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

Unlocking the potential of oncology biomarkers: advancements in clinical theranostics

INTRODUCTION

Cancer biomarkers have revolutionized the field of oncology by providing valuable insights into tumor changes and aiding in screening, diagnosis, prognosis, treatment prediction, and risk assessment. The emergence of "omic" technologies has enabled biomarkers to become reliable and accurate predictors of outcomes during cancer treatment.

CONTENT

In this review, we highlight the clinical utility of biomarkers in cancer identification and motivate researchers to establish a personalized/precision approach in oncology. By extending a multidisciplinary technology-based approach, biomarkers offer an alternative to traditional techniques, fulfilling the goal of cancer therapeutics to find a needle in a haystack.

SUMMARY AND OUTLOOK

We target different forms of cancer to establish a dynamic role of biomarkers in understanding the spectrum of malignancies and their biochemical and molecular characterization, emphasizing their prospective contribution to cancer screening. Biomarkers offer a promising avenue for the early detection of human cancers and the exploration of novel technologies to predict disease severity, facilitating maximum survival and minimum mortality rates. This review provides a comprehensive overview of the potential of biomarkers in oncology and highlights their prospects in advancing cancer diagnosis and treatment.

Combined preoperative prognostic nutritional index and D-dimer score predicts outcome in colorectal cancer

BACKGROUND

The prognostic nutritional index (PNI) and D-dimer (DD) levels represent useful prognostic indicators in colorectal cancer (CRC); however, a combination of these indicators, namely, the PNI and DD score (PDS) was less addressed.

METHODS

A retrospective study with 183 patients after curative surgery was conducted. Patients were divided into 3 subgroups: PDS 0, decreased PNI and increased DD levels; PDS 1, decreased or increased PNI and DD levels; PDS 2, increased PNI and decreased DD levels. The differences in disease-free survival (DFS) and overall survival (OS) were compared among these subgroups, and risk factors for outcome were determined.

RESULTS

A total of 56, 65 and 62 patients were assigned to the PDS 0, 1 and 2 subgroups, respectively. PDS was significant in predicting both the DFS (area under the curve (AUC) = 0.68, P < 0.001) and OS (AUC = 0.74, P < 0.001). PDS 0 patients were more likely to be associated with old age (P = 0.032), laparotomy (P < 0.001), elevated CEA (P = 0.001), T₃ + T₄ (P = 0.001) and advanced TNM stage (P = 0.031). PDS 0 patients had significantly inferior DFS (log rank = 18.35, P < 0.001) and OS (log rank = 28.34, P < 0.001) than PDS 1 or 2 patients. PDS was identified as an independent risk factor for both DFS (PDS 1: HR = 0.54, 95% CI: 0.30-1.00, P = 0.049; PDS 2: HR = 0.40, 95% CI: 0.20-0.79, P = 0.009) and OS (PDS 1: HR = 0.44, 95% CI: 0.22-0.88, P = 0.020; PDS 2: HR = 0.17, 95% CI: 0.06-0.45, P < 0.001).

CONCLUSION

The PDS is a useful prognostic indicator for CRC patients after curative surgery, and PDS 0 patients have inferior survival. Additional future studies are needed to validate these findings.

Value of the Preoperative D-Dimer to Albumin Ratio for Survival and Recurrence Patterns in Gastric Cancer

BACKGROUND

D-dimer (DDI) and albumin are prognostic markers for numerous cancers; however, the predictive value of the preoperative DDI-to-albumin ratio (DAR) on the survival and recurrence patterns of gastric cancer (GC) remains unclear.

OBJECTIVE

The aim of this study was to explore the prognostic value of the DAR in GC.

METHODS

Our study included 1766 patients with GC, divided into training and testing cohorts at a ratio of 7:3. Patients were classified into either a high-DAR group (> 0.0145) or low-DAR group (≤ 0.0145) according to the cut-off value of receiver operating characteristic (ROC) curve analysis. The relationship between the DAR and recurrence pattern was analyzed in stage II/III patients.

RESULTS

Eight preoperative hematological factors were included and 17 composite inflammatory markers were constructed. ROC and random forest analyses indicated that among 17 markers, DAR was the best predictor for overall survival (OS) in GC (p < 0.01). High DAR was significantly associated with poor OS (hazard ratio [HR] 1.89, p < 0.001) and recurrence-free survival (RFS; HR 1.85, p < 0.001). Subgroup analysis showed no differences in OS and RFS between the high- and low-DAR groups in stage I or pT1/2 or pN0/1 patients; however, in stage II/III or pT3/4 or pN2/3 patients, the high-DAR group had shorter OS and RFS rates than the low-DAR group (p < 0.001). Similar results were found in the testing cohort. According to the multivariate analysis based on the training cohort, five indices, including DAR, cT stage, cN stage, age and body mass index (BMI), were incorporated to establish a nomogram model to predict the long-term prognosis of GC. The model showed comparable forecast performance in predicting OS (C-index: 0.773 vs. 0.786) and RFS (C-index: 0.788 vs. 0.795) compared with pTNM. Recurrence pattern analysis in stage II/III patients showed that the high-DAR group had a higher incidence of peritoneal implantation and early recurrence (ER) than the low-DAR group, and the post-recurrence survival in the high-DAR group was significantly shorter than that in the low-DAR group (p = 0.016).

CONCLUSION

The preoperative DAR is a new biomarker for the long-term survival prediction of GC. In advanced GC, a preoperative DAR > 0.0145 aids the timely detection of ER and peritoneal recurrence after surgery, thus guiding individual follow-up strategies.

Prognostic Role of Preoperative D-dimer Levels in Patients With Stage I-III Colorectal Cancer

BACKGROUND/AIM

As D-dimer levels have been reported to reflect cancer activity, preoperative D-dimer levels may serve as a prognostic marker in patients with colorectal cancer. The aim of this study was to evaluate the prognostic significance of preoperative D-dimer levels in patients with stage I-III colorectal cancer who underwent curative surgery.

PATIENTS AND METHODS

A total of 264 patients who underwent curative surgery for stage I-III colorectal cancer between January 2015 and December 2019 were enrolled in this study.

RESULTS

The median preoperative D-dimer level was 0.8 μg/ml (range=0.4-42.5 μg/ml). Based on the results of a receiver operating characteristic curve analysis, we set 1.45 as the cut-off value and classified patients into the low (n=215) and high D-dimer (n=49) groups. The high D-dimer group had significantly lower relapse-free and overall survival in comparison to the low D-dimer group (p<0.0001, p<0.0001, respectively).

CONCLUSION

Preoperative D-dimer levels can serve as a prognostic marker for stage I-III colorectal cancer.

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.

Prognostic value of plasma D-dimer levels in advanced non-small cell lung cancer patients treated with immune checkpoint inhibitors: a retrospective study

BACKGROUND

Plasma D-dimer is of great significance for the clinical exclusion of tumor-related thrombosis. Previous studies have shown its predictive role in non-small cell lung cancer (NSCLC) treated with chemotherapy. However, whether pretreatment D-dimer could predict the efficacy and prognosis in NSCLC patients treated with immune checkpoint inhibitors (ICIs) remains unclear.

METHODS

Advanced NSCLC patients treated with ICIs at the Chinese PLA General Hospital between January 2015 and March 2019 were enrolled. Patients were divided into a pretreatment normal D-dimer group (≤0.5 µg/mL) and high D-dimer group (>0.5 µg/mL). Optimization-based approach was applied to balance baseline covariates between the 2 groups, including age, sex, histological type, smoking history, stage, Eastern Cooperative Oncology Group Performance Status (ECOG PS), lines of treatment, ICI drugs, brain metastasis, treatment type, and D-dimer levels. Kaplan-Meier analysis and Cox proportional hazards model were used for analyzing survival data, including progression-free survival (PFS, the time from initial ICI treatment to PD or death), overall survival (OS, the time between initial ICI treatment and death), and hazard ratio (HR). Follow-up of all patients was performed by searching electronic medical records and counseling telephone. The follow-up cut-off date was July 6, 2020.

