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Auer RC, Ott M, Karanicolas P, Brackstone MR, Ashamalla S, Weaver J, Tagalakis V, Boutros M, Stotland P, Marulanda AC, Moloo H, Jayaraman S, Patel S, Le Gal G, Spadafora S, MacLellan S, Trottier D, Jonker D, Asmis T, Mallick R, Pecarskie A, Ramsay T, Carrier M. Efficacy and safety of extended duration to perioperative thromboprophylaxis with low molecular weight heparin on disease-free survival after surgical resection of colorectal cancer (PERIOP-01): multicentre, open label, randomised controlled trial. BMJ 2022; 378:e071375. [PMID: 36100263 PMCID: PMC9468899 DOI: 10.1136/bmj-2022-071375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
OBJECTIVE To determine the efficacy and safety of extended duration perioperative thromboprophylaxis by low molecular weight heparin when assessing disease-free survival in patients undergoing resection for colorectal cancer. DESIGN Multicentre, open label, randomised controlled trial. SETTINGS 12 hospitals in Quebec and Ontario, Canada, between 25 October 2011 and 31 December 2020. PARTICIPANTS 614 adults (age ≥18 years) were eligible with pathologically confirmed invasive adenocarcinoma of the colon or rectum, no evidence of metastatic disease, a haemoglobin concentration of ≥8 g/dL, and were scheduled to undergo surgical resection. INTERVENTIONS Random assignment to extended duration thromboprophylaxis using daily subcutaneous tinzaparin at 4500 IU, beginning at decision to operate and continuing for 56 days postoperatively, compared with in-patient postoperative thromboprophylaxis only. MAIN OUTCOME MEASURES Primary outcome was disease-free survival at three years, defined as survival without locoregional recurrence, distant metastases, second primary (same cancer), second primary (other cancer), or death. Secondary outcomes included venous thromboembolism, postoperative major bleeding complications, and five year overall survival. Analyses were done in the intention-to-treat population. RESULTS The trial stopped recruitment prematurely after the interim analysis for futility. The primary outcome occurred in 235 (77%) of 307 patients in the extended duration group and in 243 (79%) of 307 patients in the in-hospital thromboprophylaxis group (hazard ratio 1.1, 95% confidence interval 0.90 to 1.33; P=0.4). Postoperative venous thromboembolism occurred in five patients (2%) in the extended duration group and in four patients (1%) in the in-hospital thromboprophylaxis group (P=0.8). Major surgery related bleeding in the first postoperative week was reported in one person (<1%) in the extended duration and in six people (2%) in the in-hospital thromboprophylaxis group (P=0.1). No difference was noted for overall survival at five years in 272 (89%) patients in the extended duration group and 280 (91%) patients in the in-hospital thromboprophylaxis group (hazard ratio 1.12; 95% confidence interval 0.72 to 1.76; P=0.1). CONCLUSIONS Extended duration to perioperative anticoagulation with tinzaparin did not improve disease-free survival or overall survival in patients with colorectal cancer undergoing surgical resection compared with in-patient postoperative thromboprophylaxis alone. The incidences of venous thromboembolism and postoperative major bleeding were low and similar between groups. TRIAL REGISTRATION ClinicalTrials.gov NCT01455831.
