Download Prognostic impact of an activation of coagulation in lung cancer

Annals of Oncology 8: 781-784, 1997.
© 1997 Kluwer Academic Publishers. Primed in the Netherlands.
Original article
Prognostic impact of an activation of coagulation in lung cancer*
R. Seitz,1 H.-H. Heidtmann, M.Wolf, A. Immel & R. Egbring
Philipps University Hospitals, Department of Haematology/Oncology, Marburg, Germany; ^Present address: Department of Haematology and
Transfusion Medicine, Paul-Ehrlich-Institute, Langen, Germany
30 of 66 (45%) NRSP, but only 4 of 33 (12%) RSP. 88% of
patients with TAT <6 ug/1 achieved remission, and 45% with
Background: There is evidence that activation of coagulation TAT > 6 ug/1 (P = 0.0014). In the subgroup of 46 patients with
by influencing tumour biology may have impact on clinical advanced disease, the six RSP showed lower TAT than the 40
course of lung cancer.
NRSP: 4.65 ± 0.94 vs. 11.92 ± 2.49 ug/1 (P < 0.01); one of six
Patients and methods: We measured the activation markers (17%) RSP, but 21 of 40 (53%) NRSP showed TAT > 6 ug/1.
thrombin-antithrombin complex (TAT) and prothrombin fragThese data suggest that in lung cancer the activation of
ment F 1+2 in 99 lung cancer patients immediately after diag- coagulation is an independent prognostic factor, since TAT
nosis, before antineoplastic treatment. Outcome was assessed levels were different between RSP and NRSP, also within the
at the end of appropriate standard primary therapy (four to six homogeneously unfavourable metastatic subgroup. It should
courses of chemotherapy, surgery or radiation).
be further studied, whether TAT can identify patients, whose
Results and conclusions: The activation markers (means ± prognosis could be improved by anticoagulation as an adjunct
SEM) were lower in the 33 responders (RSP; complete or to standard antineoplastic therapy.
partial remission) than in the 66 non-responders (NRSP): TAT
3.96 ± 0.48 vs. 9.69 ± 1.57 ug/1 (P < 0.001), and F1+21.09 ± 0.09 Key words: lung cancer, prognosis, thrombin-antithrombin
vs. 1.64 ± 0.25 nmol/1 (P < 0.05). TAT levels were > 6 ug/1 in complex
Summary
Introduction
A growing body of evidence demonstrates that activation of coagulation is involved in fundamental processes
during the evolution of cancer tissues, and is of major
importance for invasive tumour growth and metastatic
spread [1]. The activation of the clotting cascade can
be due to activities expressed by the tumour cells
themselves, or the stimulation of tumour-associated inflammatory cells, such as macrophages [2, 3]. Several
activities in cultured human lung tumour cells [4] may
contribute to activation of the tissue factor pathway, or
of factors II or X directly. The substrates of coagulation
(fibrinogen, clotting factors) are thought to reach the
tumour tissue by diffusion after extravasation of plasma,
facilitated by vascular permeability factor [1]. Also,
platelet activation may be triggered by lung cancer cells
via thrombin generation [5]. Well-documented clinical
observations [6, 7] have shown an increased risk of
thromboembolic complications early in the course of
cancer.
Formation of a fibrin matrix appears to support
tumour growth by promoting neoangiogenesis, and by
shielding tumour cells against the attack of immunocompetent cells [8]. Thrombin may even be a growth
* Dedicated to Professor KJaus Havemann on the occasion of his 65th
anniversary.
factor for tumour cells [9]. In two controlled therapy
trials, anticoagulation with warfarin as an adjuvant to
chemotherapy was found to prolong survival of small
cell lung cancer (SCLC) patients [10,11].
With sensitive molecular markers, in many lung cancer patients sustained activation of haemostasis can be
demonstrated [12-14]. We could show [12] that the degree of activation of coagulation is related to initial
tumour stage. The present study addresses the question,
whether the extent of activation of coagulation, as assessed by pretherapeutic activation marker levels, has an
impact on the response to subsequent standard antineoplastic treatment.
Patients and methods
In this prospective diagnostic study, 99 patients with newly diagnosed,
histologically proven lung cancer, or relapse of lung cancer after
previously documented complete remission, were evaluated. Patients
with malignancies other than lung cancer, with pre-existing coagulation disturbances of other causes, on oral anticoagulant therapy, or
who did not give their consent to participate, were not included. The
study was approved by the local ethics committee.
