Coagulation and cancer: implications for diagnosis and management

The Crossroads of the Coagulation System and the Immune System: Interactions and Connections

The coagulation and immune systems, two vital systems in the human body, share intimate connections that fundamentally determine patient health. These systems work together through several common regulatory pathways, including the Tissue Factor (TF) Pathway. Immune cells expressing TF and producing pro-inflammatory cytokines can influence coagulation, while coagulation factors and processes reciprocally impact immune responses by activating immune cells and controlling their functions. These shared pathways contribute to maintaining health and are also involved in various pathological conditions. Dysregulated coagulation, triggered by infection, inflammation, or tissue damage, can result in conditions such as disseminated intravascular coagulation (DIC). Concurrently, immune dysregulation may lead to coagulation disorders and thrombotic complications. This review elucidates these intricate interactions, emphasizing their roles in the pathogenesis of autoimmune diseases and cancer. Understanding the complex interplay between these systems is critical for disease management and the development of effective treatments. By exploring these common regulatory mechanisms, we can uncover innovative therapeutic strategies targeting these intricate disorders. Thus, this paper presents a comprehensive overview of the mutual interaction between the coagulation and immune systems, highlighting its significance in health maintenance and disease pathology.

A Prognostic Model Based on Clinicopathological Features and Inflammation- and Nutrition-Related Indicators Predicts Overall Survival in Surgical Patients With Tongue Squamous Cell Carcinoma

Objectives: It is reported that inflammation- and nutrition-related indicators have a prognostic impact on multiple cancers. Here we aimed to identify a prognostic nomogram model for prediction of overall survival (OS) in surgical patients with tongue squamous cell carcinoma (TSCC). Methods: The retrospective data of 172 TSCC patients were charted from the Cancer Hospital of Shantou University Medical College between 2008 and 2019. A Cox regression analysis was performed to determine prognostic factors to establish a nomogram and predict OS. The predictive accuracy of the model was analyzed by the calibration curves and the concordance index (C-index). The difference of OS was analyzed by Kaplan-Meier survival analysis. Results: Multivariate analysis showed age, tumor node metastasis (TNM) stage, red blood cell, platelets, and platelet-to-lymphocyte ratio were independent prognostic factors for OS, which were used to build the prognostic nomogram model. The C-index of the model for OS was 0.794 (95% CI = 0.729-0.860), which was higher than that of TNM stage 0.685 (95% CI = 0.605-0.765). In addition, decision curve analysis also showed the nomogram model had improved predictive accuracy and discriminatory performance for OS, compared to the TNM stage. According to the prognostic model risk score, patients in the high-risk subgroup had a lower 5-year OS rate than that in a low-risk subgroup (23% vs 49%, P < .0001). Conclusions: The nomogram model based on clinicopathological features inflammation- and nutrition-related indicators represents a promising tool that might complement the TNM stage in the prognosis of TSCC.

Cerebral embolism during edoxaban administration for venous thromboembolism in a patient with lung adenocarcinoma: A case report

RATIONALE

The efficacy of direct oral anticoagulants (DOACs) in the treatment and prophylaxis of cancer-related venous thromboembolism (VTE) is reportedly similar to that of heparin. However, the effect of DOACs on the prophylaxis of cancer-related arterial thromboembolism (ATE) remains unclear. To our knowledge, we present the 1st case where cerebral ATE was encountered during edoxaban administration for VTE in a patient with lung adenocarcinoma.

PATIENT CONCERNS

In March 2017, a 63-year-old female was diagnosed with lung adenocarcinoma (cT2aN3M1b stage IVa) along with having asymptomatic VTE; thus, 60 mg/day edoxaban administration was initiated. In addition, 1st-line chemotherapy generated a partial antitumoral response. However, owing to lung cancer progression, a secondary treatment with pembrolizumab administration was initiated. The patient suddenly experienced aphasia 11 days after pembrolizumab administration.

DIAGNOSIS

The patient was diagnosed as multiple cerebral ATE using brain magnetic resonance imaging. However, VTE recurrence was not observed. Based on the findings of lung cancer progression and increased coagulation, cerebral ATE was diagnosed as Trousseau syndrome.

INTERVENTIONS

DOAC administration was switched to heparin administration.