RESULTS

This study included 277 advanced NSCLC patients. Among the enrolled patients, 23.1% were female, 64.6% had non-squamous cell lung cancer, and 79.4% were stage IV. Univariate and multivariate analysis showed that pretreatment high D-dimer levels were independently associated with shortened PFS and OS (P<0.01). Subgroup analysis confirmed that pretreatment high D-dimer levels were associated with poor prognosis in most subsets. After balancing baseline covariates between the high D-dimer group and normal D-dimer group, the results indicated that patients with pretreatment high D-dimer levels had significantly shorter PFS [median: 6.4 vs. 11.5 months; HR, 1.70; 95% confidence ratio (CI): 1.25-2.37; P<0.001] and OS (median: 12.7 vs. 30.4 months; HR, 2.29; 95% CI: 1.54-3.41; P<0.001) than those with pretreatment normal D-dimer levels.

CONCLUSIONS

Pretreatment plasma D-dimer could serve as a convenient prognostic biomarker for advanced NSCLC patients receiving ICI treatment. Patients with pretreatment high D-dimer levels may have poor PFS and OS.

D-dimer, a predictor of bad outcome in gastric cancer patients undergoing radical resection

As a marker of hypercoagulability, plasma D-dimer is associated with progression of many cancers but remains controversial in gastric cancer (GC). We aim to investigate the predictive value of D-dimer for postoperative outcomes after radical gastrectomy of GC patients. We enrolled 903 consecutive patients with GC who underwent radical gastrectomy and the clinicopathological characteristics were compared. Risk factors for overall survival (OS) and disease-free survival (DFS) were determined using multivariate cox regression analysis. We also compared the survival difference based on Kaplan-Meier method after a one-to-one propensity score matching (PSM). Patients with elevated D-dimer had older age (p < 0.001), advanced TNM stage (p < 0.001), larger tumor size (p = 0.005), lower 5-year OS rate (32.8% vs 62.6%, p < 0.001) and DFS (29% vs 59.6%, p < 0.001). In multivariate analysis, elevated D-dimer was independently associated with shorter OS [hazard ratio (HR): 1.633, 95% confidence interval (CI) 1.178-2.264, p = 0.003] and DFS (HR: 1.58, 95% CI 1.151-2.169, P = 0.005). After PSM, the 5-year OS rate of patients with elevated D-dimer was still significantly lower than matched group (32.8% vs 40.6%, p = 0.005), so was DFS (29% vs 36.6%, p = 0.008). Preoperative elevated D-dimer is an independent risk factor for GC patients undergoing curative gastrectomy.

Application Value of Combined Detection of NLR, PNI, D-Dimer, CD3+ T Lymphocytes, and CEA in Colorectal Cancer Screening

Objective

To investigate the application value of combined detection of neutrophil-lymphocyte ratio (NLR), prognostic nutrition index (PNI), D-dimer (D-D), CD3⁺ T lymphocytes (CD3⁺ T), and carcinoembryonic antigen (CEA) in colorectal cancer screening.

Methods

The study cohort comprised 187 colorectal cancer patients and 100 mixed hemorrhoids patients as controls from January 2019 to August 2021 at the Fifth Affiliated Hospital of Sun Yat-sen University. Comparing the levels of NLR, PNI, D-D, CD3⁺ T, and CEA between the two groups of subjects, drawing receiver operating characteristic (ROC) curve evaluates the efficacy of single and combined detection for colorectal cancer screening.

Results

Compared with the control group, the levels of NLR, D-D, and CEA in the colorectal cancer group were significantly increased, while the levels of PNI and CD3⁺ T were significantly decreased (P < 0.05). ROC curve analysis showed that the combined detection of NLR, PNI, D-D, CD3⁺ T, and CEA for colorectal cancer screening had an AUC^ROC of 0.943, a sensitivity of 84.49%, a specificity of 91.00%, and a Youden index of 0.75, and its screening efficacy was significantly superior to that of a single detection (P < 0.001).

Conclusion

The combined detection of NLR, PNI, D-D, CD3⁺ T, and CEA has a high clinical application value for colorectal cancer and can provide a reference for early screening and auxiliary diagnosis of colorectal cancer.

Significance of preoperative blood tests in the prognosis of colorectal cancer: A prospective, multicenter study from Hungary

Background

The focus of this study was to analyze the prognostic value of different combinations of inflammatory and coagulation factors using preoperative blood and to appraise the clinical importance of these biomarkers in colorectal cancer patients.

Methods

A prospective, multicenter study included patients undergoing radical colorectal surgery in three county hospitals. Inflammatory and coagulation markers were analyzed preoperatively.

Results

Two hundred and one patients were included. We examined patients based on their tumor localization. Colon cancer group involved patients with the tumor localized in the colon (n = 105, 52.24%) and rectal cancer group the patients with the tumor in the rectum (n = 96, 47.76%). Examining coagulation factors, univariate Cox analysis of colon cancer patients showed that activated partial thromboplastin time (p = 0.020) was significantly associated with overall survival, but we could not prove it in multivariate analysis. In colon cancer patients, neutrophil‐to‐lymphocyte ratio (NLR, p < 0.001) was positively correlated with tumor size and had significant association (χ² = 5.48, p = 0.019, df = 1) with perineural invasion. Univariate and multivariate Cox analysis of colon cancer patients showed that NLR (p = 0.011 and p = 0.048) was significantly associated with disease‐free survival (DFS).

Conclusion

NLR was proved to be an independent prognostic factor for DFS in patients with non‐metastatic colon cancer. NLR might help to recognize the high‐risk patients between patients with the same tumor‐node‐metastasis stage and could help with the decision on adjuvant chemotherapy. Since the biomarkers in preoperative blood tests are habitually evaluated, NLR could be an inexpensive prognostic marker that can be easily assessed in clinical practice.

Hemostatic Biomarkers and Cancer Prognosis: Where Do We Stand?

Cancer patients are characterized by hypercoagulable state and an increased rate of thrombotic events, the most common being venous thromboembolism. Several hemostatic pathways that are significantly implicated in mechanisms of thromboembolic disease are also involved in growth, invasion, and metastatic spread of malignant cells as well in tumor-induced neo-angiogenesis. This close connection between cancer and the hemostatic system has prompted numerous studies on the role of alterations in the level plasma biomarkers of the different compartments of hemostasis in predicting cancer prognosis. In this review, we collect the results of several exemplificative studies that have evaluated clotting activation biomarkers in relation to different cancer outcomes with a final emphasis on current research and forthcoming directions in this field.

Prognostic value of preoperative carcinoembryonic antigen and D-dimer concentrations in patients undergoing curative resection for colorectal cancer

PURPOSE

Carcinoembryonic antigen (CEA) has limited value as a standalone predictor of the survival in patients with colorectal cancer (CRC). D-dimer (DD) is a predictor of the survival in patients with metastatic CRC. We aimed to predict the prognosis in patients undergoing curative resection for the treatment of CRC by integrating the evaluation of preoperative CEA and DD concentrations with the pathological classification for stage grouping (pStage).

METHODS

The study enrolled 304 patients between 2007 and 2012. The Combination of DD and CEA Score (CDCS) awarded 1 point each for a CEA concentration of > 5.0 ng/ml and DD concentration of > 1.0 μg/ml. Patients were classified according to the total points: CDCS 2, increased DD and CEA concentrations; CDCS 1, increased concentration of either DD or CEA; CDCS 0, normal concentrations.

RESULTS

The overall survival (OS) and relapse-free survival (RFS) were significantly lower in patients with CDCS 2 than in those with CDCS 1 or 0. The pStage and CDCS were not independent prognostic predictors of the OS but were predictors of the RFS. The C-index value of the combination of the pStage and CDCS was better than that of either alone for the OS and RFS.

CONCLUSION

The combination of the pStage and CDCS accurately predicts relapse in patients with CRC.

