Colorectal cancer and thrombosis.

SIGNIFICANCE: Colorectal cancer (CRC), results in a hypercoagulable state which manifests clinically as venous thromboembolism (VTE), often presenting as a deep vein thrombosis (DVT) or pulmonary embolism (PE). The consequences of VTE in CRC can be devastating, resulting in long-term morbidity and are a frequent cause of death, even amongst those who would have otherwise had a favourable cancer prognosis. The incidence of VTE in all cancers is increasing, whilst the exact incidence of VTE in CRC is likely to be underestimated. All cancer treatments increase the risk of VTE in an already at risk population. CRITICAL ISSUES: CRC-associated VTE is a challenging entity to manage with recurrences occurring more frequently in cancer patients, despite anticoagulation. Anticoagulation, whether treatment or prophylactic, increases the risk of bleeding, especially in patients with cancer. Although strong evidence underpins the initial management of cancer-associated VTE, there is uncertainty with regard optimum treatment duration. For VTE prevention, extended (28 days), pharmacological thromboprophylaxis post CRC surgery is internationally recommended. Pharmacological thromboprophylaxis is not routinely recommended for nonhospitalised patients receiving chemotherapy. FUTURE DIRECTIONS: There is growing evidence of a symbiotic relationship between cancer biology and the clotting system. Tissue factor (TF), the initiator of the clotting pathway, promotes cancer via clotting dependent and independent mechanisms. Clotting pathway factors, including TF, may have utility as biomarkers in CRC, for assessment of VTE risk in addition to cancer prognosis. The clotting system may also be a target for potential anti-cancer therapies, either via existing anticoagulants or experimental direct TF inhibitors.

PO-32 - Patient, tumour and operative factors influencing perioperative hypercoagulability in colorectal cancer.

INTRODUCTION: Up to 6% of patients develop venous thromboembolism (VTE) following elective colorectal cancer surgery despite thromboprophylaxis. Clinical practices for perioperative thromboprophylaxis remains variable, particularly the use and duration of extended thromboprophylaxis. Identification of factors associated with a prolonged postoperative hypercoagulable state may allow the development of algorithms that allow more targeted thromboprophylaxis. AIM: To identify patient, tumour and surgical risk factors for prolonged (two and six weeks) hypercoagulability in colorectal cancer patients undergoing surgical resection. MATERIALS AND METHODS: In a prospective cohort study (Cancer-induced Hypercoagulability As a Marker of Prognosis [CHAMPion]), plasma d-dimer was measured at 2 and 6weeks post-operatively in patients undergoing elective, curative resection for colorectal cancer. Hypercoagulability (raised D-dimer) at 2 and 6weeks was correlated with patient, tumour and operative factors. RESULTS: Of the 62 patients recruited (median age 69years [range 39-90]), 37 were male. D-dimer was increased in females compared to males at six weeks (geometric mean (GM) 1,287ng/ml [95% CI 944 - 1,755 vs. 821ng/ml (95% CI 633 - 1064) p=0.03]. Age, smoking, hypertension, use of antiplatelet medication, BMI and WHO performance status were not associated with a prolonged hypercoagulable state. There were no tumour factors (including size/T stage/lymph node involvement/differentiation) associated with a prolonged hypercoagulable state. D-dimer was increased in patients undergoing open surgery (n=39) compared to laparoscopic surgery (n=23) at 2weeks (GM 2,337ng/ml [95% CI 1,806-3,023] vs. 1,212ng/ml [95% CI 898-1,629], p=0.001) and 6weeks (GM 1,162ng/ml [95% CI 818-1647] vs. 723ng/ml [95% CI 533-982]p=0.04). Operative time was not associated with prolonged hypercoagulability. D-dimer had a trend to be increased at 2weeks in patients receiving perioperative blood transfusions (n=8) compared to those that did not (n=54) (GM 2,618ng/ml [95% CI 1,525-4,536] vs. 1613ng/ml [95% CI 1,236 - 2,100] p=0.08). CONCLUSIONS: Even in this relatively small cohort of patients female gender, open surgery and receiving a blood transfusion are associated with on-going hypercoagulability up to six weeks post operation. This may represent a group where thromboprophylaxis should be targeted.

Costimulation blockade, busulfan, and bone marrow promote titratable macrochimerism, induce transplantation tolerance, and correct genetic hemoglobinopathies with minimal myelosuppression.

