D-dimer and CA 125 levels in patients with ovarian cancer during antineoplastic therapy. Prognostic significance for the success of anti-cancer treatment

D-Dimers Variability in the Perioperative Period of Breast Cancer Surgery Helps to Predict Cancer Relapse: A Single-Centre Prospective Study

BACKGROUND

The importance of D-dimers (DD) assessment in the diagnostic algorithm of venous thromboembolic (VTE) disease is well known. Increase of DD concentration may be also associated with neoplastic disease. Many studies documented that high concentration of DD before solid tumour surgery indicates more advanced disease and poor life expectancy. The prognostic value of the DD concentration variability in the perioperative period, in women undergoing breast cancer surgery, has not been analysed so far. Thus, the aim of the present prospective study was to assess whether the trend of DD concentration changes in the perioperative period may predict cancer recurrence in women undergoing breast cancer surgery.

MATERIALS AND METHODS

189 consecutive women with histopathological diagnosis of breast cancer (BC) referred for surgical treatment were included. DD concentration was measured twice in each patient: at the time of admission to hospital and at the time of discharge home. Enoxaparin in standard dose of 40 mg daily s. c. was used as primary VTE prophylaxis in all of the patients.

RESULTS

The recurrence of BC, within 1 year observation time, occurred in 13 patients (6.8%), in 11 (5.8%) patients with DD increase after surgery and only in 2 (1.1%) without an increase in DD, P = .0179. Increase in DD concentration after BC surgery was an independent positive predictor of disease relapse (OR 8.600, LCI 1.451, UCI 96.80, P = .0371) together with the lack of postoperative radiotherapy (OR 6.009, LCI 1.305, UCI 31.95, P = .0245), whereas the lack of postoperative chemotherapy predicted no BC relapse (OR .07355, LCI .0056, UCI .58, P = .0245).

CONCLUSIONS

Increase of DD in the early postoperative period may be considered as additional independent predictor of recurrence of BC within 1 year.

Hemostasis and cancer: Impact of haemostatic biomarkers for the prediction of clinical outcomes in patients with cancer

Patients with cancer are characterized by a dysregulation of the hemostatic system and systemic hypercoagulability. Different components of the hemostatic system are involved in tumor-promoting mechanisms including primary tumor growth, cancer cell invasion, immune evasion, angiogenesis, and the metastatic process. Therefore, different degrees of systemic hemostatic activation in patients with cancer can reflect distinct underlying biological phenotypes of cancer and seem to correlate with cancer aggressiveness. Peripheral blood levels of hemostatic biomarkers, indicating the activation status of different parts of the hemostatic system including the coagulation cascade, fibrinolytic activity, platelet activation, or endothelial activation, can be used to reflect cancer-associated systemic hypercoagulability. Thereby, hemostatic biomarkers represent promising candidates to investigate as surrogate markers for underlying cancer activity and progression dynamics and therefore as biomarkers for the prediction of clinical outcomes in cancer patients. In the present review, we provide an up-to-date summary of available data on hemostatic biomarkers for prognostication of overall survival and prediction of therapy response in patients with cancer, including specific oncologic treatment settings for potential clinical application. We provide a thorough discussion on potential clinical implementation and current limitations and highlight the most promising emerging biomarkers that might be used to contribute to risk-stratified, personalized oncologic decision making in the future.

Silencing lncRNA DUXAP8 inhibits lung adenocarcinoma progression by targeting miR-26b-5p

Lung adenocarcinoma (LUAD), a common type of lung cancer, has become a popularly aggressive cancer. Long noncoding RNAs (lncRNAs) play a critical role in the pathogenesis of human cancers, while the function of double homeobox A pseudogene 8 (DUXAP8) in LUAD remains to be fully inquired. Therefore, our study was conducted to elucidate the DUXAP8 expression in LUAD and its mechanism on the biological features of LUAD cells. Loss-of-function experiments were performed to assess the function of DUXAP8 proliferation and apoptosis of H1975 and A549 cells. Functionally, silencing DUXAP8 inhibited proliferation and induced apoptosis of LUAD cells. Mechanistically, further correlation assay indicated a negative association between miR-26b-5p and DUXAP8 expression. Subsequently, we testified that DUXAP8 exerted its role in the progression and development of LUAD through targeting miR-26b-5p. In summary, our results elucidated that that DUXAP8 promoted tumor progression in LUAD by targeting miR-26b-5p, which provide a novel therapeutic target for diagnosis and therapy of LUAD.

