Thrombosis and Cancer:Apersonalview

AnniversaryIssueContribution

Thrombosis and cancer:Apersonalview

1957–2007) Maria BenedettaDonati

y( Research Laboratories, “JohnPaul II” Centrefor High Te chnologyResearchand Education in Biomedical Sciences, CatholicUniversity, Campobasso,Italy

uring our Ph.D.studiesatthe LaboratoryofMarc Ver- cells (18),aswellasindifferent humantumors (19).Itwas also straete, under the guidance of JosVermylen (Leuven Uni- the main procoagulant activity of acutepromyelocytic leukae- Anniversar D versity),Giovanni de Gaetano and myself went to visit mia,and asensitive marker of both diseaseactivity and response th some US laboratoriesin1972, including that of Eugene Cliffton to chemotherapyand ATRA treatment (20–22). Cancer pro- 50 at Sloan Kettering in NewYork. This investigator wasindeedone coagulant had been purified fromhuman amniochorial or sev- of the pioneers to propose the two-way association between eral malignant tissues as acysteine protease with apeculiarclot- thrombosis and cancer. ting mechanism by Anna FalangainGordon’sLaboratory. Des- This association, described one century earlierbyArmand pite theeffortofseveral laboratoriesinthe past 20 years,such an Trousseauintumors of the gastro-intestinaltract (1), had not important tumor cell procoagulant and malignancymarker,for a beenfurther explored, butwarrantedboth experimental and number of reasons including technicalproblems, hasnot receiv- clinicalattention,asCliffton’s work had showninthe 1960s ed so faracomplete molecularand genetic characterization, (2–6). whichremains open to future research. Back to Italyin1973, we were asked to openanew laboratory Studies in experimental models of tumor growth ledustothe on haemostasis and thrombosis in Milan at Mario NegriInsti- definition of the type of thrombocytopenia and anaemia associ- tute,anon-profit researchinstitution well known at thattime for atedwith the growth of the primary site in some murine tumors its experimental studies in the fieldofcancer chemotherapy. We (10, 11) and to the discoverythat warfarin could exertapeculiar decided therefore to match the experienceinthe physiopathol- antimetastatic effect in some models, possibly due to the in- ogyofhaemostasis and thrombosis –gained during ourMD hibition of cancerprocoagulant, characterized as anovel vitamin studiesatRome CatholicUniversity with Raffaello Breda and K-dependent factor (16, 17,24). Other studies in mice, with Ni- BrunoBizzi,two pioneers of coagulation studies in Italy,and ex- cola Semeraro, Alberto Mantovani, Mario Colucciand Roberto tendedduring our five years spent at the Leuven Laboratory– Lorenzet, led us to realize howimportant tumor/hostinteractions withthe experienceofMarioNegri Institute investigatorsinthe were in the expression of a“physiological”extravascularpro- oncologicalfield. coagulant suchastissue factor (TF)with consequent fibrin de- We started to work there at twolevels: cellbiology,looking position at the tumor/host interface(25, 26). These studies pion- with Luciano Morasca at the procoagulant/fibrinolytic activities eeredalarge seriesofexperiments on inflammation, cancerand of tumors cells (7–9) and animal models, with Andreina Poggi, host antitumor defencemechanisms. looking at changes in the haemostatic system of the host during Despite the progress ourgroupand fewothers had accom- the development of some experimental tumors (10, 11) and on plished in the field, the association of thrombosis and cancer was the treatment of murine tumors with antithromboticdrugs mainlyconsidered, till the end of the 1970s, the concernofsome (12–14). “exoteric” investigatorsand the presentations proposedathae- mostasis and thrombosis meetings were regularlyranked as Acancer procoagulant “other”or“miscellaneous”. As theywere notincludedinany

major category, theywere usually accepted as posters, to be pres- This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. Many studieswere focussedonanew procoagulant activity spe- ented during the less important sessions.Ahonourableexception cificallyconfined to the malignant phenotype,the so-called wasthe 1979 Congress of the InternationalSociety onThrombo- “CancerProcoagulant”.This factor appeared to be similartothe sis and Haemostasis (ISTH) in London, where the late Arthur one describedinrabbitV 2 carcinoma by StuartGordon’sgroupin Bloom organizedasymposium on “Malignancyand Haemosta- Denver, Colorado,and wasfound by our group in several warfa- sis”, Iwas askedtochair togetherwith JohnDavidson(27). The rin–sensitive murine tumors(9, 16, 17) and in human melanoma increasing interest of our group into “cellular aspects of haemos-

