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.  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. REFERENCES 1. Di Micco P, De Lucia D, De Vita F, Niglio A, Di Micco G, Martinelli E, Chirico G, D’ Uva M, Torella R. Acquired cancer-related thrombophilia testified by increased levels of prothrombin frament 1+2 and d-dimer in patients affected by solid tumors. Exp Oncol 2002; 24: 108–11. 2. Falanga A. Tumor cell prothrombotic properties. Haemostasis 2001; 31: 1–4. 3. Trousseau A. Plegmasia alba dolens. 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