Coagulation disorders in cancer

Pretreatment fibrinogen levels are associated with survival outcome in patients with cancer using immunotherapy as a second‑line treatment

The present study aimed to investigate the predictive value of pretreatment fibrinogen (FIB) levels in patients with cancer who received immunotherapy as a second-line treatment. A total of 61 patients with stage III-IV cancer were included. The cut-off value of FIB for predicting overall survival (OS) was determined by receiver operating characteristic curve analysis. The prognostic value of pretreatment FIB on progression-free survival (PFS) and OS was determined by univariate and multivariate analyses. Based on a cut-off point of 3.47 g/l, patients were divided into low pretreatment FIB (<3.47 g/l) and high pretreatment FIB (≥3.47 g/l) groups. A high pretreatment FIB level was more common in older patients (P=0.03). Kaplan-Meier analysis showed that patients with high pretreatment FIB levels had shorter PFS and OS times than patients with low FIB levels (P<0.05). In multivariate analysis, pretreatment FIB was an independent prognostic factor for OS [hazard ratio (HR), 6.06; 95% CI, 2.01-18.28; P<0.01] and OS from the initiation of second-line treatment (HR, 3.69; 95% CI, 1.28-10.63; P=0.02). Overall, FIB is associated with survival outcome in patients with cancer who are administered immunotherapy as a second-line treatment.

Tissue Factor Expression in Colorectal Adenocarcinoma: Association with Angiogenesis and Clinical and Pathological Aspects

Introduction Tissue factor (TF) expression has been described in various neoplasms and was correlated with angiogenesis and metastases.

Objectives To describe TF expression in colorectal cancers, correlating it with microvessel density and clinical and pathological variables.

Methods Immunohistochemistry was used to determine TF expression and microvessel density. The Student t-test was used to compare high and low TF expression with microvessel density and with age. The chi-squared test was used for other comparisons, and Kaplan-Meier curves were used for survival analyses.

Results Forty-three patients were operated with curative intent. Their mean age was 58.1 ± 12.6 years old, and 62.8% were male. The rectum was the most common location (60,4%), and most tumors reached the serosa and peri-intestinal fat (72.1%). Lymph nodes were positive in 46.5%, and 72.1% of the tumors were moderately differentiated adenocarcinomas. Death occurred in 27.6 ± 12.8 months in 51.1% of the patients who had recurrence. Tissue factor expression was intense in 88.4%. There was a positive correlation between TF expression and microvessel density (p = 0.02), and between TF and older age (p < 0.01). There was no correlation between TF expression and other variables (gender, histological type, penetration into the intestinal wall, and lymphatic and systemic metastases). Tissue factor expression did not correlate with survival.

Conclusion Tissue factor expression correlated with increased microvessel density and older age. Further studies are necessary to ascertain the clinical relevance of TF in colorectal cancer.

Clinical Significance of Preoperative Fibrinogen to Albumin Ratio in Patients with Glioblastoma: A Singe Center Experience

Objective

To explore the prognostic value of preoperative fibrinogen to albumin ratio (FAR) in patients with glioblastoma (GBM) and its association with clinical characteristics.

Patients and Methods

A retrospective analysis was carried out on patients with newly diagnosed GBM who had undergone operation at the Department of Neurosurgery at West China Hospital between June 1st 2015 to June 31st 2018. Receiver operating characteristic (ROC) curves were performed to determine the optimal cut-off values for fibrinogen, albumin, neutrophil to lymphocyte ratio (NLR), and FAR by calculating the maximum Youden index. Kaplan–Meier curves and Cox regression analyses were applied to evaluate the prognostic value of FAR in GBM. Harrell concordance index (C-index) and Akaike information criterion (AIC) were calculated to compare different prognostic models.

Results

A total of 206 GBM patients were included in this research. The optimal cut-off value for fibrinogen, albumin, NLR, and FAR were 2.57, 42.4, 2.28, and 0.068 respectively. High FAR was significantly related to older age, KPS≤80, IDH-1 wildtype, presence of preoperative seizures, higher NLR, and tumor location. In Cox regression analyses, high FAR was significantly associated with poor prognosis. Prognostic models including FAR had the largest C-index and lowest AIC.

Conclusion

FAR was determined to be an independent risk factor of prognosis in patients with newly-diagnosed GBM. And the prognostic predictive ability of FAR is stronger than fibrinogen and albumin.

Multidirectional effects of saponin fraction isolated from the leaves of sea buckthorn Elaeagnus rhamnoides (L.) A. Nelson

Many studies show that saponins isolated from various plants have a cytotoxic effect on cancer cells inducing apoptosis and autophagy. On the other hand, saponins also exhibit a number of beneficial properties, such as antioxidant properties. Thus, saponins can be considered both in terms of their therapeutic and protective effects during anticancer treatment. In this study, we investigated the effect of the saponin fraction isolated from sea buckthorn (Elaeagnus rhamnoides (L.) A. Nelson) leaves on the viability of HL-60 cancer cells using resazurin assay and its ability to induction of apoptosis with Annexin V-FITC and propidium iodide (PI) double staining. Moreover, we studied its effect on the oxidative stress induced by H₂O₂, and anti-platelet and anticoagulant potential in whole blood using T-TAS, a microchip-based flow chamber system. We observed that the saponin fraction significantly decreased the viability of HL-60 cells at the concentration above 50 µg/mL and induced apoptosis at the concentration of 100 µg/mL. Moreover, we observed that saponin fraction used at lower concentrations, such as 0.5 and 1 µg/mL, stimulated HL-60 cells and increased their viability. The saponin fraction also decreased the level of free radicals and reduced oxidative DNA damage measured by the comet assay. However, at high concentration of oxidant H₂O₂ equal 5 mM, we noticed that the saponin fraction at 50 µg/mL increased the level of free radicals in HL-60 cells. We also demonstrated anticoagulant potential of the saponin fraction at the concentration of 50 µg/mL. Our results indicate that the saponin fraction obtained from sea buckthorn leaves can show both chemotherapeutic and chemoprotective potential.

Distal Medullary Canal Decompression in Long Stem Hip Replacement in Long Bone Metastasis: Does it Reduce Cardiopulmonary Complications?

BACKGROUND

The femur is the most common long bone affected by metastatic bone disease, with 25% involving the proximal third of the femur. Long stem cemented hip replacement (LHR) is an important option for cases of impending fracture. Pulmonary embolism is a critical complication that can occur. This study evaluates the effectiveness of distal femoral canal decompression in reducing the risk of cardiopulmonary events.

