Venous Thrombosis and Cancer

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Venous Thrombosis and Cancer
72 year old female, R popliteal DVT. Dx AML -
M2 67 year old male, L leg DVT on coumadin. Dx
CLL 52 year old female, L main pulm a, LLL, RUL
PEs. Dx breast ca 97, status? 73 year old
male, DVT and PE. Dx multiple myeloma? 45 year
old female, DVT from iliacs to renal veins. Dx
polycythemia vera
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Case Presentation
CC right hemiplegia, aphasia, obtundation HPI 61
year old man living in Haiti 4 wks ago
developed pain in right leg, no abnormalities on
ultrasound, treated with ASA. 3 wks ago had
transient headache, nausea, vomiting, difficulty
with balance. 2 wks ago, balance problem
resolved and head CT was normal. 1 wk ago
developed abdominal pain and intermittent
headaches Morning of admission, flew to USA and
had difficulty signing his name on boarding,
spoke with difficulty, developed weakness in
right leg. On arrival developed right
hemiparesis, aphasia. Brought to hospital and
intubated.
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Case Presentation - Day 1
ROS No chest pain, dyspnea, fever, chills,
sweats, weight loss, recent dental
procedures. PH diabetes mellitus type 2.
FH Negative for stroke, clotting disorders
positive for diabetes. PE Obtunded, T36.4,
P137, R20, BP165/75 HEENT Icteric Chest
clear CV 2/6 apical SEM. Left carotid, PT, DP
pulses absent. Abd Liver hard, 5 cm below
costal margin Skin no rash Ext Left leg pale
and cold below mid calf Neuro PEERL. Right
hemiparesis. DTRs present.
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Case Presentation - Day 1
U/A protein, bilirubin, 3-5 rbc, 0-2
wbc. EKG sinus tach at 140, inferior and
laterial infarction. CXR patchy atelectasis at
left base.
Hct 35.3, wbc 27,900 (74N, 3B, 17L, 4M), plt
193K, MCV 81 PT 14.1, PTT 36 Na 134, K 5.7, Cl
102, CO2 19.9, BUN 66, Cr 3.9, Glc 188 Total
bili 4.9, Direct bili 3.5, Protein 7.7, Alb 2.4,
Trop 1.27, Alk phos 415, ALT 143
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Brain MRI Scans
Infarcts on fluid-attenuated inversion recovery
(Panel A) are hyperintense on diffusion-weighted
images (Panel B) and hypointense on
apparent-diffusion-coefficient images (Panel C)
suggesting they are acute.
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Abdominal CT with Contrast
Focal lesions (solid arrows). Geographic low
attenuation (open arrow) suggests abnormal
perfusion. Wedge-shaped infarct (arrowhead).
Abnormal perfusion of liver and kidneys. Minimal
uptake in the left kidney. Contrast present in
the renal arteries at their origins (arrows).
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CT Abdomen
Transesophageal Echocardiogram
Thickening of the ascending colon (arrows), with
abrupt transition to normal thickness (arrowhead).
Large vegetation on the mitral valve. No r-l
shunt.
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Clinical Course
Rx Ceftriaxone, vancomycin, metoprolol,
heparin Day 2 Fe 27, TIBC 124, Ferritin 7705,
Haptoglobin 227 BUN 70, Cr 4.1 LDH 1923 Trop
2.19 Blood cultures - no growth Day 7 Cardiac
arrest, death
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Liver Biopsy
Metastatic adenocarcinoma
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Liver Biopsy
Hematoxylin and eosin
Mucicarmine
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Diagnoses
Phlegmasia alba dolens (painful white
inflammation) caused by venous thrombosis as a
manifestation of a hypercoagulable paraneoplastic
syndrome (Trousseau syndrome) Nonbacterial
thrombotic endocarditis and multiple ischemic
strokes associated with an underlying cancer
(also a component of Trousseau syndrome)
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Trousseau(s) Syndrome
Armand Trousseau (1801-1867) 1865, lecture 95
described phlegmasia alba dolens as a
presenting symptom of occult cancer 1867,
January 1, Trousseau developed phlegmasia alba
dolens of his left leg and correctly predicted
the diagnosis of his own stomach cancer, which
soon killed him.
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Trousseau Syndrome
Sack et al (1977) Medicine 561-37
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Trousseau Syndrome
Sack et al (1977) Medicine 561-37
Any VT
Migratory VT
65
78
16
8
20
13
7
12
7
45
7
45
6
6
Hemorrhage
Arterial Emboli
Hemorrhage
Arterial Emboli
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Trousseau Syndrome
Sack et al (1977) Medicine 561-37
Recurrent symptoms on cessation
10
8
1
8
8
4
2
4
3
10
Heparin Failure
Warfarin Failure
Heparin Response
Warfarin Response
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28
36
6
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Trousseau Syndrome
What do tumors (mainly adenocarcinomas) express
to promote thrombosis? Tissue factor? Platelet
agonists? Prothrombotic proteases? Prothrombotic
mucins? Why is heparin effective and warfarin
ineffective? Might heparin function not as an
anticoagulant?
