of 30 normotensive women and 22 women with pre-eclampsia who were followed up longitudinally through pregnancy and post partum. Group 2 consisted of 20 women with established pre-eclampsia and 19 normotensive control subjects, all undergoing cesarean section. Plasma levels of thrombin–antithrombin III complex, soluble fibrin, plasmin–α 2 -antiplasmin complex, and fibrin-degradation product (D-dimer) were measured in blood drawn from the antecubital vein (group 1) and from both the antecubital and uterine veins (group 2). Data were analyzed by analysis of variance. RESULTS: In group 1 levels of thrombin–antithrombin III complex, soluble fibrin, and fibrin-degradation product were significantly higher during normal pregnancy than at 6 weeks post partum. Plasmin–α 2 -antiplasmin complex levels did not change. No differences between the pre-eclamptic and normotensive pregnancy groups were found for any of the hemostatic markers. In group 2 normotensive women undergoing cesarean section, thrombin–antithrombin III complex and soluble fibrin levels were significantly higher in the uterine vein than in the antecubital vein. In group 2 women with pre-eclampsia, thrombin–antithrombin III complex and fibrin-degradation product levels were significantly higher in the uterine vein than in the antecubital vein. In addition, plasmin–α 2 -antiplasmin complex and fibrin-degradation product levels were higher and soluble fibrin levels were lower in the uterine vein in the pre-eclamptic group than in the normotensive group. CONCLUSION: Both the coagulation and fibrinolytic systems are activated during normal pregnancy. Activation of these systems is more marked in the uteroplacental circulation than in the systemic circulation in both normotensive and pre-eclamptic pregnancies. An abnormal pattern of hemostasis occurs in the uteroplacental circulation in pre-eclampsia. (Am J Obstet Gynecol 1998;179:520-6.)

Oral contraceptives have been linked to an increased incidence of thrombovascular disease. This may be mediated by their effects on the haemostatic system. An increase in the activity of coagulation Factors VII, X and fibrinogen occur with pill usage. Increased Factor VII levels are dependent on both the oestrogen and progestogen component of the oral contraceptive. A reduction in antithrombin III levels has also been observed in some but not all studies. Increased fibrinolysis has also been shown in oral contraceptive users which should balance the changes in the coagulation pathway. The increase in fibrinolytic potential is thought to be due to a decrease in the levels of plasminogen activator inhibitor I combined with an increase in the levels of plasminogen; tissue plasminogen activator antigen is decreased in most studies. The increased levels of endpoints of coagulation and fibrinolysis in pill users indicate that enhanced activity of both systems is occuring in vivo. The increased coagulation activity appears to be balanced by the rise in fibrinolytic activity, so preserving haemostatic balance. Enhanced platelet activity has also been shown in women taking oral contraceptives. Thrombus formation can result, however, when local vascular wall damage exists, or when other risk factors for thrombo-embolism, such as older age and smoking, coexist and create a local activation resulting in a thrombus. In these situations, the small differences in levels of coagulation factors in women taking different oral contraceptive formulations may be important. Pills containing the lowest doses of oestrogen (20 μg ethinyloestradiol) have shown the least changes in haemostatic factors. The progestogen component of the pill modifies the effect of oestrogen on the haemostatic system.

Low molecular weight heparin (LMWH) prophylaxis has been recommended for morbidly obese pregnant women (40kg/m(2)). There is very little data on the anticoagulant effects of LMWH in this group. We investigated two different dosing regimens; fixed dose and weight-adjusted dose on the anticoagulant effects of the LMWH tinzaparin used for thromboprophylaxis in obese pregnant women.Twenty morbidly obese pregnant women were started on a fixed dose of tinzaparin (4,500 iu/day) at 32weeks gestation and then changed to a weight-adjusted dose (75iu/kg/day) for the remainder of their pregnancy. Four-hour post LMWH, venous bloods were taken after each initial dose and repeated every two weeks until delivery. Twenty normal weight women who did not receive LMWH at the same gestation were used as controls.Prior to LMWH prophylaxis, tissue factor pathway inhibitor (TFPI) levels in the obese group at 32weeks were significantly lower (p0.001) and endogenous thrombin potential (ETP) and peak thrombin levels in obese group were significantly higher, compared with controls (p0.0001; p0.001). There was no significant difference between ETP levels before and after fixed LMWH. However, ETP levels were significantly lower post weight-adjusted dose compared with post fixed dose. There was a significant effect of LMWH on TFPI levels, (p0.0001). ETP correlated positively with total body weight prior to LMWH (r=0.631) (p0.05) and at fixed dose (r=0.578) (p0.05).Morbidly obese pregnant women have increased thrombin generation and reduced natural anticoagulant in third trimester. This prothrombotic state was more effectively attenuated by weight-adjusted than fixed LMWH doses.