Correspondence to: Received May22, 2007 Maria B. Donati Accepted May23, 2007 ResearchLaboratories “John Paul II” Centrefor High Te chnologyResearch Prepublished onlineJune 12, 2007 and Education in Biomedical Sciences doi:10.1160/TH07–05–0363 Catholic University C. da Tappino,86100 Campobasso, Italy ThrombHaemost 2007; 98: 126–128 Te l.: +390874 312278, Fax: +39 0874 312710 E-mail: [email protected]

126 Donati: Thrombosis andcancer tasis”,was also reflected by the “BizzozeroSymposium” organ- The development of low-molecular-weightheparins izedtogether with PeterMannucci in Bergamo(1982) on the oc- (LMWH) in the prevention/treatment of thrombosis in cancer casion of the 28th ISTH SubCommitteemeeting. patients, haslatelymade availableamore patient-friendlyanti- In 1983,within the ISTH, we succeeded in establishinganew thrombotic treatment in these patients. The favourableexperi- SSC SubCommitteedevoted to “Malignancyand Haemostasis”. encewith LMWHopenedindeedthe waytonew trials with he- Its first chairman wasYaleNemerson.Itook the chair in the sub- parins to modify the natural historyofseveral tumors(42, 43).

sequent years (1985–1988), followedthen by Graham Jamieson, This happened during the last fewyears and is still goingon. 1957–2007) Fred Rickles, Mark Levine, Ajay Kakkar,Anna Falangaand From preliminarydataavailableinthe first trials (44-47)it Martin Prinz (2007).These SubCommittee meetings gradually would appear that LMWH treatment could delaymetastasis y( movedfrom 20–30attendees to over 300. growth in different tumors, butonlyifthe tumor is still at an early stage. This finding, confirmed by trials with different design and From experimental models to clinicaltrials treatment schedules(44–47), maybeexplained by the following hypothesis: LMWH would actonthe dissemination of tumor The real switchwas determinedbythe growing interest of clini- cells by anti-adhesive/anti-inflammatoryproperties(different at Anniversar cal oncologists in the association between thrombosis and least in partfrom their anticoagulant activity);these properties th cancer,along twomainlines: would enableLMWHtoprevent the adhesion of tumor cells to 50 –The association of thrombosis with cancertreatment,not the vascularwalland their extravasation to formmetastatic foci. onlysurgery, butchemotherapyand hormone therapyas Once metastases have beenformed,however,LMWHwould be well. This concernhas lately beenextendedtothe risk of unable to prevent their growth. Forthis reason onlytumors at a thrombosis associated with anti-angiogenic therapy(28–31). relativelyearlystage,i.e. with still asignificant burden of circu- –The observation of idiopathicorunprovokedvenous throm- lating tumor cells, would respond to the inhibitoryordelaying bosis as apredictorofthe clinicalmanifestation of an occult effectsofLMWH. This hypothesis is supported by recent in- cancer (32–34). vitrodatashowing the ability of some LMWH to prevent cell- cell interactions, relevant for the adhesion of cancercells to the Thesetwo clinical issueshaveprompted newresearch and in- vascularwalland subsequent extravasation (48,49). Old experi- spired experimental work in the last fewyears.Meanwhile,the mental work in micehad alreadyshown the best timewindowof work of the SubCommitteehad ledtothe establishment, in col- treatment with heparintoobtain an anti-metastatic activity: This laboration with LeoZacharski, of aRegistryofClinical Trials of effect wasindeedonlyobservedwhen tumor cells were injected Antithrombotic Drugs in cancer patients, first publishedin1989 intravenously in micepretreated with heparin(40). (35) and updatedin1993 (36).The Registry clearlyshoweda very messy situation in aperiod when, in otherfields suchasthe Conclusions cardiovascularone, the application of modernclinical trialmeth- odologyhad allowedtoreach important goals for prevention and The relationships betweenthrombosis and cancerare aparadig- treatment of ischaemic heart disease (37–38). matic exampleofthe useful cross-talk betweenexperimental Indeed,atthe experimental level, evidencehad been col- data and clinicalresults: many years after the reportsonbenefi- lected to suggest thatmodification of the host’shaemostatic sys- cial heparineffectsinexperimental tumor models (4, 5), recent tembydifferent pharmacological approaches could lead to clinicalresults (44–47) promptedustogoback to experimental changes in the degree and speed of tumor and metastasis growth systems, to find out the best conditions for heparin to favourably (12–14). Thedatacould be schematicallysummarized as fol- modifythe natural historyofsome human tumors. Presently, lows: Whateverantithrombotic drug or condition, such as anti- these studiesneed to carefullyconsider the mechanism of hepa- plateletantibodies or dysfunctional platelets, would reduce rin’saction in relation to both tissue factor expression by cancer blood cell stickiness and/or increase blood fluidity, would also and host cells and the angiogenic response, twoareas of signifi- delayand reduce the trapping of tumor cells within the lungs of cant progress in recent years (50–52).Although studiesonthe as-