Clinical characteristics of malignant melanoma in central China and predictors of metastasis

Cutaneous malignant melanoma (MM) is the most malignant type of all skin neoplasms. There is wide variability in the characteristics of MM between patients of different races. The aim of the present study was to investigate the clinicopathological characteristics of patients with MM in central China and to assess the value of specific hematological and biochemical indices for predicting metastasis. The data of 167 patients with MM from the First Affiliated Hospital of Zhengzhou University (Henan, China) were retrospectively analyzed and compared with the data of patients with MM available from cBioPortal for Cancer Genomics. Following analysis of the clinicopathological characteristics of the 167 patients, the median overall survival time was 50 months, and the median disease-free survival time was 35 months. Albumin/D-dimer prognosis score (ADPS), lactate dehydrogenase, sex, T stage, tumor-node-metastasis stage, Breslow thickness, Clark level, histological type, growth phase, ulceration and metastasis were all significantly associated with prognosis. An ADPS of <341.01 was identified as an independent predictor of metastasis. The trial registration no. is 2018-LW-037 and this clinical trial was registered in the First Affiliated Hospital of Zhengzhou University Clinical Trial Registry in March 1, 2018.

Plasma D-Dimer Measurement as a Marker of Gynecologic Tumors: Comparison with CA 125

Background

Fibrin is formed and degraded Intra-abdominally in ovarian cancer, and the cross-linked fibrin degradation product, D-dimer (D-D), has been found in increased concentrations In the plasma of these patients.

Methods

D-dimer and Ca 125 levels were determined simultaneously in 110 patients with gynecologic neoplasms. D-dimer and Ca 125 assays were performed using the Dimertest Stripwell EIA Kit (Ortho) and CA 125-11 EIA assay (Roche), respectively.

Results

D-dimer plasma and Ca 125 serum levels were significantly higher in patients with ovarian cancer (mean ± SE = 894.2 ± 173.7 ng/ml and 760.5 ± 292.7 U/ml, respectively) than in those with uterine cancer (mean DD ± SE = 109.7 ± 23.5 ng/ml and mean Ca 125 ± SE = 50.0 ± 23.1 U/ml) or those with benign disease (mean D-D ± SE = 70.5 ± 5.5 ng/ml and mean Ca 125 ± SE = 6.6 ± 2.8 U/ml). The levels of both markers Increased with regard to ovarian cancer disease status. Mean D-D ± SE was 90.0 ± 22.8 ng/ml and mean Ca 125 ± SE was 2.1 ±1.2 U/ml in patients with complete remission; mean D-D ± SE was 143.3 ± 33.5 ng/ml and mean Ca 125 ± SE was 26.2 ± 13.6 U/ml in patients with partial remission. In active disease, both markers had very high levels: D-D mean ± SE = 1021.6 ± 173.0 ng/ml and Ca 125 mean ± SE = 1154.7 ± 458.1 U/ml. In all groups of ovarian cancer patients, D-dimer sensitivity was better than that of Ca 125. In advanced ovarian cancer patients, the D-dimer concentration in ascites was up to 100 fold that in plasma.

Conclusions

Our results suggest that D-dimer can serve as a sensitive indicator to monitor the extent and course of the disease in ovarian cancer patients. The patient follow-up is ongoing to establish the predictive value of D-dimer measurement with respect to prognosis.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Prospective monitoring of cytomegalovirus, Epstein-Barr virus, BK virus, and JC virus infections on belatacept therapy after a kidney transplant

OBJECTIVES

Few data regarding viral replication in patients receiving belatacept are available. The aim of this single-center study was to compare the incidence of viral infections (cytomegalovirus, Epstein Barr virus, BK virus, and JC virus), in 62 de novo kidney transplant patients enrolled in the BENEFIT studies, receiving either belatacept (n=42) or cyclosporine (n=20).

MATERIALS AND METHODS

By means of polymerase chain reaction, belatacept-treated patients were tested for cytomegalovirus, Epstein-Barr virus, BK virus, and JC virus infections monthly for 36 months, monthly for the first 6 months, and then quarterly for 36 months in cyclosporine-treated patients. Additional samples were obtained when a viral infection was suspected.