Plasma Fibrinogen Predicts the Prognosis of Bladder Cancer Patients After Radical Cystectomy

Background

This study aimed to determine the potential utility of plasma fibrinogen as a prognostic factor in patients with bladder cancer (BCa) after radical cystectomy (RC).

Methods

Patients with BCa who underwent RC from 2014 to 2019 were analyzed retrospectively. The indexes of plasma coagulation and fibrinolysis system factors were collected. Kaplan–Meier survival curves were used to calculate the overall survival (OS) and disease-free survival (DFS). The prognostic value of plasma fibrinogen was analyzed by using Cox regression model, and a nomogram of BCa based on plasma fibrinogen was generated by R software.

Results

Among 145 patients, the optimal cut-off value of plasma fibrinogen was 3.14g/L. High level of plasma fibrinogen was related to the poor prognosis of patients with BCa, and plasma fibrinogen has a more accurate prognostic ability than other plasma coagulation and fibrinolysis system factors. Multivariate Cox regression analysis showed that plasma fibrinogen was an independent predictor of OS (>3.14 vs ≤3.14 HR, 2.58, 95% CI = 1.28–5.23; p = 0.008) and DFS (>3.14 vs ≤3.14 HR, 2.60, 95% CI = 1.20–5.65; p = 0.016), and the nomogram based on plasma fibrinogen had better accuracy and discrimination (area under the curve (AUC): OS = 0.741, DFS = 0.733).

Conclusion

Plasma fibrinogen can be used as an independent predictor of OS and DFS for RC patients, and the nomogram based on plasma fibrinogen was a reliable model for predicting the prognosis after RC.

Prognostic value of pretreatment plasma D-dimer level in dogs with intermediate to high-grade non-Hodgkin lymphoma

Pretreatment D-dimer levels have been reported to predict survival in several types of malignancies in human patients. The objective of this study was to evaluate the prognostic value of pretreatment D-dimer level in dogs with intermediate to high-grade non-Hodgkin lymphoma (NHL). In a prospective, randomized, double-blind study of F14512 vs etoposide phosphate, we assessed the prognostic value of pretreatment plasma D-dimer level in 48 client-owned dogs diagnosed with intermediate to high-grade NHL. The correlation between pretreatment plasma D-dimer level and various clinical features, progression-free survival (PFS) and overall survival (OS) was analysed. The median value of pretreatment plasma D-dimer level was 0.4 μg/mL (range: 0.1-14.3 μg/mL). High pretreatment plasma D-dimer level (>0.5 μg/mL) was detected in 44% (21/48) of dogs. High D-dimer levels were not correlated with naive vs relapsed lymphoma, clinical stage, substage, immunophenotype or treatment group. D-dimer levels >0.5 μg/mL were significantly associated with inferior median PFS (54 vs 104 days, P = .011) and OS (93 vs 169 days, P = .003). In the multivariate analysis, high D-dimer levels remained an independent predictor for worse PFS (HR: 3.21, 95% CI: 1.57-6.56, P = .001) and OS (HR: 3.87, 95% CI: 1.88-7.98; P < .001). This study suggests that pretreatment plasma D-dimer level can serve as a predictor of prognosis in dogs with intermediate to high-grade NHL. Further studies are warranted to confirm these findings.

Haemostatic biomarkers for prognosis and prediction of therapy response in patients with metastatic colorectal cancer

BACKGROUND

Haemostatic activation and hypercoagulability are frequently observed in patients with metastatic colorectal cancer (mCRC), increase risk of venous thromboembolism (VTE) and have been implicated in tumour proliferation and progression. To date, the association of haemostatic biomarkers with oncologic outcomes including overall survival (OS), progression free survival (PFS) and disease control rate (DCR) is incompletely understood.

METHODS

Within the framework of the Vienna Cancer and Thrombosis Study, a prospective observational cohort study, we conducted an exploratory analysis to investigate the association of six known biomarkers of haemostasis with oncologic outcomes in 99 patients with mCRC prior to chemotherapy initiation.

RESULTS

Patients with high levels of factor VIII activity (FVIII), D-dimer, prothrombin fragment 1 + 2 (F1 + 2) and fibrinogen (defined as levels >75th percentile) had significantly shorter median OS than patients with lower levels. Elevation of four biomarkers was associated with mortality in multivariable analysis, adjusting for age, sex, number of metastatic sites and VTE (hazard ratio [95% CI] for death per doubling of levels: FVIII: 2.06 [1.28-3.30]; sP-selectin: 1.55 [1.07-2.24]; D-dimer: 1.40 [1.18-1.65]; F1 + 2: 1.64 [1.10-2.46]). Patients with elevated levels had numerically shorter median PFS across all markers and disease control rate (DCR) was significantly smaller in those with high levels of FVIII and F1 + 2 (adjusted odds ratio [95% CI] for DCR per doubling of levels: 0.23 [0.09-0.62] and 0.36 [0.16-0.82]) compared to patients with lower levels.

CONCLUSION

Specific elevated haemostatic biomarkers are associated with higher mortality and partially with worse response to chemotherapy in patients with mCRC.

High pretreatment plasma D-dimer levels predict poor prognosis in gastrointestinal cancers: A meta-analysis

BACKGROUND

High pretreatment plasma D-dimer levels can predict poor prognosis in various types of gastrointestinal carcinomas. Our meta-analysis explored the correlation between plasma D-dimer levels and prognosis in gastrointestinal malignancies.

METHODS

Two independent reviewers conducted a comprehensive search from PubMed, ScienceDirect, Embase, Web of Science and the Cochrane Library. All articles evaluating the correlation between pretreatment plasma D-dimer levels and prognosis in gastrointestinal malignancies were searched. We chose overall survival (OS) as the primary survival outcome measure and progression-free survival (PFS), disease-free survival (DFS) and cancer-specific survival (CSS) as the secondary survival outcome measures. We extracted hazard ratios (HRs) and 95% confidence intervals (CIs) from the eligible publications.

RESULTS

We included 30 studies involving 5928 gastrointestinal cancer patients. There was an obvious correlation between high D-dimer levels and poor OS (HR = 2.01, 95% CI = 1.72-2.36, P < .01). High plasma D-dimer levels were correlated with shorter PFS (HR = 1.34, 95% CI = 1.05-1.70, P = .32), DFS (HR =  1.67, 95% CI = 1.12-2.50, P < .01) and CSS rates (HR = 1.93, 95% CI = 1.49-2.49, P = .66).

CONCLUSIONS

Elevated pretreatment plasma D-dimer levels might help predict poor prognosis in patients with gastrointestinal malignancies.

Combination of D-dimer and carcinoembryonic antigen levels as a predictive and prognostic biomarker in advanced colorectal cancer patients

In view of the controversial findings on the utility of D-dimer and carcinoembryonic antigen (CEA) as biomarkers in advanced colorectal cancer (CRC), we evaluated the predictive and prognostic value of the D-dimer and CEA levels in unresectable advanced CRC patients treated with first-line chemotherapy. A total of 57 previously untreated patients with advanced CRC were enrolled. We assessed both plasma D-dimer and CEA levels at the start (D1 and CEA1) and after two cycles (D2 and CEA2) of chemotherapy. Based on the respective optimal cut-off values of 0.8 and 5.0 ng/mL for D1 and CEA1, respectively, patients were divided into low and high D-dimer or CEA groups. The results show that D1 and CEA1 levels were correlated (r = 0.392, P = 0.003). Mean CEA2 was reduced by 26.24 ng/mL in patients with partial response and stable disease and increased by 165.95 ng/mL in patients with progressive disease relative to the CEA1 level (P < 0.001). However, no correlation was evident between changes in the D-dimer levels and chemotherapy response (P = 0.441). The overall survival (OS) of patients with high D1 was shorter than that of patients with low D1 (median OS, 16 vs 29 months, P = 0.009). Multivariate analyses further demonstrated that D1 (P = 0.042) and chemotherapy response (P = 0.016), but not CEA, were independent prognostic factors for OS in advanced CRC. Taken together, our result found that changes in CEA levels may serve as a predictive biomarker of the chemotherapy response and baseline D-dimer levels as a prognostic biomarker of OS in patients with advanced CRC.

