thromboplastin and Endometrial-Neoplasms

Although cancer-associated thrombosis (CAT) is a frequent complication in patients with malignancies, its treatment remains a challenge in daily practice. Here, we report the clinical course of a 51-year-old woman presenting with a highly thrombogenic paraneoplastic coagulopathy. Despite therapeutic anticoagulation with various agents, including rivaroxaban, fondaparinux, and low-molecular-weight heparin, the patient suffered from recurrent venous and arterial thromboembolism. Locally advanced endometrial cancer was identified. Tumor cells showed strong expression of tissue factor (TF), and significant concentrations of TF-bearing microvesicles were detected in patient plasma. Coagulopathy was controlled only by continuous intravenous anticoagulation with the direct thrombin inhibitor, argatroban. Multimodal antineoplastic treatment, including neoadjuvant chemotherapy followed by surgery and postoperative radiotherapy, resulted in clinical cancer remission, which was paralleled by normalization of tumor markers, CA125 and CA19-9, D-dimer levels, and TF-bearing microvesicles. In summary, continuous anticoagulation with argatroban and multimodal anticancer treatment may be necessary to control TF-driven coagulation activation with recurrent CAT in endometrial cancer.. Obwohl die tumorassoziierte Thrombose (CAT) eine häufige Komplikation bei Patienten mit malignen Erkrankungen darstellt, bleibt ihre Behandlung in der täglichen Praxis eine Herausforderung. Wir berichten über den klinischen Fall einer 51-jährigen Patientin, die sich mit einer hochgradig thrombogenen paraneoplastischen Gerinnungsstörung vorstellte. Trotz therapeutischer Antikoagulation mit verschiedenen Präparaten, unter anderem Rivaroxaban, Fondaparinux und niedermolekulares Heparin, entwickelte die Patientin rezidivierende venöse und arterielle Thromboembolien. Es konnte ein lokal fortgeschrittenes Endometriumkarzinom nachgewiesen werden mit starker Expression von Gewebefaktor (Tissue-Faktor, TF) auf den Tumorzellen. Es fanden sich zudem signifikant erhöhte Konzentrationen von TF-tragenden Mikrovesikeln im Plasma der Patientin. Die Koagulopathie konnte nur durch eine kontinuierliche intravenöse Antikoagulation mit dem direkten Thrombininhibitor Argatroban kontrolliert werden. Eine multimodale antineoplastische Behandlung, einschließlich einer neoadjuvanten Chemotherapie mit anschließender Operation und postoperativer Strahlentherapie, führte zu einer klinischen Remission des Tumors, welche mit einer Normalisierung der Tumormarker CA125 und CA19–9, der D-Dimere und der TF-exprimierenden Mikrovesikel einherging. Somit könnte die Kombination aus kontinuierlicher Antikoagulation mit Argatroban und multimodaler Krebstherapie erforderlich sein, um eine TF-vermittelte paraneoplastische Koagulopathie mit rezidivierender CAT bei Patientinnen mit Endometriumkarzinom zu kontrollieren.

Topics: Anticoagulants; Blood Coagulation Disorders; Endometrial Neoplasms; Female; Heparin, Low-Molecular-Weight; Humans; Middle Aged; Neoplasm Recurrence, Local; Thromboembolism; Thrombophlebitis; Thromboplastin; Venous Thromboembolism

Earlier reports have indicated that patients with endometrial clear cell carcinoma (CCC) may have an increased risk for thromboembolic events. Tissue factor is a 47-Kd transmembrane glycoprotein that plays a critical role in platelet activation, fibrinogenesis, blood clot formation, and as such, general hemostasis. The mammalian heparanase is an endo-β-glucuronidase that can cleave heparan sulfate at specific molecular sites, resulting in structural modification of the extracellular matrix barrier, facilitating cancer cell invasion, and eventual metastasis. Recent reports indicate that heparanase may also induce tissue factor expression. The purpose of this study is to assess the clinicopathologic significance of tissue factor and heparanase expression, especially as they relate to the risk of thromboembolic events, in endometrial CCC and selected other endometrial cancers. Eighty-four endometrial carcinomas, including 17 CCC, 20 endometrial serous carcinomas, 15 grade 1 endometrial endometrioid carcinomas (EEC), 15 grade 2 EEC, 10 grade 3 EEC, and 7 mixed endometrial carcinomas with at least a 10% clear cell component (mixed CCC) were evaluated for the immunophenotypic expression of heparanase and tissue factor, and their associated frequency of thromboembolic events. Seven of the 84 patients experienced 8 thromboembolic events during the follow-up period. By multivariate analysis, the pure CCC histotype [odds ratio 5.2; 95% confidence interval (CI): 2.4523-13.6754; P=0.026] was significantly associated with an elevated risk for thromboembolic events. Tissue factor expression was present in 12 (14.28%) of the 84 endometrial carcinomas, including in 7 (41.17%) of 17 pure CCC, 2 (10%) of 20 endometrial serous carcinomas, 1 (14.3%) of 7 mixed CCC, 2 (13.3%) of 15 grade 1 EEC, and in 0% of grade 2 and 3 EEC. Tissue factor expression was significantly more likely to be seen in pure CCC than in all other cancers as a group (P=0.0018) and in all other high-grade endometrial cancers (P=0.007). By multivariate analysis, tissue factor expression was significantly associated with the risk of thromboembolic events [odds ratio 4.8 (95% CI: 1.9196-11.93), P=0.013]. Tissue factor expression was not associated with patient outcome or any other clinicopathologic parameter. Heparanase expression was present in 57 (67.8%) of the 84 endometrial carcinomas, and was significantly associated with the endometrioid histotype, but not outcome or the risk of thromboembolic events.

