An assessment of monocyte procoagulant activity in patients with solid tumors

Risk Factors of Thromboembolism in Lymphoma Patients Undergoing Chemotherapy and its Clinical Significance

This study investigated the risk factors of thromboembolism (TE) in lymphoma patients undergoing chemotherapy and its clinical significance. A total of 304 lymphoma patients who received chemotherapy from January 2012 to July 2019 were retrospectively analyzed, including 111 patients with and 193 patients without TE. The clinical characteristics and related laboratory test results were compared between the 2 groups using univariate analysis, while the risk factors for TE in lymphoma patients undergoing chemotherapy were analyzed using multivariate logistic regression analysis. Univariate analysis revealed an increase in the risk of TE among lymphoma patients with chemotherapy in the following categories: female patients, patients with body mass index <18.5 or > 24, patients aged ≥60 years, those with platelet abnormality before chemotherapy, single hospital-stay patients, and Ann Arbor stage III/IV patients. Multivariate logistic regression analysis revealed that for platelet count abnormality before chemotherapy, Ann Arbor stage III/IV and female patients represented independent risk factors for TE among lymphoma patients after chemotherapy (P < .05). For lymphoma patients treated with chemotherapy, the risk of TE occurring in women, patients with platelet abnormalities before chemotherapy, and patients at Ann Arbor stage III/IV was significantly higher compared with other patients. For these patients, we recommend prophylactic anticoagulant therapy.

Tissue factor: a critical role in inflammation and cancer

A series of coordinated enzymatic reactions takes place in the body whenever blood clots. The major physiological initiator of these reactions is a membrane-bound glycoprotein known as tissue factor (TF), which is normally separated from the bloodstream by the vascular endothelium. Bleeding, caused by injury or tissue damage, activates a complex enzyme cascade as TF becomes exposed to the bloodstream. In disease states, leukocytes or the vascular endothelium may abnormally express TF to cause intravascular coagulation. The blood-coagulation cascade is also relevant to diseases such as hemophilia, in which patients are deficient in blood proteins necessary for clotting, and is linked to vascular diseases such as heart attack and stroke, in which clotting can lead to the occlusion of blood vessels. Coagulation is also activated in inflammation and cancer. In this article, we discuss characteristics of TF and review its role in inflammation and cancer.

Thromboembolic complications of cancer: epidemiology, pathogenesis, diagnosis, and treatment

The association between malignancy and clinical thrombosis has been recognized for nearly 140 years. The purpose of this review is to examine our current understanding of thrombosis as a complication of cancer and cancer therapy. The review includes a discussion of the epidemiology, pathophysiology, diagnosis and treatment.

The biology and tumour-related properties of monocyte tissue factor

Tissue factor (TF, coagulation factor III, CD142) is not only the main physiological initiator of normal blood coagulation, but is also important in the natural history of solid malignancies in that it potentiates metastasis and angiogenesis and mediates outside-in signalling. TF is expressed constitutively by many tissues which are not in contact with blood and by other cells upon injury or activation; the latter include endothelial cells, tissue macrophages, and peripheral blood monocytes. It can exist encrypted and unavailable functionally in the plasma membrane and the appearance of functional TF may be due to synthesis and/or de-encryption. Inflammatory cells often express TF and act to induce its production or de-encryption by other cells locally and, apparently, at remote sites. Inappropriate expression of TF by endothelial cells, macrophages or monocytes is thought to be an important trigger of coagulation in various pathological conditions. Several studies have shown that measurements of monocyte TF (mTF) may provide clinically significant information, particularly in patients with malignant and inflammatory diseases.

Tissue factor assays as diagnostic tools for cancer? Correlation between urinary and monocyte tissue factor activity

