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Abstract

Venous thromboembolism (VTE) during chemotherapy is common, with 7% mortality in metastatic breast cancer (MBC). In a prospective cohort study of patients with breast cancer, we investigated whether vascular endothelial cell activation (VECA), and whether apoptosis, is the cause of chemotherapy-induced VTE. Methods: Serum markers of VECA, E-selectin (E-sel), vascular cell adhesion molecule 1 (VCAM-1) and d-dimer (fibrin degradation and hypercoagulability marker) were measured prechemotherapy and at 1, 4, and 8 days following chemotherapy. Clinical deep vein thrombosis (DVT) or pulmonary embolism and occult DVT detected by duplex ultrasound imaging were recorded as VTE-positive (VTE+). In patients with MBC, hypercoagulable response to chemotherapy was compared between patients with and without cancer progression. Development of VTE and cancer progression was assessed 3 months following starting chemotherapy. Results: Of the 134 patients, 10 (7.5%) developed VTE (6 [17%] of 36 MBC receiving palliation, 0 of 11 receiving neoadjuvant to downsize tumor, and 4 [5%] of 87 early breast cancer receiving adjuvant chemotherapy, P = .06). Levels of E-sel and VCAM-1 decreased in response to chemotherapy (P < .001) in both VTE+ and patients not developing VTE (VTE−). However, decrease in VECA markers was similar in VTE+ and VTE− patients, implying this is not the cause of VTE. In patients with MBC following chemotherapy, d-dimer (geometric mean) increased by 36% in the 21 patients with MBC responding to chemotherapy but steadily decreased by 11% in the 15 who progressed (day 4, P < .01), implying patients with tumor response (apoptosis) had an early hypercoagulable response. Conclusions: During chemotherapy for breast cancer, VECA is induced; however, this is not the primary mechanism for VTE. Chemotherapy-induced apoptosis may enhance hypercoagulability and initiate VTE.

Keywords

venous thromboembolism hypercoagulability deep venous thrombosis

Introduction

Venous thromboembolism (VTE) following breast cancer chemotherapy is common. In early breast cancer (EBC), VTE occurs in 1% to 10% of patients receiving chemotherapy,^1

–4 with a mortality of 0.2% to 0.5%.^1,5 The VTE rates increase to approximately 18% in metastatic breast cancer (MBC),⁶ with a mortality of 7%.⁶ Two possible suggestions for pathogenesis are (1) vessel wall injury as a result of the direct toxic effects of chemotherapy on endothelial cells^{7

–15} and (2) apoptosis releasing procoagulant exosomes or microparticles.^16,17

The endothelial effects of intravenous chemotherapy are demonstrated clinically by the difficulty in maintaining venous access in patients. This is due to thrombophlebitis secondary to high chemotherapy concentration in peripheral venous blood proximal to the infusion site. Biochemically, chemotherapy-induced vascular endothelial cell activation (VECA) is demonstrated by increased circulating endothelial cells and plasma von Willebrand factor, markers of endothelial cell activation.^{14,18

–23} Despite evidence to support chemotherapy-induced VECA, such endothelial cell activation has yet to be shown to relate to clinical VTE.

An alternate theory for chemotherapy-induced thrombosis is tumor cell apoptosis, in response to effective chemotherapy, causing prothrombotic microparticle release,^16,17 increased tissue factor (the initiating protein of the extrinsic clotting cascade) activity, and thrombin generation.²⁴

d-Dimer, an end product of fibrin degradation, is used clinically in the diagnosis of VTE. d-Dimer also has a potential predictive role for VTE, for example, in EBC, a normal prechemotherapy d-dimer can identify a subgroup of patients at minimal risk of VTE.²⁵ d-Dimer in cancer can be used as a marker of hypercoagulability.

We aimed to determine whether chemotherapy-induced VECA or chemotherapy-induced apoptosis is the cause of VTE. In post hoc analysis of a previously reported cohort of patients with breast cancer,²⁵ we compared the endothelial response to chemotherapy in VTE+ compared to VTE− patients. In addition, in the metastatic subgroup of this cohort, we determined the hypercoagulable response to chemotherapy in patients with ongoing progression, despite chemotherapy (presumed low apoptosis) compared to response to chemotherapy (presumed high apoptosis).

Methods

In a prospective cohort study of patients commencing chemotherapy for breast cancer, VECA was compared in VTE+ and VTE−, and hypercoagulability was compared in patients responsive versus not responsive to chemotherapy.