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Affiliation(s)
- Rebecca C Auer
- Department of Surgery, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Michael Ott
- Department of Surgery, London Health Sciences Centre, London, ON, Canada
| | - Paul Karanicolas
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - Shady Ashamalla
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Joel Weaver
- Department of Surgery, Queensway Carleton Hospital, Ottawa, ON, Canada
| | - Vicky Tagalakis
- Jewish General Hospital, Lady Davis Institute for Medical Research, McGill University, Montreal, QC, Canada
| | - Marylise Boutros
- Jewish General Hospital, Lady Davis Institute for Medical Research, McGill University, Montreal, QC, Canada
| | - Peter Stotland
- Department of Surgery, North York General Hospital, North York, ON, Canada
| | | | - Husein Moloo
- Department of Surgery, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Shiva Jayaraman
- Department of Surgery, St Joseph's Health Centre, Toronto, ON, Canada
| | - Suni Patel
- Department of Surgery, Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Grégoire Le Gal
- Department of Medicine, Institut du Savoir Montfort, Ottawa, ON, Canada
- Department of Medicine University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Silvana Spadafora
- Algoma District Cancer Program, Sault Area Hospital, Sault Ste Marie, ON, Canada
| | - Steven MacLellan
- Department of Surgery, Humber River Hospital, Toronto, ON, Canada
| | - Daniel Trottier
- Department of Surgery, Montfort Hospital, Ottawa, ON, Canada
| | - Derek Jonker
- Department of Medicine University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Timothy Asmis
- Department of Medicine University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Ranjeeta Mallick
- Clinical Epidemiology Program, Method Centre, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Amanda Pecarskie
- Department of Medicine University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Tim Ramsay
- Department of Surgery, Montfort Hospital, Ottawa, ON, Canada
| | - Marc Carrier
- Department of Medicine University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Abstract
Glycosaminoglycans (GAGs) are an important component of the tumor microenvironment (TME). GAGs can interact with a variety of binding partners and thereby influence cancer progression on multiple levels. GAGs can modulate growth factor and chemokine signaling, invasion and metastasis formation. Moreover, GAGs are able to change the physical property of the extracellular matrix (ECM). Abnormalities in GAG abundance and structure (e.g., sulfation patterns and molecular weight) are found across various cancer types and show biomarker potential. Targeting GAGs, as well as the usage of GAGs and their mimetics, are promising approaches to interfere with cancer progression. In addition, GAGs can be used as drug and cytokine carriers to induce an anti-tumor response. In this review, we summarize the role of GAGs in cancer and the potential use of GAGs and GAG derivatives to target cancer.
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Affiliation(s)
- Ronja Wieboldt
- Laboratories for Cancer Immunotherapy and Immunology, Department of Biomedicine, University Hospital and University of Basel, Basel, Switzerland
| | - Heinz Läubli
- Laboratories for Cancer Immunotherapy and Immunology, Department of Biomedicine, University Hospital and University of Basel, Switzerland; Division of Oncology, Department of Theragnostics, University Hospital Basel, Basel, Switzerland
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Berdiaki A, Neagu M, Giatagana EM, Kuskov A, Tsatsakis AM, Tzanakakis GN, Nikitovic D. Glycosaminoglycans: Carriers and Targets for Tailored Anti-Cancer Therapy. Biomolecules 2021; 11:395. [PMID: 33800172 PMCID: PMC8001210 DOI: 10.3390/biom11030395] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 02/25/2021] [Accepted: 03/04/2021] [Indexed: 02/06/2023] Open
Abstract
The tumor microenvironment (TME) is composed of cancerous, non-cancerous, stromal, and immune cells that are surrounded by the components of the extracellular matrix (ECM). Glycosaminoglycans (GAGs), natural biomacromolecules, essential ECM, and cell membrane components are extensively altered in cancer tissues. During disease progression, the GAG fine structure changes in a manner associated with disease evolution. Thus, changes in the GAG sulfation pattern are immediately correlated to malignant transformation. Their molecular weight, distribution, composition, and fine modifications, including sulfation, exhibit distinct alterations during cancer development. GAGs and GAG-based molecules, due to their unique properties, are suggested as promising effectors for anticancer therapy. Considering their participation in tumorigenesis, their utilization in drug development has been the focus of both industry and academic research efforts. These efforts have been developing in two main directions; (i) utilizing GAGs as targets of therapeutic strategies and (ii) employing GAGs specificity and excellent physicochemical properties for targeted delivery of cancer therapeutics. This review will comprehensively discuss recent developments and the broad potential of GAG utilization for cancer therapy.