Monocyte and urinary tissue factors (mTF and uTF) are both elevated in a number of pathologic conditions, including cancer. This study validates the best available uTF and mTF assays as diagnostic tools for cancer and examines if uTF levels reflect monocyte activation. Using kinetic chromogenic assays for uTF and mTF (measured on fresh resting cells [baseline], unstimulated cells, and lipopolysaccharide [LPS]-stimulated cells), we assessed TF levels in normal individuals, surgical controls, and patients with benign and malignant diseases. Each benign disease group was stratified as inflammatory or noninflammatory. Controls and benign noninflammatory results were indistinguishable. The malignant and inflammatory groups showed raised uTF levels over controls (p < 0.001). mTF levels differ similarly. For mTF and uTF assays, there was no significant difference between the malignant and inflammatory groups. The relative operating characteristic (ROC) curve plots sensitivity against false positive rate (1-specificity) for all possible cutoff values of a diagnostic test. Assay performance is assessed as the area under the curve (AUC). The ROC curve for the uTF assay displayed both sensitivity and specificity for cancer, the AUC being 0.83. Of the three mTF levels, LPS-stimulated cells gave the optimum curve (AUC = 0.71). uTF showed a weak to moderate association with mTF levels but correlated best and was statistically significant when compared with levels in the LPS-stimulated cells. uTF represents an intrinsic, kidney-derived, physiologic concentration rather than that of preactivated or postactivated monocytes. In conclusion, both uTF and LPS-stimulated mTF levels showed sensitivity and specificity in detecting cancer and inflammatory diseases. However, the two forms of TF appear to be independently derived.

The significance of measuring monocyte tissue factor activity in patients with breast and colorectal cancer

Monocytes express tissue factor (mTF) in several conditions including cancer where levels may be valuable in assessing tumour presence and progression. Using a two-stage kinetic chromogenic assay (KCA), mTF levels were measured in controls [normal subjects (n = 60) and patients undergoing hernia repair or cholecystectomy (n = 60)], in patients with benign and malignant disease of the breast (n = 83) and of the large bowel (n = 62). This was performed under fresh (resting) conditions and after incubation for 6 h without (unstimulated) and with (stimulated) Escherichia coli endotoxin. The malignant groups showed higher mTF levels than each of the three controls for resting (P < 0.05 breast, P < 0.05 colorectal) unstimulated (P < 0.05 breast, P < 0.05 colorectal) and stimulated cells (P < 0.001 breast, P < 0.01 colorectal). Similarly, the benign inflammatory groups had higher mTF levels than controls for resting (P < 0.05 colorectal), unstimulated (P < 0.05 colorectal) and stimulated cells (P < 0.01 breast, P < 0.01 colorectal). There was no significant difference between malignant and benign inflammatory groups in each organ. mTF levels showed an increase corresponding to that of histological tumour progression and were higher in non-surviving patients. In conclusion, mTF levels are raised in malignant and inflammatory disease compared to controls and patients with non-inflammatory conditions. Stimulated cells give better discrimination between the groups and may be of value in identifying high risk individuals. mTF levels showed an association with tumour grade or stage and the patients' survival time.

Monocyte tissue factor levels in patients with urological tumours: an association between tumour presence and progression

OBJECTIVE

To examine the hypothesis that increased monocyte tissue factor (mTF) levels may reflect urological tumour presence and progression.

PATIENTS, SUBJECTS AND METHODS

Using a two-stage kinetic chromogenic assay, mTF levels were measured in 60 controls (normal subjects [60] and patients awaiting hernia repair or cholecystectomy [60]), patients with benign and malignant disease of the bladder (73), or prostate (81), and in patients with and without recurrent malignant disease of the bladder (30). The levels were assessed under fresh resting conditions (baseline) and after incubation for 6 h without (unstimulated) and with (stimulated) Escherichia coli endotoxin. Each benign disease group was subdivided into inflammatory and non-inflammatory categories.

RESULTS

Patients with bladder and prostate malignancy showed significantly higher mTF levels than did each control for baseline and stimulated cells. The benign inflammatory groups for both organs had significantly higher mTF levels than had each control for baseline cells. There was no difference between malignant and benign inflammatory groups. Stimulated mTF levels showed better discrimination between the study groups. The mTF levels were associated with histological tumour progression, serum prostate specific antigen level and static bone scan images. Levels were also higher in patients with bladder cancer recurrence than in those with a normal check cystoscopy.

CONCLUSION

Stimulated mTF levels are raised in malignant and inflammatory disease compared with controls and patients with non-inflammatory conditions, and give maximal discrimination between these groups. mTF levels showed an association with tumour grade and other markers of tumour progression.