RESULTS

The number of positive cytomegalovirus, BK virus, or JC virus viremias over the number of polymerase chain reactions performed through all 3 years was similar in both groups. Conversely, over the 3-year study, the number of positive Epstein-Barr virus viremias over the number of Epstein-Barr virus polymerase chain reactions performed was significantly higher in the belatacept group (76% vs 50%; P = .047). The number of Epstein-Barr virus primary infection was similar in both groups, while the number of Epstein-Barr virus reactivation was higher in the belatacept group.

CONCLUSIONS

Epstein-Barr virus replication occurs more often in patients receiving belatacept, than it does in those receiving cyclosporine.

Risk factors for subclavian vein thrombosis in cancer patients with total parenteral nutrition

Background

There are few reports on total parenteral nutrition (TPN) and its possible prothrombotic effect. The purpose of this study was to identify risk factors for subclavian vein thrombosis (SVT) in patients receiving TPN.

Method

Cancer patients with indwelling subclavian catheters and TPN were followed in a cohort study. Doppler ultrasound examination was performed 8 and 30 days after catheter placement.

Results

One hundred twenty-one patients were included, with a mean of 61 (± 11.8) years of age. We detected 36 SVT events at day 8 (29.8%) and 47 (38.8%) at day 30 after central catheter placement. Mean length of subclavian catheterization was 17.2 (± 8.2) days. Fifty-three point three percent of patients receiving ≥ 3,050 mOsm TPN in 24 hours developed SVT (relative risk (RR) = 2.01, 95% CI, 1.14 - 3.57; P = 0.016) at day 8 and 60% (RR = 1.67, 95% CI, 1.30 - 2.71; P = 0.038) at day 30 post-catheter placement. Protein administration of > 97.5 g/day was shown to be a risk factor for early thrombosis with a mean of 16.88 days for the development of SVT (95% CI, 10 - 23.7) versus 27.8 days (95% CI, 25.8 - 29.9) in the group with nutritional protein content < 97.5 g/day (P = 0.000).

Conclusion

High-osmolarity and high-protein nutrition formulas were shown to be risk factors for SVT in cancer patients receiving TPN.

D-dimer: not just an indicator of venous thrombosis but a predictor of asymptomatic hematogenous metastasis in gastric cancer patients

Background

Plasma D-dimer levels have been shown to be high in advanced tumor stage patients and can be used to predict clinical outcome in cancer patients. As most advanced tumor stage patients exhibit asymptomatic metastasis, which contributes to early tumor recurrence after surgery, we hypothesized that plasma D-dimer levels can be used to predict patients with potential metastasis.

Methods

We enrolled 1042 primary gastric cancer patients in three multiple cancer centers in Northwest China and examined plasma D-dimer levels using the latex-enhanced immunoturbidimetric assay (LEIA) method. Plasma D-dimer levels were compared with the clinicopathological characteristics in this large-scale case-control study with follow up. We also performed regular follow-up studies for 395 patients to analyze the 2-year survival rate and early tumor recurrence.

Results

In this large-scale clinical study, we found that plasma D-dimer levels were increased in patients with distant metastasis and especially hematogenous metastasis patients. The cut-off value of the D-dimer levels was determined to be 1.5 mg/ml based on the ROC curve, and the sensitivity and specificity for metastasis prediction were 61.9% and 86.6%, respectively. Additionally, patients with high D-dimer levels displayed early tumor recurrence and poor outcome during the follow-up study.

Conclusion

Plasma D-dimer may represent an easy to measure and lower cost marker for the testing of gastric cancer patients to predict asymptomatic hematogenous metastasis.

New combinational assay using soluble fibrin and d-dimer determinations: a promising strategy for identifying patients with suspected venous thromboembolism

Aim

To establish a new and reliable assay for quantification of the soluble fibrin (SF) in combination with that of D-dimer for early diagnosis of venous thromboembolism.