the host by diverting cancer cells towards the spleen or the liver, sociation betweenthrombosis and cancerare no moreconfined This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. to be destroyed there by the reticulo-endothelialsystem. As are- to fewlaboratories, the great numberofopen questions at experi- sult, the subsequent growth of lung metastasis would be signifi- mental and clinicallevelswill certainlykeep the scientific com- cantly delayedorinhibited (12, 14, 39, 40). These data did not munity busy formanyyears to come. find initiallyany translation into clinical application, and for many years astriking lack of appropriate clinical trials wasre- Acknowledgments flected in the SSC Registry. It would be difficult to individuallyacknowledge all co-workerswho con- One of themajor difficultiestoprove the effectivenessof tributed during the lastfour decades to the research developed in my labora- anticoagulants in cancer patients wasthat the use of antivitamin toryonhaemostasis, thrombosis and cancer.The name of manyofthem can Kdrugs –remarkably effectiveinsome animal models (13, 16, be found in the reference list. This manuscript wasprepared with the care- 24) –required laboratorymonitoring and inducedserioushaem- fulassistance of Milena Rosiello and the supportofagrant fromthe Italian orrhagic risk in patients with cancer, whoare often thrombocyto- Research Ministry(MIUR,Decreto no, 1588). penic due to chemotherapyand/or radiotherapy.

127 Donati: Thrombosis andcancer

References 1. Trousseau A. Phlegmasia AlbaDolens. Clinique 20. FalangaA,AlessioMG, Donati MB, et al. Anew pectedacute myocardialinfarction:ISIS-2.ISIS-2(Sec- Médicale de l’HçtelDieudeParis,2nd edition. Vol3. procoagulant in acute leukemia. Blood 1988; 71: ond InternationalStudy of Infarct Survival).Collabor- Paris, JB Baillère, 1865:659–712. 870–875. ative Group.Lancet 1988; 2: 349–360. 2. Cliffton EE, Grossi CE. Fibrinolyticactivityof 21. Donati MB, FalangaA,ConsonniR,etal. Cancer 38. GISSI-2:afactorial randomised trialofalteplase human tumors as measured by thefibrin-platemethod. procoagulant in acute non lymphoid leukemia: Rela- versus streptokinase and heparinversus no heparin Cancer1955;8:1146–1154. tionship of enzyme detection to diseaseactivity. among 12,490 patients withacute myocardialinfarc- 3. GrossiCE, AgostinoD,Cliffton EE. Theeffect of ThrombHaemost1990;64: 11–16. tion. GruppoItaliano per lo StudiodellaSopravvivenza 1957–2007) human fibrinolysin on pulmonary metastases of 22. FalangaA,Iacoviello L,EvangelistaV, et al. Lossof nell’Infarto Miocardio. Lancet1990;336: 65–71.

y( Walker 256 carcinoma. CancerRes 1960; 20: 605–608. blastcell procoagulant activityand improvement of he- 39. Donati MB, Poggi A. Malignancy and haemostasis. 4. AgostinoD,Grossi CE, Cliffton EE. Effect of hepa- mostatic variablesinpatients withacute promyelocytic Br JHaematol 1980; 44: 173–182. rinoncirculatingWalker carcinosarcoma 256 cells.J leukemiaadministered all-trans-retinoic acid. Blood 40. Poggi A, Donati MB, GarattiniS.Fibrinand cancer Natl Cancer Inst1961;5:463–473. 1995; 86: 1072–1081. cell growth:Problems in theevaluation of experimental 5. Cliffton EE, AgostinoD.Factors affecting thede- 23. FalangaA,Gordon SG. Isolationand characteriz- models. In:Malignancyand thehemostatic system, velopment of metastatic cancer.Effect of alterations in ation of cancer procoagulant: acysteineproteinase RavenPress, NewYork, 1981: pp. 89–101. clottingmechanism. Cancer1962;15: 276–283. from malignanttissue. Biochemistry1985; 24: 41. Bani MR, FalangaA,AlessioMG, et al. Blood co-