Patients With Breast Cancer Commencing Chemotherapy

Consecutive women commencing adjuvant, neoadjuvant, or palliative chemotherapy for breast cancer at Christie Hospital NHS Trust were approached. Over a 2-year period, 134 women (median age 52 [range, 31-78] years) were recruited. Of these, 87 were patients with EBC commencing adjuvant chemotherapy following curative surgery, 11 commencing neoadjuvant chemotherapy for large or inflammatory breast cancers, and 36 commencing palliative chemotherapy for radiographically proven metastatic breast disease (Table 1). Patients were excluded if they were on anticoagulants, had a past history of VTE, had undergone previous chemotherapy within 3 months, were on hormone therapy, had implanted vascular access devices, or a World Health Organization performance status below 3.²⁶

Table 1.

Chemotherapy Regimens used in Patients With Breast Cancer.

Chemotherapy Regimen	Number of Patients
Adjuvant regimens
5-Fluorouracil, epirubicin, cyclophosphamide (±docetaxel)	65
Cyclophosphamide, methotrexate, fluorouracil	15
Epirubicin, cyclophosphamide	4
Epirubicin	3
Neoadjuvant regimens
Doxorubicin, cyclophoshamide	9
Epirubicin, vinorelbine	2
Metastatic regimens
Docetaxel	15
Cyclophosphamide, methotrexate, fluorouracil	8
Epirubicin, docetaxel	6
Vinorelbine, mitomycin	3
Epirubicin	2
Fluorouracil, epirubicin, cyclophosphamide	1
Vinorelbine, fluorouracil	1

Protocol

Serum markers of endothelial cell activation (vascular cell adhesion molecule 1 [VCAM-1] and E-selectin [E-sel]) and d-dimer were measured prior to chemotherapy (baseline) and at 24 hours, 4, and 8 days following commencement of chemotherapy. Markers of acute-phase response (fibrinogen, platelet count, and C-reactive protein [CRP]) were also measured at baseline. All samples were anonymized prior to analysis. Bilateral full-leg duplex ultrasound imaging for deep vein thrombosis was performed by accredited vascular scientists (Society of Vascular Technologists) in all patients 1 month following commencement of chemotherapy, and repeated if symptoms of VTE developed, up to 3 months following commencement of chemotherapy. Clinical and radiological assessment of response to chemotherapy was performed at 3 months following commencement of chemotherapy.

Blood Sampling and Analytical Methods

Atraumatic venous blood samples, taken from the antecubital vein, were stored in citrate (plasma) or allowed to clot at room temperature (serum), separated, and stored within 2 hours. Samples were centrifuged (2500g) for 20 minutes at 4°C and the serum or plasma removed. Samples were then divided into 0.3-mL aliquots and stored at −80°C until analysis.

Serum VCAM-1 and E-sel were analyzed using enzyme-linked immunosorbent assays (ELISAs) by R&D Systems (Oxon, United Kingdom) with a sensitivity of 2 ng/mL and less than 0.1 ng/mL, respectively. Plasma d-dimer was analyzed by a quantitative fully automated ELISA using the VIDASs d-dimer (bioMerieux, Marcy l’Etoile, France) system, with a sensitivity of 45 ng/mL and upper limit of normal of 500 ng/mL. Fibrinogen analysis was performed on an Instrumentation Laboratory ACL 3000 (Bedford, Massachusetts). Normal ranges were 1.5 to 5.0 g/L for derived fibrinogen. Platelet count was performed by the hematology department, South Manchester University Hospital, using the Advia 120 Haematology System by Bayer (Bayer Healthcare, Newbury, UK). A highly sensitive CRP assay was performed, with a BNII automated system from BN Systems (Germany). The assay uses particle-enhanced immunonephelometry to quantitate CRP in serum samples.

Ethical Approval

The study was approved by the South Manchester Local Research Ethics Committee, and all patients gave written informed consent.

Statistical Methods and Sample Size

Data on VCAM-1, E-sel, and d-dimer were reported as geometric means (confidence interval). Comparative group analysis (VTE+ and VTE−) of patient values was by independent t test. Changes in patient serum/plasma values following chemotherapy were analyzed using paired t test. Repeated measures analysis, with Greenhouse Geiser correction, was used to compare trends over time in VTE+ versus VTE−. Changes in serum/plasma parameters with chemotherapy from pretreatment values were performed by analysis of covariance (VTE+ vs VTE−). Correlations of VECA and d-dimer were performed using Spearman coefficient. Fisher exact test compared rate of VTE in EBC and MBC. A significance value of P < .05 was used.

