Brandon McMahon

The Plasminogen Activator System and Cancer

The fibrinolytic system, more appropriately referred to as the plasminogen activator system, controls not only the intravascular fibrin deposition but also participates in a wide variety of physiologic and pathologic processes. In cancer, the components of this system are involved in tumor growth, invasion and metastasis, through their effect on angiogenesis and cell migration. These components are found in most tumors and their expression signifies not only their function but also carries a prognostic value. Their expression is in turn modulated by cytokines and growth factors, many of which are up-regulated in cancer. Though both plasminogen activators, tPA and uPA, are expressed in tumor cells, uPA with its receptor (uPAR) is mostly involved in cellular functions, while tPA with its receptor annexin II on endothelial surface regulates intravascular fibrin deposition. Among the inhibitors of fibrinolysis, PAI-1 is a major player in the pathogenesis of many vascular diseases as well as in cancer. Therapeutic intervention, either using plasminogen activators or use of experimental inhibitor agents against PAI-1, has shown encouraging results in experimental tumors but not verified clinically. Information provided in this brief review is aimed to promote greater interest in the role of the plasminogen activator system in cancer.

The Role of Plasminogen-Plasmin System in Cancer

Components of the plasminogen-plasmin system participate in a wide variety of physiologic and pathologic processes, including tumor growth, invasion and metastasis, through their effect on angiogenesis and cell migration. These components are found in most tumors and their expression not only signifies their function but also carries a prognostic value. Their expression is in turn modulated by cytokines and growth factors, many of which are up-regulated in cancer. Though both tPA and uPA are expressed in tumor cells, uPA with its receptor (uPAR) is mostly involved in cellular functions, while tPA with its receptor Annexin II on endothelial surface, regulates intravascular fibrin deposition. Among the inhibitors of fibrinolysis, PAI-1 is a major player in the pathogenesis of many vascular diseases as well as in cancer. Therapeutic interventions, either using plasminogen activators or experimental inhibitor agents against PAI-1, have shown encouraging results in experimental tumors but not been verified clinically.

The coagulopathy of acute promyelocytic leukaemia revisited

Since the initial description of the disease, the life-threatening coagulopathy associated with acute promyelocytic leukaemia (APL) has been the defining clinical characteristic. Historically, this uncommon subtype of acute myeloid leukaemia has been associated with a high mortality rate during induction therapy, most frequently attributable to haemorrhage. Since the introduction of all-trans retinoic acid (ATRA) into the therapy of all patients with APL, disease-free survival and overall survival have improved dramatically, such that the disease is now highly curable. However, induction mortality remains a major problem and haemorrhage still accounts for the majority of such early deaths. Pathogenesis of the coagulopathy is complex and includes disseminated intravascular coagulation (DIC), fibrinolysis and proteolysis. As a result, while the predominant clinical manifestation of the coagulopathy is haemorrhage, thromboembolic events may occur both at presentation and during therapy. A major recent finding is the high expression of annexin II in the leukaemic cells from patients with APL. Annexin II is a protein with high affinity for plasminogen and tissue-type plasminogen activator (tPA), and also acts as a cofactor for plasminogen activation by tPA. As a result, both plasminogen and tPA are increased on the cell surface of the leukaemic cell, increasing plasmin activity. Annexin II is expressed in high amounts in cerebral microvascular endothelial cells, perhaps accounting for the relatively high incidence of intracranial haemorrhage in APL compared with other sites. Microparticles are cell-derived membrane fragments originating from normal cells or released from malignant cells involved in activating coagulation. Recent studies have found that microparticles containing tissue factor, tPA, plasminogen activator inhibitor-1 and annexin II have been found in the plasma of APL patients, suggesting a role in pathogenesis of the coagulopathy. Treatment of the coagulopathy remains primarily supportive. Aggressive transfusions of platelets and cryoprecipitate appear to be important. There is no clear role for the routine use of heparin or antifibrinolytic therapy. The most important factor may be the early introduction of ATRA at the first suspicion of a diagnosis of APL, before it is confirmed genetically.