Methods and Samples

The SF assay is based on D-dimer generated after incubation of plasma with tissue-type plasminogen activator (t-PA). SF and standard D-dimer assays, run in blind, were used to test 119 untreated outpatients with clinically suspected deep-vein thrombosis (DVT, 49 patients) or pulmonary embolism (PE, 70 patients) consulting at the emergency unit of the hospital. Thromboses were confirmed by current imaging methods such as ultrasonography, scintigraphy, computed tomographic pulmonary angiography (CTPA) and ventilation/perfusion scan.

Results

SF assay was validated in 270 healthy volunteers [51.8% males; mean age years ± SD: 41±13; age range 19 to 65]. Among these normal plasmas, SF levels were ≤200 ng/mL in 97.8% of them, and 200–250 ng/mL in the remainder [26–46 years old; 50% males]. ROC curves were used to determine the SF cut-off value for plasma SF positivity, which was found to be 300 ng/mL. In patients with suspected venous thromboembolism, SF sensitivities for DVT and PE (92% and 94%, respectively) were comparable to those of D-dimer (96% and 94%), whereas SF specificities (86% and 95%) were higher than those of D-dimer (50% and 54%). Positive-predictive values for SF (89% and 94%) were again higher than those of D-dimer (70% and 65%) in DVT and PE. The amount of circulating SF normalized rapidly after anticoagulant therapy.

Conclusion

Results from this small group of patients suggest that the evaluation of plasma SF, in combination with that of D-dimer, represents a potentially useful tool for the early diagnosis of venous thromboembolism, provided that the patients have not been treated previously by anticoagulants.

High D-dimer levels are associated with poor prognosis in cancer patients

BACKGROUND

Systemic activation of hemostasis is frequently observed in cancer patients, even in the absence of thrombosis. Moreover, this activation has been implicated in tumor progression, angiogenesis and metastatic spread. Increased levels of D-dimer, which is a degradation product of cross-linked fibrin, indicate a global activation of hemostasis and fibrinolysis.

DESIGN AND METHODS

In a prospective and observational cohort study, we assessed the prognostic value of D-dimer levels for overall survival and mortality risk in 1178 cancer patients included in the Vienna Cancer and Thrombosis Study (CATS). Patients were followed over 2 years at regular intervals until occurrence of symptomatic venous thromboembolism or death. D-dimer levels were measured with a quantitative D-dimer latex agglutination assay

RESULTS

The main solid tumors were malignancies of the lung (n=182), breast (n=157), lower gastrointestinal tract (n=133), pancreas (n=74), stomach (n=50), kidney (n=37), prostate (n=133), and brain (n=148); 201 of the patients had hematologic malignancies; 63 had other tumors. During a median follow-up of 731 days, 460 (39.0%) patients died. The overall survival probabilities for patients with D-dimer levels categorized into four groups based on the 1(st), 2(nd) and 3(rd) quartiles of the D-dimer distribution in the total study population were 88%, 82%, 66% and 53% after 1 year, and 78%, 66%, 50% and 30% after 2 years, respectively (P<0.001). The univariate hazard ratio of D-dimer (per double increase) for mortality was 1.5 (95% confidence interval: 1.4-1.6, P<0.001) and remained increased in multivariable analysis including tumor subgroups, age, sex and venous thromboembolism.

CONCLUSIONS

High D-dimer levels were associated with poor overall survival and increased mortality risk in cancer patients.

Arterial and venous thrombosis in cancer patients

The most frequent ultimate cause of death is myocardial arrest. In many cases this is due to myocardial hypoxia, generally arising from failure of the coronary macro- and microcirculation to deliver enough oxygenated red cells to the cardiomyocytes. The principle reason for this is occlusive thrombosis, either by isolated circulating thrombi, or by rupture of upstream plaque. However, an additionally serious pathology causing potentially fatal stress to the heart is extra-cardiac disease, such as pulmonary hypertension. A primary cause of the latter is pulmonary embolus, considered to be a venous thromboembolism. Whilst the thrombotic scenario has for decades been the dominating paradigm in cardiovascular disease, these issues have, until recently, been infrequently considered in cancer. However, there is now a developing view that cancer is also a thrombotic disease, and notably a disease predominantly of the venous circulation, manifesting as deep vein thrombosis and pulmonary embolism. Indeed, for many, a venous thromboembolism is one of the first symptoms of a developing cancer. Furthermore, many of the standard chemotherapies in cancer are prothrombotic. Accordingly, thromboprophylaxis in cancer with heparins or oral anticoagulation (such as Warfarin), especially in high risk groups (such as those who are immobile and on high dose chemotherapy), may be an important therapy. The objective of this communication is to summarise current views on the epidemiology and pathophysiology of arterial and venous thrombosis in cancer.