Anniversar 6. AgostinoD,Cliffton EE, Girolami A. Effect of pro- 5558–5567. agulationchanges in nudemicebearinghuman colon th longedcoumadin treatment on theproductionofpul- 24. Roncaglioni MC, D’Alessandro AP,Casali B, et al. carcinomas. IntJCancer1992;50: 75–79. monarymetastasesinthe rat. Cancer 1966; 19: Gamma-glutamyl carboxylaseactivityinexperimental 42. FalangaA.The effect of anticoagulant drugs on 50 284–288. tumortissues: abiochemical basis for vitamin Kdepen- cancer.JThrombHaemost2004;2:1263–1265. 7. DolfiniE,Azzarone B, PedullaD,etal. Character- dence of cancer procoagulant. Haemostasis1986;16: 43. Lee AY, Levine MN,Baker RI, et al. Low-molecu- ization of human fibroblastsfrom cancer patients: Loss 295–299. lar-weight heparin versus acoumarin for theprevention of fibrin clot retractile activityafter 'invitro' sponta- 25. Lorenzet R, Peri G, Locati D, et al. Generation of of recurrent venousthromboembolisminpatients with neous transformation. Eur JCancer 1976; 12: 823–825. procoagulant activitybymononuclear phagocytes: A cancer.NEngl JMed 2003; 349:146–153. 8. Donati MB, DolfiniE,Morasca L, et al. Fibrin clot possible mechanism contributingtoblood clottingacti- 44. Altinbas M,Coskun HS,ErO, et al. Arandomized retraction by arat rhabdomyosarcomacell line.Thromb vationwithin malignanttissues. Blood1983;62: clinical trialofcombination chemotherapywith and Res 1976; 8: 707–711. 271–273. withoutlow-molecular-weight heparin in smallcell 9. CuratoloL,Colucci M,Cambini AL,etal. Evi- 26. Rambaldi A,AlessioG,Casali B, et al. Inductionof lung cancer.JThrombHaemost2004;2:1266–1271. dence that cellsfrom experimental tumourscan acti- monocyte-macrophage procoagulant activitybytrans- 45. KakkarAK, LevineMN, KadziolaZ,etal. Low vate coagulationfactor X. BrJCancer1979;40: formedcell lines.JImmunol 1986; 136:3848–3855. molecular weight heparin therapywith dalteparin and 228–233. 27. Donati MB, DavidsonJD, GarattiniS.Malignancy survivalinadvanced cancer:the framing advanced ma- 10. PoggiA, PolentaruttiN,Donati MB,etal. Blood co- and theHemostatic System. Raven Press,N.Y.1981. lignancy outcome study (FAMOUS).JClin Oncol agulationchanges in micebearingLewis lung carcino- 28. Levine MN, Gent M,Hirsh J, et al. The thrombo- 2004; 22: 1944–1948. ma,ametastasizing tumor. CancerRes 1977; 37: geniceffect of anticancer drug therapyinwomen with 46. Klerk CP,SmorenburgSM, Otten HM,etal.The ef- 272–277. stage II breast cancer.NEngl JMed 1988; 318: fect of lowmolecular weight heparin on survivalinpa- 11. Chmielewska J, Poggi A, Mussoni L, etal. Blood 404–407. tients withadvanced malignancy.JClin Oncol2005; coagulationchanges in JW sarcoma, anew metastasiz- 29. Levine M,Hirsh J, Gent M,etal. Double-blindran- 23: 2130–2135. ingtumour in mice. Eur JCancer 1980; 16: 1399–1407. domised trialofavery-low-dosewarfarinfor preven- 47. Lee AY, Rickles FR, JulianJA, et al. Randomized 12. Mussoni L, Poggi A, de Gaetano G, et al. Effect of tionofthromboembolisminstage IV breastcancer. comparison of lowmolecular weight heparin and cou- ditazole,aninhibitorofplateletaggregation, on ameta- Lancet1994;343: 886–889. marinderivativesonthe survivalofpatients with stasizing tumour in mice. Br JCancer 1978; 37: 30. BarbuiT,FalangaA.Thalidomide and thrombosis cancer and venousthromboembolism. JClin Oncol 126–129. in multiple myeloma. JThromb Haemost2003;3: 2005; 23: 2123–2129. 13. Poggi A, Mussoni L, Kornblihtt L,etal. Warfarin 421–422. 48. MaugeriN,deGaetano G, Barbanti M, et al.Pre- enantiomers,anticoagulation, and experimental tumor 31. Donati MB, FalangaA.Pathogeneticmechanisms vention of platelet-polymorphonuclear leukocyte inter- metastasis. Lancet1978;1:163–164. of thrombosisinmalignancy. Acta Haematol 2001; actions:new clues to theantithrombotic propertiesof 14. Chmielewska J, Poggi A, JanikP,etal. Effect of 106:18–24. parnaparin,alow molecular weight heparins. Haema- defibrinationwith batroxobin on growth and metasta- 32. Prandoni P, LensingAW,Buller HR et al. Deep-vein tologica 2005; 90: 815–821. sisofJWsarcoma in mice. Eur JCancer 1980; 16: thrombosisand theincidenceofsubsequent sympto- 49. MaugeriN,DiFabio G, Barbanti M, et al.Parnapa- 919–923. matic cancer.NEngl JMed 1992; 327:1128–1133. rin, alow molecular weight heparin,prevents P-selec- 15. Gordon SG,Franks JJ,Lewis B. Cancerprocoagu- 33. Prandoni P, FalangaA,PiccioliA.Cancer and ve- tin-dependent formation of platelet-leukocyte aggre- lant A: afactor X-activatingprocoagulant from malig- nousthromboembolism. Lancet Oncol 2005; 6: gatesinhuman whole blood.Thromb Haemost2007; nanttissue. ThrombRes 1975; 6: 127–137. 401–410. 97: 965–973. 16. Colucci M,Delaini F, De Bellis Vitti G, et al. War- 34. Lee AYY. Thrombosisand cancer:The role of 50. Lorenzet R, Donati MB. Bloodclottingactivation, farininhibits both procoagulant activityand metastatic screeningfor occult cancer and recognizing theunder- angiogenesis and tumormetastasis: anyrole forTFPI? capacityofLewis lungcarcinoma cells.Role of vit- lyingbiological mechanisms. In:Hematology 2006, ThrombHaemost2002;87: 928–929.