The apparent uPA/PAI-1 paradox in cancer: More than meets the eye

The expression of several components of the plasminogen-plasmin (P-P) system in tumor tissues has been shown to have prognostic significance in many human cancers, including those of the breast, prostate, lung, brain, ovary, stomach, colon, rectum, oral cavity, kidney, and bone. Mechanisms of action of the individual components have been extensively studied in tumor cells in vitro and in animal models. By interrupting various putative pathways involved in tumor progression in several experimental tumor models in animals, varying degrees of tumor control have been achieved. However, these efforts have thus far not been able to exert any impact in oncologic clinical practice. A possible explanation is our incomplete understanding of the complex involvement of the P-P system and its interactions with other tumorigenic factors. In this article, the role of various members of the P-P system in cancer is reviewed. Proteolysis via the urokinase-type plasminogen activator-plasminogen activation pathway tends to enhance tumor growth and invasion, and its natural inhibitor plasminogen activator inhibitor type 1 may also enhance tumor growth through the inhibition of apoptosis, enhancing cell proliferation and the promotion of angiogenesis. Meaningful drug designs for therapeutic intervention require a thorough understanding of the role of all of the components involved in this complex mechanism of tumor progression.

Catastrophic multiple organ ischemia due to an anti-Pr cold agglutinin developing in a patient with mixed cryoglobulinemia after treatment with rituximab.

Cold agglutinin disease occurring with cryoglobulinemia is a rare occurrence. Here, we report a patient with mixed cryoglobulinemia that was treated with rituximab and, after response, developed an anti‐Pr cold agglutinin that manifested with hemolysis and microvascular occlusion causing mesenteric ischemia and cerebral infarction. Unlike previous reports of patients with cryoglobulinemia and cold agglutinin disease, our patient did not have a detectable cryoprecipitate when his cold agglutinin manifested. Am. J. Hematol, 2009.

Age-related differences in disease characteristics and clinical outcomes in polycythemia vera

Abstract The natural history and prognosis for young patients with polycythemia vera (PV) in the post-JAK2 V617F era are not well defined. Therefore, we retrospectively analyzed disease characteristics and clinical outcomes in 120 patients ≤ 45 years and 84 patients ≥ 65 years at diagnosis. Despite lower white blood counts (9.2 vs. 13.4 × 109/L, p = 0.004) and a lower JAK2 V617F allele burden (51% vs. 66%, p = 0.015), younger patients with PV had comparable rates of vascular complications compared to older patients (27% vs. 31%, p = 0.64). However, splanchnic vein thrombosis occurred more frequently in younger patients (13% vs. 2%, p = 0.0056). Myelofibrotic and leukemic transformation, the most serious complications of myeloproliferative neoplasms (MPN), occurred with similar frequencies in young versus older patients (15% vs. 10%, p = 0.29). Prevention or delay of these complications is currently the most urgent challenge in the care of younger patients with PV.

Sprouty Proteins Are Negative Regulators of Interferon (IFN) Signaling and IFN-inducible Biological Responses

Background: The potential involvement of Spry proteins in IFN signaling is unknown. Results: Type I IFN treatment results in up-regulation of Spry proteins, which negatively control generation of IFN responses. Conclusion: Spry proteins play important regulatory roles in IFN signaling and the generation of the biological effects of IFNs. Significance: This study provides evidence for the existence of a key signaling pathway that controls IFN responses. Interferons (IFNs) have important antiviral and antineoplastic properties, but the precise mechanisms required for generation of these responses remain to be defined. We provide evidence that during engagement of the Type I IFN receptor (IFNR), there is up-regulation of expression of Sprouty (Spry) proteins 1, 2, and 4. Our studies demonstrate that IFN-inducible up-regulation of Spry proteins is Mnk kinase-dependent and results in suppressive effects on the IFN-activated p38 MAP kinase (MAPK), the function of which is required for transcription of interferon-stimulated genes (ISGs). Our data establish that ISG15 mRNA expression and IFN-dependent antiviral responses are enhanced in Spry1,2,4 triple knock-out mouse embryonic fibroblasts, consistent with negative feedback regulatory roles for Spry proteins in IFN-mediated signaling. In other studies, we found that siRNA-mediated knockdown of Spry1, Spry2, or Spry4 promotes IFN-inducible antileukemic effects in vitro and results in enhanced suppressive effects on malignant hematopoietic progenitors from patients with polycythemia vera. Altogether, our findings demonstrate that Spry proteins are potent regulators of Type I IFN signaling and negatively control induction of Type I IFN-mediated biological responses.