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Selectins Bind Mucins
On Activated endothelium (transcriptional) Binds
PSGL-1 on leukocytes
On Neutrophils, monocytes, lymphocytes Binds
PSGL-1 on leukocytes CD34, GlyCAM1, podocalyxin
on HEV, endothelium
On Activated platelets, endothelium (acute
secretion) Binds PSGL-1 on leukocytes
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PSGL-1, a Mucin-Like Selectin Ligand
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(No Transcript)
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Purification of LS180 Mucins
Human colon adenocarcinoma LS180 tumors in
RAG2-/- mice Homogenize, solubilize Acid
precipitation, chloroform/methanol
extraction Digest with Proteinase
K Heparinase ChondroitinaseABC DNase Sephacryl
HR-S-200 size exclusion chromatography Collect
void volume fraction, mass gt 200 kDa
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Purified Mucin Preparations
Mucins are large and retain calcium-dependent
binding sites for all three selectins. (a) A 4
SDS-PAGE gel with detection of carbohydrates by
PAS reagent. (b) ELISA in which immobilized mucin
preparations are probed with recombinant soluble
murine selectins. Values represent mean SEM n
5 individual mucin preparations. P, P-selectin
L, L-selectin E, E-selectin.
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Composition of LS180 Mucin Preparation
Man 0 Little N-linked CHO Xyl, Glc, GalA,
GlcA, IdoA 0 No glycosaminoglycans Rib, dRib
0 No nucleic acids Heptose, KDO 0 No
lipopolysaccharide
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Assays of Mucin for Procoagulants, Endotoxin
Blood clotting initiation in the fluid phase No
detectable tissue factor (lt1 ng sensitivity) No
detectable procoagulant lipids in PTT
assays Platelet activating activity in
vitro No effect on platelet activation by ADP,
arachadonic acid, epinephrine, or
collagen Pyrogenicity No IL-6 released on 20 h
incubation with mouse MNCs (a very sensitive test
for endotoxin)
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Mouse Lung After Mucin Injection
Average number of CD41-positive pixels per 200x
view field (mean value of 20 random fields). Each
bar represents the mean SEM. P lt 0.001
compared with PBS-injected mice, n 7 P lt
0.05, n 5.
In vivo platelet-rich microthrombi in wild-type
lung observed with fluorescent anti-platelet CD41
( GPIIB).
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Selectin Deficiency Attenuates Thrombosis
CD41 in lung sections. Values represent the mean
SEM. P lt 0.001 compared with mucin-injected
wild-type mice, n 7 P lt 0.05, n 7. White
bars, PBS-injected mice black bars,
mucin-injected mice.
Platelet-rich thrombi in lung 5 min after mucin
injection.
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Thrombosis is Independent of Thrombin
CD41 in lung sections 5 minutes after injection.
(a) Ability of heparin or hirudin to block the
effects of mucin in wild-type mice. P lt 0.05
compared with mucin alone, n 5 P lt 0.001
compared with PBS-injected mice, n 5.
Heparin blocks P-selectin and L-selectin
interactions
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Thrombosis is Independent of Thrombin
Immunofluorescence of microthrombi in wild-type
mice injected with mucin (with or without
hirudin) to demonstrate fibrin, an indicator of
thrombin activity. Bright green indicates fibrin
pale green indicates autofluorescence of luminal
surface of venule red indicates platelets blue
indicates nuclei.
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Microangiopathic Features in Tumor-Bearing Mice
Anemia, reticulocytosis, shistocytosis, hemolysis
(increased LDH and bilirubin), and circulating
platelet aggregates
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Role of Leukocyte L-Selectin
Flow-cytometric quantification of platelet
activation based on P-selectin expression in
stirred, hirudin-anticoagulated whole blood.
Black bars, wild-type mouse blood gray bars,
L-sel/ mouse blood. Values represent the mean
SEM (n 3) P 0.007 relative to PBS-treated
controls P 0.003 relative to mucin-treated
wild-type blood.
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Model for Mucin and Selectin-Mediated Thrombosis
L indicates L-selectin (L-sel) ligands on mucins.
P indicates P-selectin (P-sel) ligands,
including mucins and leukocyte PSGL-1.
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Questions
What do leukocytes do to expose platelet
P-selectin? Signal transduction
pathway Mediators Any synergy with other
mechanisms for platelet activation, blood
coagulation? Physiological relevance to
thrombosis in human cancers?
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Mucins and Cancer
Many adenocarcinomas upregulate MUC1, MUC2,
MUC5AC, MUC4, MUC16 These mucins often bear
Sialyl-Lex structures CA125 MUC16 CEA is a
mucin, levels of 4.6 µg/ml in patients with colon
and rectal cancer CA 19-9 detects Sialyl-Lex on
mucins, present at up to 100 µg/ml in pancreatic
cancers. Q Correlation between mucin/marker
level and Trousseau syndrome? A Not yet
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Relevance to Medical Practice?
Heparin (LMWH) should be considered for
thrombosis in patients with adenocarcinoma, and
especially for recurrent thrombosis. The
relationship between Trousseau syndrome and
circulating mucins could be addressed. Additional
targets for intervention could include
leukocyte-platelet signaling pathways binding
sites on selectins Mucin-selectin interactions
suggest another mechanism for thrombotic
microangiopathy
34
Mucins and Thrombotic Microangiopathy?
Standard Model
Cancer Model?
X
Rx Plasma exchange Immunosuppression
Rx Plasma Exchange? Heparin? Cytokine
antagonists?