MATERIALS AND METHODS

Thirty two patients with metastatic bone disease of the proximal femur undergoing LHR were recruited and randomized. Conventional technique was used in 16 cases and distal decompression of the medullary canal was carried out for the other 16 patients. The decompression was carried out through a trocar inserted into the distal medullary canal, connected to a vacuum suction. Quantity of emboli was detected through A4 chambers transesophageal echocardiography; the blood pressure and oxygen saturation readings were also recorded.

RESULTS

The decompression group experienced significantly lower Grade 2 and Grade 3 embolic events compared to the conventional group (11 vs. 26), and the duration of the embolic phenomena was shorter. Insertion of the stem and relocating the hip gave the highest amount embolic events. There was a significant drop in systolic blood pressure (SBP) in 12 out of 16 patients (75.0%) in the conventional group and 5 out of 16 patients in the decompression group (31.3%). This is statically significant (P = 0.0124). The average drop in SBP for the conventional group is 45.8 mmHg and the decompression group was 32.9 mmHg. Oxygen saturation remained at above 96% in the decompression group. However, in the conventional group, 25% of the patients had their oxygen saturation drop to below 96% during the insertion of stem and relocation of hip joint.

CONCLUSION

Distal femoral canal decompression is an effective method in reducing the risk of cardiopulmonary embolic events associated with LHR.

Association of ABO blood groups with von Willebrand factor, factor VIII and ADAMTS-13 in patients with lung cancer

Coagulative and fibrinolytic disorders appear to be associated with the development of lung cancer. The aim of the present study was to determine plasma levels of von Willebrand factor (VWF) and a disintegrin and metalloproteinase with a thrombospondin type 1 motif 13 (ADAMTS-13), and factor VIII (FVIII) activity, in association with O and non-O blood groups in patients with lung cancer. Plasma levels of VWF and ADAMTS-13, and FVIII activity were measured in 115 patients with lung cancer and 98 healthy subjects. Phenotyping of the ABO blood groups was also performed for the two groups. Significantly increased VWF levels and FVIII activity, as well as significantly decreased ADAMTS-13 levels, were observed in patients with distant metastasis as compared with those without distant metastasis and the healthy controls. Plasma VWF levels and FVIII activity were significantly increased in subjects with non-O type blood compared with those with type O blood in the two groups. However, a significant decrease in ADAMTS-13 levels was observed only in the control group among those with non-O type blood, compared with those with type O blood. The results of the present study indicate that increased VWF and decreased ADAMTS-13 levels facilitate the invasiveness and metastasis of lung cancer. Non-O blood groups constitute a risk factor for increased VWF and FVIII in plasma. Continued monitoring of VWF and ADAMTS-13 levels, and of FVIII activity in patients with lung cancer with distinct blood groups may help to minimize the incidence of thrombotic events and improve assessment of disease progression.

Increased von Willebrand factor over decreased ADAMTS-13 activity is associated with poor prognosis in patients with advanced non-small-cell lung cancer

BACKGROUND

Hypercoagulability induced by the imbalance between von Willebrand factor (VWF) secretion and its cleaving protease (ADAMTS-13) has been correlated with cancer metastasis. The aim of this study was to explore the prognostic significance of the VWF/ADAMTS-13 ratio in advanced non-small-cell lung cancer (NSCLC).

METHODS

Pre-treatment sera/plasma levels of VWF, ADAMTS-13, VWF/ADAMTS-13 ratio, factor (F) VIII, and other clinical/laboratory parameters were measured in 119 patients with advanced NSCLC and 102 healthy controls. All patients were followed up to determine the predictive value of these parameters for prognosis of advanced NSCLC.

RESULTS

Elevated VWF, VWF/ADAMTS-13 ratio, and reduced ADAMTS-13 were significantly correlated with the stage and grade of advanced NSCLC and the final status of disease (P<.05). VWF levels and the VWF/ADAMTS-13 ratio were also associated with response to chemotherapy (P<.05). Multivariate analysis identified the VWF/ADAMTS-13 ratio and D-dimer as significant independent predictors of patient mortality. The area under the curve showed that the VWF/ADAMTS-13 ratio was more useful than VWF, ADAMTS-13, and D-dimer to predict mortality. Kaplan-Meier analysis showed that a low VWF/ADAMTS-13 ratio was significantly predictive of improved survival (P=.004).

CONCLUSION

These results suggest that the imbalance between VWF secretion and ADAMTS-13 may play a critical role in the hypercoagulability state in advanced NSCLC. Moreover, elevation of the plasma VWF/ADAMTS-13 ratio may serve as an independent predictive factor for mortality in patients with advanced NSCLC.

Global Fibrinolytic Capacity Increased Exponentially in Metastatic Colorectal Cancer

Colorectal cancers are one of the most common malignancies associated with coagulation abnormalities ranging from asymptomatic laboratory changes to massive thromboembolism or hemorrhage. It was previously shown that global fibrinolytic was increased in non-metastatic colorectal cancer. In this study global fibrinolytic capacity was measured in patients with colorectal cancer and metastatic liver disease, which always more commonly displays various coagulation disorders. Nineteen patients with biopsy-proven colorectal cancer, 30 patients with metastatic colorectal cancer, and 20 healthy control subjects were involved into the study. Using standart silicated fibrin pellets and tissue plasminogen activator, fibrinolytic capacity of the plasmas was detected with the amount of D-dimer produced before the reaction was stopped by adding aprotinin to the medium. Mean global fibrinolytic capacity (GFC) was increased to higher levels in patients with metastatic disease compared to levels in non-metastatic disease (p<0.05). Fibrinogen/GFC ratio correlated to the increase of D-dimer levels. Global fibrinolytic capacity was much higher in metastatic disease, reflecting a progression to overt disseminated intravascular coagulation.

