Tissue specific expression and serum levels of human tissue factor in patients with urological cancer

The Tissue Factor Pathway in Cancer: Overview and Role of Heparan Sulfate Proteoglycans

Historically, the only focus on tissue factor (TF) in clinical pathophysiology has been on its function as the initiation of the extrinsic coagulation cascade. This obsolete vessel-wall TF dogma is now being challenged by the findings that TF circulates throughout the body as a soluble form, a cell-associated protein, and a binding microparticle. Furthermore, it has been observed that TF is expressed by various cell types, including T-lymphocytes and platelets, and that certain pathological situations, such as chronic and acute inflammatory states, and cancer, may increase its expression and activity. Transmembrane G protein-coupled protease-activated receptors can be proteolytically cleaved by the TF:FVIIa complex that develops when TF binds to Factor VII (PARs). The TF:FVIIa complex can activate integrins, receptor tyrosine kinases (RTKs), and PARs in addition to PARs. Cancer cells use these signaling pathways to promote cell division, angiogenesis, metastasis, and the maintenance of cancer stem-like cells. Proteoglycans play a crucial role in the biochemical and mechanical properties of the cellular extracellular matrix, where they control cellular behavior via interacting with transmembrane receptors. For TFPI.fXa complexes, heparan sulfate proteoglycans (HSPGs) may serve as the primary receptor for uptake and degradation. The regulation of TF expression, TF signaling mechanisms, their pathogenic effects, and their therapeutic targeting in cancer are all covered in detail here.

Tumor Cell-Induced Platelet Aggregation as an Emerging Therapeutic Target for Cancer Therapy

Tumor cells have the ability to induce platelet activation and aggregation. This has been documented to be involved in tumor progression in several types of cancers, such as lung, colon, breast, pancreatic, ovarian, and brain. During the process, platelets protect circulating tumor cells from the deleterious effects of shear forces, shield tumor cells from the immune system, and provide growth factors, facilitating metastatic spread and tumor growth at the original site as well as at the site of metastasis. Herein, we present a wider view on the induction of platelet aggregation by specific factors primarily developed by cancer, including coagulation factors, adhesion receptors, growth factors, cysteine proteases, matrix metalloproteinases, glycoproteins, soluble mediators, and selectins. These factors may be presented on the surface of tumor cells as well as in their microenvironment, and some may trigger more than just one simple receptor-ligand mechanism. For a better understanding, we briefly discuss the physiological role of the factors in the platelet activation process, and subsequently, we provide scientific evidence and discuss their potential role in the progression of specific cancers. Targeting tumor cell-induced platelet aggregation (TCIPA) by antiplatelet drugs may open ways to develop new treatment modalities. On the one hand, it may affect patients' prognosis by enhancing known therapies in advanced-stage tumors. On the other hand, the use of drugs that are mostly easily accessible and widely used in general practice may be an opportunity to propose an unparalleled antitumor prophylaxis. In this review, we present the recent discoveries of mechanisms by which cancer cells activate platelets, and discuss new platelet-targeted therapeutic strategies.

Urothelial Carcinoma of the Bladder Induces Endothelial Cell Activation and Hypercoagulation

Cancer-related venous thromboembolisms (VTE) are associated with metastasis and reduced survival in patients with urothelial cancer of the bladder. Although previous reports suggest the contribution of tissue factor and podoplanin, the mechanistic linkage between VTE and bladder cancer cell-derived molecules is unknown. Therefore, we compared distinct procoagulant pathways in four different cell lines. In vitro findings were further confirmed by microfluidic experiments mimicking the pathophysiology of tumor blood vessels and in tissue samples of patients with bladder cancer by transcriptome analysis and immunohistology. In vitro and microfluidic experiments identified bladder cancer-derived VEGF-A as highly procoagulant because it promoted the release of von Willebrand factor (VWF) from endothelial cells and thus platelet aggregation. In tissue sections from patients with bladder cancer, we found that VWF-mediated blood vessel occlusions were associated with a poor outcome. Transcriptome data further indicate that elevated expression levels of enzymes modulating VEGF-A availability were significantly connected to a decreased survival in patients with bladder cancer. In comparison with previously postulated molecular players, we identified tumor cell-derived VEGF-A and endothelial VWF as procoagulant mediators in bladder cancer. Therapeutic strategies that prevent the VEGF-A-mediated release of VWF may reduce tumor-associated hypercoagulation and metastasis in patients with bladder cancer. IMPLICATIONS: We identified the VEGF-A-mediated release of VWF from endothelial cells to be associated with bladder cancer progression.