OUTCOMES

Coagulation profile normalized and aphasia improved without any further disease symptoms.

LESSONS

We considered that DOACs are effective for the treatment and prophylaxis of VTE but may be insufficient for ATE prevention. Therefore, DOACs should be replaced with heparin to prevent ATE when cancer and coagulation become uncontrollable with DOAC.

Thrombotic characteristics of extracellular vesicles derived from prostate cancer cells

BACKGROUND

Prostate cancer (PC) patients in advanced stages of the disease have high risk of blood coagulation complications. The procoagulant molecule Tissue factor (TF), and the fibrinolysis inhibitor plasminogen activator inhibitor-1 PAI-1 play important role in this complication. Extracellular vesicles (EV) shed from cancer cells may contribute to the regulation of TF and PAI-1. The procoagulant activity of EV can be associated with the oncogenic and metastatic characteristics of their cells.

METHODS

We have expressed EGFRvIII in DU145 cells to assess the role of this oncogene in the procoagulant activity of EV. The intercellular exchange of TF via EV was assessed by downregulating its expression in DU145 cells using shRNA vector, and determining the transfer of TF via EV enriched with the protein. Two PC cell lines with different metastatic potential were used to assess the correlation between the procoagulant activity of EV and the metastatic potential of PC cells. Photometric assays were used to determine FXa-activity and thrombin generation as indicators for the procoagulant activity of EV. Double-tagged proteinase-activated receptor 1(PAR-1) expressed in CHO cells to assess its activation by EV.

RESULTS

The expression of EGFRvIII in DU145 cells led to increased mRNA levels for TF and PAI-1, but the increase in these proteins expression was detected mostly in the EV. EV with enhanced levels of TF protein conferred higher TF procoagulant activity on the acceptor cells by intercellular exchange of this protein. Procoagulant activity of EV, assessed by FXa activity, and thrombin generation, was correlated with the oncogenic and metastatic potential of PC cells. The ability of EV to generate thrombin led to the activation of PAR-1, which was evident by the truncation of tagged-PAR-1.

CONCLUSION

The active oncogene EGFRvIII increases the concentration of TF and PAI-1 in EV. The procoagulant activity of EV is associated with the oncogenic and metastatic characteristics of their PC cells. Also, EV may contribute to the high procoagulant activity in the tumour microenvironment by the intercellular exchange of TF. Finally, through the generation of thrombin, EV can activate PAR-1, which evidently contributes to cancer progression, linking the coagulation system to tumor progression.

Pulmonary embolism concurrent with lung cancer and central emboli predict mortality in patients with lung cancer and pulmonary embolism

Background

Patients with lung cancer commonly experience pulmonary embolism (PE). The aim of the present study was to examine the clinical features of patients with lung cancer and PE and to investigate prognostic factors in these patients.

Methods

This retrospective study divided patients with lung cancer and PE into a group of patients with PE diagnosed concomitantly with lung cancer (concurrent group) and a group with PE detected after lung cancer (sequential group), compared the clinical characteristics of patients in the two groups, and investigated prognostic factors in these patients.

Results

The study population consisted of the concurrent group [27 patients (10.1%)] and the sequential group [240 patients (89.9%)]. The concurrent group exhibited higher percentages of stage I cancer at the diagnosis of PE [6 (22.2%) vs. 8 (3.3%), P<0.001] and right ventricular (RV) dilation on computed tomography (CT) [14 (51.9%) vs. 41 (17.1%), P<0.001], as well as lower rate of small cell carcinoma [1 (3.7%) vs. 49 (20.4%), P=0.036] than the sequential group. PE concurrent with lung cancer [hazard ratio (HR) =2.64, 95% confidence interval (CI): 1.57-4.43, P<0.001] and central PE (HR =1.46, 95% CI: 1.02-2.10, P=0.04) were independent predictors of mortality in patients with lung cancer and PE.

Conclusions

PE concurrent with lung cancer is characterized by more severe PE and infrequent small cell carcinoma. PE concurrent with lung cancer and central emboli may be independent prognostic factors in patients with lung cancer and PE.

The red distribution width and the platelet distribution width as prognostic predictors in gastric cancer

Background

Increasing attention is focused on the relationship of inflammation biomarkers with malignant tumors. The purpose of the present study was to detect whether the preoperative the red distribution width (RDW) and the platelet distribution width (PDW) can be used to distinguish patients with gastric cancer (GC) or early stage GC from the healthy controls and predict the progression and prognosis of the GC.