Cancer-related coagulopathies

The association between cancer and thrombosis is known for years. Besides the well-recognized connection between venous thromboembolism and malignancies, there are, however, also other manifestations of cancer-related activation of coagulation and (micro)vascular dysfunction. In fact, coagulation derangements and vascular disturbances in patients with cancer cover a wide spectrum of diseases and various clinical manifestations. In this review we will highlight the mechanisms that play a role in the systemic activation of coagulation in cancer patients, in its most severe form manifested as disseminated intravascular coagulation. Clinically, disseminated intravascular coagulation (DIC) in cancer has in general a less fulminant presentation than the types of DIC complicating sepsis and trauma. A more gradual, but also more chronic, systemic activation of coagulation can proceed subclinically. The relationship between venous thromboembolism and cancer as a consequence of the hypercoagulability will be discussed as well. Furthermore, the role of perturbed endothelium in the pathogenesis of microvascular dysfunction and microangiopathy in particular in the setting of cancer and chemo- or radiotherapy will be reviewed.

Elevated serum C-reactive protein, carcinoembryonic antigen and N2 disease are poor prognostic indicators in non-small cell lung cancer

AIM

To assess the prognostic value of mediastinal lymph node metastases (N2 disease), carcinoembryonic antigen (CEA) levels and C-reactive protein (CRP) in non-small cell lung cancer (NSCLC), according to the 7th edition of the TNM classification.

METHODS

Newly diagnosed stage III-IV NSCLC were enrolled, including 75 patients with malignant pleural effusion. The relationship between serum CRP levels and other relevant variables such as sex, Eastern Cooperative Oncology Group status, smoking status, initial staging, N2 disease, serum albumin, white blood cell count, platelet count, CEA, comorbidity and pathology were analyzed. Univariate and multivariate analyses were performed to find prognostic markers using Cox's proportional hazards model.

RESULTS

Of the 127 patients enrolled, 55 (43%) had elevated CRP levels. There was a significant correlation between serum CRP level and platelet count (P = 0.011). Median overall survival (OS) in the normal CRP group was significantly longer than in the high CRP group (15.7 months vs 9.1 months, P = 0.013). Hypoalbuminemia (P = 0.047), higher CEA (P = 0.043) and N2 disease (P = 0.040) were additional prognostic factors on univariate analysis. On multivariate analysis an elevated CRP serum level (HR = 1.796; P = 0.005), higher CEA (HR = 1.563; P = 0.031) and N2 disease (HR = 1.723; P = 0.012) were independent prognostic factors for poor survival.

CONCLUSION

High levels of serum CRP and CEA, and N2 disease are independent prognostic indicators for the survival of patients with stage III-IV NSCLC.

[Central retinal vein occlusion as the first symptom of ovarian cancer]

CASE REPORT

A healthy 57-year-old woman presented with decreased vision in her right eye. Dilated fundus examination revealed central retinal vein occlusion (CRVO). The laboratory test results for hypercoagulability state showed an abnormal protein S. A few months later she developed an ovarian malignancy.

DISCUSSION

This case illustrates an association between CRVO and ovarian tumour. Coagulation disorders in cancer may be a mechanism for CRVO.

Prognostic role of D-dimer in patients with lung cancer: a meta-analysis

D-dimer detection in patients suffering from a variety of different types of cancer has become a hot point as an emerging and promising biomarker. In this study, therefore, we evaluated the prognostic role of D-dimer in lung cancer. Initial literature was identified using the PubMed, EMBASE, and CNKI. The primary data was hazard ratio (HR) with 95% confidence interval (CI) of survival outcomes in candidate articles, including overall survival (OS) and disease-free survival (DFS). Finally, 11 eligible studies were included in this meta-analysis, which were published between 1996 and 2013. The estimated pooled HR and 95% CI for OS of all studies was 2.06 (95% CI 1.64-2.58, p < 0.00001) and the HR and 95% CI for DFS in one study was 3.38 (95% CI 1.17-9.75, p = 0.002). The HRs and 95% CIs for OS in Asian and non-Asian patients were 2.48 (95% CI 1.60-3.84, p < 0.0001) and 1.89 (95% CI 1.44-2.47, p < 0.00001), respectively. When we further analyzed the data by various detecting methods, the pooled HR and 95% CI for OS were 3.22 (95% CI 1.99-5.21, p < 0.00001) for ELISA, 1.52 (95% CI 1.25-1.86, p < 0.0001) for Latex assay, and 1.79 (95% CI 1.19-2.69, p = 0.005) for immunoturbidimetry assay. We also did subgroup analysis according to the ratio of histological type and clinical stage. All the above analysis had positive results. This meta-analysis showed that D-dimer had a fine predictive role in lung cancer patients, especially in Asian group. Also, it demonstrated that D-dimer had a stronger predictive value by using the method ELISA.

The platelet-cancer loop

The relationship between cancer and thrombosis has been established since 1865 when Armand Trousseau described superficial thrombophlebitis as forewarning sign of occult visceral malignancy. Platelets are the primary hemostatic tool and play a primordial role in cancer-induced thrombosis. Tumor-induced numerical and functional platelet abnormalities have been described in conjunction to changes in coagulation. Such changes are reported even in the absence of clinically detectable thrombosis and correlate with tumor progression and metastasis. Reciprocally, platelets seem to interplay with the tumors and the immune system, both directly and indirectly favoring tumor progressions, tethering and distant spread. A number of growth factors supporting tumor growth, angiogenesis and metastasis are released from the platelets. A reciprocating loop of tumor-induced platelet activation/platelet-induced tumor growth and dissemination is initiated, acting as a thrombosis trigger/tumor amplifier. Recent studies have demonstrated that the use of anti-platelet agents can break this loop resulting in a reduction of short-term risk for incident cancer, cancer mortality and metastasis. The beneficial effect in reduction in cancer-induced thrombosis remains to be established. The current review aims at shedding the light on the intimate reciprocal cross-talk between platelets and cancer and on exploring the potential beneficial effect of anti-platelet agents in breaking the deadly loop of tumor amplification.