Hemostatic biomarkers in cancer progression

Malignant disease is characterized by a hemostatic imbalance, usually shifted towards a procoagulant direction, and a high incidence of thrombotic complications. The mechanisms of hemostasis that are critically involved in thrombosis are also implicated in tumor progression, angiogenesis, and metastatic spread. As there is a close relationship between cancer and the clotting system, circulating biomarkers of activation of various hemostasis compartments (i.e. coagulation, fibrinolysis, platelets, endothelium, and other blood cells) have been extensively studied to predict cancer outcomes along with predicting the thrombotic risk. In this review, we will summarize the results of published studies and will focus on ongoing research and future directions of clotting activation bioproducts as biomarkers of cancer disease and progression.

Usefulness of plasma D-dimer level for monitoring development of distant organ metastasis in colorectal cancer patients after curative resection

Purpose

To investigate the usefulness of plasma D-dimer level for monitoring the development of distant organ metastasis in colorectal cancer (CRC) patients after curative resection.

Patients and methods

One hundred and seventy-eight CRC patients after curative resection were enrolled in the study. Ninety-two patients developed distant organ metastasis during follow-up (metachronous metastasis), and blood was collected on the day metastasis was confirmed. Eighty-six patients had no evidence of metastasis yet, and their blood samples were evaluated at last return visit. The levels of D-dimer, carcinoembryonic antigen (CEA), and lactate dehydrogenase (LDH) between two patient groups were compared. The agreement between D-dimer and CEA (or LDH) was examined. The receiver operator characteristic (ROC) curve was used to evaluate the performance of D-dimer, CEA, LDH, and their combination in detection of distant organ metastasis.

Results

The level of D-dimer in CRC patients with metachronous metastasis was higher than that in non-metastasis patients (P<0.0001). Agreement between D-dimer and CEA was fair (κ=0.416, P<0.0001). D-dimer had a larger area under ROC (AUC) (0.85) compared to CEA (0.72) or LDH (0.68). The specificity of D-dimer (73.3%) was lower than that of CEA (74.4%), but the sensitivity (88.0%) of D-dimer assay was superior to that of CEA assay (65.2%). LDH showed the lowest sensitivity (42.4%) and highest specificity (95.3%) among the three bio-markers. The sensitivity and negative predictive value (NPV) of a combination assay (either D-dimer elevation or CEA elevation) were 94.6% and 91.1%, respectively, and the specificity and positive predictive value of another combination assay (both D-dimer elevation and LDH elevation) were 97.7% and 94.9%, respectively. Parallel test of the three markers improved the sensitivity and NPV to 95.7% and 92.7%, respectively.

Conclusion

Combining with CEA and/or LDH, D-dimer could be a useful surveillance marker for distant organ metastasis in CRC patients after curative resection.

High pretreatment plasma D-dimer levels are associated with shorter overall survival in patients with small cell lung cancer

Objective

To investigate the relationship between pretreatment plasma D-dimer levels and survival in Chinese patients with small cell lung cancer (SCLC).

Methods

This retrospective study enrolled 82 patients with SCLC treated at Beijing Chaoyang Hospital, Capital Medical University, from January 2012 to January 2015. All patients were followed up. Associations between pretreatment plasma D-dimer levels measured by immunoturbidimetric assay and clinical outcomes were analyzed by Kaplan–Meier and multivariate analyses, using a cut-off level of 0.55 mg/L fibrinogen equivalent units (FEU).

Results

Median progression-free survival (PFS) and overall survival (OS) were significantly higher in patients with low D-dimer levels (≤0.55 mg/L FEU; 8.0 and 17.0 months, respectively) compared with patients with high levels (>0.55 mg/L FEU; 5.0 and 9.0 months, respectively). Plasma D-dimer levels, Karnofsky performance status, N stage, TNM stage, treatment, and neuron-specific enolase (NSE) levels were significantly associated with PFS, while D-dimer levels, N stage, TNM stage, and treatment were significantly associated with OS. Multivariate analysis revealed that TNM stage, treatment, and NSE levels were independently associated with PFS, while D-dimer levels and treatment were independently associated with OS.

Conclusions

Pretreatment plasma D-dimer levels were independently associated with OS in patients with SCLC.

Preoperative Biomarker Panel, Including Fibrinogen and FVIII, Improves Diagnostic Accuracy for Pancreatic Ductal Adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) is a deadly cancer often diagnosed late. Earlier detection is urgently needed. Pancreatic ductal adenocarcinoma is known to associate with increased coagulation activity. We studied whether preoperative coagulation biomarkers are useful in distinguishing PDAC from a benign tumor, intraductal papillary mucinous neoplasm (IPMN) in this observational study. We analyzed standard clinical and coagulation variables in patients operated during 2010 and 2015 at Helsinki University Hospital. Pancreatic ductal adenocarcinoma with preoperative coagulation variables available and no neoadjuvant treatment or other active cancer was observed in 80 patients (stage I-III in 67 and IV in 13) and IPMN in 18 patients. Fibrinogen, factor VIII (FVIII), carbohydrate antigen (CA) 19-9, albumin, alkaline phosphatase, and conjugated bilirubin were higher in both stages I to III and IV PDAC compared to IPMN (P < .05). Factor VIII was highest in stage IV (P < .05). Combining these variables in a panel increased sensitivity and specificity for PDAC. In receiver operating characteristic analysis, the area under the curve (95% confidence interval) was 0.95 (0.90-1.00) for the panel, compared to 0.80 (0.71-0.88) for CA 19-9 alone (P < .01). In conclusion, PDAC was associated with increased fibrinogen and FVIII. Combining these coagulation biomarkers with CA 19-9, albumin, and alkaline phosphatase improves diagnostic accuracy.

D-dimer predicts postoperative recurrence and prognosis in patients with liver metastasis of colorectal cancer

BACKGROUND

Colorectal cancer is common, and its incidence is increasing throughout the world. The liver is a major metastatic site, and colorectal liver metastasis (CRLM) has a poor prognosis. Although liver resection is the most effective therapy for CRLM, postoperative recurrence is common. Thus, prognostic markers for CRLM are greatly needed. D-dimer, a fibrin cleavage product, has been shown to be related to colorectal tumor progression, and is also associated with malignant progression and recurrence in various cancers. Therefore, we evaluated the value of D-dimer in predicting the prognosis in CRLM.

METHODS

We retrospectively evaluated 90 cases of resected CRLM to determine the correlation between D-dimer and patient survival. The cut-off value for D-dimer levels was determined using receiver operating characteristic curve analysis.

RESULTS

Significant differences occurred in the recurrence group with higher D-dimer levels (P = 0.00736*), while the optimal cut-off value was 0.6 µg/mL. High D-dimer levels (≥ 0.6 µg/mL) were associated with poor recurrence-free survival (RFS; P = 0.0000841*) and cancer-specific survival (CSS; P = 0.00615*). In the multivariate analysis, D-dimer correlated with CRLM prognosis and independently predicted RFS (P = 0.0179*).

CONCLUSION

High D-dimer levels were associated with poor RFS and CSS. D-dimer was an independent prognostic factor of RFS. Therefore, D-dimer may help predict recurrence and prognosis in patients with CRLM.

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.

Elevated preoperative plasma D-dimer dose not adversely affect survival of gastric cancer after gastrectomy with curative intent: A propensity score analysis

Objective

Elevated plasma D-dimer has been reported to be associated with advanced tumor stage and poor survival in several types of malignancies. The purpose of this study was to assess the potential impact of preoperative plasma D-dimer level (PDL) on overall survival (OS) of gastric cancer (GC) patients undergoing curative surgery by applying propensity score analysis.

Methods

A total of 1,025 curatively resected GC patients in Tianjin Medical University Cancer Institute & Hospital were enrolled. Patients were categorized into two groups based on preoperative PDL: the elevated group (EG) and the normal group (NG). To overcome bias due to the different distribution of covariates for the two groups, a one-to-one match was applied using propensity score analysis, after matching, prognostic factors were analyzed.