Methods

The RDW and PDW values of 227 patients with GC and 164 patients with early GC were retrospectively analyzed comparing with 101 healthy controls. In addition, the clinicopathological features, survival curves and prognosis of the patients with GC were compared between the high and low groups according to the RDW and PDW values.

Results

Significant higher RDW and lower PDW were detected in patients with GC and early GC compared to the healthy controls. A higher RDW was significantly associated with older age, a larger tumor diameter, deeper tumor infiltration, and lymph node metastasis while a lower PDW was significantly associated with male, older age, a larger tumor diameter, deeper tumor infiltration, elevated CEA and CA125. Increased RDW was significantly associated with worse overall survival (OS) and disease-free survival (DFS) for GC (P = 0.042 and P = 0.033, respectively) and early GC (P = 0.037 and P = 0.009, respectively) while decreased PDW indicated a significantly association with poor DFS for early GC (P = 0.006). Univariate and multivariate survival analysis showed that RDW and PDW can act as independent prognostic factors for DFS (P = 0.028 and P = 0.020) in patients with early GC.

Conclusion

The preoperative RDW and PDW were simple and convenient predictive factors for the progression and prognosis of patients with GC.

A retrospective discussion of the prognostic value of combining prothrombin time(PT) and fibrinogen(Fbg) in patients with Hepatocellular carcinoma

Aims: The levels of coagulation system tests have been studied in various cancers. In this study, our aim is to evaluate the prognostic value of pretreatment plasma coagulation tests in hepatocellular carcinoma (HCC) patients. Patient and methods: A retrospective study was performed in 539 patients with HCC, and follow-up period was at least 60 months until recurrence or death. The prognostic significance of coagulation system tests (prothrombin time, activated partial thromboplastin time, thrombin time, fibrinogen) were determined by univariate and multivariate Cox hazard models. Then, according to the results of the multivariate analyses, we proposed the coagulation-Based Stage, which combined the independent risk factors (prothrombin time and fibrinogen). Results: Coagulation system tests including prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT), fibrinogen (Fbg) were analyzed. Patients with prolonged PT (≥12.1 sec) levels had significantly poor overall survival (OS) and disease-free survival (DFS), not only in the entire cohort (HR: 1.661, 95%CI: 1.125-2.451, p=0.011 vs. HR: 1.660, 95%CI: 1.125-2.451, p=0.011), but also in the subgroups stratified by pathological stage (stage I-II and stage III-IV). Additionally, high Fbg (≥2.83 g/L) levels experienced significantly decreased OS and DFS (HR: 2.158, 95%CI: 1.427-3.263, p<0.001 vs. HR: 2.161, 95%CI: 1.429-3.267, p<0.001), not only in the entire cohort but also in the subgroups stratified by pathological stage (stage I-II and stage III-IV). All the patients were then stratified (based on combined PT and Fbg) into three groups, The OS for HCC patients were (41.37±17.76), (31.83±19.84) and (18.68±18.41) months, and the DFS for HCC patients were (41.15±17.88), (31.65±19.81) and (18.66±18.39) months. Conclusions: Our findings suggest that the combination of plasma PT and Fbg levels should be evaluated as the valuable predictor of survival in patients with HCC.

Neck Mass Due to Thrombosis of the Jugular Vein in Patients with Cancer

The hypothesis that jugular thrombosis (JT) may cause a mass in the cervical region is usually overlooked. The objective of the present study was to identify the characteristics of neck masses resulting from JT in cancer patients and to analyze the possible reasons for their formation. A retrospective study was conducted on 8 patients with JT affected by 3 types of neoplasia, ie, carcinomas (3 cases), adenocarcinomas (3 cases), and lymphomas (2 cases) located in the breast, digestive apparatus, lymphatic system (2 cases each), lung and an undetermined site (1 case each), diagnosed over the last 12 years. The most frequent symptom of JT was the presence of a mass in the supraclavicular space (62.5% of cases) deeply located on the anterior margin of the sternocleidomastoid muscle and diagnosed by computed tomography and ultrasound. The masses were slightly hardened, with a clearly defined upper limit and an imprecise lower limit and with an irregular surface. The patients also presented with cough, hoarseness, pain during movements, facial edema, and collateral circulation. In one of the patients with a lung cancer, JT symptoms preceded the symptoms of cancer by 2 months. Hypercoagulation, compression, and invasion of a vessel possibly explain the occurrence of JT in these patients.