The sample size calculation was based on estimated rates of VTE in patients with MBC receiving chemotherapy compared to patients with EBC receiving chemotherapy, using a chi-square test with Yates correction.^4,6 This study was originally powered to detect a difference in rate of VTE between patients with MBC and EBC, with 120 patients in each group providing 80% power to detect a difference (5% significance) between the expected frequency of VTE of 17% with chemotherapy for advanced cancer and 5% for early carcinoma. The study was closed before recruitment targets were reached.

Results

Of 134 patients with breast cancer commencing chemotherapy, 10 (7.5%) patients were VTE+ of which 6 (60%) were symptomatic (Table 2).

Table 2.

Demographics and VTE Data on Patients Developing VTE.

Patient Number	Day Post Start of Chemotherapy	Stage	Site of VTE	Diagnostic Investigation	Age	Chemotherapy Regimen	Screen Detected or Symptomatic
48	27	MBC	Calf	Duplex	41	Epirubicin Docetaxel	Symptomatic
56	59	MBC	PE	V/Q	77	CMF	Symptomatic
67	35	MBC	Calf	Duplex	49	Docetaxel	Screen
69	35	EBC	Calf	Duplex	49	FEC	Screen
70	40	EBC	Calf	Duplex	54	FEC-T	Symptomatic
73	54	MBC	Femoral	Duplex	52	Docetaxel	Symptomatic
85	21	EBC	Femoral	Duplex	61	CMF	Symptomatic
122	55	MBC	PE	CTPA	40	FEC	Symptomatic
125	19	MBC	Femoral	Duplex	67	Paclitaxel	Screen
126	36	EBC	Calf	Duplex	61	FEC	Screen

Abbreviations: PE, pulmonary embolism; V/Q, ventilation-perfusion scan; duplex, duplex ultrasound imaging; CMF, cyclophosphamide, methotrexate, and fluorouracil; FEC, fluorouracil, epirubicin, and cyclophosphamide; FEC-T, FEC-docetaxel; VTE, venous thromboembolism; MBC, metastatic breast cancer; EBC, early breast cancer.

No patients were lost to follow-up. Of the 36, 6 (17%) patients with MBC and of the 87, 4 (4.6%) patients with EBC were VTE+. The increased rate of VTE in MBC compared to EBC approached significance (P = .06). None of the 11 patients receiving neoadjuvant chemotherapy developed VTE. At baseline, d-dimer and VCAM-1, but not E-sel, were significantly increased in patients with MBC compared to patients with EBC (Table 3).

Table 3.

The E-sel, VCAM-1, and d-Dimer Levels in EBC and MBC Prior to Commencement of Chemotherapy.^a

	EBC (CI)	MBC (CI)	P
E-sel, ng/mL	28.0 (25.3-30.9)	33.0 (26.4-41.2)	.1
VCAM-1, ng/mL	629 (586-674)	733 (617-870)	.05
d-Dimer, ng/mL	667 (585-764)	1335 (970-1838)	<.0001

Abbreviations: CI, confidence interval; EBC, early breast cancer; E-sel, E-selectin; MBC, metastatic breast cancer; VCAM-1, vascular cell adhesion molecule 1.

^aGeometric mean (95% confidence interval).

Baseline Hypercoagulability and Endothelial activation

Baseline d-dimer was elevated in patients who subsequently became VTE+ compared to VTE− (P = .003; Table 4). Baseline fibrinogen was also elevated in patients subsequently developing VTE (VTE+: mean 5.1 [standard deviation, SD: 2.8-7.5] g/L; VTE− mean 3.4 (SD: 3.2-3.7) g/L, P = .004). d-Dimer remained elevated in VTE+ patients at all times (P < .01). The VCAM-1 was increased prior to chemotherapy (P = .04) and remained elevated in VTE+ patients, with increased levels at 24 hours (P = .02) and day 4 following chemotherapy (P = .05; Table 4). There was no difference in E-sel in VTE+ compared to VTE− patients.

Table 4.