Results

In analysis for the whole study series, patients in the EG were more likely to have a larger proportion of tumor size ≥5 cm (67.5% vs. 55.8%, P=0.006), elder mean age (64.0±10.8 years vs. 60.5±11.6 years, P<0.001) and advanced tumor (T), node (N), and TNM stage. Patients with elevated PDL demonstrated a significantly lower 5-year OS than those with normal PDL (27.0%vs. 42.6%, P<0.001), however, the PDL was not an independent prognostic factor for OS in multivariate analysis [hazard ratio: 1.13, 95% confidence interval (95% CI): 0.92-1.39, P=0.236]. After matching, 163 patients in the EG and 163 patients in the NG had the same characteristics. The 5-year OS rate for patients in the EG was 27.0% compared with 25.8% for those in the NG (P=0.809, log-rank).

Conclusions

The poor prognosis of GC patients with elevated preoperative PDL was due to the advanced tumor stage and elder age rather than the elevated D-dimer itself.

Prognostic significance of preoperative plasma D-dimer level in patients with surgically resected clinical stage I non-small cell lung cancer: a retrospective cohort study

BACKGROUND

Plasma D-dimer level, a marker of hypercoagulation, has been reported to be associated with survival in several types of cancers. The present study aimed to evaluate the prognostic significance of preoperative D-dimer levels in patients with surgically resected clinical stage I non-small cell lung cancer (NSCLC).

METHODS

Participants comprised 237 patients with surgically resected clinical stage I NSCLC. In addition to factors such as age, sex, and smoking status, the association between preoperative D-dimer level and survival was explored.

RESULTS

Patients were divided into two groups according to D-dimer level: Group A, ≤ 1.0 μg/ml (n = 170); and Group B, > 1.0 μg/ml (n = 67). The 5-year recurrence-free survival rate was 81.6% for Group A and 66.6% for Group B (p < 0.001). The 5-year overall survival rate was 93.6% for Group A and 84.7% for Group B (p = 0.002). Multivariate survival analysis identified D-dimer level as an independent prognostic factor, along with age, maximum standardized uptake value of the primary tumor, and pathological stage.

CONCLUSIONS

Preoperative D-dimer level is an independent prognostic factor in patients with surgically resected clinical stage I NSCLC.

Methodology and Applications of Disease Biomarker Identification in Human Serum

Biomarkers are biomolecules that serve as indicators of biological and pathological processes, or physiological and pharmacological responses to a drug treatment. Because of the high abundance of albumin and heterogeneity of plasma lipoproteins and glycoproteins, biomarkers are difficult to identify in human serum. Due to the clinical significance the identification of disease biomarkers in serum holds great promise for personalized medicine, especially for disease diagnosis and prognosis. This review summarizes some common and emerging proteomics techniques utilized in the separation of serum samples and identification of disease signatures. The practical application of each protein separation or identification technique is analyzed using specific examples. Biomarkers of cancers of prostate, breast, ovary, and lung in human serum have been reviewed, as well as those of heart disease, arthritis, asthma, and cystic fibrosis. Despite the advancement of technology few biomarkers have been approved by the Food and Drug Administration for disease diagnosis and prognosis due to the complexity of structure and function of protein biomarkers and lack of high sensitivity, specificity, and reproducibility for those putative biomarkers. The combination of different types of technologies and statistical analysis may provide more effective methods to identify and validate new disease biomarkers in blood.

High pretreatment plasma D-dimer predicts poor survival of colorectal cancer: insight from a meta-analysis of observational studies

D-dimer, one of the canonical markers of hypercoagulability, was reported to be a potential prognostic marker of colorectal cancer. However, an inconsistent conclusion existed in several published studies. Thus, we performed this meta-analysis to provide a comprehensive insight into the prognostic role for pretreatment D-dimer in colorectal cancer. Six databases (English: Pubmed, Embase and Web of Science; Chinese: CNKI, Wangfang and VIP) were utilized for the literature retrieval. Hazard ratio (HR) was pooled by Stata 12.0. A total of fifteen studies (2283 cases) corresponded to this meta-analysis and provided available data to evaluate the prognostic role of D-dimer for colorectal cancer. The pooled HR reached 2.167 (95%. CI (confidence interval): 1.672-2.809, P < 0.001) utilizing random effect model due to obvious heterogeneity among the included studies (I²: 73.3%; P < 0.001). To explore the heterogeneity among the studies, we conducted a sensitivity analysis and found a heterogeneous study. After removing it, the heterogeneity reduced substantially (I²: 0%; P = 0.549) and we obtained a more convincing result by fixed effect model (HR = 2.143, 95% CI = 1.922-2.390, P < 0.001, 14 studies with 2179 cases). In summary, high pretreatment plasma D-dimer predicts poor survival of colorectal cancer based on the current evidence. Further prospective researches are necessary to confirm the role of D-dimer in colorectal cancer.

D-dimer levels and cerebral infarction in critically ill cancer patients

BACKGROUND

D-dimer levels have been used in the diagnosis of a variety of thrombosis-related diseases. In this study, we evaluated whether measuring D-dimer levels can help to diagnose cerebral infarction (CI) in critically ill cancer patients.

METHODS

We retrospectively evaluated all cancer patients who underwent brain magnetic resonance imaging (MRI) between March 2010 and February 2014 at the medical oncology intensive care unit (ICU) of Samsung Medical Center. Brain MRI scanning was performed when CI was suspected due to acute neurological deficits. We compared D-dimer levels between patients ultimately diagnosed as having or not having CI and analyzed diffusion-weighted imaging (DWI) lesion patterns.

RESULTS

A total of 88 patients underwent brain MRI scanning due to clinical suspicion of CI; altered mental status and unilateral hemiparesis were the most common neurological deficits. CI was ultimately diagnosed in 43 (49%) patients. According to the DWI patterns, multiple arterial infarctions (40%) were more common than single arterial infarctions (9%). Cryptogenic stroke etiologies were more common (63%) than determined etiologies. There was no significant difference in D-dimer levels between patients with and without CI (P = 0.319). Although D-dimer levels were not helpful in diagnosing CI, D-dimer levels were associated with cryptogenic etiologies in critically ill cancer patients; D-dimer levels were higher in the cryptogenic etiology group than in the determined etiology group or the non-infarction group (P = 0.001). In multivariate analysis, elevated D-dimer levels (> 8.89 μg/mL) were only associated with cryptogenic stroke (adjusted OR 5.46; 95% confidence interval, 1.876-15.857).

CONCLUSIONS

Abnormal D-dimer levels may support the diagnosis of cryptogenic stroke in critically ill cancer patients.

Coagulation and fibrinolysis in gastric cancer

Coagulation is a highly conserved process occurring after an injury to a blood vessel and resulting in hemostasis. In the thrombus microenvironment, finely orchestrated events restore vessel integrity through platelet activation, adhesion, and aggregation (primary hemostasis), followed by the coagulation cascades, thrombin generation, and fibrin clot deposition (secondary hemostasis). Several studies on cancer have provided insight into dramatic changes to coagulation-related events (i.e., fibrin clot deposition, fibrinolysis) during tumor pathogenesis, progression, and metastasis, in addition to a tumor-driven systemic activation of hemostasis and thrombosis (Trousseau's syndrome). Diverse molecular and cellular effectors participate in the cross talk between hemostasis and tumors. Here, we focus on some aspects of the interconnection between cancer biology and hemostatic components, with particular attention to some key coagulation-related proteins (e.g., tissue factor, thrombin, fibrinogen, and D-dimers) in the particular case of gastric cancer (GC). Recent advances in deciphering the complex molecular link between GC and the coagulation system are described, showing their important roles in better management of patients affected by GC.

Clinical significance of plasma D-dimer in ovarian cancer: A meta-analysis

BACKGROUND

D-dimer has been widely used for the diagnosis and prognosis of ovarian cancer, but there is still controversy on its prediction value of ovarian cancer.