Prognostic value of plasma D-dimer levels in patients with colorectal cancer

OBJECTIVE

Plasma D-dimer levels have been shown to be increased in patients with various solid tumours including lung, prostate, cervical, ovarian, breast and colon cancer. The purpose of this prospective study was to estimate the plasma D-dimer level of patients with colorectal cancer before surgery and to assess whether it has a prognostic value.

METHOD

The study comprised 51 patients with colorectal cancer. Variables including demographic, clinical, operative and pathological findings and routine laboratory tests were recorded. In addition, tumour markers, coagulation tests and plasma D-dimer levels were evaluated.

RESULTS

Histological types other than well-differentiated adenocarcinoma, relatively advanced tumour stage and a high preoperative plasma D-dimer level were the prognostic factors that were associated with shorter postoperative survival according to univariate analyses. The presence of vascular invasion was associated with higher preoperative D-dimer levels. However, there was no statistically significant relationship between postoperative survival and the presence of vascular invasion.

CONCLUSION

Postoperative survival was significantly shorter in colorectal cancer patients with elevated preoperative D-dimer levels. Evaluation of preoperative D-dimer level can be used to predict postoperative survival.

High incidence of silent venous thromboembolism before treatment in ovarian cancer

Venous thromboembolism (VTE) such as deep-vein thrombosis (DVT) and pulmonary thromboembolism (PTE) often occurs after surgery and rarely occurs even before surgery in patients with ovarian cancer. It is well known that levels of plasma D-dimer (DD) before treatment in most ovarian cancer patients are increased. This study therefore examined whether increased levels of DD are associated with presence of VTE before treatment of ovarian cancer. Between November 2004 and March 2007, DD levels prior to initial treatment were measured in 72 consecutive patients with presumed epithelial ovarian cancer (final diagnosis: epithelial ovarian cancer, n=60; and epithelial ovarian borderline malignancy, n=12). Venous ultrasound imaging (VUI) of the lower extremity was conducted for all patients except for two patients in whom DVT was detected by pelvic computed tomography (CT). When DVT was found, pulmonary scintigraphy was subsequently performed to ascertain presence of PTE. D-dimer levels were above the cut-off value (0.5 μg ml⁻¹) in 65 of 72 patients (90.2%). Venous ultrasound imaging or CT revealed DVT in 18 of 72 patients (25.0%) and pulmonary scintigraphy found PTE in 8 patients (11.1%). All patients with VTE were asymptomatic when VTE was found. D-dimer levels were associated with incidence of VTE (0–1.4 μg ml⁻¹; 0 of 26 (0%), 1.5–7.4 μg ml⁻¹; 9 of 30 (30%) and ⩾7.5 μg ml⁻¹; 9 of 16 (56.3%), P for trend=0.0003). However, even if 1.5 μg ml⁻¹ was used as a cut-off value, this had low specificity and positive predictive value (47.2, 38.3%), though it had high sensitivity and negative predictive value (100, 100%). Therefore, ovarian cancer patients with DD level ⩾1.5 μg ml⁻¹ should be examined using VUI to detect silent DVT. Patients with VTE underwent preventive managements including anticoagulant therapy before initial treatment, chemotherapy or surgery, and after surgery. There was no clinical onset of postoperative VTE in all 72 patients. Measurement of DD levels and subsequent ultrasonography revealed that silent or subclinical VTE frequently occurs before surgery in ovarian cancer. The usefulness of preoperative assessment of VTE needs further confirmation in randomised controlled trials.