Thrombin activatable fibrinolysis inhibitor and thrombin-antithrombin-III-complex levels in patients with gastric cancer

The relation between cancer and coagulation is the subject of investigation since a relation between tumor and thrombosis has been determined. Antithrombin III is an important thrombin inhibitor, and increased thrombin-antithrombin (TAT) complex levels activate coagulation. Activated thrombin activatable fibrinolysis inhibitor (TAFI) inhibits the conversion of plasminogen to plasmin. In addition, it directly inactivates plasmin. Defective fibrinolysis increases the risk of thrombosis. In this study, we evaluated homeostatic parameters, TAFI, and TAT levels in patients with gastric cancer applying to the medical oncology outpatient clinic. Fifty-two patients and 35 healthy controls were included. ELISA was used to measure TAFI and TAT complex levels. These were statistically higher in the patient group (p < 0.05 and p = 0.001, respectively). D-dimer levels were higher in stage IV (p = 0.05). Correlations between lymph nodes and TAFI and TAT levels were examined. Weak but positive correlation between lymph nodes and TAFI was detected (R = 0.452, p = 0.027). TAFI and TAT levels were evaluated using relative operating characteristic analysis to differentiate the disease. TAT was more specific than TAFI according to this analysis (TAFI area under curve (AUC), 0.676; TAT AUC, 0.874). Thrombotic events and bleeding disorders need to be borne in mind in gastric cancer. This situation is due to the impairment of the balance between coagulation and fibrinolysis. Further studies are now needed to evaluate the effects of TAFI and TAT on survey and prognosis as well as the potential of these parameters as tumor markers for gastric cancer.

Relationship between thiol, tyrosine nitration and carbonyl formation as biomarkers of oxidative stress and changes of hemostatic function of plasma from breast cancer patients before surgery

OBJECTIVES

In breast cancer patients dysregulation of reactive oxygen species metabolism, as detected by various indicators in plasma or various blood cells, including red blood cells and blood platelets, is observed.

DESIGN AND METHODS

The aim of our study was to explain the effect of oxidative/nitrative stress on hemostatic activity of plasma from breast cancer patients. Different methods were used to analyze oxidative/nitrative stress (carbonyl groups and 3-nitrotyrosine levels - ELISA and C-ELISA method, respectively and free thiol groups was estimated with 5,5'-dithio-bis(2-nitro-benzoic acid)). We also measured total antioxidant status (TAS) in plasma.

RESULTS

Our results showed the correlation between the oxidative stress and changes of hemostasis in breast cancer patients; the correlation between the increased amount of carbonylated or nitrated plasma proteins and fibrin polymerization or lysis in plasma isolated from invasive breast cancer patients. We also observed that the relationship between TAS and fibrin polymerization or lysis in plasma from invasive breast cancer exists.

CONCLUSION

Considering the data presented in this study, we suggest that the oxidative/nitrative stress in breast cancer patients may induce the changes of hemostasis in these patients.

[Pre-operative plasma D-dimer level may predict the poor prognosis within one year after the surgery for non-small cell lung cancer]

BACKGROUND AND OBJECTIVE

Some operable non-small cell lung cancer (NSCLC) patients have poor prognosis shortly after the surgery. D-dimer (DD) is an independent prognosis factor of lung cancer, especially for inoperable patients. The aim of the study is to investigate whether the pre-operative plasma DD level could predict the poor prognosis shortly after the surgery in operable NSCLC patients.

METHODS

The pre-operative plasma DD level of 56 newly diagnosed NSCLC patients without metastasis was examined. All the patients had been followed for one year post-operatively and the end-point was the occurrence of the poor prognosis incident including any sign of the metastasis, local recurrence or death related with the lung cancer. Difference of prognosis according to pre-operative plasma DD level was compared by Chi-square test. Diseases progress was analyzed by Kaplan-Meier method.

RESULTS

Among 56 NSCLC patients, 91% had received the curative resections (44 lobectomy and 7 pneumonectomy). There were still 2 cases of the wedge resection and 3 cases of the exploration. The median of the pre-operative plasma DD level was 1.05 (0.55) mg/L. The patients were allocated into two subgroups by the median of the DD levels. There were 11 patients with poor prognosis within one year after the resection in the high DD subgroup, while 3 patients in the low DD subgroup (P=0.03, OR=4.89, 95%CI: 1.2-20.1). The diseases progress curves were significantly different between the high and low subgroups (P=0.024). Based on plasma DD level, the poor prognosis incident within one year after the surgery was best predicted in the early stage (I, II) of the NSCLC, especially in adenocarcinoma patients.

CONCLUSION

The pre-operative plasma DD levels may predict the poor prognosis within one year after the surgery in NSCLC. The measurement of the fibrinolysis marker may help to exclude the unfit patients for the surgery.

The elevated homocysteine stimulates changes of haemostatic function of plasma isolated from breast cancer patients

The aim of our study was to explain the effect of elevated homocysteine (measured by HPLC) on haemostatic activity of plasma from breast cancer patients (fibrin polymerization and lysis; the thrombin and prothrombin time), because homocysteine (Hcys) induces changes in haemostasis, as well blood clotting as fibrinolysis. Patients were hospitalized in Department of Oncological Surgery, Medical University of Lodz, Poland. All patients have not had preadjuvant therapy, and samples from patients were taken before surgery. We observed that changes of selected parameters of haemostatic properties of plasma, e.g., the prothrombin time and thrombin time were prolonged in plasma from invasive breast cancer when compared with the control group (healthy subjects) and patients with benign breast diseases. Our results showed also that the correlation between the increased amount of Hcys and changes of selected parameters of haemostasis in invasive breast cancer patients exists. Considering the data presented in this study, we suggest that the elevated Hcys in invasive breast cancer patients may induce the changes of haemostatic properties of plasma isolated from these patients.

Retinal vein thrombosis in a patient with metastatic colon cancer receiving XELOX chemotherapy combined with bevacizumab pre-hepatic resection

Retinal vein thrombosis is a common vascular occlusive disorder of the retina responsible for varying degrees of vision impairment. It is an adverse effect rarely associated with cancer and its treatment. We report the case of a patient with metastatic colon cancer who developed central retinal vein thrombosis (CRVT) in the right eye following two cycles of chemotherapy with capecitabine and oxaliplatin (XELOX) plus bevacizumab given prior to hepatic resection. Despite cessation of chemotherapy, vision has not improved. The etiology of the CRVT in this case is not clear due to risk factors for venous thrombotic events including colonic malignancy and previous major surgery. However, the proximity of chemotherapy administration to the initial development of symptoms suggests the possibility of a medication-related cause, with bevacizumab and capecitabine the most likely suspects.