Phytoestrogens are popular alternatives to estrogen therapy however their effects on hemostasis in post-menopausal women are unknown. The aim of this study was to determine the effect of the phytoestrogens, genistein, daidzein and equol on the expression of key genes from the hemostatic system in human hepatocyte cell models and to determine the role of estrogen receptors in mediating any response seen. HepG2 cells and Hep89 cells (expressing estrogen receptor alpha (ERα)) were incubated for 24 h with 50 nM 17β-estradiol, genistein, daidzein or equol. Tissue plasminogen activator (tPA), plasminogen activator inhibitor-1 (PAI-1), Factor VII, fibrinogen γ, protein C and protein S mRNA expression were determined using TaqMan PCR. Genistein and equol increased tPA and PAI-1 expression in Hep89 cells with fold changes greater than those observed for estradiol. In HepG2 cells (which do not express ERα), PAI-1 and tPA expression were unchanged. Increased expression of Factor VII was observed in phytoestrogen treated Hep89 cells but not in similarly treated HepG2s. Prothrombin gene expression was increased in equol and daidzein treated HepG2 cells in the absence of the classical estrogen receptors. These data suggest that phytoestrogens can regulate the expression of coagulation and fibrinolytic genes in a human hepatocyte cell line; an effect which is augmented by ERα.

article i nfo Article history: Introduction: Ovarian cancer is known to display a particular association with venous thromboembolism (VTE) with reports up to 42% of patients developing thromboembolic complications. Tissue Factor (TF) and its inhibitor Tissue Factor Pathway Inhibitor (TFPI) have been implicated in VTE risk in cancer. The aim of this study was to measure tumour derived TF and TFPI and to investigate their potential role in VTE in ovarian cancer patients. Methods: TF and TFPI mRNA expression was measured using TaqMan real time PCR in 99 ovarian tumour samples. Nineteen cases complicated by VTE were matched to 19 cases without VTE. TF and TFPI protein levels weremeasuredusingELISAandimmunohistochemistrywasusedtolocalizeTFexpression.TheroleofTFexpres- sion on overall survival was also determined. Results: TF mRNA and protein expression was increased in tumours from patients with clear cell carcinoma (p b 0.001). TF protein expression was also increased in endometroid carcinoma (P b 0.01) compared with benign tumours. TFPI mRNA expression was increased in clear cell carcinoma (P b 0.01). TF mRNA and antigen level was increased in malignant tumours of patients who developed VTE compared with matched malignant otumours of patients who remained thrombosis free (P b 0.01). There was no difference in TFPI expression between the two groups. Conclusion:TFexpressioninovariancancerissignificantlyhigherinpatientswhodevelopVTE.TFexpressionwas increasedinclearcellovariancancerandendometroidcancerandthismayexplainthehigherriskofVTEinthese subgroups. TF derived from these tumours may be the trigger for VTE in ovarian cancer.

Ovarian cancer has a higher incidence of venous thromboembolism (VTE) than other cancers. Clear cell cancers carry the highest risk at 11-27%. The aim of this study was to identify the predisposing factors for VTE in a population of ovarian cancer patients and to determine the influence of VTE on overall survival.VTE events were identified from hospital and general practice/community care records for all patients with ovarian cancer who were diagnosed and treated in a tertiary cancer center between 2006 and 2010.The overall incidence of VTE was 9.7% (33) in 344 patients. Sixteen (48%) had pulmonary embolism. Six (18%) presented with VTE. Five (15%) had VTE diagnosed during pre-treatment routine CT scanning. Eleven (33%) developed VTE following surgery and eleven (33%) developed VTE during chemotherapy. Risk factors associated with the occurrence of VTE were BMI≥30 (p0.01), clear cell carcinoma (p0.05), advanced stage (p0.01), high grade (p0.01) and CA125500 IU/ml (p0.001). The occurrence of VTE was associated with decreased overall survival time (p0.001).The incidence of VTE is high in ovarian cancer especially in the clear cell subtype. VTE adversely affects survival in ovarian cancer. Obesity, high grade and stage of cancer, clear cell subtype and high CA 125 level should be incorporated into protocols of VTE prophylaxis in women with ovarian cancer.