The E-sel, VCAM-1, and d-Dimer at Baseline and Following Chemotherapy in VTE+ and VTE− Patients.^a

	Baseline (Prechemotherapy), ng/mL	24 Hours Following Chemotherapy, ng/mL	Day 4 Following Chemotherapy, ng/mL	Day 8 Following Chemotherapy, ng/mL
E-sel
VTE+ (n = 10)	31.5 (18.8-52.7)	29.3 (17.1–50.3)	27.5 (17.5-43.3)	21.0 (13.1-33.8)
VTE− (n = 124)	29.3 (26.7-32.2)	28.2 (25.6-31.0)	24.9 (22.7-27.4)	22.4 (20.3-24.7)
P	.7	.8	.6	.7
VCAM-1
VTE+ (n = 10)	820 (680-989)	775 (629–956)	752 (630–898)	705 (572–868)
VTE− (n = 124)	636 (593-682)	575 (533–620)	591 (550–635)	571 (534–611)
P	.04	.02	.05	.08
d-Dimer
VTE+ (n = 10)	1614 (884-2944)	1748 (1007-3034)	1471 (638-3394)	1448 (686-3056)
VTE− (n = 124)	723 (628-833)	743 (642-861)	694 (598-806)	703 (609-810)
P	.003	.001	.007	.006

Abbreviations: E-sel, E-selectin; VCAM-1, vascular cell adhesion molecule 1; VTE, venous thromboembolism; VTE+, VTE positive; VTE−, VTE negative.

^aStudent t test to compare difference at each time point between patients with and without subsequent VTE. Geometric mean (95% confidence interval).

Chemotherapy-Induced VECA in VTE+ Compared to VTE− Patients

Analyzing all patients, irrespective of subsequent development of VTE, both E-sel and VCAM-1 decreased following chemotherapy (repeated measures analysis, P < .001), suggesting an endothelial response to chemotherapy. E-sel and VCAM-1 did not correlate with markers of the acute-phase response such as CRP, platelet count, and fibrinogen. However, this decrease was similar in VTE+ and VTE− patients (Figures 1 and 2), implying no difference in VECA between VTE+ and VTE−. Separate analysis comparing symptomatic VTE+ and VTE− also revealed no difference in VECA. Surprisingly, d-dimer did not change in response to chemotherapy.

Figure 1.

Change in serum E-selectin (E-sel) in response to chemotherapy in venous thromboembolism-positive (VTE+) and venous thromboembolism-negative (VTE−) patients. Geometric mean. Repeated measures analysis with Greenhouse-Geiser correction.

Figure 2.

Change in serum vascular cell adhesion molecule 1 (VCAM-1) in response to chemotherapy in venous thromboembolism-positive (VTE+) and venous thromboembolism-negative (VTE−) patients. Geometric mean. Repeated measures analysis with Greenhouse-Geiser correction.

Changes in E-sel did not correlate with d-dimer, but there was a possible correlation between VCAM-1 and d-dimer (P = .08, r = .13). As expected, VCAM-1 and E-sel were significantly related (P = .007, r = .19).

Hypercoagulable Response to Chemotherapy in MBC With early Progression Compared to Patients Responding to Chemotherapy

In subgroup analysis of the 36 patients with MBC, 15 had cancer progression at 3 months. In the 8 days following commencement of chemotherapy, d-dimer demonstrated a trend for decreasing levels in patients with progression of disease (percentage decrease in geometric mean from prechemotherapy to day 1: 0%; to day 4: 11%; and to day 8: 16%) and increasing level in patients responding to chemotherapy (percentage increase in geometric mean from prechemotherapy to day 1: 20%; to day 4: 36%; and to day 8: 10%; Figure 3). This difference in change from baseline between progressors and nonprogressors was significant at day 4 (P < .01).

Figure 3.

Change in plasma d-dimer in response to chemotherapy in patients with metastatic breast cancer (MBC) with and without evidence of cancer progression at 3 months following commencement of chemotherapy. Geometric mean and confidence intervals. P values shown are independent t tests comparing change from baseline to the relevant timepoint, comparing patients with MBC with (n = 15) and without (n = 21) progression.