Does tranexamic acid reduce blood loss during head and neck cancer surgery?

Background and Aims:

Transfusion of blood and blood products poses several hazards. Antifibrinolytic agents are used to reduce perioperative blood loss. We decided to assess the effect of tranexamic acid (TA) on blood loss and the need for transfusion in head and neck cancer surgery.

Methods:

After Institutional Review Board approval, 240 patients undergoing supramajor head and neck cancer surgeries were prospectively randomised to either TA (10 mg/kg) group or placebo (P) group. After induction, the drug was infused by the anaesthesiologist, who was blinded to allocation, over 20 min. The dose was repeated every 3 h. Perioperative (up to 24 h) blood loss, need for transfusion and fluid therapy was recorded. Thromboelastography (TEG) was performed at fixed intervals in the first 100 patients. Patients were watched for post-operative complications.

Results:

Two hundred and nineteen records were evaluable. We found no difference in intraoperative blood loss (TA - 750 [600–1000] ml vs. P - 780 [150–2600] ml, P = 0.22). Post-operative blood loss was significantly more in the placebo group at 24 h (P - 200 [120–250] ml vs. TA - 250 [50–1050] ml, P = 0.009), but this did not result in higher number of patients needing transfusions (TA - 22/108 and P - 27/111 patients, P = 0.51). TEG revealed faster clot formation and minimal fibrinolysis. Two patients died of causes unrelated to study drug. Incidence of wound complications and deep venous thrombosis was similar.

Conclusion:

In head and neck cancer surgery, TA did not reduce intraoperative blood loss or need for transfusions. Perioperative TEG variables were similar. This may be attributed to pre-existing hypercoagulable state and minimal fibrinolysis in cancer patients.

Clinical Significance of Preoperative Thrombin Time in Patients with Esophageal Squamous Cell Carcinoma following Surgical Resection

Background

Noninvasive tools for the prognosis of ESCC are urgently needed. To this end, serum coagulation tests have been researched in some cancers, but the prognostic value of the TT in ESCC has not been described.

Methods

The levels of pre-treatment serum coagulation markers (including the PT, APTT, PTA, INR, fibrinogen level, TT and PLT) were retrospectively analyzed in 204 patients with ESCC who underwent surgical resection at our department and in 200 healthy controls, and the two groups were compared. The prognostic significance of the coagulation tests was then determined with univariate and multivariate cox hazard analyses in patients with ESCC.

Results

Compared with those in normal controls, the PT, APTT, and fibrinogen levels were significantly increased, whereas the TT values significantly decreased in the 204 ESCC patients. The TT directly correlated with the 5-year survival rate, not only in the entire ESCC cohort (p = 0.023) but also in the subgroups stratified according to the T and N classifications and metastasis. Conversely, the other tests were not independent prognostic factors for ESCC. Of the clotting markers, the TT inversely correlated with the fibrinogen level (p = 0.005).

Conclusions

The 5-year survival was shorter in ESCC patients exhibiting decreased pre-treatment TT values. Thus, the serum TT may be a clinical prognostic factor for ESCC patients.

The incidence and predictors of thromboembolic events in patients with lung cancer

Patients with lung cancer experience elevated risk of venous thromboembolism. Cancer patients with thrombosis have a shorter life expectancy and the occurrence of VTE worsens the quality of life and may delay, interrupt, or completely halt the cancer therapy. In a large cohort of lung cancer patients we monitored the incidence of venous thromboembolism and we identified groups of patients with the highest risk of venous thromboembolism suitable for antithrombotic prophylaxis, which could favourably affect their morbidity and mortality.