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Affiliation(s)
- Aikaterini Berdiaki
- Laboratory of Histology-Embryology, School of Medicine, University of Crete, 71003 Heraklion, Greece; (A.B.); (E.-M.G.); (G.N.T.)
| | - Monica Neagu
- Department of Immunology, Victor Babes National Institute of Pathology, 050096 Bucharest, Romania;
| | - Eirini-Maria Giatagana
- Laboratory of Histology-Embryology, School of Medicine, University of Crete, 71003 Heraklion, Greece; (A.B.); (E.-M.G.); (G.N.T.)
| | - Andrey Kuskov
- Department of Technology of Chemical Pharmaceutical and Cosmetic Substances, D. Mendeleev University of Chemical Technology of Russia, 125047 Moscow, Russia;
| | - Aristidis M. Tsatsakis
- Laboratory of Toxicology, School of Medicine, University of Crete, 71003 Heraklion, Greece;
| | - George N. Tzanakakis
- Laboratory of Histology-Embryology, School of Medicine, University of Crete, 71003 Heraklion, Greece; (A.B.); (E.-M.G.); (G.N.T.)
- Laboratory of Anatomy, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Dragana Nikitovic
- Laboratory of Histology-Embryology, School of Medicine, University of Crete, 71003 Heraklion, Greece; (A.B.); (E.-M.G.); (G.N.T.)
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Lanzi C, Cassinelli G. Heparan Sulfate Mimetics in Cancer Therapy: The Challenge to Define Structural Determinants and the Relevance of Targets for Optimal Activity. Molecules 2018; 23:E2915. [PMID: 30413079 PMCID: PMC6278363 DOI: 10.3390/molecules23112915] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 11/06/2018] [Accepted: 11/06/2018] [Indexed: 12/21/2022] Open
Abstract
Beyond anticoagulation, the therapeutic potential of heparin derivatives and heparan sulfate (HS) mimetics (functionally defined HS mimetics) in oncology is related to their ability to bind and modulate the function of a vast array of HS-binding proteins with pivotal roles in cancer growth and progression. The definition of structural/functional determinants and the introduction of chemical modifications enabled heparin derivatives to be identified with greatly reduced or absent anticoagulant activity, but conserved/enhanced anticancer activity. These studies paved the way for the disclosure of structural requirements for the inhibitory effects of HS mimetics on heparanase, selectins, and growth factor receptor signaling, as well as for the limitation of side effects. Actually, HS mimetics affect the tumor biological behavior via a multi-target mechanism of action based on their effects on tumor cells and various components of the tumor microenvironment. Emerging evidence indicates that immunomodulation can participate in the antitumor activity of these agents. Significant ability to enhance the antitumor effects of combination treatments with standard therapies was shown in several tumor models. While the first HS mimetics are undergoing early clinical evaluation, an improved understanding of the molecular contexts favoring the antitumor action in certain malignancies or subgroups is needed to fully exploit their potential.
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Affiliation(s)
- Cinzia Lanzi
- Molecular Pharmacology Unit, Department of Applied Research and Technological Development, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy.
| | - Giuliana Cassinelli
- Molecular Pharmacology Unit, Department of Applied Research and Technological Development, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy.
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Zhao HF, Wang J, Shao W, Wu CP, Chen ZP, To SST, Li WP. Recent advances in the use of PI3K inhibitors for glioblastoma multiforme: current preclinical and clinical development. Mol Cancer 2017; 16:100. [PMID: 28592260 PMCID: PMC5463420 DOI: 10.1186/s12943-017-0670-3] [Citation(s) in RCA: 177] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 05/26/2017] [Indexed: 02/08/2023] Open
Abstract
Glioblastoma multiforme (GBM) is the most common and aggressive malignant primary tumor in the central nervous system. One of the most widely used chemotherapeutic drugs for GBM is temozolomide, which is a DNA-alkylating agent and its efficacy is dependent on MGMT methylation status. Little progress in improving the prognosis of GBM patients has been made in the past ten years, urging the development of more effective molecular targeted therapies. Hyper-activation of the phosphatidylinositol 3-kinase (PI3K)/Akt pathway is frequently found in a variety of cancers including GBM, and it plays a central role in the regulation of tumor cell survival, growth, motility, angiogenesis and metabolism. Numerous PI3K inhibitors including pan-PI3K, isoform-selective and dual PI3K/mammalian target of rapamycin (mTOR) inhibitors have exhibited favorable preclinical results and entered clinical trials in a range of hematologic malignancies and solid tumors. Furthermore, combination of inhibitors targeting PI3K and other related pathways may exert synergism on suppressing tumor growth and improving patients' prognosis. Currently, only a handful of PI3K inhibitors are in phase I/II clinical trials for GBM treatment. In this review, we focus on the importance of PI3K/Akt pathway in GBM, and summarize the current development of PI3K inhibitors alone or in combination with other inhibitors for GBM treatment from preclinical to clinical studies.