Role of the Coagulation System in Genitourinary Cancers: Review

Tumor progression is associated with aberrant hemostasis, and patients with malignant diseases have an elevated risk of developing thrombosis. A crosstalk among the vascular endothelium, components of the coagulation cascade, and cancer cells transforms the intravascular milieu to a prothrombotic, proinflammatory, and cell-adhesive state. We review the existing evidence on activation of the coagulation system and its implication in genitourinary malignancies and discuss the potential therapeutic benefit of antithrombotic agents. A literature review was performed searching the Medline database and the Cochrane Library for original articles and reviews. A second search identified studies reporting on oncological benefit of anticoagulants in genitourinary cancer. An elevated expression of procoagulatory tissue factor on tumor cells and tumor-derived microparticles seems to stimulate cancer development and progression. Several components of the hemostatic system, including D-dimers, von Willebrand Factor, thrombin, fibrin-/ogen, soluble P-selectin, and prothrombin fragments 1 + 2 were either overexpressed or overactive in genitourinary cancers. Hypercoagulation was in general associated with a poorer prognosis. Experimental models and small trials in humans showed reduced cancer progression after treatment with anticoagulants. Main limitations of these studies were heterogeneous experimental methodology, small patient numbers, and a lack of prospective validation. In conclusion, experimental and clinical evidence suggests procoagulatory activity of genitourinary neoplasms, particularly in prostate, bladder and kidney cancer. This may promote the risk of vascular thrombosis but also metastatic progression. Clinical studies linked elevated biomarkers of hemostasis with poor prognosis in patients with genitourinary cancers. Thus, anticoagulation may have a therapeutic role beyond prevention of thromboembolism.

Serum tissue factor as a biomarker for renal clear cell carcinoma

Purpose

to determine the usefulness of serum TF as a potential marker for patients with clear cell RCC.

Materials and Methods

prospective study of 30 patients with clear cell RCC submitted to nephrectomy and 16 controls without clear cell RCC treated surgically for other conditions. TF is a endothelium marker that was correlated with worse prognosis in a variety of solid tumors including RCC. Serum TF was collected before surgery at the operating room and in the postoperative setting after at least four weeks. Serum samples were analyzed with a commercial ELISA kit for human TF (R&D Systems^®).

Results

Mean preoperative serum TF levels in clear cell RCC patients and in controls were 66.8 pg/dL and 28.4 pg/dL, respectively (p<0.001). Mean postoperative serum TF levels in clear cell RCC patients were 26.3 pg/dL. In all patients with clear cell RCC postoperative serum levels of TF were lower, with a mean reduction of 41.6 pg/dL in the postoperative setting (p<0.001). Linear regression revealed that tumor size was correlated with the postoperative reduction of serum TF levels (p=0.037).

Conclusions

We have shown a 3-fold reduction in the median preoperative serum levels of TF in patients with clear cell RCC after surgery. We have also shown a difference of the same magnitude in the serum levels of TF compared with those of a control group of patients with benign diseases. TF appears to be a useful serum marker for the presence of clear cell RCC. Further studies are needed to validate these findings.

Increased Levels of NF-kB-Dependent Markers in Cancer-Associated Deep Venous Thrombosis

Several studies highlight the role of inflammatory markers in thrombosis as well as in cancer. However, their combined role in cancer-associated deep vein thrombosis (DVT) and the molecular mechanisms, involved in its pathophysiology, needs further investigations. In the present study, C-reactive protein, interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), interleukin-1 (IL-1β), matrix metalloproteases-9 (MMP-9), vascular endothelial growth factor (VEGF), tissue factor (TF), fibrinogen and soluble P-selectin, were analyzed in plasma and in monocyte samples from 385 cancer patients, of whom 64 were concomitantly affected by DVT (+). All these markers were higher in cancer patients DVT+ than in those DVT-. Accordingly, significantly higher NF-kB activity was observed in cancer patients DVT+ than DVT-. Significant correlation between data obtained in plasma and monocyte samples was observed. NF-kB inhibition was associated with decreased levels of all molecules in both cancer DVT+ and DVT-. To further demonstrate the involvement of NF-kB activation by the above mentioned molecules, we treated monocyte derived from healthy donors with a pool of sera from cancer patients with and without DVT. These set of experiments further suggest the significant role played by some molecules, regulated by NF-kB, and detected in cancer patients with DVT. Our data support the notion that NF-kB may be considered as a therapeutic target for cancer patients, especially those complicated by DVT. Treatment with NF-kB inhibitors may represent a possible strategy to prevent or reduce the risk of DVT in cancer patients.