aminKdeficiency. BiochemPharmacol1983;32: Am Soc Hemat, Education Program Book,Bajus JL. 51. Donati MB, LorenzetR.Coagulationfactors and This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. 1689–1691. Ed. p438–443. tumorcell biology: therole of tissue factor.Pathophy- 17. Lorenzet R, Bottazzi B, Locati D, et al. Failure of 35. Zacharski LR, Donati MB. Registryofclinical siolHaemostThromb 2003; 33 (Suppl1): 22–25. warfarintoaffect thetissue factor activityand themeta- trials of antithrombotic drugs in cancer.The Scientific 52. Donati MB, FalangaA,Lorenzet R. Cancerand static potential of murine fibrosarcoma cells.Eur J and StandardizationCommitteeoftheInternational thrombosis: atwo wayinteraction. In:Thrombosis. CancerClin Oncol 1985; 21: 263–265. Society on Thrombosis and Haemostasis. Subcommit- Fundamental and clinical aspects. Leuven University 18. Donati MB, GambacortiP,Casali B, et al. Cancer teeonHemostasisand Malignancy. ThrombHaemost Press,2003:pp. 417–31. procoagulant in human tumorcells:Evidence from 1989; 61: 526–528. melanoma patients. CancerRes 1986; 46: 6471–6474. 36. Zacharski LR, Donati MB, Rickles FR. Registryof 19. GrignaniG,FalangaA,Pacchiarini L, et al. Human clinical trials of antithrombotic drugs in cancer:Sec- breastand colon carcinomas expresscysteineprotei- ond report. Thromb Haemost1993;70: 357–360. naseactivitieswith pro-aggregatingand pro-coagulant 37. Randomised trialofintravenousstreptokinase, oral properties. Int JCancer 1988; 42: 554–557. aspirin, both, or neither among 17,187 cases of sus-

128