Human ovarian cancer ascites fluid contains a mixture of incompletely degraded soluble products of fibrin that collectively possess an antiangiogenic property

Ovarian cancer ascites fluid (OCAF) displayed an antiangiogenic property in a chick chorioallantoic membrane (CAM) assay. This property was attributed in part to angiostatin although angiostatin-free OCAF retained a net antiangiogenic property. Recently, immunopurified fibrin(ogen) degradation products (FDPs) from malignant effusions of VX2 tumor-burdened rabbits exhibited antiangiogenic activity on the CAM. We questioned whether the FDPs of OCAF were also antiangiogenic. FDPs were immunopurified from individual OCAF samples, characterized by sodium dodecyl sulfate-polyacrylamide gel electrophoresis /western blots, enzyme-linked immunosorbent assays, and CAM assays. FDPs of OCAFs consisted of soluble high molecular weight (MW) fragments (>200 kd; approximately 40% of total FDPs), D-dimer (approximately 180 kd; approximately 37%), fragment D (approximately 90 kd; approximately 15%), and fragment E (approximately 50 kd; approximately 8%); intact fibrinogen was absent. When applied to CAM surfaces (0.5-1.6 mg/10 mL), purified FDPs significantly reduced the area of chorionic capillaries from 90% (in controls) to 47% over a 48-h period; from CAM sections, capillary density was reduced from 60% (controls) to 26%. FDPs prepared from fibrinogen displayed a similar antiangiogenic effect. Further digestion of OCAF FDPs by human plasmin caused degradation of high MW fragments, releasing additional D-dimer, fragment D, and fragment E. Of the fibrinogen-related components, OCAF contained only soluble FDPs (including incompletely digested fibrin fragments). Collectively, these FDPs contributed to the net antiangiogenic property of ascites fluid.

Venous thromboembolism syndrome in gynecological cancer

Venous thromboembolism (VTE) could be presented as an initial clinical feature in some cancer patients or a complication followed by various cancer treatments, which all indicates a poor outcome. This review focuses on elucidating the relationship of VTE and the main gynecological cancers including ovarian, endometrial, and cervical cancers. First, the general VTE information about gynecological cancer are introduced; second, the risk factors of VTE developing in gynecological cancer were discussed; third, we do a retrospective analysis on a novel treatment targeting coagulation cascade; and last, we analyze VTE as a remarkable complication followed by recombinant human erythropoietin and anti-vascular endothelial growth factor treatment in gynecological cancer patients. In summary, the interaction between the coagulation system and cancer progression is a novel promising area to be explored in the study of VTE in patients with gynecological cancer.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Plasma levels of D-dimer in lung carcinoma: clinical and prognostic significance

BACKGROUND

The activation of the clotting-fibrinolytic system in cancer patients is common and represents an unfavorable clinical sign. D-dimer (DD) is a sensitive marker of fibrinolysis.

METHODS

The current study comprised 826 new lung carcinoma patients seen consecutively in a single institution over a 10-year period (1992-2001). For each patient, 31 variables, including DD and survival duration, were available for analysis.

RESULTS

Only weak relationships between DD and the other variables were found. The DD variable correlated best with the level of lactate dehydrogenase, performance status, tissue polypeptide antigen, stage of disease, and the number of metastases (rho = 0.33, -0.25, 0.18, 0.18, and 0.15, respectively). The D-dimer distinguished patients with different prognoses. The median survival periods were 154 days (95% confidence interval [CI], 122-189 days) and 308 days (95% CI, 227-409 days; log rank statistic, 26.56; P < 0.01), respectively, for abnormally elevated and normal values. The difference was greater in patients with adenocarcinoma and in patients presenting with a less advanced disease, especially in patients with pathologic Stage Ia disease. The best multivariate survival model selected 10 significant covariates, including DD.

CONCLUSIONS

The authors recommend measuring the plasma level of DD in all new lung carcinoma patients. This measurement may help to formulate individual prognoses and can be used to indicate adjuvant treatment for surgical patients.

Cancer and the prothrombotic state

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.

Chemotherapy and thrombosis in gynecologic malignancy

Thromboembolism is a severe and frequent problem in gynecologic malignancy. The average DVT incidence during chemotherapy of 5% might represent the lower range of incidence because < 55% of thrombotic complication manifest clinical signs. However, it seems likely that in addition to chemotherapy other risk factors such as menopausal status, BMI of patients, or type of preceding surgery must coincide before thrombosis manifests. While monitoring of patients using sophisticated coagulation tests did not identify patients' risk for DVT during chemotherapy, an evaluation of the coagulation status before initiating chemotherapy is recommended. Patients with a venous access device (e.g., indwelling central venous catheter or with port cart) are at a particularly high risk for DVT. This has to be considered when cytoreductive therapy is given. Thrombosis prophylaxis, orally or subcutaneously, should only be considered in a subpopulation of patients who offer a combination of the aforementioned risk factors. Thrombosis prevention trials during chemotherapy found a significant reduction of DVT in patients treated with anticoagulants.