OBJECTIVES

To explore the clinical significance of plasma D-dimer level on ovarian cancer systematically.

METHODS

Using PubMed, Cochrane Library, and Web of Science libraries, all the relevant studies for the diagnostic and prognostic value of plasma D-dimer for ovarian cancer and the relationship between elevated D-dimer level and venous thromboembolism (VTE) risk of ovarian cancer were searched till May 30, 2016. Standardized mean difference (SMD), odds ratio (OR), hazard ratio (HR), and 95% confidence interval (CI) were appropriately pooled.

RESULTS

A total of 15 eligible studies involving a total of 1437 cancer patients were included. No significant association was found between high D-dimer level and overall survival of patients with ovarian cancer (HR 1.32, 95% CI: 0.90-1.95, P  =  .044). However, subgroup analysis indicated that the sample sizes could explain the heterogeneity between studies. And elevated D-dimer could predict increased risk of mortality when the sample sizes were >100 (HR 1.800, 95% CI: 1.283-2.523, P  =  .845). Besides, plasma D-dimer level was significantly higher in malignant ovarian cancer patients compared with benign controls (SMD 0.774, 95% CI: 0.597-0.951, P  =  .39), higher in advanced ovarian cancer patients (International Federation of Gynecology and Obstetrics [FIGO] classification III and IV) than in early stage ovarian cancer patients (FIGO classification I and II, SMD 0.611, 95% CI: 0.373-0.849, P  =  .442). And high D-dimer level indicated high VTE risk (OR 4.068, 95% CI: 2.423-6.829, P  =  .629) of ovarian cancer patients.

CONCLUSION

The plasma D-dimer level in ovarian cancer patients can predict the changes that correlated with disease progression and the VTE risk. But its predictive value for the prognosis of ovarian cancer was significantly dependent on the sample sizes. More well-designed studies with large sample sizes are needed to validate and update the findings of present study.

Biomarkers for monitoring chemotherapy-induced cardiotoxicity

Cardiotoxicity, including acute and late-onset cardiotoxicity, is a well-known adverse effect of many types of antitumor agents. Early identification of patients with cardiotoxicity is important to ensure prompt treatment and minimize toxic effects. The etiology of chemotherapy-induced cardiotoxicity is multifactorial. Traditional methods for assessment of chemotherapy-induced cardiotoxicity typically involve serial measurements of cardiac function via multi-modality imaging techniques. Typically, however, significant left ventricular dysfunction has already occurred when cardiotoxicity is detected by imaging techniques. Biomarkers, most importantly cardiac natriuretic peptides and troponins, are promising markers for identifying patients potentially at risk for clinical heart failure symptoms. This review summarizes the recent progress in clinical utilization of biomarkers for early diagnosis of acute cardiotoxicity and for prediction of late-onset cardiotoxicity. We also discuss the conflicting results of different studies and the association of results with study design.

D-Dimer and Carcinoembryonic Antigen Levels: Useful Indicators for Predicting the Tumor Stage and Postoperative Survival

The purpose of this prospective study is to determine the preoperative plasma D-dimer and serum Carcinoembryonic Antigen (CEA) levels of patients scheduled for curative surgical resection for colorectal cancer and to evaluate the significance of these levels on the prognosis and postoperative survival rate. One hundred sixty-five patients with colorectal cancer, who were scheduled to have elective resection between January 2008 and January 2011, were included in the study. A significant increase was observed in the D-dimer levels, particularly in poorly differentiated tumors. The distance covered by the tumor inside the walls of the colon and rectum (T-stage) was significant for both D-dimer and CEA levels. As the T-stage increased, there was also a significant increase in the D-dimer and CEA levels. A high significance and correlation level was detected between the TNM staging and both D-dimer and CEA. A significant relationship was found between the advanced tumor stage and short postoperative survival rate of patients with colorectal cancer. Therefore, the analysis of preoperative D-dimer and CEA levels can be useful in predicting the stage and differentiation of the tumor and the postoperative survival rate.

High Pretreatment D-Dimer Levels Correlate with Adverse Clinical Features and Predict Poor Survival in Patients with Natural Killer/T-Cell Lymphoma

Pretreatment plasma D-dimer levels have been reported to predict survival in several types of malignancies. The aim of this study was to evaluate the prognostic value of D-dimer levels in patients with newly diagnosed natural killer/T-cell lymphoma (NKTCL). The cut-off value of D-dimer to predict survival was set as 1.2 μg/mL based on the receiver operating curve analysis. Patients with a D-dimer level ≥ 1.2 μg/mL had significantly more adverse clinical features, including poor performance status, advanced stage diseases, B symptoms, elevated serum lactic dehydrogenase levels, involvement of regional lymph nodes, more extranodal diseases, and higher International Prognostic Index and natural killer/T-cell lymphoma prognostic index scores. A D-dimer level ≥ 1.2 μg/mL was significantly associated with inferior 3-year overall survival (OS, 13.0 vs. 68.5%, P < 0.001). In the multivariate analysis, a D-dimer level ≥ 1.2 μg/mL remained an independent predictor for worse OS (HR: 3.13, 95% CI: 1.47-6.68, P = 0.003) after adjusting for other confounding prognostic factors. Among patients with Ann Arbor stage I-II diseases, those with a D-dimer level ≥ 1.2 μg/mL had a significantly worse survival than those with a D-dimer level < 1.2 μg/mL (3 year-OS: 76.2 vs. 22.2%, P < 0.001). Survival of early-stage patients with a high D-dimer level was similar to that of the advanced-stage patients. In conclusion, pretreatment plasma D-dimer level may serve as a simple but effective predictor of prognosis in patients with NKTCL.

Widely Used Types and Clinical Applications of D-Dimer Assay

D-dimers are formed by the breakdown of fibrinogen and fibrin during fibrinolysis. D-dimer analysis is critical for the diagnosis of deep vein thrombosis, pulmonary embolism, and disseminated intravascular coagulation. Modern assays for D-dimer are monoclonal antibody based. The enzyme-linked immunosorbent assay (ELISA) is the reference method for D-dimer analysis in the central clinical laboratory, but is time consuming to perform. Recently, a number of rapid, point-of-care D-dimer assays have been developed for acute care settings that utilize a variety of methodologies. In view of the diversity of D-dimer assays used in central laboratory and point-of-care settings, several caveats must be taken to assure the proper interpretation and clinical application of the results. These include consideration of preanalytical variables and interfering substances, as well as patient drug therapy and underlying disease. D-dimer assays should also be validated in clinical studies, have established cut-off values, and reported according to the reagent manufacturers recommendations.

Pretreatment plasma D-dimer, fibrinogen, and platelet levels significantly impact prognosis in patients with epithelial ovarian cancer independently of venous thromboembolism

OBJECTIVE

The study aimed to evaluate the prognostic value of pretreatment plasma dimerized plasmin fragment D (D-dimer), fibrinogen, and platelet levels in epithelial ovarian cancer (EOC) after adjusting for venous thromboembolism (VTE) and to screen out the patients with the greatest risk for poor prognosis.

METHODS

The study comprised 190 patients with EOC. The plasma D-dimer, fibrinogen, and platelet levels were examined before treatment and analyzed with patient clinicopathological parameters, progression-free survival (PFS), and overall survival (OS). The survival analysis was performed using the Kaplan-Meier method, and prognostic factors were assessed using the Cox proportional hazards regression model.

RESULTS

The incidences of elevated plasma D-dimer levels, hyperfibrinogenemia, and thrombocytosis were 40%, 42.11%, and 45.26%, respectively. Elevated plasma D-dimer level, hyperfibrinogenemia, and thrombocytosis were associated with advanced tumor stage (P < 0.001, P = 0.013, P < 0.001). In addition, the elevated plasma D-dimer levels were associated with macroscopic postoperative residual disease (P = 0.002) and VTE events (P = 0.006). In multivariate Cox regression model, plasma D-dimer, fibrinogen, and platelet levels were identified as independent prognostic factors for OS (P = 0.039, P = 0.002, and P = 0.049). However, plasma fibrinogen and platelet levels, but not D-dimer levels, had independent prognostic value for PFS (P = 0.012 and P = 0.022). Patients with at least any 2 abnormalities of plasma D-dimer, fibrinogen, and platelet levels showed shorter PFS and OS than did patients with at most 1 abnormality of 3 parameters (P < 0.001).