Pathological definition and clinical significance of vascular invasion in thyroid carcinomas of follicular epithelial derivation

There are many controversies involving the diagnostic criteria and treatment of well-differentiated thyroid carcinoma. Vascular invasion has been identified as an important and independent prognosticator in many cancers. The majority of pathologists recognize the importance of vascular invasion as a diagnostic marker of malignancy in follicular lesions of thyroid; however, several reports have suggested that angioinvasion is not a predictor of bad prognosis in thyroid carcinomas. We suggest that the criteria for diagnosing angioinvasion in thyroid carcinomas as well as in other endocrine tumors are inconsistent and the controversy may be attributed to application of inappropriate criteria. We carried out a study of a potential cause of artefactual vascular invasion in a series of autopsy thyroids and established the morphology of mimics of angioinvasion. We then reviewed retrospectively the clinicopathological features of a series of 4000 thyroid carcinomas of follicular epithelial derivation to identify the features and significance of the most rigid criteria of vascular invasion: tumor cells invading through a vessel wall and thrombus adherent to intravascular tumor. These features were identified in 118 (3%) lesions. Follow-up information was available for 98 patients. Of these, 35% developed distant metastases. When using the rigid criteria, ∼1/3 of angioinvasive well-differentiated thyroid carcinomas and 1/2 of angioinvasive poorly differentiated thyroid carcinomas developed distant metastases at a mean 5.3 years of follow-up. Our results indicate that the application of rigid criteria for vascular invasion provide a clinically relevant prediction of distant metastasis in patients with thyroid carcinomas, especially in well-differentiated thyroid carcinomas.

Haemolytic uraemic syndrome associated with gemcitabine

Haemolytic uraemic syndrome (HUS) is a rare thromboembolic complication observed in patients with cancer. It is characterised by the clinical triad of acute renal failure, microangiopathic haemolytic anaemia and thrombocytopaenia. It may be associated with a variety of aetiologies, including chemotherapeutic agents such as mitomycin, cisplatin, bleomycin, 5-fluorouracil and, most recently, gemcitabine. We report a 70-year-old patient treated with gemcitabine who developed haemolytic uraemic syndrome.

Relation between hemostatic parameters and prognostic/predictive factors in breast cancer

BACKGROUND

In our study, we searched for a relation between various prognostic and predictive factors and hemostatic parameters.

METHODS

One hundred women with newly diagnosed breast cancer after surgery were included. Patients did not receive systemic therapy or radiotherapy. The control group included 100 healthy, age-matched women. In the patient group, age, menopausal status, tumor size, grade, axillary lymph node status, steroid receptor status, p53, and HER2/neu were evaluated. Plasma levels of factor VIII, factor IX, D-dimer, fibrinogen, protein C, protein S, vWF, and antithrombin III were measured in both groups.

RESULTS

Plasma levels of factor VIII, factor IX, vWF, and CRP in patients with breast cancer were higher than those in controls. Protein S levels in patients were lower than in controls. There was no significant difference in other hemostatic parameters between the groups. In patients with axillary lymph node metastasis, factor VIII levels were significantly higher than in node-negative patients. There was a strong correlation between axillary lymph node status, number of metastatic nodes, and factor VIII levels. There was no correlation between factor VIII levels and CRP. Factor VIII levels were higher in the group having high HER2/neu (3+) than in the group with negativity for HER2/neu.

CONCLUSION

There was a strong correlation between axillary lymph node involvement, number of metastatic nodules, overexpression of HER2/neu, hemostatic parameters, and factor VIII levels. Our study showed that factor VIII level measurement can provide additional data for evaluation of breast cancer patients' prognosis.

The incidence of venous thromboembolism among patients with primary lung cancer

BACKGROUND

The incidence of venous thromboembolism (VTE) by lung cancer histology and stage is unknown.

OBJECTIVES

To determine the incidence of VTE and the risk factors associated with development of VTE in a large population-based study of patients with non-small cell and small cell lung cancer.

METHODS

The California Cancer Registry was merged with the Patient Discharge Data Set to determine the incidence of VTE among lung cancer cases diagnosed between 1993 and 1999.

