## Abstract

Introduction. In patients with lung adenocarcinoma, metastasis, advanced stage and chemotherapy (CTx) are factors which increase the risk of venous thromboembolism (VTE). However, routine pharmacological thromboprophylaxis is not recommended but individualized risk assessment for VTE is encouraged. The incorporation of hypercoagulability biomarkers (HB) into the risk assessment models (RAM) could improve their sensitivity to identify patients eligible for thromboprophylaxis. To this aim we conducted an observational prospective study to investigate the variability of HB associated with hypercoagulability, with respect to cancer-related characteristics.

Patients & Methods. Patients with documented lung adenocarcinoma eligible for CTx at distance of at least 3 months from surgery or hospitalization were included in the study (n=79). Patients were either CTx naive (n=29) or had already received CTx (n=50). The control group (CG) consisted of 30 healthy age & sex-matched individuals. Thrombin generation (TGT) in citrated PPP was assessed with the Thrombogram-Thrombinoscope® assay using PPP-reagent®5 pm TF by Diagnostica Stago. The levels of P-Selectin, heparanase(HPA) in plasma were measured with ELISA Kit (Cusabio Biotech and R&D Systems). The procoagulant phospholipids (PPL) were measured with STA-Procoag-PPL® , Factor VIIa by Staclot VIIa-rTF®, D-Dimers (DDi) by Liatest D-Di (Diagnostica Stago, France), and Tissue Factor activity (TFa) by specific clotting based home test. Mortality and thrombotic events were recorded in 3-month follow-up.

Results. Patients showed significantly shortened PPL and significantly higher levels of TFa, D-Dimer and HPA as compared to the CG. The levels of FVIIa were significantly lower in patients compared to CG. P-Selectin levels and endogenous thrombin potential (ETP) did not differ between the two groups. The chronometric parameters of TGT (lag-time, ttPeak) were significantly prolonged, consequently the velocity of the propagation phase of TGT (MRI) was significantly lower in patients as compared to CG. The Naive Group (NG) showed significantly shorter lag-time of TGT and lower ETP as compared to the On Treatment Group (OTG). It showed significantly higher levels of HPA as compared to the OTG. These data are summarized in Table I.

The increase of TGT as well as that of HPA, P-Selectin, FVIIa was associated with the grade of the disease. Patients with metastatic cancer had higher levels of P-Selectin, TFa, DDi, FVIIa, TGT and HPA as compared to patients with localized or advanced disease. Patients who experienced a thrombotic episode (8%) had significantly higher baseline levels of DDi, TGT, shorter PPL and lower levels of HPA as compared to those who were without thrombosis. Patients who died within 3-month follow-up (26%) had higher baseline levels of DDi and lower HPA levels as compared to those who were still alive.

Conclusion. Our study evaluated a wide spectrum of HB of cellular and plasma hypercoagulability in patients with lung adenocarcinoma. It established that the increase of procoagulant phospholipids in plasma, up regulation of TF pathway, DD formation and HPA release is a universal phenomenon in lung cancer. Variations of TGT and FVIIa levels allow us to identify subgroups of patients who present increased hypercoagulability. CTx has an impact on TGT and HPA levels. Finally, baseline values of TGT, PPL, HPA , DDi were found to be related with 3-month mortality and the incidence of thrombotic episodes. These data allow us to propose that the weighted incorporation of HB of cellular and plasma hypercoagulabilty in RAM for VTE might improve their predictive value. This concept is being studied on an ongoing trial.

Table I.

HB in patients with lung adenocarcinoma.

HBAll Patients (n=79)NG
(n=29)
OTG
(n=50)
CG
(n = 30)
PPL-ct (sec) 27±6* 27±7* 27,6±7,5* 62,8±9
TFa (ng/ml) 6.2±4.7* 6,2±4* 6,6±5,2* 0,26±0.1
DD (μg/ml) 1,8±2,2* 1,1±1* 1,4±1,2* 0,3±0.01
HPNS (ng/ml) 0,4±1,2* 0,32±0.12$0,23±0,1* 0,12±0,02 FVIIa (U/ml) 37±20* 34±16* 34±20* 50,9±11 P-Selectin (ng/ml) 65,4±20 64,8±15 62,6±19 62,6±10 Lag-time (min) 4,3±0,8* 3,9±1$ 4,5±0,9* 2,5±0.01
ttPeak (min) 7.7±1.4* 7±1 8,7±1,3* 5±1
MRI (nM/min) 91±40* 94±41 87,3±33* 110±24
Peak (nM) 279±71* 279±76 284±62* 288±36
ETP (nM.min) 1583±328 1567±326 1673±315*$1496±191 HBAll Patients (n=79)NG (n=29) OTG (n=50) CG (n = 30) PPL-ct (sec) 27±6* 27±7* 27,6±7,5* 62,8±9 TFa (ng/ml) 6.2±4.7* 6,2±4* 6,6±5,2* 0,26±0.1 DD (μg/ml) 1,8±2,2* 1,1±1* 1,4±1,2* 0,3±0.01 HPNS (ng/ml) 0,4±1,2* 0,32±0.12$0,23±0,1* 0,12±0,02
FVIIa (U/ml) 37±20* 34±16* 34±20* 50,9±11
P-Selectin (ng/ml) 65,4±20 64,8±15 62,6±19 62,6±10
Lag-time (min) 4,3±0,8* 3,9±1$4,5±0,9* 2,5±0.01 ttPeak (min) 7.7±1.4* 7±1 8,7±1,3* 5±1 MRI (nM/min) 91±40* 94±41 87,3±33* 110±24 Peak (nM) 279±71* 279±76 284±62* 288±36 ETP (nM.min) 1583±328 1567±326 1673±315*$ 1496±191

* p<0,05 versus CG

\$ p<0,05 versus NG

Disclosures

No relevant conflicts of interest to declare.

## Author notes

*

Asterisk with author names denotes non-ASH members.