CONCLUSIONS

Pretreatment plasma D-dimer, fibrinogen, and platelet levels, which impact prognosis independently of VTE, were demonstrated to be potential markers to predict disease progression and surgery outcome in patients with EOC. The combined use of plasma D-dimer, fibrinogen, and platelet levels may help to identify the high-risk populations for treatment decisions.

Clinical significance of plasma fibrinogen and D-dimer in predicting the chemotherapy efficacy and prognosis for small cell lung cancer patients

PURPOSE

Elevated plasma fibrinogen and D-dimer levels indicate activation of hemostasis and fibrinolysis, and this activation is required for tumor angiogenesis, metastasis, and invasion. Previous studies demonstrated that the plasma fibrinogen and D-dimer levels correlate with patient's prognosis in several solid tumors. The aim of this study is to examine the relationship between plasma fibrinogen and D-dimer levels before and during chemotherapy and treatment response and survival in patients with small cell lung cancer (SCLC).

METHODS

Plasma fibrinogen and D-dimer levels before and during chemotherapy were prospectively measured in 74 SCLC patients who received first-line therapy. The results were analyzed for correlation between fibrinogen and D-dimer levels and treatment response, as well as progressive-free survival (PFS) and overall survival (OS).

RESULTS

The levels of fibrinogen and D-dimer in SCLC patients before (C0) and after two cycles (C2) of chemotherapy were significantly higher than those in controls. Fibrinogen and D-dimer levels decreased during chemotherapy, and changes in fibrinogen and D-dimer levels between at C0 and at C2 were associated with treatment response. No matter which disease stage, patients with fibrinogen or D-dimer positivities at C0 and C2 time points had worse PFS and OS than those with fibrinogen or D-dimer negativities. Multivariate analyses revealed that fibrinogen and D-dimer positivities after two chemotherapy cycles were independently unfavorable factors for PFS and OS.

CONCLUSION

Fibrinogen and D-dimer levels after two cycles of chemotherapy are predictors for response on chemotherapy and prognosis in SCLC patients.

Can D-Dimer Measurement Reduce the Frequency of Radiological Assessment in Patients Receiving Palliative Imatinib for Gastrointestinal Stromal Tumor (GIST)?

Imatinib therapy has improved outcomes in advanced GISTs. Current guidelines suggest monitoring with CT scanning every 12 weeks. There are no validated biomarkers to assist disease evaluation. We identified 50 patients treated with imatinib for GIST in a single tertiary center. We assessed the prognostic value of D-dimers by Cox regression, and the utility as a biomarker for radiological progression (rPD) using receiver-operator curve (ROC) analysis. In asymptomatic patients with D-dimer levels <1,000 and falling levels, the negative predictive value for rPD was 92%. D-dimers may reduce the burden of CT scanning in a proportion of patients in this setting.

D-Dimer Can Serve as a Prognostic and Predictive Biomarker for Metastatic Gastric Cancer Treated by Chemotherapy

Systemic activation of hemostasis and thrombosis has been implicated in tumor progression and metastasis. D-dimer has been used as an indicator for the thrombosis. Here, we investigated the role of the activation of coagulation in patients with metastatic gastric cancer by measuring D-dimer level.We conducted an observation study of 46 metastatic gastric cancer patients who received palliative chemotherapy (CTx). D-dimer levels were assessed before CTx and at the first response evaluation after CTx.The overall survival (OS) of patients with pretreatment D-dimer levels <1.5 μg/mL was significantly longer than that of patients with D-dimer levels ≥1.5 μg/mL (22.0 vs 7.9 months, P = 0.019). At the first response evaluation, the mean level of D-dimer was significantly decreased by 2.11 μg/mL in patients either with partial response or stable disease (P = 0.011) whereas the mean level of D-dimer, although the difference did not reach statistical significance, was increased by 2.46 μg/mL in patients with progressive disease. In addition, the OS of patients with D-dimer levels <1.0 μg/mL at the first response evaluation was significantly longer than that of patients with D-dimer levels ≥1.0 μg/mL (22.0 vs 7.0 months, P = 0.009). The lower D-dimer levels (<1.0 μg/mL) at the first response evaluation after CTx was independent predictive factor for better survival in multivariate analysis (P = 0.037).This study suggests that D-dimer levels may serve as a biomarker for response to CTx and OS in patients with metastatic gastric cancer.

Cancer therapy and cardiovascular risk: focus on bevacizumab

Recognition and management of treatment-related cardiovascular toxicity, defined as either an acute cardiac event or a chronic condition, has been tightly integrated into routine cancer care and has become an important component in treatment selection. Several chemotherapeutic agents, such as anthracyclines, are traditionally characterized as cardiotoxic, but cardiovascular adverse events are also associated with commonly used molecular targeted therapies. In the past decade, bevacizumab, a monoclonal humanized antibody against vascular endothelial growth factor, has been introduced in the treatment of a variety of metastatic malignancies. Despite its efficacy, bevacizumab has been associated with significant risk of cardiovascular complications, such as hypertension, cardiac ischemia, and congestive heart failure. This review will focus on the cardiovascular toxicity of bevacizumab, providing the latest evidence on the incidence, clinical spectrum, risk factors, and responsible mechanisms.

Predictive value of plasma D-dimer levels in patients with advanced non-small-cell lung cancer

Purpose

The relationship between plasma D-dimer level and the prognosis of advanced non-small-cell lung cancer (NSCLC) is not well studied. This study investigated the role of plasma D-dimer as a prognostic factor in advanced NSCLC.

Methods

The plasma D-dimer was measured in 1,931 newly diagnosed advanced NSCLC patients by enzyme-linked immunosorbent assay. Correlations between plasma D-dimer levels and other clinical parameters were analyzed. Survival curves were plotted using the Kaplan–Meier method. The Cox proportional hazard model was used for multivariate analysis.

Results

Plasma D-dimer concentrations were within the normal range in 1,393 patients (72.1%) and elevated in 538 patients (27.9%). The median overall survival was 11.5 and 8.8 months in the normal and high plasma D-dimer group, respectively (P<0.001). The progression-free survival of first-line chemotherapy was 5.0 months and 4.4 months in the groups with normal and high levels of plasma D-dimer, respectively, (P<0.001). By multivariate analyses, the elevated plasma D-dimer level was found to be an independent prognostic factor for poor survival (hazard ratio =1.245; P<0.001).

Conclusion

Plasma D-dimer is an independent determinant of poor prognosis in advanced NSCLC.

Prognostic value of preoperative D-dimer and carcinoembryonic antigen levels in patients undergoing intended curative resection for colorectal cancer: a prospective cohort study

PURPOSE

Carcinoembryonic antigen (CEA) has limited value as an isolated predictor for survival among colorectal cancer (CRC) patients. D-dimer (DD) is a strong predictor of survival among metastatic CRC patients, but the prognostic value in non-metastatic CRC patients remains controversial. We examined the prognostic value of preoperative DD levels in relation to CEA levels in non-metastatic, resectable CRC patients.

METHODS

Between October 2003 and November 2005, 166 patients were included. We used the Kaplan-Meier method to compute 5-year mortality rates, stratified by preoperative DD and CEA levels. Adjusted Cox regression analysis was used to compute mortality rate ratios (MRRs) during postoperative years 0-1 and 1-5 based on the preoperative CEA and DD levels.