The nitrative and oxidative stress in blood platelets isolated from breast cancer patients: the protectory action of aronia melanocarpa extract

Since mechanisms involved in the relationship between oxidative stress and breast cancer are still unclear, the aim of our present study was to evaluate oxidative/nitrative modifications of blood platelet proteins by measuring the level of biomarkers of oxidative/nitrative stress such as carbonyl groups, thiol groups and 3-nitrotyrosine in proteins in patients with benign breast diseases and in patients with invasive breast cancer, and compare with the control group. Levels of carbonyl groups and 3-nitrotyrosine residues in platelet proteins were measured by ELISA and a competition ELISA, respectively. The method with 5,5′-dithio-bis(2-nitro-benzoic acid) has been used to analyse free thiol groups in platelet proteins. Patients were hospitalized in the Department of Oncological Surgery, Medical University of Lodz, Poland. Exogenous antioxidants reduce oxidative stress, therefore we also investigated in a model system in vitro the effects of a polyphenol rich extract of Aronia melanocarpa (Rosaceae, final concentration of 50 µg/ml, 5 min, 37°C) on modified blood platelet proteins as well from patients with breast cancer and from the healthy group. We demonstrated in platelet proteins from patients with invasive breast cancer a higher level of carbonyl groups than in the control healthy group (p < 0.02). The level of 3-nitrotyrosine in platelet proteins from patients with invasive breast cancer was also significantly higher than in the healthy subject group (p < 0.001). In contrast, the amount of thiol groups in platelet proteins from patients was significantly lower (about < 50%) than in control blood platelets. In a model system in vitro we also observed that the extract from berries of A. melanocarpa (50 µg/ml, 5 min, 37°C) due to antioxidant action, significantly reduced the oxidative/nitrative stress (measured by thiol groups and 3-nitrotyrosine) in platelets, not only from the healthy group, but also from patients with benign breast diseases and in patients with invasive breast cancer.

Thrombin-activatable fibrinolysis inhibitor in breast cancer patients

OBJECTIVE

To evaluate the levels of thrombin-activatable fibrinolysis inhibitor (TAFI) activity and also its relationship with other homeostasis markers in breast cancer patients.

SUBJECTS AND METHODS

Forty-two female patients with breast cancer and 24 healthy women (controls) were enrolled in the study and fasting blood samples of all cases were drawn from a large antecubital vein for assay of TAFI and other homeostasis tests.

RESULTS

The TAFI levels were 79.5 ± 15.5 and 39.3 ± 12.1 in patients and controls, respectively, and the difference was statistically significant (p < 0.001). In the patient group, the serum fibrinogen level was 504.9 ± 224.8, while in the control group it was 393.9 ± 100.5, and the difference was also statistically significant (p < 0.001).

CONCLUSION

The data showed that increased levels of TAFI are a contributing factor of thrombotic disorders in breast cancer patients.

Anesthetic considerations for the pediatric oncology patient--part 2: systems-based approach to anesthesia

One of the prices paid for chemo- and radiotherapy of cancer in children is damage to the vulnerable and developing healthy tissues of the body. Such damage can exist clinically or subclinically and can become apparent during active antineoplastic treatment or during remission decades later. Furthermore, effects of the tumor itself can significantly impact the physiologic state of the child. The anesthesiologist who cares for children with cancer or for survivors of childhood cancer should understand what effects cancer and its therapy can have on various organ systems. In part two of this three-part review, we review the anesthetic issues associated with childhood cancer. Specifically, this review presents a systems-based approach to the impact from both tumor and its treatment in children, followed by a discussion of the relevant anesthetic considerations.

Clinical significance of the ratio between the alpha 2 plasmin inhibitor-plasmin complex and the thrombin-antithrombin complex in advanced non-small cell lung cancer

The aims of this study are to: (a) confirm the prognostic significance of the procoagulant molecules D dimer, thrombin-antithrombin complex (TAT), and plasmin-α2-plasmin inhibitor complex (PIC); (b) to evaluate hemostatic activation in patients with advanced non-small cell lung cancer (NSCLC); and (c) to delineate the relationships between markers of hemostasis and other clinical characteristics. In this study, a low PIC/TAT ratio and poor PS were significant independent negative prognostic factors for survival in patients with advanced NSCLC. The PIC/TAT ratio may become a surrogate marker for treatment with anticoagulants in the future.

Primary Arteriovenous Fistulas in the Forearm for Hemodialysis: Effect of Miscellaneous Factors in Fistula Patency

BACKGROUND

The provision and maintenance of vascular access remains a major cost to end-stage renal failure programs. In addition, vascular access occlusion, results in significant morbidity in hemodialysis patients. Age, gender, diabetes mellitus, malignancy, smoking habits, administration of heparin per hemodialysis session, previous dialysis catheter insertion, number of hemodialysis sessions and location of the fistula may be associated with survival of the primary arteriovenous fistula. We examined the effects of various factors on fistulas in 412 chronic renal insufficiency patients.

METHODS

From 1995 to 2004, 412 arteriovenous fistulas were created by the Department of Cardiovascular Surgery at the Medical Faculty of Atatürk University for hemodialysis. The mean age of the patients was 45 years (range 6 to 62 years). We evaluated the effects of various factors for patency rates in the patients who had primary arteriovenous fistulas. Primary patency was defined as the duration of fistula patency without revision. Twenty-eight patients (6.7%) with ischemic cardiac disease did not require surgical interference. Analyzed data were age, gender, smoking habits, diabetes mellitus, malignant neoplasm, previous dialysis catheter insertion, number of hemodialysis sessions, and fistula location.

RESULTS

In 298 patients, where lower-arm radiocephalic fistulas were created, the fistula patency was 74.1%, 64.2%, 49.8%, 33.7%, and 4.1% after 1, 2, 3, 4, and 5 years, respectively, in the other 114 patients, where upper-arm fistulas were created, these rates were 84.0%, 72.2%, 53.3%, 39.8%, and 12.3%, respectively. There was no significantly difference between the upper-arm fistulas and the lower-arm fistulas statistically (p = 0.069). Factors affecting the primary patency of arteriovenous fistulas were diabetes mellitus (p = 0.0001), hemodialysis counts > or =3 per week (p < 0.0005), presence of malignancy (p < 0.0005), previous catheter insertion (p < 0.0007), and administration of heparin per hemodialysis session (p = 0.0008).

CONCLUSION

While primary arteriovenous fistula patency was shortened in chronic renal insufficiency patients with diabetes mellitus, presence of malignancy, and previous catheter insertion, patency was longer in patients with heparin used for hemodialysis and hemodialysis count per week (> or =3).

