Urinary Tissue Factor in Bladder Cancer
Bladder cancer tumour growth and consequently improve the
In Western society cancer remains second to effectiveness of the current treatment (surgery,
cardiovascular disease as the most common radiotherapy, and chemotherapy). Clinical
cause of death. Bladder cancer is the seventh manifestation of the haemostatic disorders may
most common malignancy worldwide. Every vary according to tumour type, but generally
year in the United Kingdom, about 10,100 thromboembolic disorders are more frequent in
people are diagnosed with bladder cancer and patients with solid tumours. Production of
Bashir A Lwaleed, around 4,700 die from it (Cancer Research procoagulant activity by endothelial cells,
Research Fellow, UK). It is a potentially curable disease with up blood monocytes, tumour-associated
Department of Urology,
Southampton University to 80% of cases being superficial and macrophages, tumour cells and stroma may be
Hospitals NHS Trust, amenable to surgical resection . However, increased in patients with cancer. Malignant
bladder cancer is one of the most prevalent tissue and cultured tumour cells may express
Correspondence to: malignancies, mostly because it has the cancer procoagulant (an apparently cancer-
Dr Bashir A Lwaleed, highest rate of recurrence among all cancer specific procoagulant that can directly generate
Department of Urology,
Central block, Level E, West types. Up to 80% of treated superficial bladder thrombin through the activation of factor X) 
Wing, Mailpoint 67, cancers recur. The propensity to recur and the and/or tissue factor (TF)  which facilitate
Hospitals NHS Trust, possibility of disease progression require fibrin deposition and aid tumour growth and
Tremona Road, aggressive surveillance. This ranks bladder metastasis . The mechanisms of TF
SO16 6YD, UK.
cancer as one of the most expensive activation in a tumour-bearing organism are
Tel: +44 (0)2380 796559, malignancies to treat. The necessity of outlined in Figure 1. The role of TF in tumour
Fax: +44 (0)2380 796922, repeated screening for recurrence indicates the neovascularisation and angiogenesis has been
urgent need for novel biological or molecular the subject of increased interest [10–12]. Tissue
markers as alternatives to invasive standard factor is also involved in a variety of other
procedures. biological processes, independent of its role as
the primary physiological initiator of blood
Haemostasis and cancer coagulation activation. These include blood
Since Armand Trousseau (1865)  reported vessel development, intra-cellular signalling,
the frequent occurrence of venous thrombosis cell migration, cell adhesion and inflammation
in patients with gastric carcinoma, a [13-15].
considerable clinical, laboratory and
pharmacological body of evidence, both Tissue factor
human and experimental, have emerged to Tissue factor is a single chain transmembrane
suggest that haemostasis is frequently activated glycoprotein with no intrinsic protease activity
in malignancy [3–6] and that interfering with (Figure 2). It serves as a cellular receptor and
the haemostatic mechanisms may compromise essential cofactor for the blood coagulation
Figure 1 (left): Potential mechanisms mediating tissue factor (TF) expression in patients with cancer. Macrophages and peripheral blood monocytes can be stimulat-
ed by tumour cells or their related products to produce TF, which activates the clotting cascade. Tumour cells may themselves produce TF or synthesise cancer pro-
coagulant (CP), which directly activates FX. Prothrombin generation may be facilitated by shed tumour-membrane vesicles. Thrombin then cleaves fibrinogen
derived from plasma under the influence of the vascular permeability factor (VPF). Fibrin is deposited around the tumour, liberated fibrinopeptide A (FpA) leaks
back into the circulating blood (adapted from ref 37).
Figure 2 (right): A model of tissue factor. This diagram shows the extracellular, transmembrane, and intracellular domains of tissue factor.
14 Volume 2 Issue 5 • February/March 2008
Figure 3 (left): Cellular tissue-factor–initiated coagulation. Factor (F) VII binds tissue factor (TF) on TF-bearing cells and is auto-activated to FVIIa. A trace
amount of FVIIa is also found in the circulation. The resulting complex (TF:FVIIa) activates FX and FIX. The activated FX generates a small amount of thrombin
(IIa). In an FXa dependent feedback system, TF-pathway inhibitor (TFPI) quickly binds and inhibits the TF:FVIIa complex. However, the little FIIa burst activates
platelets and FV, releases and activates FVIII from von Willebrand (vWF), and activates FXI. Activated FIX binds to the activated platelets and activates FX.
Platelet-generated FXa then generates large amounts of FIIa, which is needed to form the fibrin clot (adapted from ref 37).
Figure 4 (right): Urinary tissue factor levels in controls and patients with bladder cancer. The distribution of urinary tissue factor level (ng/ml) in normal controls,
renal stone, non-inflammatory (negative cystoscopy following haematuria) and inflammatory benign disease (cystitis) and malignant disease of the bladder. Boxes
show median and interquartile ranges. Red circles represent benign inflammatory disease.