Discussion

The chemotherapy-induced VTE rate of 4.6% in EBC and 17% in MBC reported in this study supports previously quoted figures.^1
–3,6,25 The risk of chemotherapy-induced VTE is underrecognized,²⁷ and thromboprophylaxis during chemotherapy is rarely used.²⁷ Irrespective of the cause of VTE, mortality from pulmonary embolism (PE) is 5% to 17%.²⁸ Development of VTE has an important impact on the mortality and morbidity of patients with cancer. Up to 60% of patients dying of cancer-associated VTE have localized cancer or limited metastatic disease, which would have allowed for reasonable survival in the absence of fatal PE.²⁹ In addition, the clinical course of VTE is complicated in up to 30% of patients by development of postthrombotic sequelae, such as pain, edema, hyperpigmentation, and ultimately venous ulceration.³⁰ Following development of VTE, there is a risk of VTE recurrence of 25% at 5 years, with this risk almost doubled in patients with cancer.³⁰ We have previously reported that a normal d-dimer may identify patients at low risk of VTE.²⁵ Here we also demonstrate that VCAM is increased prior to diagnosis of VTE and therefore may also have a predictive role for identifying patients who may benefit from thromboprophylaxis.

Bolus chemotherapy administration causes the vascular endothelium to be temporarily exposed to high concentrations of circulating toxic drugs, prior to peripheral tissue uptake. In addition, many chemotherapies have specific endothelial cytotoxic effects. At clinically relevant doses, bleomycin, vincristine, and adriamycin cause endothelial cell retraction with exposure of subendothelial matrix in vascular endothelial cell monolayers.³¹ Paclitaxel, cyclophosphamide, methotrexate, and fluorouracil are all cytotoxic to endothelial cells.^32

–35 Doxorubicin and cisplatin induce endothelial cell apoptosis, with the later causing release of endothelial microparticles.^17,36 Cultured human endothelial cells incubated with the plasma of patients with breast cancer receiving monthly adjuvant cyclophosphamide, epirubicin and 5-fluorouracil chemotherapy demonstrated increased endothelial cell reactivity¹³ providing further evidence that chemotherapy induces endothelial cell activation. In support of this, we have shown a marked endothelial response to chemotherapy, with both E-sel and VCAM-1. The E-sel is a recognized marker of endothelial cell activation³⁷ that has been shown, in mouse models, to be important for intravascular thrombus formation.³⁸ Levels of E-sel are increased in patients with myeloproliferative disease and venous thrombosis compared to patients with myeloproliferative disease without thrombosis.³⁹ The VCAM-1 is an endothelial adhesion protein. Expression of VCAM-1 is induced on endothelial cells by inflammation, where it acts as an adhesive receptor to facilitate adhesion, migration, and transmigration of circulating leukocytes into damaged vascular tissues. Circulating levels are increased in vasculitis.⁴⁰ There is a close relationship between inflammation and VECA; however, we found no correlation between VECA and markers of the acute-phase response such as platelet count, fibrinogen, or CRP in our cohort of patients, highlighting that E-sel and VCAM are not simply surrogate markers of inflammation.

The E-sel, VCAM-1, and d-dimer increase with increasing breast cancer stage.^41,42 In our data, the increased baseline VCAM-1 in the VTE+ subgroup may therefore reflect the higher proportion of patients with MBC in the VTE+ compared to VTE− group. However, it is possible that the higher baseline VCAM-1 in VTE+ represents subclinical VTE, as duplex imaging was not performed prior to commencement of chemotherapy.

The lack of baseline duplex ultrasound imaging is a potential weakness of this study; however, all patients were asymptomatic at recruitment. More importantly, chemotherapy-induced VTE in breast cancer is well documented, with baseline VTE rates in breast cancer one of the lowest cancers. A recent UK epidemiological study of 13 202 patients with breast cancer has highlighted that VTE in breast cancer is primarily associated with chemotherapy, with a greater than 10-fold increased risk of VTE following chemotherapy.⁴³

It is noteworthy that in our study both plasma E-sel and VCAM-1 decreased over time rather than increased. This may represent increased uptake of the circulating molecules by endothelial cells to allow increased expression of E-sel and VCAM-1 by activated endothelial cells, a marker of endothelial cell activation.⁴⁴ A similar response was seen in a study of patients undergoing hip surgery, with reducing E-sel levels, and stable VCAM-1 in response to the endothelial cell stimulus of surgery.^45,46 This hypothesis of particular polymorphisms of E-sel anchoring to the endothelial surface, thereby limiting the shedding of this molecule into the bloodstream is supported by the inverse relationship between E-sel and prognosis in end-stage renal disease.⁴⁷

However, this study was designed to investigate whether such chemotherapy-induced endothelial cell activation correlated with development of VTE. Many authors have assumed this causal relationship.^{7

–15} In vitro, Swystun et al demonstrated that exposure of plasma to either doxorubicin- or epirubicin-treated endothelial cells resulted in an increase in plasma thrombin generation.⁴⁸ However, for the first time, in this study we have demonstrated that there is no increased endothelial response in VTE+ compared to VTE− patients.