Associations of factor VIIIc, D-dimer, and plasmin-antiplasmin with incident cardiovascular disease and all-cause mortality

To examine the associations of three understudied hemostatic factors--D-dimer, factor VIII(c), and plasmin-antiplasmin (PAP) complex--with incident cardiovascular disease (CVD) and all cause mortality in the Multiethnic Study of Atherosclerosis cohort. Hemostatic factors were measured at baseline in 45-84-year-old patients (n = 6,391) who were free of clinically recognized CVD. Over 4.6 years of follow-up, we identified 307 CVD events, 207 hard coronary heart disease events, and 210 deaths. D-dimer, factor VIII(c), and PAP were not associated with CVD incidence after adjustment for other risk factors. In contrast, each factor was associated positively with total mortality, and D-dimer and factor VIII(c) were associated positively with cancer mortality. When modeled as ordinal variables and adjusted for risk factors, total mortality was greater by 33% (95% CI 15-54) for each quartile increment of D-dimer, 26% (11-44) for factor VIIIc, and 20% (4-38) for PAP. This prospective cohort study did not find D-dimer, factor VIII(c), or PAP to be risk factors for CVD. Instead, elevated levels of these three hemostatic factors were associated independently with increased risk of death. Elevated D-dimer and factor VIII(c) were associated with increased cancer death.

High plasma D-dimer level is associated with decreased survival in patients with lung cancer

AIMS

An elevated plasma D-dimer level indicates the activation of coagulation and fibrinolysis. In the present study, we investigated the association of pre-treatment haemostatic parameters (D-dimer, fibrinogen and prothrombin fragment 1+2) with clinicopathological parameters and outcome in patients with lung cancer.

MATERIALS AND METHODS

Plasma levels of D-dimer and other parameters were measured in 78 evaluable patients with lung cancer (60 non-small cell lung cancers, 18 small cell lung cancers). At diagnosis, 35 patients (44.9%) were locally advanced stage (IIIA/B) and 43 patients (55.1%) had metastatic disease (IV). Multivariate statistical analysis was carried out using Cox's proportional hazards model. The receiver operating characteristic curve was used to determine the cut-off values for D-dimer, fibrinogen and prothrombin fragment 1+2.

RESULTS

The median survival for all patients was 264 days (95% confidence interval 200-328 days). A significant association between the plasma levels of D-dimer and the response to chemotherapy was observed (P=0.03). With the univariate analysis, tumour stage, pre-treatment plasma levels of D-dimer, fibrinogen, platelet count, lactate dehydrogenase concentration and Karnofsky performance status were predictive for survival. With the multivariate analysis (P< or =0.1), the plasma level of D-dimer (P<0.001), tumour stage (P=0.01) and Karnofsky performance status (P=0.02) were identified as independent predictive factors. The median survival times were 405 days (95% confidence interval 165-644 days) and 207 days (95% confidence interval 146-267 days, P<0.001), respectively, for patients with a low D-dimer level (< or =0.65 microg/ml) and a high D-dimer level (>0.65 microg/ml).

CONCLUSIONS

Elevated plasma levels of D-dimer in patients with lung cancer are associated with decreased survival and a poor response to treatment. Pre-treatment for the D-dimer level may be useful in the prediction of survival and the response to treatment.

Trousseau's syndrome: multiple definitions and multiple mechanisms

In 1865, Armand Trousseau noted that unexpected or migratory thrombophlebitis could be a forewarning of an occult visceral malignancy. An analysis by Sack and colleagues in 1977 extended the term Trousseau's syndrome to include chronic disseminated intravascular coagulopathy associated with microangiopathy, verrucous endocarditis, and arterial emboli in patients with cancer, often occurring with mucin-positive carcinomas. In recent times the term has been ascribed to various clinical situations, ranging all the way from these classic descriptions to any kind of coagulopathy occurring in the setting of any kind of malignancy. These multiple definitions of Trousseau's syndrome are partly the consequence of multiple pathophysiologic mechanisms that apparently contribute to the hypercoagulability associated with cancer. Even the classic syndrome probably represents a spectrum of disorders, ranging from exaggerated fluid-phased thrombosis dependent on prothrombotic agents such as tissue factor to a platelet- and endotheliumum-based selectin-dependent microangiopathy associated with mucin-producing carcinomas, along with thrombin and fibrin production. Also considered here are recent hypotheses about genetic pathways within tumor cells that might trigger these thrombotic phenomena, and the reasons why therapy with heparins of various kinds remain the preferred treatment, probably because of their salutary actions on several of the proposed pathologic mechanisms.

Venous Thromboembolism in Patients With Cancer Part I: Survey of Oncology Nurses' Attitudes and Treatment Practices for Ambulatory Settings

Patients with cancer have a higher incidence of venous thromboembolism (VTE). Little information currently exists on VTE and the understanding and beliefs of oncology nurses. Therefore, the attitudes and treatment practices of ambulatory oncology nurses were surveyed to determine the current knowledge base of VTE in patients with cancer. Survey results are presented along with a thorough literature review of thromboembolism and the unique risk factors for this frequent complication in patients with cancer. The causes of VTE in this patient population often are multifactorial and include hypercoagulability, stasis, and vascular endothelial damage from procedures or the neoplastic process itself. In particular, chemotherapy administration can increase the risk of thrombosis considerably. New therapies, including thalidomide, require oncology nurses caring for these patients to have heightened awareness of the potential for thrombogenic complications. This is the first of two articles that address the problem of thromboembolism in patients with cancer, including the survey results. (See part II on page 465.) Oncology nurses are essential in the care of VTE in patients with cancer and can help with patient identification, treatment, and compliance for improved patient outcomes.

Paraneoplastic syndromes affecting the nervous system

The paraneoplastic neurologic disorders (PND) are a diverse group of diseases characterized by the presence of neurologic dysfunction in the setting of a remote cancer. PND can affect almost any part of the nervous system, and are most commonly associated with lung cancer (small cell) and gynecologic tumors. Laboratory studies have demonstrated that an autoimmune response links the neurologic disorder and the cancer, and established a model whereby the cancer is believed to initiate the syndrome by expressing a protein antigen normally expressed in the nervous system, leading to anti-tumor immune response followed by autoimmune neurologic symptoms. We review the currently known PND and their pathogenesis.

Advances in the pathologic diagnosis and biology of acute myeloid leukemia

In a general surgical pathology practice, cases of acute myeloid leukemia (AML), including myeloid sarcoma, are relatively rare; the diagnosis is very often difficult, however, and consequences of a missed or improper diagnosis compromise patient care. Currently, accurate diagnosis of every case of AML requires integration of the morphological features and results of cytochemical and immunohistochemical stains, flow cytometric immunophenotyping, cytogenetics, and molecular studies. This review focuses on a practical approach to diagnosis of AML according to current standard of practice and discusses some of recent changes in the field of AML.