Components of the Plasminogen-Plasmin System as Biologic Markers for Cancer

Members of the plasminogen-plasmin (PP) system participate in many physiologic functions. In particular, uPA, its receptor (uPAR) and its inhibitor PAI-1 play an important role in cell migration, cell proliferation and tissue remodeling. Through a number of interactions, these components of the PP system are also involved in the pathogenesis of many diseases. In cancer, they modulate the essential processes of tumor development, growth, invasion and metastasis as well as angiogenesis and fibrosis. Thus, quantification of uPA, uPAR and PAI-1 in tumors and, in some cases in the circulating blood, became of potential value in the prognostication of many types of cancer. These include cancer of the breast, stomach, colon and rectum, esophagus, pancreas, glioma, lung, kidney, prostate, uterine cervix, ovary, liver and bone. Published data are reviewed in this chapter. Clinical validation of the prognostic value has also been made, particularly in cancer of the breast. Inclusion of these biomarkers in the risk assessment of cancer patients is now considered in the risk-adapted management in carcinoma of the breast. Factors limiting its broader use are discussed with suggestions how these can be overcome. Hopefully the use of these biomarkers will be applied to other types of cancer in the near future.

Central Role of ULK1 in Type I Interferon Signaling

We provide evidence that the Unc-51-like kinase 1 (ULK1) is activated during engagement of the type I interferon (IFN) receptor (IFNR). Our studies demonstrate that the function of ULK1 is required for gene transcription mediated via IFN-stimulated response elements (ISRE) and IFNγ activation site (GAS) elements and controls expression of key IFN-stimulated genes (ISGs). We identify ULK1 as an upstream regulator of p38α mitogen-activated protein kinase (MAPK) and establish that the regulatory effects of ULK1 on ISG expression are mediated possibly by engagement of the p38 MAPK pathway. Importantly, we demonstrate that ULK1 is essential for antiproliferative responses and type I IFN-induced antineoplastic effects against malignant erythroid precursors from patients with myeloproliferative neoplasms. Together, these data reveal a role for ULK1 as a key mediator of type I IFNR-generated signals that control gene transcription and induction of antineoplastic responses.

Thrombotic and bleeding complications in classical myeloproliferative neoplasms.

The Philadelphia chromosome-negative myeloproliferative neoplasms (MPNs) share an increased risk of thrombotic and hemorrhagic complications. The thromboses are more commonly arterial than venous, but unique to the BCR-ABL-negative MPNs is the involvement of the abdominal veins. Commonly accepted thrombotic risk factors include advanced age and a prior thrombotic episode, although these risk factors are associated with thrombosis regardless of the presence of an MPN. Emerging risk factors may include leukocytosis and presence of the JAK2 V617F mutation or an increase in its allelic burden. Interventions to prevent and/or treat MPN-related thromboses include aspirin, anticoagulation, and cytoreductive therapy. Although phlebotomy is a cornerstone of management in polycythemia vera to lower the risk for thrombosis, the target hematocrit is being reevaluated. Hemorrhagic complications occur with extreme thrombocytosis and may be related to acquired platelet defects such as acquired von Willebrand syndrome. The impact of new mutations and novel therapies, including JAK-inhibitors and interferon, on the thrombotic and hemorrhagic tendency remains to be determined.