RESULTS

The cumulative 5-year mortality rate was 15 % (95 % confidence interval [CI], 9-25 %) in patients with normal DD and CEA levels, 30 % (CI, 16-53 %) in patients with isolated elevated CEA levels, 37 % (CI, 25-53 %) in patients with isolated elevated DD levels, and 60 % (CI, 37-83 %) in patients with elevated CEA and DD levels. Elevated CEA was associated with an approximately ten-fold increase in mortality within the first postoperative year (adjusted MRR 9.8, CI 2.5-38.3); this association was lost during postoperative years 1-5 (adjusted MRR 1.1, CI 0.5-2.7). Elevated DD was associated with a greater than two-fold increase in mortality during postoperative years 0-1 (adjusted MRR 2.8, CI 0.7-11.0) and 1-5 (adjusted MRR 2.2, CI 1.1-4.8).

CONCLUSION

DD is a strong predictor of survival among non-metastatic curatively resected CRC patients, particularly in combination with CEA.

A systematic review of the pathophysiology of 5-fluorouracil-induced cardiotoxicity

Background

Cardiotoxicity is a serious side effect to treatment with 5-fluorouracil (5-FU), but the underlying mechanisms are not fully understood. The objective of this systematic review was to evaluate the pathophysiology of 5-FU- induced cardiotoxicity.

Methods

We systematically searched PubMed for articles in English using the search terms: 5-FU OR 5-fluorouracil OR capecitabine AND cardiotoxicity. Papers evaluating the pathophysiology of this cardiotoxicity were included.

Results

We identified 27 articles of 26 studies concerning the pathophysiology of 5-FU-induced cardiotoxicity. The studies demonstrated 5-FU-induced: hemorrhagic infarction, interstitial fibrosis and inflammatory reaction in the myocardium; damage of the arterial endothelium followed by platelet aggregation; increased myocardial energy metabolism and depletion of high energy phosphate compounds; increased superoxide anion levels and a reduced antioxidant capacity; vasoconstriction of arteries; changes in red blood cell (RBC) structure, function and metabolism; alterations in plasma levels of substances involved in coagulation and fibrinolysis and increased endothelin-1 levels and N-terminal-pro brain natriuretic peptide levels. Based on these findings the proposed mechanisms are: endothelial injury followed by thrombosis, increased metabolism leading to energy depletion and ischemia, oxidative stress causing cellular damage, coronary artery spasm leading to myocardial ischemia and diminished ability of RBCs to transfer oxygen resulting in myocardial ischemia.

Conclusions

There is no evidence for a single mechanism responsible for 5-FU-induced cardiotoxicity, and the underlying mechanisms might be multifactorial. Further research is needed to elucidate the pathogenesis of this side effect.

Elevated levels of plasma D-dimer predict a worse outcome in patients with nasopharyngeal carcinoma

BACKGROUND

Hemostatic alterations occur during the development of cancer. Plasma D-dimer is a hypercoagulability and fibrinolytic system marker that is increased in patients with various solid tumours. The aim of this study was to evaluate the hemostatic status of nasopharyngeal carcinoma (NPC) patients by assessing plasma D-dimer levels to investigate its value as a prognostic marker.

METHODS

We retrospectively analysed 717 patients with nasopharyngeal carcinoma, and we applied Cox regression and log-rank tests to assess the association of D-dimer levels with disease-free survival (DFS), distant metastasis-free survival (DMFS), and overall survival (OS). D-dimer levels were measured using a quantitative D-dimer latex agglutination assay.

RESULTS

Using the 3rd quartile values (0.8 μg/L) as the optimal cut-offs, we found that patients with high D-dimer levels have a shorter 3-year DFS, (79%, 95%CI (73.1-84.9)) vs. (69%, 95%CI (59.2-78.8)), DMFS (87%, 95%CI (83.1-90.9)) vs. (77%, 95%CI (69.2-84.8)), and overall survival (82%, 95%CI (76.1-87.9)) vs. (76%, 95%CI (66.2-85.8)). Multivariate analysis revealed that pre-treatment D-dimer levels and EBV DNA were significant independent factors for DFS, DMFS, and OS in NPC patients. Subgroup analyses indicated that the plasma D-dimer levels could effectively stratify patient prognosis for early cancer, advanced stage cancer, and patients with EBV DNA ≥4000 copies/ml.

CONCLUSIONS

High D-dimer levels were associated with poor disease-free survival, distant metastasis-free survival, overall survival, and increased risk of mortality in NPC patients. Prospective trials are required to assess the prognostic value of D-dimer levels.

Clinical significance of coagulation assays in metastatic pancreatic adenocarcinoma

PURPOSE

Activated coagulation and fibrinolytic system in cancer patients is associated with tumor stroma formation and metastasis in different cancer types. The aim of this study is to explore the correlation of blood coagulation tests for various clinicopathologic factors in patients with metastatic pancreatic adenocarcinoma (MPA).

MATERIAL

A total of 17 MPA patients were enrolled into the study. All the patients were treatment-naïve. Pretreatment blood coagulation tests including prothrombin time, activated partial thromboplastin time (APTT), international normalized ratio (INR), D-dimer, fibrinogen levels, and platelet counts were evaluated. Control group comprised 50 age- and sex-matched individuals without history of malignancy and coagulation disorder.

RESULTS

Median age of diagnosis was 59 years old (range, 35-72). The plasma level of all coagulation factors revealed statistically significant difference between patient and control group (p < 0.01). Anemic patients had associated with higher D-dimer levels (p = 0.001). Similarly, the ones with elevated serum CA19-9 exhibited significantly higher D-dimer values (p = 0.011). For APTT, significant differences were found in both between gender of patients (p = 0.01) and response to chemotherapy (p = 0.01). The patients with elevated erythrocyte sedimentation rates had associated with higher INR (p = 0.05). Univariate analysis of survival revealed that the patients with unresponsive to chemotherapy (p = 0.06) and higher INR (p = 0.078) had poor overall outcome.

CONCLUSION

Serum D-dimer level is elevated among MPA patients with higher serum CA19-9 and higher INR levels seem to be a poor prognostic factor in MPA.

Elevated plasma D-dimer levels correlate with long term survival of gastric cancer patients

Background

Increasing evidence indicated plasma D-dimer could be regarded as a marker in cancers, however, its role in gastric cancer is still largely unknown.

Methods

Plasma D-dimer levels were measured by enzyme linked fluorescent immunoassays and evaluated by receiver operating characteristic (ROC) curves for peritoneal dissemination in gastric cancer and healthy subjects. The overall survival (OS) characteristics were determined using Kaplan–Meier and Cox regression analyses.

Results

The average of the plasma D-dimer levels for gastric cancer patients was significantly higher than the healthy subjects. A Spearman correlation analysis showed that plasma D-dimer levels correlated with the depth of invasion, lymph node metastasis, peritoneal dissemination, distant metastasis, tumor size and TNM stage. The mean plasma D-dimer level was 2.20±1.51 µg/mL in peritoneal dissemination patients and 1.01±0.79 µg/mL in non-peritoneal dissemination patients (P<0.001). Additionally, the mean plasma D-dimer concentration in patients alive at the final follow-up evaluation was 0.79±0.72 µg/mL,which was significantly lower than the amounts determined for the deceased patients (1.36±1.13 µg/mL) (P<0.001). The AUC of D-dimer was 0.833 (95%CI: 0.780–0.885). At a cut-off value of 1.465 µg/mL, the D-dimer measurement had a sensitivity of 78.00%, a specificity of 83.76% and an accuracy of 82.59%. The median OS was 48.10 months (95% CI: 43.88–52.31) in patients with plasma D-dimer levels less than 1.465 µg/mL and 22.39 months (95% CI: 16.95–27.82) in patients with plasma D-dimer levels exceeding 1.465 µg/mL (log-rank test, P<0.001). Importantly, plasma D-dimer levels exceeding 1.465 µg/mL were significantly associated with poor OS, as determined using a multivariate Cox regression analysis (hazard ratio [HR], 2.28; 95%CI: 1.36–3.81; P = 0.002).

Conclusions

Plasma D-dimer levels are increased in gastric cancer patients and may be a valuable biomarker for peritoneal dissemination, with high D-dimer levels predicting poor outcomes for gastric cancer patients.