Urinary tissue factor levels in patients with breast and colorectal cancer

Activation of blood coagulation is a common complication of cancer in man and experimental animals. The causes of such activation may be multifactorial, but increased production of tissue factor (TF) by the host mononuclear cells may be involved. TF is not only produced by human monocytes (mTF) and tumour cells, but is also found in urine (uTF), where measurements might be clinically important. Using a highly reproducible (intra-assay CV 2.3 per cent and inter-assay CV 8.1 per cent) one-stage kinetic chromogenic assay (KCA) developed by this group, uTF levels were measured in controls [healthy volunteers (n = 57), patients with renal stones and a normal ESR (n = 30)] and in patients with benign and malignant diseases of the breast (n = 94) and large bowel (n = 62). Each benign disease group was sub-divided into inflammatory and non-inflammatory categories. There were no significant differences between the controls and the benign non-inflammatory groups, so they were unified for further analysis. Malignant groups, irrespective of tumour types, showed significantly higher uTF levels than controls (p < 0.001 for breast and p < 0.01 for large bowel). Similarly, breast and colorectal benign inflammatory groups showed significant increases over controls (p < 0.01 and p < 0.001, respectively). Patients with malignant disease showed uTF activity above the upper quartile range of the normal control group for breast, 77.3 per cent, and large bowel, 73 per cent. uTF levels were related to histological tumour grading and were higher in non-surviving patients. In conclusion, uTF levels are raised in malignant and inflammatory disease compared with controls and patients with non-inflammatory conditions. uTF levels may reflect tumour progression.

Coagulation disorders in cancer

Coagulation disorders are common in cancer patients. This article reviews the coagulation laboratory findings in these patients and the thromboembolic and hemorrhagic manifestations of malignancy. Among the many topics addressed are Trousseau's syndrome, disseminated intravascular coagulation, and acquired von Willebrand disease. Pathogenesis of the coagulation disorders and recommendations for treatment of various syndromes are discussed.

Urinary tissue factor levels in prostatic carcinoma: a potential marker of metastatic spread?

Recent investigations have suggested that levels of urinary tissue factor (UTF) may be elevated in some forms of cancer. We have determined UTF levels in healthy controls, patients presenting for surgery with benign prostatic hypertrophy (BPH) and untreated prostate cancer. Patients undergoing check cystoscopy, who were free of recurrent bladder cancer, and a cohort of men with bone scan positive prostate cancer recently treated by androgen ablation were also studied. UTF levels were higher in patients with prostate cancer when compared with controls, those undergoing check cystoscopy and patients with BPH. In patients with prostate cancer, bone scan positive patients had higher levels than bone scan negative subjects. The androgen ablated group had UTF levels similar to those of the control groups and significantly lower than the bone scan positive group. A weak correlation was found between UTF and serum prostate specific antigen (PSA) levels when patients with BPH and untreated cancer were analysed, but no correlation was demonstrable between PSA and UTF when cancer patients alone were evaluated. It was concluded that UTF levels are elevated in untreated prostate cancer and reflect bone scan status. In patients with bone scan positive disease UTF also reflects disease activity and may therefore be a useful disease marker in prostate cancer.

Tissue factor as a tumor procoagulant

Tissue factor is a cell surface glycoprotein responsible for initiating the extrinsic pathway of coagulation. Many tumor cell homogenates and intact tumor cells have been shown to contain tissue factor activity. Immunohistochemical studies show that many tumors associated with Trousseau's syndrome express tissue factor on their cell surfaces. Tumor cells shed membrane fragments which carry tissue factor that can account for the activation of the clotting system. Tumor cells also produce soluble substances that can induce tissue factor expression on host cells, such as endothelium and monocytes, at sites distant from the tumor. Although, all the functional TF molecules are localized on the outer cell membrane in many tumor cells, the procoagulant activity on the intact cell surface is largely dormant and can be greatly enhanced upon cell injury or damage. Tissue factor procoagulant activity on the cell surface can be modulated by alterations in the plasma membrane without loss of cell viability. Tissue factor activity on cell surfaces is largely regulated by a plasma inhibitor, tissue factor pathway inhibitor. This inhibitor binds to both functional and non-functional tissue factor/VIIa complexes on the cell surface and prevents non-functional tissue factor/VIIa complexes from becoming functional after cell injury or lysis. Heparin, but not warfarin, therapy is effective in preventing the occurrence of devastating thrombotic events in patients with Trousseau's syndrome and the reason(s) for this are still unknown.