Role of thrombomodulin in cancer biology

Effects of malignancy on haemostasis have long been recognized. The role of coagulation factors, anticoagulants and fibrinolytic agents in cancer biology have emerged more recently. Thrombomodulin is a naturally occurring anticoagulant, expressed by numerous epithelial and lymphovascular tumour cells. It may have a role in tumour metastasis.

Thromboembolic Events in the Cancer Patient

Thromboembolic events are a major cause of morbidity in cancer patients and may be harbingers of occult malignancy. Trousseau's syndrome (TS) is probably the best known thromboembolic syndrome in the cancer patient, encompassing a variety of paraneoplastic thromboembolic disorders. These include spontaneous recurrent or migratory venous thromboses and arterial emboli caused by nonbacterial thrombotic endocarditis in a patient with malignancy. Although linked to almost all cancers, venous thromboembolism (VTE) is a terminal event in many cancers occurring in women, such as breast, uterine, and lung cancers (Monreal et al. Thrombosis and Haemostasis 1997;78:1316). Appropriate recognition of the syndrome is paramount because TS often requires careful medical surveillance and management. Significant complications of thromboembolic events in the cancer patient include limb ischemia and deep venous thrombosis/pulmonary embolism, which can cause devastating and permanent consequences. The rehabilitation management of these complications is reviewed, with an emphasis on diagnostic and therapeutic approaches in this patient population.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Global fibrinolytic capacity in colorectal cancer: a new clue to occult fibrinolysis

Hemostatic disorders in cancer patients range from asymptomatic laboratory changes to massive thromboembolism or hemorrhage. Routine laboratory tests often fail to identify patients at high risk for hemostatic complications. The postoperative risk of thromboembolic events in colorectal cancer was reported as approximately 2% to 5%. A new diagnostic test was used to assess global fibrinolytic activity, which may detect occult fibrinolysis or disseminated intravascular coagulation in patients with colorectal cancer. Twenty patients with colorectal cancer and 20 healthy control subjects were involved. Using standard silicated fibrin pellets and tissue plasminogen activator, the fibrinolytic capacity of the plasma samples was detected with the amount of D-dimer produced before the reaction was stopped by adding aprotinin to the medium. Mean global fibrinolytic capacity was increased in patients before and after surgery when compared to controls (p = 0.002, p = 0.001, respectively). In conclusion, a hemostatic imbalance was detected toward primary fibrinolysis in the preoperative period and low-grade disseminated intravascular coagulation postoperatively.

Acquired resistance to activated protein C in breast cancer patients

In 56 women with a lymph-node-positive breast carcinoma and 28 matched healthy control subjects, the sensitivity to activated protein C (APC-sr) was determined with an APC resistance test that quantifies the effect of APC on thrombin generation initiated via the extrinsic coagulation pathway. Carriers of the Factor V Leiden mutation were excluded from the study. Significant resistance to APC was found in the breast cancer patients: median APC-sr 2.02 vs 1.03 in the healthy control subjects (P < 0.001). No difference in APC-sr was found between patients with metastases and without metastases. In patients with metastases, protein S levels were significantly elevated compared with patients without metastases and healthy control subjects: 108.0%vs 96.0% and 94.5% (P = 0.008 and P = 0.007). The APC-sr correlated with protein S in the control subjects and in patients without metastases but not in patients with metastases. The disturbance of the haemostatic balance probed by the tissue-factor-based APC resistance test might contribute to the cancer-related hypercoagulability.

Bleeding and thrombotic complications in critically ill patients with cancer

Alterations in hemostasis are common in patients with cancer admitted to the ICU. Depending on the underlying disease and specific hemostatic abnormality, the patient with cancer may develop bleeding, thrombosis, or both, such as DIC. Bleeding complications usually result from abnormalities in platelets or deficiency of coagulation factors and require specific blood or coagulation factor replacement. Similarly, critically ill patients with cancer are predisposed to thrombotic complications such as DVT, PE, and central vein thrombosis, the last as a result of the widespread use of long-term indwelling catheter devices. Advances in diagnostic imaging and the availability of newer and more potent anticoagulant agents have facilitated the care of these patients greatly. Ultimately, it is hoped that a thorough understanding of the various disturbances in hemostasis, innovative treatment approaches, and implementation of preventive strategies in patients with cancer will lead to decreased morbidity and improved survival rates of critically ill patients with cancer in the ICU.

Cancer and thrombosis revisited

Remarkable progress has been made since the first description of the association between cancer and thrombosis by Trousseau over 100 years ago. Now, it is clear that there is a two-way connection between coagulation and cancer as tumor results in alterations in hemostatic balance, and thrombosis may promote tumor cell growth. A variety of clinical thrombotic syndromes may present in cancer patients including local and systemic venous and arterial thromboses. More evidence is now being gathered on the potential of antithrombotic regimens to prolong survival of cancer patients. Whether the use of novel antithrombotic drugs may result in a better outcome remains to be determined.

Effects of high-dose methotrexate on the hemostatic system in childhood acute lymphoblastic leukemia

BACKGROUND

Thromboembolic and hemorrhagic complications are significant causes of death in patients with malignancy. These are well-known with the use of certain drugs. This study was planned to investigate whether there was any effect of high-dose methotrexate on the hemostatic system in childhood acute lymphoblastic leukemia.

PROCEDURE

To evaluate the hemostatic system, we investigated coagulation screening tests (prothrombin time, activated partial thromboplastin time, and fibrinogen), coagulation inhibitors (protein C, protein S, and antithrombin III), and fibrinolytic system (fibrin degradation products and tissue plasminogen activator). These parameters were measured in 35 cycles of high dose-methotrexate (3 g/m(2)) of 20 childhood acute lymphoblastic leukemia cases at baseline and on days 1 and 7 after the therapy.

RESULTS

We found that high-dose methotrexate administration adversely affected both the coagulation system (prolonged prothrombin time and activated partial thromboplastin time and decreased fibrinogen levels) and coagulation inhibitors (decreased protein C, protein S, antithrombin III) on day 1 after chemotherapy compared to the baseline values. The hemostatic parameters began to improve on day 7 after chemotherapy, except for fibrin degradation products. Tissue plasminogen activator levels were not changed with the therapy.