The histologic type was small cell lung cancer (SCLC) in 41
patients, and non-small cell lung cancer (NSCLQ in 58 patients (29
squamous cell, 12 adeno, 17 large cell and mixed cell type). Complete
tumour staging was carried out using standard procedures. In SCLC,
the categories of tumour stage were adapted from criteria approved in
a previous multicentre chemotherapy trial [15], Extensive disease (ED)
Table 1. Activation marker levels (means ± SEM) of the patients
acheiving remission (RSP, n = 33) and the non-responders (NRSP,
7i = 66); for comparison, values of 32 healthy volunteers.
TAT
RSP
NRSP
Volunteers
3.96 ± 0.48
P = 0.0008
9.69 ± 1.57
2.1210.09
1.09 ±0.09
/> = 0.0415
1.64 ±0.25
0.71 ±0.04
SCLC was defined as tumour with involvement of contralateral lymph
nodes and/or metastases to other structures of the thorax and/or
distant sites. In NSCLC, the non-resectable stages HIB and IV according to IUCC, were defined as ED. Altogether, the study included 46
ED patients (24 SCLC, six squamous cell, eight adeno, and eight large
or mixed cell type). The other patients were assigned to the group of
localised disease (LD).
All patients received primary standard antineoplastic treatment
(typically four to six courses of chemotherapy, surgery or radiation) as
appropriate for their histologic tumour type, stage, and their general
condition. The outcome was documented by standard restaging procedures [15]; for the purpose of this study, response (RSP) to treatment
was defined as achievement of complete or partial remission, and nonresponse (NRSP) as no change, progressive disease or death before
therapy could be completed.
None of the patients showed clinical signs or symptoms suggestive
of recent thromboembolic disorders at the tune of inclusion into the
study and blood sampling; diagnostic procedures such as Doppler
sonography or phlebography to exclude occult thrombosis were not
performed.
Blood samples were obtained before the start of antineoplastic
treatment; the measured values of coagulation activation did not have
any influence on decisions about modalities of tumour therapy. In
order to determine in our laboratory reference ranges of the parameters in normal individuals, citrated blood samples were obtained from
32 healthy volunteers.
Methods
Blood samples were obtained using 10 ml syringes containing one part
3.8% sodium citrate to nine parts blood The citrated blood samples
were immediately centrifuged at 1500 g for 15 min at room temperature. Aliquots were frozen at —40 °C until assay.
The activation markers thrombin-antithrombin complex (TAT)
and prothrombin fragment Fi +2 (F 1+2 ) were determined by ELISA,
using kits from Behringwerke (Marburg, Germany).
RSP
Figure 1. Distribution of the entire study patients according to their
TAT levels (cut-off 6 ug/1) into the outcome categories RSP and
NRSP.
(data not shown). The analysis of the entire study population showed that the values of RSP and NRSP were
significantly different, as shown in Table 1. In addition,
the values of 32 healthy volunteers are displayed in order
to show a reference range of the parameters in our
laboratory; this group was not sex- and age-matched
with the study population. The distribution of RSP
and NRSP patients according to their TAT levels (cutoff 6 ug/1) is shown in Figure 1; the odds ratio was
found to be 8.7 (95% confidence interval (CI) 2.7-27.6;
P = 0.0014) for patients with TAT «S6 ug/1 to reach
remission.
The TAT values were significantly higher in the patients with ED than in those with LD (Table 2). Within
the ED subgroup, as shown in Table 3, the TAT values
were lower in the RSP than in the NRSP patients; this
difference was statistically significant despite the low
number of RSP in the ED collective. The distribution of
RSP and NRSP patients according to their TAT levels
Table 2. Activation marker levels (means ± SEM) of the patients with
localized disease (LD, n = 53) and those with extensive disease (ED,
Statistical evaluation
The mean values and standard errors of means were calculated for
groups according to the histologic types, the tumour stage at the time
of diagnosis, the outcome in the entire study population and in the
subgroup with ED, as well as for the healthy volunteer group. Differences between the groups were tested for significance by means of the
alternate Welch's (-test for different variances, and significance was
assumed at P values below 0.05. The distribution of patients with TAT
levels above 6 ug/1 into the groups RSP and NRSP was analysed using
contingency tables and Fisher's exact test.
Results
There was no difference in activation marker levels between patients with different histologic tumour types
NRSP
LD
ED
TAT
F1+2
5.26 ± 0.69
/> = 0.0182
10.75 ±2.15
1.28 ±0.09
NS
1.67 ±0.35
Table 3. Activation marker levels (means ± SEM) within the subgroup
with extensive disease (ED); patients achieving remission (RSP, n = 6)
compared with the non-responders (NRSP, n - 40).