RESULTS

Among 91 933 patients with newly diagnosed lung cancer, the 1-year and 2-year cumulative VTE incidences were 3.0% and 3.4%, respectively, with a person-time rate of 7.2 events/100 patient-years during the first 6 months. The 1-year incidence of VTE was significantly increased in comparison to the general population [standardized incidence ratio = 21.2, 95% confidence interval (CI) = 20.4-22.0]. In a multivariate model, significant predictors of developing VTE within 1 year of non-small cell lung cancer (NSCLC) diagnosis were: younger age, the number of chronic medical comorbidities [hazard ratio (HR) = 2.8 if 3 vs. 0, 95% CI = 2.5-3.1], advancing cancer stage (HR = 4.0 for metastatic vs. local disease, 95% CI = 3.4-4.6) and adenocarcinoma histology (HR = 1.9 vs. squamous cell, 95% CI = 1.7-2.1). In multivariate models, VTE was a significant predictor of death within 2 years for both NSCLC and small cell lung cancer (SCLC), HR = 2.3, 95% CI = 2.2-2.4, and HR = 1.5, 95% CI = 1.3-1.7, respectively.

CONCLUSIONS

Approximately 3% of lung cancer patients developed VTE within 2 years. The diagnosis of VTE was associated with a higher risk of death within 2 years for NSCLC and SCLC.

Cutaneous vascular disorders associated with internal malignancy

This article provides a detailed review of the vascular manifestations affecting the skin in relationship to internal malignancies. Vascular abnormalities heralding internal malignancies can be divided into three main categories, consisting of disorders related to vascular dilatation (flushing, palmar erythema, and telangiaectasia), and disorders related to vascular occlusion or hypercoagulability states (purpura, cutaneous ischemia, and thrombophlebitis). Entities are discussed according to etiology. The treatment of these entities is mostly related to treating the underlying malignancy. The goal of this article is to enlighten the practicing dermatologist about the association of these vascular manifestations with internal malignancy, thus leading to prompt initiation of the proper workup and management.

Increased metastatic potential of tumor cells in von Willebrand factor-deficient mice

BACKGROUND

The key role played by von Willebrand factor (VWF) in platelet adhesion suggests a potential implication in various pathologies, where this process is involved. In cancer metastasis development, tumor cells interact with platelets and the vessel wall to extravasate from the circulation. As a potential mediator of platelet-tumor cell interactions, VWF could influence this early step of tumor spread and therefore play a role in cancer metastasis.

OBJECTIVES

To investigate whether VWF is involved in metastasis development.

METHODS

In a first step, we characterized the interaction between murine melanoma cells B16-BL6 and VWF in vitro. In a second step, an experimental metastasis model was used to compare the formation of pulmonary metastatic foci in C57BL/6 wild-type and VWF-null mice following the injection of B16-BL6 cells or Lewis lung carcinoma cells.

RESULTS

In vitro adhesion assays revealed that VWF is able to promote a dose-dependent adhesion of B16-BL6 cells via its Arg-Gly-Asp (RGD) sequence. In the experimental metastasis model, we found a significant increase in the number of pulmonary metastatic foci in VWF-null mice compared with the wild-type mice, a phenotype that could be corrected by restoring VWF plasma levels. We also showed that increased survival of the tumor cells in the lungs during the first 24 h in the absence of VWF was the cause of this increased metastasis.

CONCLUSION

These findings suggest that VWF plays a protective role against tumor cell dissemination in vivo. Underlying mechanisms remain to be investigated.

Platelet--cancer interactions: mechanisms and pharmacology of tumour cell-induced platelet aggregation

During haematogenous metastasis, cancer cells migrate to the vasculature and interact with platelets resulting in tumour cell-induced platelet aggregation (TCIPA). We review: 1. The biological and clinical significance of TCIPA; 2. Molecular mechanisms involved in platelet aggregation by cancer cells; 3. Strategies for pharmacological regulation of these interactions. We conclude that pharmacological regulation of platelet-cancer cell interactions may reduce the impact of TCIPA on cancer biology.

The prothrombotic state in cancer: pathogenic mechanisms

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

Molecular pathology of tumor metastasis III. Target array and combinatorial therapies

Therapy of tumor progression and the metastatic disease is the biggest challenge of clinical oncology. Discovery of the diverse molecular pathways behind this complex disease outlined an approach to better treatment strategies. The development of combined cytotoxic treatment protocols has produced promising results but no breakthrough in the clinical management of metastatic disease. The multiple - specific and non-specific pathways and cellular targets of tumor progression are outlined in this review. Such an approach, individually designed for various cancer types, may have a better chance to treat or even cure cancer patients with progressive disease.