Mixed hemopoietic chimerism has the potential to correct genetic hemological diseases (sickle cell anemia, thalassemia) and eliminate chronic immunosuppressive therapy following organ transplantation. To date, most strategies require either recipient conditioning (gamma-irradiation, depletion of the peripheral immune system) or administration of "mega" doses of bone marrow to facilitate reliable engraftment. Although encouraging, many issues remain that may restrict or prevent clinical application of such strategies. We describe an alternative, nonirradiation based strategy using a single dose of busulfan, costimulation blockade, and T cell-depleted donor bone marrow, which promotes titratable macrochimerism and a reshaping of the T cell repertoire. Chimeras exhibit robust donor-specific tolerance, evidenced by acceptance of fully allogeneic skin grafts and failure to generate donor-specific proliferative responses in an in vivo graft-versus-host disease model of alloreactivity. In this model, donor cell infusion and costimulation blockade without busulfan were insufficient for tolerance induction as donor-specific IFN-gamma-producing T cells re-emerged and skin grafts were rejected at approximately 100 days. When applied to a murine beta-thalassemia model, this approach allows for the normalization of hemologic parameters and replacement of the diseased red cell compartment. Such a protocol may allow for clinical application of mixed chimerism strategies in patients with end-stage organ disease or hemoglobinopathies.

Cloning, analysis and expression of the HindIII R-M-encoding genes.

The genes encoding the HindIII restriction endonuclease (R.HindIII ENase) and methyltransferase (M.HindIII MTase) from Haemophilus influenzae Rd were cloned and expressed in Escherichia coli and their nucleotide (nt) sequences were determined. The genes are transcribed in the same orientation, with the ENase-encoding gene (hindIIIR) preceding the MTase-encoding gene (hindIIIM). The two genes overlap by several nt. The ENase is predicted to be 300 amino acids (aa) in length (34,950 Da); the MTase is predicted to be 309 aa (35,550 Da). The HindIII ENase and MTase activities increased approx. 20-fold when the genes were brought under the control of an inducible lambda pL promoter. Highly purified HindIII ENase and MTase proteins were prepared and their N-terminal aa sequences determined. In H. influenzae Rd, the HindIII R-M genes are located between the holC and valS genes; they are not closely linked to the HindII R-M genes.

Characterization of BcgI, a new kind of restriction-modification system.

The BcgI restriction enzyme from Bacillus coagulans is unusual in that it cleaves on both sides of its recognition site, CGAN6TGC, releasing a fragment that includes the site and several bases on each side. We report the organization and nucleotide sequences of the genes for the BcgI restriction-modification system and the properties of the proteins that they encode. The system comprises two adjacent, similarly oriented genes. The proximal gene, bcgIA, codes for a 637-amino acid protein (molecular mass = 71.6 kDa) that resembles certain m6A-specific DNA-methyltransferases, particularly those that constitute the modification subunits of type I restriction-modification systems. The distal gene, bcgIB, codes for a 341-amino acid protein (molecular mass = 39.2 kDa) that resembles none of the sequences in the sequence data bases. The two genes overlap by several nucleotides. Alone, neither protein restricts or modifies DNA, but, together, they form a complex in the proportion A2B that does both. DNA binding assays showed that the DNA-protein complex can be formed only in the presence of both subunits, suggesting that the association of inactive subunits generates the active BcgI enzyme that can bind DNA and then either cleaves or methylates at target site.

Characterization and expression of the Escherichia coli Mrr restriction system.

The mrr gene of Escherichia coli K-12 is involved in the acceptance of foreign DNA which is modified. The introduction of plasmids carrying the HincII, HpaI, and TaqI R and M genes is severely restricted in E. coli strains that are Mrr+. A 2-kb EcoRI fragment from the plasmid pBg3 (B. Sain and N. E. Murray, Mol. Gen. Genet. 180:35-46, 1980) was cloned. The resulting plasmid restores Mrr function to mrr strains of E. coli. The boundaries of the mrr gene were determined from an analysis of subclones, and plasmids with a functional mrr gene produce a polypeptide of 33.5 kDa. The nucleotide sequence of the entire fragment was determined; in addition to mrr, it includes two open reading frames, one of which encodes part of the hsdR. By using Southern blot analysis, E. coli RR1 and HB101 were found to lack the region containing mrr. The acceptance of various cloned methylases in E. coli containing the cloned mrr gene was tested. Plasmid constructs containing the AccI, CviRI, HincII, Hinfl (HhaII), HpaI, NlaIII, PstI, and TaqI N6-adenine methylases and SssI and HhaI C5-cytosine methylases were found to be restricted. Plasmid constructs containing 16 other adenine methylases and 12 cytosine methylases were not restricted. No simple consensus sequence causing restriction has been determined. The Mrr protein has been overproduced, an antibody has been prepared, and the expression of mrr under various conditions has been examined. The use of mrr strains of E. coli is suggested for the cloning of N6-adenine and C5-cytosine methyl-containing DNA.