Although we cannot exclude the possibility that VECA plays a minor role in the multifactorial complication of chemotherapy-induced VTE, this study shows that endothelial cell activation is not a primary mechanism for causing VTE.

As patients with EBC are to some extent representing patients who are “cancer free” yet receiving chemotherapy, it may be reasonable to assume that VTE in this group is truly chemotherapy induced. The increased rate of VTE in MBC, compared to EBC, in our study implies that VTE is not simply a “chemotherapy” effect but may also be a “tumor response to chemotherapy” effect. The increased VTE rate in MBC supports the hypothesis of chemotherapy causing procoagulant release from the tumor (a factor that is missing in the EBC group, if it is presumed that patients with EBC are largely tumor free). This hypothesis is further strengthened by the chemotherapy-responsive patients having the greatest hypercoagulable response to chemotherapy. Patients with MBC responding to chemotherapy will have increased early tumor death or apoptosis, potentially enhancing the release of tumor-derived procoagulant exosomes or microparticles into the systemic circulation. This finding has important clinical implications, as it suggests that it is the patients who are responding to chemotherapy that may be succumbing to VTE. This increases the importance of thromboprophylaxis in this subgroup, as they will have a relatively promising cancer prognosis, compared to nonresponding patients with MBC. It is however acknowledged that patient numbers are limited in this subgroup and so this is hypothesis-generating data.

Conclusion

This study provides evidence that chemotherapy-induced VTE is not primarily due to endothelial cell activation. It further provides evidence that chemotherapy-induced apoptosis may initiate VTE. This may allow identification of patients at increased risk of VTE and allow more targeted thromboprophylaxis.

Footnotes

Authors’ Note

Presented at International Conference of Thrombosis and Haemostasis Issues in Cancer, Bergamo, Italy, April 2010.

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: During the course of this study, CCK was in receipt of a Royal College of Surgeons of England research fellowship.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by Cancer Research UK (grant number GD253EYS) and the Royal College of Surgeons of England.

References

Weiss

Tormey

Holland

Weinberg

. Venous thrombosis during multimodal treatment of primary breast carcinoma. Cancer Treat Rep. 1981;65 (7-8):677–679.

Levine

Gent

Hirsh

. The thrombogenic effect of anticancer drug therapy in women with stage II breast cancer. N Engl J Med. 1988;318 (7):404–407.

von Tempelhoff

Dietrich

Hommel

Heilmann

. Blood coagulation during adjuvant epirubicin/cyclophosphamide chemotherapy in patients with primary operable breast cancer. J Clin Oncol. 1996;14 (9):2560–2568.

Saphner

Tormey

Gray

. Venous and arterial thrombosis in patients who received adjuvant therapy for breast cancer. J Clin Oncol. 1991;9 (2):286–294.

Clahsen

van de Velde

Julien

Floiras

Mignolet

. Thromboembolic complications after perioperative chemotherapy in women with early breast cancer: a European Organization for Research and Treatment of Cancer Breast Cancer Cooperative Group study. J Clin Oncol. 1994;12 (6):1266–1271.

Goodnough

Saito

Manni

Jones

Pearson

. Increased incidence of thromboembolism in stage IV breast cancer patients treated with a five-drug chemotherapy regimen. A study of 159 patients. Cancer. 1984;54 (7):1264–1268.

Rickles

. Mechanisms of cancer-induced thrombosis in cancer. Pathophysiol Haemost Thromb. 2006;35 (1-2):103–110.

Numico

Garrone

Dongiovanni

. Prospective evaluation of major vascular events in patients with nonsmall cell lung carcinoma treated with cisplatin and gemcitabine. Cancer. 2005;103 (5):994–999.

Falanga

. Mechanisms of hypercoagulation in malignancy and during chemotherapy. Haemostasis. 1998;28 (suppl S3 ):50–60.

10.

De Cicco

. The prothrombotic state in cancer: pathogenic mechanisms. Crit Rev Oncol Hematol. 2004;50 (3):187–196.