Increased tissue factor expression is an independent predictor of mortality in clear cell carcinoma of the kidney

PURPOSE

Increased expression of tissue factor (TF), a primary initiator of the extrinsic coagulation pathway, has been associated with a worse prognosis in a variety of solid tumors. We report for the first time the correlation of the immunohistochemical expression of tissue factor with clinical and pathological outcomes in clear cell carcinomas of the kidney.

MATERIALS AND METHODS

immunohistochemical expression of tissue factor was evaluated in 58 paraffin-embedded samples of clear cell carcinomas of the kidney treated at the same university hospital, that was correlated with clinical and pathological variables and with overall survival.

RESULTS

high intensity tissue factor expression (TF area > 10 µ m2) was observed in 22.4% of the tumors (13 patients), and was an important predictor of overall mortality, both in univariate and multivariate analysis (p < 0.05). Median overall survival for both groups was 66 months; 78.2 months for patients in the group of lower TF expression and 27.5 months for patients in the group of higher TF expression (log rank p < 0.001). The hazard ratio for mortality was 9.7 (CI 3.7-25.6) for tumors with increased TF expression.

CONCLUSIONS

Increased immunohistochemical expression of TF was an important independent predictor of mortality in a contemporary cohort of patients with clear cell carcinoma of the kidney. Further studies are necessary to define the role of TF in clinical practice.

Expression of tissue factor and tissue factor pathway inhibitor in microparticles and subcellular fractions of normal and malignant prostate cell lines

The association between cancer and thrombogenesis has been recognized since 1865, and tissue factor (TF) is important at various stages in the natural history of the disease. It is involved in cancer angiogenesis, growth and metastasis. TF pathway inhibitor (TFPI), being the major physiological regulator of the TF-dependent coagulation pathway, is also important in establishing net procoagulant potential. In this study, we determine TF and TFPI levels in three prostate epithelial cell lines, one of normal and two of malignant origin. Cells were grown in standard maintenance conditions and harvested at more than 90% confluence. These were fractionated into cytosol, membrane and nuclei for analysis. Microparticles secreted into the culture medium were also analysed. TF and TFPI levels were determined using an ELISA. TF expression in these cells was also visualized using immunocytochemistry. There was absence of TF and TFPI in nuclei of all cell lines. TF expression was higher in subcellular fractions and microparticles of normal prostate cells than cancer cells. In contrast, levels of TFPI (structurally resembling a secreted, rather than transmembrane protein) in microparticles of normal prostate cells were much lower than tumour cells. In conclusion, the activity of prostate cancer cells themselves is unlikely to be the source of hypercoagulability in patients, but might precipitate chains of events that would produce such an effect.

Early growth response gene-1 and hypoxia-inducible factor-1α affect tumor metastasis via regulation of tissue factor

BACKGROUND

Hypoxia up-regulated expression of tissue factor (TF) may facilitate tumor cell metastasis, but transcriptional mechanisms remain undefined.

MATERIAL AND METHODS

To verify the role of Egr-1 in hypoxia-induced TF expression in breast cancer cells, quantitative PCR and Western blot analysis were performed. The secretion of VEGF under hypoxia was detected by enzyme-linked immunosorbent assay (ELISA). Egr-1 and HIF-1α siRNA were transiently transfected into breast cancer cells to evaluate their specific roles.

RESULTS

The increased Egr-1 expression occurring in hypoxic breast cancer cells can up-regulate TF expression and stimulating protein 1(Sp1) was not responsible for the hypoxia-induced expression of TF. HIF-1α mediated the hypoxia-induced up-regulation of TF expression through vascular endothelial growth factor (VEGF). The regulatory effects of Egr-1 on TF under hypoxia were independent of HIF-1α. Either Egr-1 or HIF-1α was responsible for hypoxic induction of tumor cells adhesion. HIF-1α, but not Egr-1, had a pivotal role in human breast cancer cells invasion. Both Egr-1 and HIF-1α were critical to angiogenesis induced by hypoxic conditions in MDA-MB-231 and HUVEC co-cultures. In nude mice, both Egr-1 and HIF-1α small interfering RNA (siRNA) could decrease extravasation of MDA-MB-435 cells in the lung after tail vein injection.

CONCLUSIONS

Hypoxia-induced expression of TF in human breast cancer cells depends on Egr-1 and HIF-1α, and both of these proteins may play an important role in breast cancer metastasis, either directly or indirectly through the TF pathway.