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Affiliation(s)
- Hua-fu Zhao
- Department of Neurosurgery & Shenzhen Key Laboratory of Neurosurgery, the First Affiliated Hospital of Shenzhen University, Shenzhen Second People’s Hospital, Shenzhen, 518035 China
- Department of Neurosurgery/Neuro-oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060 China
| | - Jing Wang
- Department of Neurosurgery/Neuro-oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060 China
| | - Wei Shao
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong, China
| | - Chang-peng Wu
- Department of Neurosurgery & Shenzhen Key Laboratory of Neurosurgery, the First Affiliated Hospital of Shenzhen University, Shenzhen Second People’s Hospital, Shenzhen, 518035 China
- College of Clinical Medicine, Anhui Medical University, Hefei, 230032 China
| | - Zhong-ping Chen
- Department of Neurosurgery/Neuro-oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060 China
| | - Shing-shun Tony To
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong, China
| | - Wei-ping Li
- Department of Neurosurgery & Shenzhen Key Laboratory of Neurosurgery, the First Affiliated Hospital of Shenzhen University, Shenzhen Second People’s Hospital, Shenzhen, 518035 China
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Lima M, Rudd T, Yates E. New Applications of Heparin and Other Glycosaminoglycans. Molecules 2017; 22:molecules22050749. [PMID: 28481236 PMCID: PMC6154012 DOI: 10.3390/molecules22050749] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 04/24/2017] [Accepted: 04/28/2017] [Indexed: 11/20/2022] Open
Abstract
Heparin, the widely used pharmaceutical anticoagulant, has been in clinical use for well over half a century. Its introduction reduced clotting risks substantially and subsequent developments, including the introduction of low-molecular-weight heparin, made possible many major surgical interventions that today make heparin an indispensable drug. There has been a recent burgeoning of interest in heparin and related glycosaminoglycan (GAG) polysaccharides, such as chondroitin sulfates, heparan sulfate, and hyaluronate, as potential agents in various applications. This ability arises mainly from the ability of GAGs to interact with, and alter the activity of, a wide range of proteins. Here, we review new developments (since 2010) in the application of heparin and related GAGs across diverse fields ranging from thrombosis and neurodegenerative disorders to microbiology and biotechnology.
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Affiliation(s)
- Marcelo Lima
- Department of Biochemistry, Federal University of São Paulo (UNIFESP), Vila Clementino, São Paulo, S.P. 04044-020, Brazil.
- Department of Biochemistry, Institute of Integrative Biology, University of Liverpool, Crown Street, Liverpool L69 7ZB, UK.
| | - Timothy Rudd
- Department of Biochemistry, Institute of Integrative Biology, University of Liverpool, Crown Street, Liverpool L69 7ZB, UK.
- National Institute of Biological Standards and Controls (NIBSC), Blanche Lane, Potters Bar, Herts EN6 3QG, UK.
| | - Edwin Yates
- Department of Biochemistry, Federal University of São Paulo (UNIFESP), Vila Clementino, São Paulo, S.P. 04044-020, Brazil.
- Department of Biochemistry, Institute of Integrative Biology, University of Liverpool, Crown Street, Liverpool L69 7ZB, UK.
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