absence of activated protein c resistance in nonmetastatic gastric

Experimental Oncology 25, 231-232, 2003 (September)
Exp Oncol 2003
25, 3, 231-232
231
ABSENCE OF ACTIVATED PROTEIN C RESISTANCE
IN NONMETASTATIC GASTRIC CANCER PATIENTS
P. Di Micco*, G. Castaldo, G. Granata, A. Niglio
IV Division of Internal Medicine, Second University of Naples, Naples, Italy
ÎÒÑÓÒÑÒÂÈÅ ÐÅÇÈÑÒÅÍÒÍÎÑÒÈ ÀÊÒÈÂÈÐÎÂÀÍÍÎÃÎ ÏÐÎÒÅÈÍÀ Ñ
Ó ÁÎËÜÍÛÕ Ñ ÍÅÌÅÒÀÑÒÀÒÈ×ÅÑÊÈÌ ÐÀÊÎÌ ÆÅËÓÄÊÀ
Ï. Äè Ìèêêî*, Ã. Êàñòàëäî, Ã. Ãðàíàòà, A. Íèãëèî
IV îòäåëåíèå âíóòðåííåé ìåäèöèíû, Âòîðîé óíèâåðñèòåò Íåàïîëÿ, Íåàïîëü, Èòàëèÿ
Studies on thrombophilia of gastric cancer patients, in particular in nonmetastatic gastric cancer, are lacking in
literature. Previous reports showed hypofibrinolysis in advanced gastric cancer patients and acquired activated
protein C resistance in advanced gastric cancer patients ongoing chemotherapy. In 2001 Di Micco et al described
thrombophilia of nonmetastatic gastric cancer patients for the first time, but without correlation with hypofibrinolysis. Data of this report confirmed acquired thrombophilia of nonmetastatic gastric cancer patients but did not
show acquired activated protein C resistance (APCr) in this stage of the disease.
Key Words: hypercoagulable state, cancer acquired thrombophilia, gastric cancer, factor V Leiden.
 ëèòåðàòóðå îòñóòñòâóþò äàííûå ïî èññëåäîâàíèþ òðîìáîôèëèè ó áîëüíûõ ðàêîì æåëóäêà.  ïðåäûäóùèõ
ñîîáùåíèÿõ óêàçûâàëîñü íà íàëè÷èå ãèïîôèáðèíîëèçà ó áîëüíûõ ñ ïðîãðåññèðóþùèì ðàêîì æåëóäêà è
ïðèîáðåòåííîé ðåçèñòåíòíîñòüþ àêòèâèðîâàííîãî ïðîòåèíà Ñ ó áîëüíûõ ñ ïðîãðåññèðóþùèì ðàêîì æåëóäêà,
êîòîðûì ïðîâîäèëè õèìèîòåðàïèþ. Â 2001 ã. Di Micco è ñîàâòîðû âïåðâûå îïèñàëè òðîìáîôèëèþ, íå
êîððåëèðóþùóþ ñ ãèïîôèáðèíîëèçîì, ó áîëüíûõ c íåìåòàñòàòè÷åñêèì ðàêîì æåëóäêà. Íàñòîÿùåå èññëåäîâàíèå
ïîäòâåðæäàåò íàëè÷èå ïðèîáðåòåííîé òðîìáîôèëèè ó áîëüíûõ ñ íåìåòàñòàòè÷åñêèì ðàêîì æåëóäêà ïðè
îòñóòñòâèè ïðèîáðåòåííîé ðåçèñòåíòíîñòè àêòèâèðîâàííîãî ïðîòåèíà Ñ (APCr) íà äàííîé ñòàäèè çàáîëåâàíèÿ.
Êëþ÷åâûå ñëîâà: ñîñòîÿíèå ãèïåðêîàãóëÿöèè, òðîìáîôèëèÿ, ðàê æåëóäêà, ôàêòîð V Ëåéäåíà.
Lot of reports showed cancer acquired thrombophilia
[1, 2], since Trousseau described this clinical association the first time [3]. Oncological disease, in fact, is the
more common cause of acquired thrombophilia [4] and
for this reason thromboembolic complications are frequent in cancer patients [5]. However, many pathways
seem to be involved in pathophysiology of hypercoagulable state of cancer patients [6], so confirming venous
thromboembolism is a multifactorial disease.
Previous reports, in particular by Tiutrin et al and by
De Lucia et al [7, 8], showed acquired thrombophilia of
gastric cancer patients in advanced stage involving
hypofibrinolysis and an acquired activated protein C
resistance (APCr) respectively. In 2001 Di Micco et al
[9] showed cancer acquired thrombophilia also in non
advanced stage of gastric cancer patients. The aim of
this study is to investigate APCr in nonmetastatic gastric cancer patients in order to explain thrombophilia in
this stage of the disease.
We selected 9 patients affected by nonmetastatic
gastric cancer (8 males and 1 female, mean age 50 ±
8 years, 8 intestinal type and 1 diffuse type) and
10 healthy age matched subjects (8 males and 2 females, mean age 49 ± 9 years) as control group.
Received: July 26, 2003.
* Correspondence:
E-mail: pdimicco@libero.it
Abbreviations used: APCr — acquired activated protein C resistance; aPTT — activated partial thromboplastin time; F 1+2 — prothrombin fragment 1+2; FVL — factor V Leiden mutation; PT —
prothrombin time.
