Biologically Active Tissue Factor-Bearing Larger Ectosome-Like Extracellular Vesicles in Malignant Effusions from Ovarian Cancer Patients: Correlation with Incidence of Thrombosis

Abstract

The development of malignant effusions such as ascites reflects a massive progression of a malignant disease. In patients with ovarian carcinoma, a high amount of ascites (>500 mL) is an independent negative prognostic marker. The composition and constituents of ascites reflect the inflammatory environment of the underlying tumor. Increased cellular resistance of ascites-derived tumor cells and the development of venous thromboembolic events (VTE) are major risks for these patients, especially in patients with advanced ovarian carcinoma. In this study, we discuss the release of tissue factor-bearing extracellular vesicles (TF+ EVs) from tumor cells into the environment (ascites fluid) and their systemic spreading as a possible causal explanation of the pathologic coagulation status in these patients. We obtained ascites from patients with advanced ovarian carcinoma, collected during surgery or therapeutic paracentesis (n = 20). Larger ectosome-like EVs were isolated using sequential centrifugation, quantified by high-resolution flow cytometry and analyzed using nanoparticle tracking analysis. Furthermore, the pro-coagulant properties (TF activity) of EVs were determined. Compared to published TF activities of EVs from healthy persons, TF activities of EVs derived from ascites of patients with ovarian cancer were very high, with a median of 80 pg/mL. The rate of VTE, as reported in the patient files, was high as well (35%, 7 out of 20). Furthermore, all but one patient with VTE had EV concentrations above the median within their ascetic fluid (p < 0.02). Since VTE continues to be a frequent cause of death in cancer patients, prophylactic antithrombotic treatment might be worth considering in these patients. However, given the risk of bleeding, more clinical data are warranted. Although the study is too small to enable reaching a conclusion on direct clinical implementation, it can well serve as a proof of principle and a rationale to initiate a prospective clinical study with different patient subgroups. We also show ex vivo that these larger ectosome-like EVs induce intracellular ERK phosphorylation and tumor cell migration, which is not directly related to their pro-coagulative potency, but might help to understand why cancer patients with thromboembolic events have a poorer prognosis.

Incidence and Risk Factors for Postoperative Venous Thromboembolism in Patients with Endometrial Cancer: Systematic Review and Meta-analysis

“…Tumor-related factors including extensive tumor lesion,massive ascites, clear cell cancer and advanced stage were identi ed associated with VTE. The volume of ascites indicated the in ammatory conditions in tumors, which contribute to the development of venous thromboembolic events [27]. Moreover, the patients with malignant disease usually suffered with hypercoagulable state, which may be the reason of massive ascites and contribute to VTE after operation [28].…”

Interactions between Platelets and Tumor Microenvironment Components in Ovarian Cancer and Their Implications for Treatment and Clinical Outcomes

“…TGF-β derived from ascites and activated platelets is one of the main stimulating factors for MMT [160,162]. In addition, tissue factor (TF), present in high amounts in ascites, cancer cell masses, and cancer cell-derived microparticles, induces thrombin generation, which activates platelets and produces fibrin [163]. Activated platelets further increase the expression of TF, prompting ovarian cancer migration [164].…”

“…Cancer cells and activated monocytes can release extracellular vesicles containing TF that contribute to venous thromboembolism [163,230]. Moreover, the coincubation of platelets with extracellular vesicles upregulates the TF activity of monocytes [231].…”

Platelet Activation in Ovarian Cancer Ascites: Assessment of GPIIb/IIIa and PF4 in Small Extracellular Vesicles by Nano-Flow Cytometry Analysis

“…The ascites are a fluid developing in the peritoneum of HGSOC patients in an advanced stage, and its cellular and extracellular vesicle (EV) composition can reveal the inflammatory environment state of the malignant disease [ 3 ]. The evidence that tumour cells release more EVs than healthy cells points to their role in tumour progression and the potential of EVs-based liquid biopsy as diagnostic biomarkers in ovarian cancer [ 4 ].…”