CONCLUSIONS

Coagulation cascade (prolonged prothrombin time and activated partial thromboplastin time and decreased fibrinogen) and coagulation inhibitors (decreased protein C, protein S, and antithrombin III levels) have been found to be affected by high-dose methotrexate therapy, but these transient changes did not cause clinical thromboembolic or hemorrhagic complications.

Increased D-dimer levels correlate with binding of activated protein C, but not tissue factor expression, on peripheral blood monocytes in cancer patients

Monocyte tissue factor expression is supposed to play an important role in the hypercoagulability of blood in cancer patients. The relation between coagulation parameters and the expression of monocyte membrane proteins involved in hemostasis or monocyte activation was studied in 21 patients with a disseminated malignancy and 21 age- and sex-matched healthy controls. In the cancer patient group no increase of monocyte tissue factor expression was found (8. 4% vs. 7.8%; P = 0.83), but a significant increase of monocyte-bound activated protein C (APC) (28.8% vs. 13.4%; P = 0.009) and monocyte CD16 expression (34.5% vs. 27.0%; P = 0.007) was observed. There was also a significant increase of D-dimers (2.0 vs. 0.2 microg/ml; P = 0.001), a decrease of antithrombin (83.5% vs. 102.0%; P = 0.004), but no increase of TAT complexes (1.7 vs. 1.5 microg/l; P = 0.38) or factor VII(a) (68.5% vs. 75.0%; P = 0.52). The increase of D-dimers was significantly correlated with the monocyte APC (R = 0.60; P = 0. 005), but not with monocyte tissue factor levels (R = -0.22; P = 0. 35) or TAT complexes (R = 0.12; P = 0.60). These results reflect a local rather than systemic thrombin and fibrin formation. It is suggested that the APC formed locally enters the circulation and binds to peripheral blood monocytes. APC bound on monocytes is known to inhibit monocyte cytokine production and might therefore be involved in regulatory responses of monocytes in cancer patients.

Serum cardiolipin antibodies in cancer patients with thromboembolic events

This study was undertaken to investigate a possible association of anticardiolipin antibodies (ACLAs) in cancer patients with thromboembolic events. Twenty-five patients with solid tumors complicated with acute thrombosis, 36 cancer patients without any thrombotic events, and a group of 20 healthy volunteers without thrombosis or malignancy were included. The mean age of the cancer patients with and without thrombosis and healthy subjects were 50 years (range 20-75), 45 years (range 23-66), and 40 years (range 20-68), respectively. Deep venous thrombosis (n = 16) and thrombosis of the central venous port-catheter systems (n = 9) were confirmed by Doppler sonography in all patients. IgG and IgM isotypes of ACLAs were quantitated by enzyme-linked immunosorbent assay with normal levels of < 23 GPL and < 11 MPL, respectively. Mean values of IgG ACLAs were found similar in cancer patients with acute thrombosis (13.8 +/- 4.9 GPL), without thrombosis (12.8 +/- 5.4 GPL) or in healthy subjects (14.8 +/- 5.5 GPL). Although the mean values of IgM ACLAs were within normal limits in all groups, cancer patients with thrombotic events had higher levels of IgM ACLAs (mean = 10.5 +/- 2.2 MPL) than cancer patients without thrombosis (mean = 4.6 +/- 2.4 MPL) (p = .01). Healthy subjects also had lower levels of IgM ACLAs (mean = 7.1 +/- 3.2 MPL) than cancer patients with thrombosis (p = .16). In addition, a higher percentage of cancer patients with or without thrombosis had IgM and IgG ACLA levels above normal limits compared with healthy controls. In conclusion, our study suggests an association between ACLAs or IgG and particularly IgM isotypes and venous thrombosis in malignancy. Identification of cancer patients who are at higher risk for developing thromboembolic events might lead to a better selection of patients for prophylactic anticoagulant therapy.

Changes of hemostatic factors in children with acute lymphoblastic leukemia receiving combined chemotherapy including high dose methylprednisolone and L-asparaginase

In this study, protein C (PC), protein S (PS), heparin cofactor II (HCFII), prothrombin fragment 1+2 (PF 1,2), thrombin-antithrombin III complex (TAT), von Willebrand factor (vWF) and thrombomodulin (TM) were investigated in 19 patients with acute lymphoblastic leukemia, (ALL) receiving combined chemotherapy including L-asparaginase (L-ASP) and high dose methylprednisolone (HDMP). HDMP was administered in doses of 30 mg/kg/day for 7 days, and 20 mg/kg/day for another 7 days. In order to evaluate the effect of HDMP on the hemostatic system, the 8 patients studied here received HDMP (30 mg/kg/day) therapy for 4 days before the combined chemotherapy. These parameters were also studied in 12 healthy children as a control group. PC levels were normal in the patients while PS levels were decreased both before and after combined chemotherapies. Patients with ALL have laboratory signs of coagulation activation such as PF 1,2, TAT prior to initiation of chemotherapy. With combined chemotherapy, TAT levels were found to be normal while PF1,2 were not. TM levels were found to be increased both before and after therapies whereas HCFII and vWF levels were not different from those of the control group. The short course of HDMP therapy did not prominently influence these hemostatic parameters. These results indicate that both the malignant process and the drugs used in combined chemotherapy cause a decrease in natural inhibitors and an increase in procoagulant activity and endothelial injury. These hemostatic changes may contribute to a thrombotic tendency in the patients with ALL.

Cutaneous necrosis as a terminal paraneoplastic thromboembolic event in a patient with non-Hodgkin's lymphoma

Thrombotic complications in non-Hodgkin's lymphoma often originate in the large veins. We describe a patient with refractory advanced high-grade lymphoma who presented with the rare complication of extensive cutaneous necrosis due to thrombosis of dermal vessels; there was also a recent new peak of monoclonal IgM-kappa protein. Direct immunofluorescence demonstrated immune deposits with complement in the dermal vessel wall. Based on these observations and on published data, we suggest that these complexes were the trigger for the thrombotic events and that the monoclonal IgM acted as xenoreactive antibodies, initiating a cascade of events. The first step of this cascade was activation of the complement and the membrane attack complex, which caused secretion of IL-1 alpha by endothelial cells, followed by overexpression of tissue factor on the surface of the dermal vessel wall endothelium. Dermal vessel thrombosis was the final event in this cascade.