Preoperative D-dimer plasma assay is not a predictor of clinical outcome for patients with advanced ovarian cancer

D-dimer (DD) plasma levels are significantly higher in patients with ovarian cancer than in those with benign ovarian masses. The aim of this paper is to assess whether preoperative DD plasma assay has a prognostic relevance for 35 patients with advanced ovarian cancer receiving platinum-based chemotherapy. Preoperative DD levels ranged from 162 to 3720 ng/ml. The 25, 50, and 75% quartiles of DD levels were 1600, 1894, and 2069 ng/ml, respectively. Preoperative DD levels correlated neither with the common clinicopathological prognostic variables nor with the disease status at the end of first-line chemotherapy. Survival was related to residual disease after initial surgery (> or =2 cm vs <2 cm, P = 0.003), but not to preoperative DD levels. In conclusion, the present data seem to show that preoperative DD plasma assay is not a predictor of clinical outcome for patients with advanced ovarian cancer.

Plasma D-dimer and peritoneal CA-125 levels as predictors of disease status in ovarian carcinoma

Although serum CA-125 has improved our ability to monitor tumor response in ovarian carcinoma, approximately 50% of patients with normalization of CA-125 have persistent disease at second look laparotomy. Peritoneal CA-125 and plasma D-Dimer levels were studied to determine if their use could increase the sensitivity for persistent ovarian carcinoma in a population of patients with normal physical examinations, radiologic studies, and serum CA-125 values. Plasma D-Dimer levels were obtained prior to second look laparotomy. The results of peritoneal CA-125 and plasma D-Dimer studies were compared to second look laparotomy results. Differences were evaluated with a one-way analysis of variance. Twenty-seven patients were studied. Peritoneal CA-125 was evaluated in 23 patients and ranged from < 6.3-223 U/ml. There was no statistical difference in peritoneal CA-125 levels between patients whose second look laparotomies were negative, or microscopically or macroscopically positive. D-Dimer was elevated in three patients, all of whom had macroscopically positive second look findings. The sensitivity for positive second look findings was only 27%. Minimally elevated plasma D-Dimer levels were specific but not sensitive for persistent disease and peritoneal CA-125 was not predictive of disease status.

Hemostatic changes in patients with brain tumors

Abnormal hemostasis is a functional property of cancer. Hemostatic abnormalities are common in patients with systemic malignant disease and brain tumors. However, the incidence of thromboembolism is higher in patients with brain tumors than in those with systemic disease. This raises the question of whether or not hemostatic abnormalities found in the blood of the two groups of patients differs, suggesting different pathogeneses. The purpose of this report is to review abnormalities in blood and clinical manifestations of abnormal hemostasis found in brain tumors and cancer patients in an attempt to answer this question. Normal hemostasis, as currently understood, will be considered with an emphasis on features unique to the central nervous system.

The plasminogen-activation system in ovarian tumors

We studied the plasminogen activation system in tumor tissue by measuring the antigen level of the 2 plasminogen activators, tissue-type (t-PA) and urokinase-type (U-PA) and their inhibitors, plasminogen-activator inhibitors type-I (PAI-I) and type-2 (PAI-2) in the tissue extracts of 43 human benign and malignant ovarian tumors. U-PA levels were significantly higher in malignant than in benign tumors. In addition, U-PA antigen levels were higher in the metastatic tissue of advanced disease (FIGO stage III) than in the primary localized tumor (FIGO stage I/II). Also PAI-I concentrations tended to be higher in malignant than in benign tumors, but this difference was not statistically significant. In contrast, t-PA levels were lower in metastatic than in non-metastatic tumors, whereas PAI-2 levels were unrelated to the stage of ovarian malignancy. These results were integrated in a plasminogen-activation-dependent malignancy index (U-PA x PAI-I/t-PA). This index distinguished the different groups of benign ovarian tumors, localized and metastatic ovarian carcinomas better than U-PA levels. It could be useful as a prognostic indicator in ovarian cancer.