RSP
NRSP
TAT
F ,1+2
+
4.65 ± 0.94
P = 0.0092
11.92 ±2.49
0.97 ±0.18
NS
1.78 ±0.41
783
ciated with worse outcome after subsequent treatment.
However, this finding might have been due to the fact
that among the patients with poor outcome there was
a higher proportion with metastatic tumour disease
and thus higher TAT levels. Therefore, we decided to
analyse the subgroup of patients with prognostically
unfavourable extensive disease separately. Also in this
more homogenous patient group, there was a considerable difference of the TAT values between patients with
effective therapy and the others. Remission was achieved
byfiveof 24 ED patients with TAT ^ 6 ug/1, but only by
1 of 22 patients with TAT > 6 ug/1. Though this difference was not statistically significant in Fisher's exact
test, probably due to the low number of remissions in
the ED group, it appears to be remarkable (Figure 2).
NRSP
RSP
Since the tumour extension as could be assessed by
Figure 2. Distribution of the patients with extensive disease according
standard diagnostic procedures and according to acto their TAT levels (cut-off 6 ug/1) into the outcome categories RSP and
cepted staging criteria was comparable within the ED
NRSP.
group, the higher levels in NRSP can not be explained
merely by a more advanced tumour stage at the time of
diagnosis and TAT determination. The data suggest
(cut-off 6 ug/1) is displayed in Figure 2. The analysis that, in patients with lung cancer, the activation of
shows that remission of their metastatic disease was coagulation is an independent prognostic factor. This
achieved by 5 of 24 (20%) of patients with TAT ^ 6 ug/1, interpretation is supported by experimental evidence
but only by 1 of 22 (4.5%) of patients with TAT > 6 ug/1. pointing to several advantages for the tumour brought
The odds ratio was 5.5 (95% CI 0.6-51.7); however, the about by activated coagulation [1, 8, 9].
difference was not significant in Fisher's exact test.
It would be a major step forward in the so far often
frustrating treatment of lung cancer, if a new, easy-tomeasure prognostic marker could support therapeutic
decisions. In two controlled therapy trials, low grade
Discussion
anticoagulation with warfarin as an adjunct to regular
This study confirmed previous results of this and other chemotherapy has been found to prolong survival of
groups that activation of coagulation takes place in a small-cell lung cancer (SCLC) patients [10, 11]. This
large part of patient with lung cancer of any histologic effect was statistically significant in both trials. Howtype. In a previous paper [12], we had been able to ever, it was not strong enough to prompt the adoption of
show that the plasma levels of markers demonstrating this approach as part of the standard treatment of lung
thrombin (TAT) and fibrin formations (D-dimers) are cancer. Two aspects might be considered in the interpresignificantly higher in metastatic lung cancer. Since the tation of the two trials: 1) since unselected patients were
difference was particularly pronounced for TAT, we treated, it appears likely that also patients without sigdecided to use the markers of thrombin generation TAT nificantly increased coagulation received anticoagulaand Fi+2 for assessment of the prognostic impact of an tion; 2) the warfarin doses were relatively low, possibly
activation of coagulation. In this study, 40% of patients due to the fear of severe bleeding in those patients. The
showed elevated TAT levels; the TAT levels were much results of the present study raise the possibility that the
higher in patients with metastases. This might not only determination of TAT could identify patients, who might
be due to their higher tumour mass, leading to a more have an advantage from anticoagulation as an adjunct to
pronounced activation of coagulation. It might also standard antineoplastic therapy. If this could be verified
indicate that thrombin is mainly formed in the tumour by further studies, TAT and other activation markers
tissue and 'leaks out' into the circulation, when the might also be helpful to monitor anticoagulation and
tumour is spreading. In this direction points also our find the appropriate individual therapeutic levels.
finding that the difference between localised and metaFurther research should evaluate the potential value
static disease is much more pronounced for TAT than of diagnostic tests and therapeutic interventions directed
for Fi +2 . This suggests that thrombin generation with at the activation of coagulation in the ongoing struggle
cleavage of the large peptide prothrombin fragment Fi +2 to improve the outcome of lung cancer patients.
might take place predominantly in a different compartment, i.e., tumour tissue, than the formation of complexes of thrombin with its inhibitor antithrombin in Acknowledgement
plasma.
Already in our previous study [12], we had found that This study was supported by a grant from Deutsche
elevated TAT values at the time of diagnosis were asso- Krebshilfe, M 73/92/Se 2.
784
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Received 24 March; accepted 12 June 1997.
Correspondence to:
R. Seitz, MD
Head, Dept. of Haematology and Transfusion Medicine
Paul-Ehrlich-Institute
Paul-Ehrlich-Street 51-59
D-63225 Langen
Germany