The relationship between tissue factor and cancer progression: insights from bench and bedside

It is now widely recognized that a strong correlation exists between cancer and aberrant hemostasis. Patients with various types of cancers, including pancreatic, colorectal, and gastric cancer, often develop thrombosis, a phenomenon commonly referred to as Trousseau syndrome. Reciprocally, components from the coagulation cascade also influence cancer progression. The primary initiator of coagulation, the transmembrane receptor tissue factor (TF), has gained considerable attention as a determinant of tumor progression. On complex formation with its ligand, coagulation factor VIIa, TF influences protease-activated receptor-dependent tumor cell behavior, and regulates integrin function, which facilitate tumor angiogenesis both in vitro and in mouse models. Furthermore, evidence exists that an alternatively spliced isoform of TF also affects tumor growth and tumor angiogenesis. In patient material, TF expression and TF cytoplasmic domain phosphorylation correlate with disease outcome in many, but not in all, cancer subtypes, suggesting that TF-dependent signal transduction events are a potential target for therapeutic intervention in selected types of cancer. In this review, we summarize our current understanding of the role of TF in tumor growth and metastasis, and speculate on anticancer therapy by targeting TF.

Tissue factor in tumour progression

The linkage between activation of the coagulation system and cancer is well established, as is deregulation of tissue factor (TF) by cancer cells, their vascular stroma and cancer-associated inflammatory cells. TF is no longer perceived as an 'alternative' coagulation factor, but rather as a central trigger of the coagulation cascade and an important cell-associated signalling receptor activated by factor VIIa, and interacting with several other regulatory entities, most notably protease-activated receptors (PAR-1 and PAR-2). Preclinical studies revealed the role of oncogenic transformation and tumour micro-environment as TF regulators in cancer, along with the impact of this receptor on gene expression, tumour growth, metastasis, angiogenesis and, possibly, formation of the cancer stem cell niche. Increasing interest surrounds the shedding of TF-containing microvesicles from cancer cells, their entry into the circulation and their role in the intercellular transfer of TF activity, cancer coagulopathy and other processes. Recent data also suggest differential roles of cell autonomous versus global effects of TF in various settings. Questions are raised regarding the consequences of TF expression by tumour cells themselves and by their associated host stroma. Progress in these areas may soon begin to impact on clinical practice and, as such, raises several important questions. Can TF be exploited as a therapeutic target in cancer? Where and when may this be safe and beneficial? Is expression of TF in various disease settings useful as a biomarker of cancer progression or the associated hypercoagulability? What clinical questions related to TF are especially worthy of further exploration, at present and in the near future? Some of these developments and questions will be discussed in this chapter.

Efficient suppression of tissue factor synthesis using antisense oligonucleotides selected by an enhanced strategy for evaluation of structural characteristics

Selection of optimal antisense constructs is still a problem. Among a huge number of antisense oligonucleotides (AS-ONs) only a small piece show inhibitory efficacy. We want to develop an enhanced strategy for specific selection of effective AS-ONs based on prediction of secondary structure of the target messenger RNA (mRNA) and analysis of thermodynamic properties of the mRNA/AS-ON hybrid. Numerous AS-ONs targeted on human tissue factor (TF) mRNA were investigated to evaluate the relevance of different thermodynamic and structural properties on inhibitory efficacy. Cell viability, TF protein and TF mRNA were determined after transfection of bladder cancer cell line J82. Inhibitory efficacy was related to GC content, target region within the TF mRNA and stability of the mRNA/AS-ON hybrid or affinity of the AS-ON to the target mRNA. We found effective AS-ONs targeted on translated region or 3'-untranslated region of TF RNA. We also detected a great correlation between inhibitory efficacy and GC content as well as stability of the mRNA/AS-ON hybrid.

Cancer-associated thrombosis

There is strong evidence linking venous thromboembolic events and malignancy. Laboratory markers of coagulation activation such as thrombin-antithrombin complex or prothrombin fragments 1+2 support the premise that malignancy is a hypercoagulable state. Inflammatory cytokines (e.g. tumor necrosis factor and interferon-gamma), coagulation proteins (e.g. tissue factor and factor VIII), and procoagulant microparticles may be elevated in patients with malignancy. However, the molecular basis for cancer associated thrombosis remains unknown and the relative contribution of chemotherapeutics, tumor cells, endothelium, and circulating procoagulants in promoting thrombus formation continues to be investigated.

Preoperative serum tissue factor levels are an independent prognostic factor in patients with ovarian carcinoma

PURPOSE

Tissue factor (TF) is a procoagulant that plays an important part in tumor angiogenesis. We sought to determine the role of preoperative serum TF levels in predicting clinical outcome in patients with ovarian cancer.