11.

Doll

Yarbro

. Vascular toxicity associated with chemotherapy and hormonotherapy. Curr Opin Oncol. 1994;6 (4):345–350.

12.

Meinardi

Gietema

van Veldhuisen

van der Graaf

de Vries

Sleijfer

. Long-term chemotherapy-related cardiovascular morbidity. Cancer Treat Rev. 2000;26 (6):429–447.

13.

Bertomeu

Gallo

Lauri

Levine

Orr

Buchanan

. Chemotherapy enhances endothelial cell reactivity to platelets. Clin Exp Metastasis. 1990;8:511–518.

14.

Goon

Lip

Boos

Stonelake

Blann

. Circulating endothelial cells, endothelial progenitor cells, and endothelial microparticles in cancer. Neoplasia. 2006;8:79–88.

15.

Levine

. Adjuvant therapy and thrombosis: how to avoid the problem? Breast. 2007;16 (suppl 2 ):S169–S174.

16.

Nakamura

Yagata

Ohno

. Multi-center study evaluating circulating tumor cells as a surrogate for response to treatment and overall survival in metastatic breast cancer. Breast Cancer. 2010;17 (3):199–204. 10.1007/s12282-009-0139-3.

17.

Lechner

Kollars

Gleiss

Kyrle

Weltermann

. Chemotherapy-induced thrombin generation via procoagulant endothelial microparticles is independent of tissue factor activity. J Thromb Haemost. 2007;5 (12):2445–2452.

18.

Roodhart

Langenberg

Vermaat

. Late release of circulating endothelial cells and endothelial progenitor cells after chemotherapy predicts response and survival in cancer patients. Neoplasia. 2010;12 (1):87–94.

19.

Blann

Lip

. Assessment of endothelial function using plasma markers. Heart. 1997;78:321–322.

20.

Lee

Lip

Tayebjee

Foster

Blann

. Circulating endothelial cells, von Willebrand factor, interleukin-6, and prognosis in patients with acute coronary syndromes. Blood. 2005;105 (2):526–532.

21.

Landray

Wheeler

Lip

. Inflammation, endothelial dysfunction, and platelet activation in patients with chronic kidney disease: the chronic renal impairment in Birmingham (CRIB) study. Am J Kidney Dis. 2004;43 (2):244–253.

22.

Licciardello

Moake

Rudy

Karp

Hong

. Elevated plasma von Willebrand factor levels and arterial occlusive complications associated with cisplatin-based chemotherapy. Oncology. 1985;42 (5):296–300.

23.

Eissner

Multhoff

Gerbitz

. Fludarabine induces apoptosis, activation, and allogenicity in human endothelial and epithelial cells: protective effect of defibrotide. Blood. 2002;100 (1):334–340.

24.

Eccles

Aboagye

Ali

. Critical research gaps and translational priorities for the successful prevention and treatment of breast cancer. Breast Cancer Res. 2013;15 (5):R92.

25.

Kirwan

McDowell

McCollum

Kumar

Byrne

. Early changes in the haemostatic and procoagulant systems after chemotherapy for breast cancer. Br J Cancer. 2008;99 (7):1000–1006.

26.

Oken

Creech

Tormey

. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol. 1982;5 (6):649–655.

27.

Kirwan

Nath

Byrne

McCollum

. Prophylaxis for venous thromboembolism during treatment for cancer: questionnaire survey. BMJ. 2003;327 (7415):597–598.

28.

Punukollu

Khan

Punukollu

Gowda

Mendoza

Sacchi

. Acute pulmonary embolism in elderly: clinical characteristics and outcome. Int J Cardiol. 2005;99 (2):213–216. doi:10.1016/j.ijcard.2004.01.011.

29.

Shen

Pollak

. Fatal pulmonary embolism in cancer patients: is heparin prophylaxis justified? South Med J. 1980;73 (7):841–843.

30.

Prandoni

Lensing

Cogo

. The long-term clinical course of acute deep venous thrombosis. Ann Intern Med. 1996;125 (1):1–7.

31.

Nicolson

Custead

. Effects of chemotherapeutic drugs on platelet and metastatic tumor cell–endothelial cell interactions as a model for assessing vascular endothelial integrity. Cancer Res. 1985;45 (1):331–336.

32.

