Thrombotic complications are the second leading cause of death among oncology patients worldwide. Enhanced thrombogenesis has multiple origins and may result from a deregulation of megakaryocyte platelet production in the bone marrow, the synthesis of coagulation factors in the liver, and coagulation factor signaling upon cancer and the tumor microenvironment (TME). While a hypercoagulable state has been attributed to factors such as thrombocytosis, enhanced platelet aggregation and Tissue Factor (TF) expression on cancer cells, further reports have suggested that coagulation factors can enhance metastasis through increased endothelial-cancer cell adhesion and enhanced endothelial cell activation. Autophagy is highly associated with cancer survival as a double-edged sword, as can both inhibit and promote cancer progression. In this review, we shall dissect the crosstalk between the coagulation cascade and autophagic pathway and its possible role in metastasis and cancer-associated thrombosis formation. The signaling of the coagulation cascade through the autophagic pathway within the hematopoietic stem cells, the endothelial cell and the cancer cell are discussed. Relevant to the coagulation cascade, we also examine the role of autophagy-related pathways in cancer treatment. In this review, we aim to bring to light possible new areas of cancer investigation and elucidate strategies for future therapeutic intervention.

CTCs)) and tumour biopsy samples. Results: The median age of pts was 56 (range 32-75). 48% (33/68) were colon tumours, 34% (23/68) rectal, 9% (6/68) rectosigmoid and 7% (5/68) small bowel. Pts had failed an average of 3 lines (range 1-5) of treatment prior to recruitment. 74% (50/68) of patients had both sufficient tumour DNA in their plasma, and archival biopsies for analysis. Sequencing of ctDNA detected all mutations reported in tumour in 76% (38/ 50) of pts. ctDNA analysis picked up additional mutations in 30% (15/50) of pts. The interval between collection of archival biopsies and blood tests (p ¼ 0.300) did not affect detection of new mutations. 31% (6/19) of pts treated with anti-EGFR therapy developed recognised resistance mutations (KRAS and EGFR) in ctDNA on serial analysis. The most commonly detected mutations were TP53 (60%), KRAS (51%), PIK3CA (15%) and PTEN (3%). Other mutated genes included CTNNB1, BRAF, FGFR3 and ERRB2. Pre-clinical models (organoids and patient-derived xenografts (PDX)) were attempted from blood (CTCs) and/or tumour tissue in 29% (20/68) of pts. CTC organoid cultures were optimised and successful in 1/17 pts. Conclusions: ctDNA may be used for routine molecular characterisation of metastatic SBC/CRC and results can be analysed to track the development of resistance.

Methods: OE19 and NCIN87, HER2þ GC cell lines were treated with increasing doses of Lapatinib (L) and Trastuzumab (T) to obtain resistant clones. These were isolated and characterized by performing mutational analysis and protein expression by Western blot (WB). Genome expression profile was done by ClariomS microarray. Inhibition of the altered pathways was evaluated using a panel of selected drugs. siRNAs were performed to characterise the role of the inhibition of selected proteins. An in vivo experiment was conducted to corroborate results. A retrospective cohort of HER2 amplified patients treated with T was analysed. An immunohistochemistry (IHC) analysis to evaluate the altered pathway detected in preclinical models was conducted. Results: L and T resistant clones were obtained. In resistant cells, protein expression underlined the activation of PI3K pathway and of its downstream effector RPS6 protein. Analysing microarray, it was possible to identify, the activation of a large number of genes regulated by NFR2. Its expression was confirmed by WB; NRF2 nuclear activation was detected by nuclear fractionating WB and immunofluorescence. A panel of target agents was used to evaluate NRF2 changes. It was possible to observe the its expression strongly decrease by using PI3K pathway inhibitors, suggesting a relation between this pathway and NRF2. To better clarify this phenomenon, siRNA of RPS6, that was detected to be activated in resistant cells, was performed and it was possible to observe a strong decrease of NRF2 expression and sensitivity to antiHER2 drugs was restored. IHC of both RPS6 and NRF2 were performed suggesting that the activation of both RPS6 and NRF2 related with less clinical benefit of T. Conclusions: RPS6 through the activation of NRF2 should be considered a new mechanism responsible for antiHER2 drugs resistance in GC. Further investigations are needed.