Immunohistochemical identification of tissue factor in solid tumors

Patients with cancer experience a much higher than expected incidence of thromboembolic disorders, commonly referred as Trousseau syndrome. Although this association has been well documented, the etiology of the hypercoagulable state is not known. The expression on tumor cells of tissue factor (TF), a membrane-bound lipoprotein that functions as a cofactor to factor VIIa in the initiation of the extrinsic pathway of blood coagulation, has been postulated as a possible mechanism. Whereas the distribution of TF in normal tissues is known, no large survey of TF expression in malignant tissues has been reported. In this study a polyclonal, monospecific rabbit anti-human TF IgG was used for immunohistochemical localization of TF antigen in 85 different tumor specimens. In general, cell types which normally express TF continued to do so after malignant transformation (41 of 60 epithelial tumor specimens were positive for TF). Tumors of nonepithelial origin frequently lacked TF, with only 3 of 19 specimens containing evidence of TF antigen. In addition five of six benign tumors did not express TF. Many tumor types commonly associated with Trousseau syndrome, for example lung, pancreatic, breast, colon and gastric carcinomas, stained positively for TF. Based on this survey, it appears that TF expression by tumors may be an important factor in the pathogenesis of a hypercoagulable state in some patients with cancer.

Urinary tissue factor levels in transitional cell carcinoma of the bladder

Production of procoagulant activity by host and tumour cells may be increased in patients with cancer. Using a simple chromogenic assay, we have determined urinary tissue factor (TF) levels in patients presenting with transitional cell carcinoma of the bladder (TCC, n = 63), normal controls (n = 20) and patients with benign prostatic hypertrophy (BPH, n = 35). In addition, a separate cohort of patients undergoing endoscopic surveillance for superficial bladder cancer were studied to determine whether there was any difference in levels in those with recurrent disease compared to those with normal cystoscopies. Urinary TF activity was higher in TCC compared to controls (p less than 0.001) and patients with BPH (p less than 0.05). In patients undergoing check cystoscopy, those with recurrent disease (n = 32) had higher levels (p less than 0.01) than those with normal examinations (n = 21). It is concluded that urinary TF levels are elevated in bladder cancer and that this reflects disease activity in those at risk of recurrent superficial disease.

Contribution of the monocyte to thrombotic potential

The circulating monocyte exhibits the capacity to initiate and accelerate the coagulation cascade. We have devised a simple whole blood clotting assay which quantitates the monocyte's contribution of procoagulant (a marker of monocyte activation) to the clotting process and in addition, measures the in vivo activation of the cell. Citrated whole blood is added to saline and the recalcification time (RT) determined without incubation (RT control), with two hours incubation (RT saline), or added to endotoxin with incubation (RT endotoxin). The reduction in value between RT control and RT saline is a measure of monocyte activation in vivo. The reduction in time between RT saline and RT endotoxin is a marker of monocyte activation in vitro. This simple test enables the measurement of monocyte activation and this cells contribution to the hypercoagulability described in many disease states.

Whole blood re-calcification time in equine colic

Whole blood re-calcification times were evaluated as a measure of endotoxin-associated coagulopathy in horses. First, the effects of endotoxin concentration and duration of in vitro incubation of citrated whole blood with endotoxin on the whole blood re-calcification time of blood collected from healthy horses were determined. Increasing concentrations or incubation times of endotoxin accelerated the whole blood re-calcification time. This effect was attributed mainly to increased monocyte thromboplastin activity. Second, whole blood re-calcification time, a clotting profile, plasma factor VII activity and plasma endotoxin concentration on blood samples obtained from 35 equine colic patients and 10 healthy horses were determined. Compared with healthy horses, colic patients had a longer mean whole blood re-calcification and prothrombin time, lower per cent factor VII activity and higher mean fibrin degradation products concentration. Within the colic patient group, horses that did not survive had detectable endotoxin in plasma, longer whole blood re-calcification and prothrombin times, and lower plasma factor VII activity, compared with colic patients that survived. These data indicate that colic patients with endotoxaemia experience hypercoagulable states, followed by consumptive coagulopathy. Although the cause of endotoxin-associated coagulopathy is likely multi-factorial, increased expression of monocyte thromboplastin activity may be involved in the pathogenesis of coagulopathy. The whole blood recalcification time is a simple, fast and inexpensive way to detect coagulopathy during endotoxaemia and determine the prognosis for survival.