We studied in all subjects prothrombin time (PT, as
INR, Roche, Milan, Italy), activated partial thromboplastin time (aPTT, as ratio, Roche, Milan, Italy), fibrinogen
(Behring, Scoppito, AQ, Italy), activated protein C resistance (APCr, according to the method described by
Dahlabck [10]), and prothrombin fragment 1+2 (F1+2,
Enzygnost, Behring, Scoppito, AQ, Italy) as marker of
thrombin generation.
Inherited thrombophilia leading to APCr (i.e. presence of factor V Leiden [9]) had been performed only
in subjects with APCr. Test was based on DNA extraction and PCR from a whole blood sample (5 ml) collected in EDTA. Factor V Leiden mutation (FVLG1691A)
was researched using specific primers that allow to
amplify interesting regions where point mutations are
eventually situated. The analysis was performed on
Light Cycler (Roche, Italy).
Statistical analysis was based on Student’s t-test
for unpaired data. Differences were considered to be
significant if p < 0.05.
Coagulation screening (data are summarized in the
Table) showed comparable values for PT INR (0.99 ±
Table. Coagulation tests on nonmetatstatic gastric cancer patients
and control subjects
Parameters
Gastric cancer Control subjects
p
patients (n = 9)
(n = 10)
PT INR
0.99 ± 0.06
1.00 ± 0.08
0.58, ns
aPTT ratio
1.06 ± 0.06
1.09 ± 0.08
0.18, ns
Fibrinogen, mg/dl
385 ± 35
335 ± 90
0.08, ns
F1 +2 nM
2.9 ± 0.6
0.73 ± 0.12
<0.05, s
APCr (Dahlback m.)
2.89 ± 0.03
2.86 ± 0.05
0.28, ns
Abbreviation: INR: international normalized ratio.
232
0.06 vs 1.00 ± 0.08; p = 0.58, ns) and aPTT ratio (1.06 ±
0.06 vs 1.09 ± 0.08; p = 0.18, ns). Plasma fibrinogen
levels were higher in cancer patients compared to control subjects, but this did not reach statistical significance
(385 ± 35 mg/dl vs 335 ± 90 mg/dl; p = 0.08, ns). F1+2
was approximately 3 folds higher in cancer patients compared to control group (2.8 ± 0.6 nM vs 0.73 ± 0.12 nM;
p < 0.05, s). Finally, APCr, measured with the method
described by Dahlback, was comparable in both groups
(2.89 ± 0.03 vs 2.86 ± 0.05; p = 0.28, ns).
Moreover, only 1 male of control group showed APCr
(1.57, normal value < 2.0, according to the method
described by Dahlback) and genetic analysis showed
he was heterozy gous for FVL.
Venous thrombosis is a multifactorial disease and
its pathogenesis often involves genetic and acquired
risk factors [11]. Hypercoagulable state, in fact, is associated to venous thrombosis and it may equally be
related to genetic and environmental risk factors [10,
11]. The most common known genetic thrombotic risk
factor is a point mutation in the gene of clotting factor V
where Arg506 is replaced with Gln (i.e. FVLG1691A) [10].
Via a complicated series of reactions this mutation leads
to hypercoagulable state inducing an activated protein C
resistance [10] and the following increased thrombotic
risk of carrying subjects [10]. Therefore, APCr is usually referred to a genetic predisposition but in few cases we can find an acquired APCr [8, 11].
Cancer is recognised as one of eventual cause of acquired APCr and overall is the most common cause of
acquired thrombophilia [1, 4, 12]. According to these fin dings, oncological patients are often affected by DVT [5].
However, studies on incidence of thrombosis in
gastric cancer patients are lacking. Literature data, in
fact, showed only an increased incidence of DVT in
advanced stage of gastric cancer patients [7]. Moreover, Di Micco et al [9] showed that hypercoagulable
state is present also in non advanced stage of gastric
cancer patients without a clear relationship with clinical
signs of DVT. Data of present report confirmed hypercoagulable state in nonmetastatic gastric cancer patients, testified by increased F1+2 as marker of thrombin
generation; y et APCr test, according to the method
described by Dahlback, did not show any differences
between nonmetastatic gastric cancer patients and
control subjects. Only 1 male of control group, in fact,
showed APCr and the following genetic test showed
that he was heterozygous for FVL mutation.
Finally, we can argue one more time the hypercoagulable state in oncological patients, in particular in nonmetastatic gastric cancer patients, so confirming cancer
acquired thrombophilia. Moreover, we can postulate that
Experimental Oncology 25, 231-232, 2003 (September)
cancer acquired thrombophilia is present since first phases
of disease. Furthermore, we may underline that referred
cancer acquired thrombophilia is not related to APCr counteracting previous reported data of patients affected by
advanced gastric cancer ongoing chemotherapy [8]. Yet,
this described APCr of advanced gastric cancer patients
ongoing chemotherapy could be due not only to oncological disease but also to pharmacological treatment. So,
although our data are so strong to do not refer to acquired
APCr the hypercoagulable state of nonmetastatic gastric
cancer patients but to other pathways, they should be
confirmed by large population studies.
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