[Thesis]. Manchester, UK: The University of Manchester; 2018.
Malignancy is associated with a hypercoagulable state manifested clinically by an
increased incidence of venous thromboembolism (VTE). Colorectal cancer (CRC) patients
who develop VTE have reduced survival. This increased mortality extends beyond the
acute VTE event, suggesting that VTE is associated with aggressive tumour biology.
Tissue factor (TF) and other clotting factors have been implicated in this process.
However, the significance of clotting factors in the tumour microenvironment (TME)
remains unknown. The aim of this thesis is to i) determine if a procoagulant TME is
a biomarker for poor prognosis and VTE in patients undergoing resectional surgery
for CRC and ii) determine the effect of TF, thrombin and FXa on proliferation and
migration in vitro in CRC and if their inhibitors have potential as anticancer therapies.
In the in vitro studies, epithelial expression of TF had a modest effect on proliferation
and migration when quantified using the PrestoBlue proliferation and transwell migration
assays. Exogenous TF, FXa and thrombin all increased migration in DLD-1 wild type
cells. In addition, exogenous thrombin increased proliferation amongst SW620 wild
type cells. This suggests that coagulation factors from the TME, rather than epithelial
expression, may influence tumour biology. Moreover, dabigatran, a direct thrombin
inhibitor, abrogated the pro-proliferative effects of thrombin, which highlights its
potential role as an anticancer therapy.
In a multicentre, prospective cohort study of 159 CRC patients undergoing resectional
surgery, rates of duplex screen detected deep vein thrombosis (DVT) were correlated
to plasma and tumour markers of hypercoagulability. TF is upregulated in the stroma
of cancer compared to normal tissue. However, stromal TF expression decreased in more
advanced (T4) tumours. This suggests that a procoagulant TME has a role in early tumourigenesis.
In total, 5.4%, 7.0% and 9.1% of patients had an asymptomatic DVT pre- operatively,
at six weeks post-surgery and after the commencement of adjuvant chemotherapy respectively.
The development of a post-operative complication was a risk factor for DVT, whilst
locally advanced tumours resulted in a prolonged hypercoagulable state i.e. raised
D-dimer at six weeks. This highlights a possible role for pre- and post- operative
screening duplex ultrasonography and super-extended VTE prophylaxis in selected patients.
In conclusion, this thesis establishes a role for exogenous coagulation factors in
promoting tumour biology in CRC. VTE is more common amongst patients undergoing resectional
surgery for CRC than previously estimated. The utility of tumour and plasma hypercoagulabilty
as biomarkers for survival in CRC will be further analysed when long term follow-up
data is available.