Wang

Lou

Lesniewski

Henkin

. Paclitaxel at ultra low concentrations inhibits angiogenesis without affecting cellular microtubule assembly. Anticancer Drugs. 2003;14 (1):13–19.

33.

Browder

Butterfield

Kraling

. Antiangiogenic scheduling of chemotherapy improves efficacy against experimental drug-resistant cancer. Cancer Res. 2000;60 (7):1878–1886.

34.

Basaki

Chikahisa

Aoyagi

. Gamma-hydroxybutyric acid and 5-fluorouracil, metabolites of UFT, inhibit the angiogenesis induced by vascular endothelial growth factor. Angiogenesis. 2001;4 (3):163–173.

35.

Cwikiel

Eskilsson

Albertsson

Stavenow

. The influence of 5-fluorouracil and methotrexate on vascular endothelium. An experimental study using endothelial cells in the culture. Ann Oncol. 1996;7 (7):731–737.

36.

Kalivendi

Kotamraju

Zhao

Joseph

Kalyanaraman

. Doxorubicin-induced apoptosis is associated with increased transcription of endothelial nitric-oxide synthase. Effect of antiapoptotic antioxidants and calcium. J Biol Chem. 2001;276 (50):47266–47276.

37.

Chong

Freestone

Patel

. Endothelial activation, dysfunction, and damage in congestive heart failure and the relation to brain natriuretic peptide and outcomes. Am J Cardiol. 2006;97 (5):671–675.

38.

Myers

Jr Farris

Hawley

. Selectins influence thrombosis in a mouse model of experimental deep venous thrombosis. J Surg Res. 2002;108 (2):212–221.

39.

Musolino

Alonci

Allegra

. Increased levels of the soluble adhesion molecule E-selectin in patients with chronic myeloproliferative disorders and thromboembolic complications. Am J Hematol. 1998;57 (2):109–112.

40.

Schneeweis

Rafalowicz

Feist

. Increased levels of BLyS and sVCAM-1 in anti-neutrophil cytoplasmatic antibody (ANCA)-associated vasculitides (AAV). Clin Exp Rheumatol. 2010;28 (1 suppl 57):62–66.

41.

O'Hanlon

Fitzsimons

Lynch

Tormey

Malone

Given

. Soluble adhesion molecules (E-selectin, ICAM-1 and VCAM-1) in breast carcinoma. Eur J Cancer. 2002;38 (17):2252–2257.

42.

Blackwell

Haroon

Broadwater

. Plasma d-dimer levels in operable breast cancer patients correlate with clinical stage and axillary lymph node status. J Clin Oncol. 2000;18 (3):600–608.

43.

Walker

West

Card

Kirwan

Grainge

. Chemotherapy is associated with the highest risk of VTE in breast cancer patients. Thromb Res. 2014;133(S2):S194–5.

44.

Hunt

Jurd

. Endothelial cell activation. A central pathophysiological process. BMJ. 1998;316:1328–1329.

45.

Smith

Quarmby

Collins

Lockhart

Burnand

. Changes in the levels of soluble adhesion molecules and coagulation factors in patients with deep vein thrombosis. Thromb Haemost. 1999;82 (6):1593–1599.

46.

Aosasa

Ono

Mochizuki

. Activation of monocytes and endothelial cells depends on the severity of surgical stress. World J Surg. 2000;24 (1):10–16.

47.

Malatino

Stancanelli

Cataliotti

. Circulating E-selectin as a risk marker in patients with end-stage renal disease. J Intern Med. 2007;262 (4):479–487.

48.

Swystun

Shin

Beaudin

Liaw

. Chemotherapeutic agents doxorubicin and epirubicin induce a procoagulant phenotype on endothelial cells and blood monocytes. J Thromb Haemost. 2009;7 (4):619–626.

Investigation of Proposed Mechanisms of Chemotherapy-Induced Venous Thromboembolism

Abstract

Keywords

Introduction

Methods

Patients With Breast Cancer Commencing Chemotherapy

Protocol

Blood Sampling and Analytical Methods

Ethical Approval

Statistical Methods and Sample Size

Results

Baseline Hypercoagulability and Endothelial activation

Chemotherapy-Induced VECA in VTE+ Compared to VTE− Patients

Hypercoagulable Response to Chemotherapy in MBC With early Progression Compared to Patients Responding to Chemotherapy

Discussion

Conclusion

Footnotes

Authors’ Note

Declaration of Conflicting Interests

Funding

References