Fibrin formation on vessel walls in hyperplastic and malignant prostate tissue

To explore mechanisms of coagulation activation in adenocarcinoma of the prostate, the occurrence and distribution of components of coagulation and fibrinolysis pathways in situ were studied by means of immunohistochemical techniques applied to frozen sections of fresh malignant and benign hyperplastic prostatic tissue obtained at transurethral resection. Fibrinogen was distributed throughout the perivascular and tumor connective tissue in both malignant and benign disease but was not present in adjacent areas of normal prostate. Antibodies specific for fibrin and D-dimer crosslink sites stained vascular endothelium focally in both malignant and benign tissues. Both neoplastic cells and benign hyperplastic glandular epithelial cells stained weakly and in a patchy distribution for tissue factor and focally for low-molecular-weight urokinase-type plasminogen activator. Focal staining of vascular endothelium was also observed for tissue plasminogen activator and plasmin-antiplasmin complex neoantigen. By contrast, no tissue staining was observed for factor VII, factor X, factor XIII "a" subunit, high-molecular-weight urokinase-type plasminogen activator, plasminogen activator inhibitors 1 to 3, protein C, and protein S. Thus, the similarity in findings between benign hyperplastic and neoplastic prostate tissue, the lack of either an intact tumor cell-associated coagulation pathway or fibrin formation, and the presence of fibrin on vascular endothelium are consistent with the concept that coagulation activation in prostatic cancer may not be due to a direct effect of the tumor cells on the clotting mechanism. Rather, such activation may be induced by a soluble tumor product that activates procoagulant activity on certain host (for example, vascular endothelial) cells. These findings, together with the lack of effect of warfarin anticoagulation on the clinical course of patients with prostatic cancer, contrast with findings in certain other tumor types and suggest that coagulation activation may not contribute to progression of adenocarcinoma of the prostate.

A turbidimetric assay in an ELISA reader for the determination of mononuclear phagocyte procoagulant activity

A method is described for the simultaneous determination of plasma recalcification time in 60-96 replicates. It is based on turbidimetry in a thermostatic (37 degrees C) ELISA reader photometer. Dose-response curves with thromboplastin showed a double-logarithmic correlation between recalcification time and thromboplastin concentration. Various ways of determining the coagulation time by turbidimetry were compared. Samples of mononuclear cells or monocyte-derived macrophages showed that procoagulant activity (PCA), expressed in thromboplastin units, was directly proportional to the cell number. The method may be of value for the determination of mononuclear phagocyte PCA and for the other applications of plasma recalcification time.

Hypercoagulability in arterial disease

Isolated human monocytes generate tissue factor when stimulated with endotoxin. Tissue factor generation provides a marker for activation of the monocyte and of the clotting system. Determination of the recalcification time of blood after incubation with endotoxin detects minute changes in coagulability. This clotting assay was utilized to assess the presence of a hypercoagulable state in patients with peripheral arterial occlusive disease when compared with healthy volunteers. Citrated blood was incubated with endotoxin for two hours, CaCl2 was added, and the recalcification time determined. Hypercoagulability was indicated by shortened recalcification time. The recalcification time +/- standard deviation for saline (control) and endotoxin-activated samples from 19 healthy volunteers was 6.55 +/- 0.8 and 5.69 +/- 0.7 minutes, respectively, whereas it was 4.93 +/- 1.2 and 4.55 +/- 0.9 minutes for 31 patients with peripheral arterial occlusive disease (p less than .001 for each). This hypercoagulable state can accentuate the arterial occlusive process in patients with peripheral vascular disease and may prove to be of diagnostic, therapeutic, and prognostic significance.

Whole blood procoagulant activity in breast and colorectal cancer

Whole blood procoagulant activity was determined by measuring the recalcification time of citrated blood, with and without the addition of bacterial endotoxin, in patients with breast cancer (n = 39), colorectal cancer (n = 20), benign breast disease (n = 15), benign colorectal disease (n = 11), normal volunteers (n = 15) and inpatients with non-malignant disease (n = 22). The median clotting times of those samples incubated with endotoxin were significantly shorter in the patients with breast and colorectal cancer compared with normal controls. Furthermore, significant differences between the median clotting times of stimulated and unstimulated samples within each subject group were observed only in the two cancer groups. There was no correlation between whole blood procoagulant activity and absolute monocyte counts, with histological staging or with plasma concentrations of plasma fibrinopeptide A. The results suggest that blood from patients with cancer is more sensitive to endotoxin stimulation than that from normal or benign controls, but that in its present form the technique cannot be used to distinguish between malignant and non-malignant disease.