factor VII and factor VIIa in the activation of factor X and associated with lipid-particles that are too large to pass through
factor IX, respectively . After injury or damage to the the glomerular basement membrane unless glomeruli are
vascular wall, TF is exposed to blood and binds plasma factor damaged. Thus, uTF is produced by the kidney, and is probably
VII (TF:Factor VII), which, upon binding TF, attains greatly of tubular origin. Positive signals for TF antigen were found in
increased activity. No proteolytic modifications are involved in both distal and proximal tubules but not glomeruli . We
the association between TF and factor VII. Factor VII is then believe that, in patients with cancer or inflammatory disease,
auto-cleaved within the complex to activated factor VII (Factor bioactive stimulants released from malignant or inflammatory
VIIa). The TF:Factor VII/Factor VIIa complex then directly cells into the vascular compartment are excreted via the kidney,
catalyses the conversion of factor IX to factor IXa and factor X concentrating in urine to stimulate, in transit, tubular
to factor Xa. The transformation of factor X to factor Xa in the epithelium to release TF . Indeed, uTF measurements are
presence of factor Va, Ca2+ and phospholipids forms what is not significantly affected by glomerular permeability and
commonly known as ‘the prothrombinase complex’ which filtration, tubular function or by the presence of urinary
then converts prothrombin (Factor II) to thrombin (Factor IIa), contaminants . Urinary TF levels are elevated in patients
resulting ultimately in platelet activation and fibrin formation with colorectal cancer, inflammatory bowel disease and breast
(Figure 3). The thrombin generation triggers both pro- cancer. Although patients with benign colorectal and breast
coagulant and anticoagulant pathways. disease also had increased levels compared to normal controls
or patients with rheumatoid arthritis, these were less than those
Urinary tissue factor in the malignant group [26,30]. Subsequently, Adamson et al
Normal and malignant bladder tissue both express TF . showed increased levels of uTF in patients with transitional cell
Nonetheless, TF is over-expressed in malignant tissues and its carcinoma of the bladder and prostate cancer compared with
expression has recently been shown to be an independent controls and patients with benign prostatic hypertrophy [31,32].
predictor of disease-specific survival in N0-classified muscle- Recently, using a highly reproducible one-stage kinetic
invasive transitional cell carcinoma of the bladder, treated by
radical cystectomy . It has also been suggested that studying
TF-expression in such patients may help identify those who are
at higher risk of disease progression . Tissue factor is found
in various biological fluids where it is easily accessible and its
levels correlate with different pathologies. Its use as a diagnostic
and/or prognostic indicator in various disease conditions,
particular those that are associated with a hypercoagulable state
or inflammatory reactions, has been proposed by various
investigators. For instance, elevated levels of TF were found in
plasma and serum samples obtained from individuals with
different types of solid tumours [19-21]. Patients with bladder
cancer showed significantly higher plasma TF levels compared
with healthy volunteers . The evaluation of urinary
parameters as a cancer marker has long been seen as attractive
[23,24]. Urine is known to possess a powerful procoagulant
activity that appears to facilitate haemostasis in the urinary tract Figure 5: Urinary tissue factor and malignant bladder recurrence. The distribu-
tion of urinary tissue factor level (ng/ml) in patients with and without malig-
. This urinary procoagulant was found to be TF . It is nant bladder recurrence. Results are shown with superimposed medians and
not likely that uTF is derived from the blood, since it is interquartile ranges.
Volume 2 Issue 5 • February/March 2008 15
chromogenic assay, we showed a significant increase in uTF phenomenon in bladder cancer . Classical MDR causes
levels in patients with malignant disease of the bladder membrane charge alterations comparable to those occurring
compared with normal controls or subjects with benign non- when monocytes are stimulated to produce TF as detected
inflammatory disease (Figure 4). Urinary TF levels also showed by binding of Annexin V and MGH-u1. MDR clones resistant
a positive and significant correlation with markers of disease to both adriamycin and mitomycin-c are reported to express
progression, metastasis (e.g., bone scan status) and malignant 6-fold more immunological and functional TF than their
recurrence, Figure 5 . parental line under the same culture conditions .
4. Cell lysis as a result of exposure to urine may also enhance
Urinary tissue factor in patients with advanced bladder the amount of the released TF by cancer cells. Therefore, the
cancer total amount of the detectable TF will be higher in the urine
Interestingly, patients with advanced bladder cancer showed a of some patients with advanced bladder cancer. This
marked increase in their uTF values of between 70 and 115 suggests that TF may reflect a feature of the biology of
ng/ml (normal levels are around 27 ng/ml) . The normal advanced bladder tumours, with levels related to disease
source of uTF is assumed to be the kidney [27,28], but several stages. Tissue factor is also linked to angiogenesis, cell
other possible sources could be considered, especially in mugration, cell adhesion and intra-cellular signaling and this
patients with bladder cancer: may have a bearing on its role in the natural history of
1. Exfoliated tumour cells. In our laboratory TF localised to a bladder cancer. The mechanistic basis for TF induction and
bladder cancer cell line (MGH-u 1) as assessed by its diagnostic and/or prognostic value value as a marker for
Transmission Electron Microscopy and Confocal Microscopy. bladder cancer may warrant further investigation.
In addition, the activity of both exfoliated tumour cells and
MGH-u 1 cells was significantly inhibited by murine Conclusion
monoclonal antibody to human TF. Increased uTF levels in patients with advanced bladder cancer
2. Residual tumour still resident in the bladder wall may release provide further evidence of abnormal haemostasis in
TF, especially in patients with muscle invasive disease. malignancy and suggest that the determination of uTF may
3. Charge-related changes in the plasma membrane, to which provide a useful screening and/or prognostic test in patients
tumour cells are susceptible can affect TF expression or de- with bladder cancer, particularly if the similar and
encryption and consequently enhance TF functional activity confounding influence of inflammation on secreted TF can be
. Multi-drug resistance (MDR) is a common overcome. n
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