MATERIALS AND METHODS

TF expression was determined by reverse transcriptase polymerase chain reaction in ovarian cell lines. Using enzyme-linked immunosorbent assay, we assessed preoperative serum TF levels in 98 women with invasive epithelial ovarian carcinoma, 30 with low malignant potential (LMP) tumors, 16 with benign tumors, and a separate validation group of 39 women with adnexal masses. Clinical information was gathered from chart review.

RESULTS

TF was expressed in four of the five ovarian cancer cell lines, but absent in the nontransformed cells. Ovarian cancer patients had a median preoperative serum TF level of 85.2 pg/mL, which was significantly higher than in those with LMP tumors (12.8 pg/mL; P < .01) and benign adnexal disease (30.7 pg/mL; P < .01). TF >or= 190 pg/mL was significantly associated with decreased patient survival (P < .01). After adjusting for other clinical variables in a multivariate Cox regression model, TF >or= 190 pg/mL was an independent prognostic factor (P < .01). Analysis of serum TF levels from the validation set confirmed that high TF (>or=190 pg/mL) was associated with a 3.4-fold increase in risk of death from disease (P = .02) and shorter survival (P = .01).

CONCLUSION

Preoperative serum TF levels are significantly elevated in patients with ovarian carcinoma. Elevated preoperative TF level is an independent prognostic factor for death from disease.

Tissue factor and tumor: clinical and laboratory aspects

This review summarizes data demonstrating the role of TF in tumor development, metastasis and angiogenesis. TF is a transmembrane protein that is expressed constitutively in some kinds of extravascular cells and transiently in intravascular cells after stimulation with cytokines and growth factors. Originally TF was considered to have a function in the initiation of coagulation. In the last years it became evident that TF plays a role in physiological and pathological processes outside the hemostasis. Up-regulation of TF expression appears to be characteristic of tumor tissue. In a variety of human tumors it was shown by immunohistochemistry, that TF can be expressed in malignant cells as well as in tumor-infiltrating macrophages or endothelial cells. Such abnormal TF expression contributes to the angiogenic process by a shift in the balance between endogenous proangiogenic and antiangiogenic factors. Observations of a significant correlation between elevated TF expression with increased microvessel density and VEGF expression underline the TF involvement in tumor angiogenesis. Furthermore, TF expression influences also metastasis. The effect of TF on metastasis may result from its angiogenic effect, but also from the production of growth factors or adhesion proteins.

Analysis of combination anti-angiogenesis therapy on markers of coagulation, platelet activation and angiogenesis in patients with advanced cancer

The effects of combination anti-angiogenesis therapy (marimastat, captopril and fragmin) on plasma levels of coagulation initiator tissue factor (TF), platelet marker soluble P-selectin and angiogenic vascular endothelial growth factor (VEGF) were tested in 25 patients with advanced cancer. They had higher soluble P-selectin (P<0.001) and TF (P<0.001), but not VEGF (P=0.066) than 25 age and sex-matched controls. VEGF and TF correlated significantly (r=0.8, P<0.001) in cancer patients. Soluble P-selectin, TF and VEGF did not change at 4- and 8-weeks whilst on treatment. We provide further evidence linking coagulation and angiogenesis but combination anti-angiogenesis therapy does not influence plasma soluble P-selectin, TF or VEGF.

Thrombin Inhibitor, Argatroban, Prevents Tumor Cell Migration and Bone Metastasis

It is well known that malignant cells show procoagulant activity, which is associated with their metastatic potential. Thrombin, the key enzyme of the blood coagulation system, is generated around tumor cells, promoting the migration and metastasis of tumor cells. In this study, we evaluated the effect of argatroban, a specific thrombin inhibitor, on the migration and metastasis of B16BL6 melanoma cells. In vitro argatroban dose-dependently inhibited cell migration, the maximum inhibition being observed in the presence of 10 microM argatroban (p < 0.0001). In order to investigate the antimetastatic effect of the thrombin inhibitor, we used an animal model that we have reported previously. C57BL6 mice which had received a bone (femur or tibia) transplanted into the dorsal subcutis were injected with B16 melanoma cells into the left heart ventricle. Intraperitoneal injection of argatroban (9 mg/kg/day for 4 weeks) significantly reduced the number of limbs with metastatic lesions as compared to a placebo (p < 0.05). These results suggest that argatroban was associated with reduced melanoma metastases by inhibiting cell migration. Our results showed that argatroban is effective for treatment of bone metastasis.