Topics: Adenocarcinoma, Clear Cell; Adult; Aged; Aged, 80 and over; Endometrial Neoplasms; Female; Glucuronidase; Humans; Immunohistochemistry; Middle Aged; Risk Factors; Thromboembolism; Thromboplastin

Progesterone in hormonal preparations increases the incidence of breast cancer. Tissue factor (TF), the initiator of the extrinsic coagulation pathway, is associated with metastasis in a wide variety of cancers. We demonstrate herein that TF mRNA and protein are up-regulated by progesterone in the breast cancer cell line ZR-75. Epidermal growth factor, also associated with increased breast cancer risk, did not regulate TF. The increase in TF is both rapid and transient; increasing after 6 h, reaching a maximum at 24 h, before decreasing to basal levels at 72 h. Sucrose gradient experiments demonstrated that TF is located in the heavy fraction of the plasma membrane, although caveolin-1 is not expressed in ZR-75. To understand the physiological implications of an increase in TF, we performed coagulation and invasion assays. An increase in TF corresponded to an increase in procoagulant activity. Furthermore, progesterone increased the invasion of ZR-75 cells through a matrigel, an effect that was blocked by an antibody against TF. Because TF expression is associated with an enhanced risk of metastasis, we postulate that the progesterone-dependent up-regulation of TF provides a survival advantage to burgeoning breast cancer cells and may contribute to the increased risk of cancer associated with combined hormone replacement therapy.

Topics: Breast Neoplasms; Cell Line, Tumor; Cell Survival; Endometrial Neoplasms; Epidermal Growth Factor; Female; Gene Expression Regulation, Neoplastic; Humans; Neoplasm Invasiveness; Progesterone; Reverse Transcriptase Polymerase Chain Reaction; Sucrose; Thromboplastin

Tissue Factor (TF), the initiator of the extrinsic coagulation cascade, is overexpressed in a variety of cancers. TF is also expressed in normal human endometrium but little is known about its expression or regulation in endometrial cancer. We demonstrate herein that TF is expressed in the endometrial adenocarcinoma cell line Ishikawa. Furthermore, epidermal growth factor (EGF) induces a rapid and sustained increase in TF expression. Estradiol and progesterone had no effect on basal or EGF-induced TF expression in Ishikawa cells. In contrast to the pronounced and sustained upregulation at the protein level, EGF treatment elicited only a modest and transient increase in TF mRNA levels. This activity corresponded to the response observed from an exogenous TF promoter construct. However, the induction of TF was abrogated by cycloheximide as well as actinomycin-D, inhibitors or protein- and mRNA-synthesis, respectively, demonstrating that EGF mediates its effect through activation of the TF gene. Fractionation experiments showed that EGF increases TF presence in caveolin-I containing membrane fractions. Coagulation and invasion assays were used to explore the physiological implications of TF regulation. The results demonstrate that EGF-mediated induction of TF increases the procoagulant activity and invasive potential of Ishikawa cells. Furthermore, immunocytochemistry confirmed that TF is regulated by EGF in primary cultures of normal endometrial epithelial cells and malignant tumor cells. In conclusion, EGF-mediated upregulation of TF results in accumulation of this glycoprotein in caveolae-like membrane fractions and increased coagulative and invasive potential. Our results suggest that TF may play an integral role in endometrial carcinogenesis.

Topics: Adenocarcinoma; Anticoagulants; Blotting, Western; Cell Line, Tumor; Cells, Cultured; Coagulants; Cycloheximide; Dactinomycin; Detergents; Endometrial Neoplasms; Endometrium; Epidermal Growth Factor; Estradiol; Female; Gene Expression Regulation, Neoplastic; Glycoproteins; Humans; Immunohistochemistry; Nucleic Acid Synthesis Inhibitors; Octoxynol; Progesterone; Promoter Regions, Genetic; RNA, Messenger; Sucrose; Thromboplastin; Time Factors; Transfection; Ultracentrifugation; Up-Regulation

Vascular targeting agents (VTAs) can be produced by linking antibodies or antibody fragments directed against endothelial cell markers to effector moieties. So far, it has been necessary to produce the components of VTAs (antibody, antibody fragment, linker, and effector) separately and, subsequently, to conjugate them by biochemical reactions. We devised a cloning and expression system to allow rapid generation of recombinant VTAs from hybridoma cell lines. The VTAs consist of a single chain Fv antibody fragment as a targeting moiety and either truncated Pseudomonas exotoxin (resulting in immunotoxins) or truncated human tissue factor (resulting in coaguligands) as effectors. The system was applied to generate recombinant immunotoxins and coaguligands directed against endoglin, vascular endothelial growth factor (VEGF):VEGF receptor (VEGFR) complex and vascular cell adhesion molecule 1 (VCAM-1). The fusion proteins exhibited similar functional activity to analogous biochemical constructs. This is the first report to describe the generation and characterization of recombinant coaguligands.

Topics: Animals; Antigens, CD; Cell Division; Cell Line; Cloning, Molecular; Dose-Response Relationship, Drug; Endoglin; Endometrial Neoplasms; Endothelial Growth Factors; Endothelium, Vascular; Factor Xa; Female; Humans; Hybridomas; Immunoglobulin Fragments; Immunohistochemistry; Immunotoxins; Lymphokines; Mice; Neovascularization, Pathologic; Plasmids; Protein Binding; Receptor Protein-Tyrosine Kinases; Receptors, Cell Surface; Receptors, Growth Factor; Receptors, Vascular Endothelial Growth Factor; Recombinant Fusion Proteins; Thromboplastin; Vascular Cell Adhesion Molecule-1; Vascular Endothelial Growth Factor A; Vascular Endothelial Growth Factors