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<p>Thrombosis is a common complication of chemotherapy for breast cancer patients. However, the specific mechanisms by which chemotherapy agents modulate these hemostatic pathways are not well understood. In this thesis, we investigated the mechanism(s) by which chemotherapy agents can upregulate procoagulant pathways (tissue factor (TF), phosphatidylserine exposure, and cell-free DNA (CFDNA) release) and impair the protein C (PC) anticoagulant pathway. We examined the effects of chemotherapy agents doxorubicin, epirubicin and the cyclophosphamide metabolite acrolein on cell surface procoagulant activity. We found that treatment of endothelial cells with the chemotherapy drugs increased phosphatidylserine exposure and TF activity on treated endothelial cells, blood monocytes and/or smooth muscle cells. This corresponded to an increase in thrombin generation on chemotherapy-treated cells exposed to recalcified, defibrinated plasma. We also found that found that doxorubicin and epirubicin can increase CFDNA release from breast cancer chemotherapy patients and healthy mice, which corresponds to an increase in thrombin-antithrombin levels. Treatment of venous whole blood and isolated neutrophils with doxorubicin and epirubicin increased CFDNA release. We found that exposure of recalcified plasma to CFDNA isolated from epirubicin-treated whole blood increased thrombin generation by activating the contact pathway. We investigated the effects of chemotherapy on the PC anticoagulant pathway. We found that acrolein decreased EPCR while increasing thrombomodulin expression on treated endothelial cells. A corresponding decrease in activated PC generation was measured on acrolein-treated endothelial cells exposed to recalcified, defibrinated plasma. Healthy mice treated with acrolein and cyclophosphamide increased PC antigen levels, but no measurable increase in plasma APC levels. Breast cancer chemotherapy drugs elevate thrombin generation by activating coagulation through the TF and contact pathways, and by promoting phosphatidylserine exposure, as well as by impairing PC activation EPCR expression. These studies provide insight into the mechanisms of breast cancer chemotherapy-induced hypercoagulation.</p> / Doctor of Philosophy (Medical Science)

<p>Cancer patients undergoing chemotherapy have an elevated risk for thrombosis. Although thrombosis is a common complication in cancer patients, the mechanisms of chemotherapy-induced thrombosis remain unclear. We investigated the procoagulant effects of lung cancer chemotherapy agents (carboplatin, paclitaxel, cisplatin, and gemcitabine) on endothelial cells, A549 cells, and monocytes. We also investigated the <em>in </em>vivo procoagulant effects of the aforementioned chemotherapeutic agents as well as the anti-angiogenic agent bevacizumab. Tissue factor (TF) activity, TF antigen and phosphatidylserine (PS) levels were measured on chemotherapy-treated human umbilical vein endothelial cells (HUVEC), A549 cells, and monocytes. Treatment of HUVECs, A549 cells, and monocytes with lung cancer single agent and combination chemotherapy resulted in significant increases in TF activity. However, only cisplatin- and gemcitabine- treated monocytes were found to have increased TF antigen levels. PS exposure was increased only on HUVEC and monocytes treated with cisplatin/gemcitabine combination therapy. Interestingly, addition of paclitaxel to carboplatin resulted in reduced levels of PS exposure on monocytes. This study is the first to explore the procoagulant effects of lung cancer chemotherapy agents on monocyte and A549 cell TF activity levels, as well as to investigate the mechanisms by which lung cancer agents may promote TF decryption on these cell lines<strong>.</strong> Our <em>in vivo</em> results demonstrated that treatment of healthy mice with bevacizumab, paclitaxel and carboplatin moderately increased plasma TAT levels in healthy mice. These studies reveal potential mechanisms by which lung cancer chemotherapy may increase the risk of thrombosis. These studies reveal potential mechanisms by which lung cancer chemotherapy agents induce a hypercoagulable state.</p> / Master of Science (MSc)

<p>The effect of direction thrombin inhibition on acute deep vein thrombosis (DVT) stability has not been defined and could contribute to pulmonary embolism (PE) risk. Direct thrombin inhibitors (DTIs) effectively inhibit free and clot-bound thrombin, which could potentiate thrombus instability through disruption of platelet, fibrin, and FXIIIa stabilizing mechanisms. This could manifest as increased thrombus embolization. A clinically relevant mouse model of DVT stability could further our understanding of venous thrombosis pathophysiology and define the effect of direct thrombin inhibition on PE. We hypothesized that acute DTI administration would decrease acute DVT stability and potentially increase PE risk. Platelets were labeled <em>in vivo</em>, femoral vein thrombosis was induced using FeCl₃, and lepirudin (8U/g) was administered <em>after</em> clot formation. Using intravital videomicroscopy (IVM), real time embolization was quantified as a measurement of thrombus stability. Thrombus stability increased in the control group and decreased in the lepirudin-treated group over two hours. The decrease in α₂-antiplasmin (α₂-AP) content within lepirudin-treated thrombi, compared to control thrombi, could possibly contribute to the observed decrease in thrombus stability. Continued growth and embolization established the dynamic nature of formed thrombi. In both groups, emboli were detected in the pulmonary artery circulation. Therefore, we successfully developed a mouse model of venous thrombus stability, which imitated the clinical progression of DVT to PE. DTI administration in the acute DVT setting could decrease thrombus stability, demonstrated through increased embolization and PE. This model could be useful in examining the effect of other antithrombotics and risk factors settings on DVT stability.</p> / Master of Science (MSc)

<p>Medical devices used for diagnosis and treatment often involve the exposure of the patient’s blood to biomaterials that are foreign to the body, and blood-material contact may trigger coagulation and lead to thrombotic complications. Therefore, the risk of thrombosis and the issue of blood compatibility are limitations in the development of biomaterials for blood-contacting applications. The objective of this research was to develop a dual strategy for surface modification of polydimethylsiloxane (PDMS) to prevent thrombosis by (1) grafting polyethylene glycol (PEG) to inhibit non-specific protein adsorption, and (2) covalently attaching an antithrombin-heparin (ATH) covalent complex to the distal end of the PEG chains to inhibit coagulation at the surface.</p> <p>Surface characterization via contact angle measurements confirmed reductions in hydrophobicity for the modified surfaces and x-ray photoelectron spectroscopy (XPS) indicated that heparin and ATH were present. The predisposition of PDMS to induce blood coagulation was investigated, and advantages of ATH over heparin in inhibiting coagulation on PDMS were demonstrated. Studies of protein interactions using radiolabelling and Western blotting demonstrated the ability of PEG-modified surfaces to resist non-specific protein adsorption, and the ability of ATH- and heparin-modified surfaces to specifically bind AT present in plasma, thereby providing anticoagulant activity. Through specific interactions with the pentasaccharide sequence on the heparin moiety, the ATH-modified surfaces bound AT more efficiently than the heparin-modified surfaces. Thromboelastography (TEG) was used to evaluate further the anticoagulant potential of the ATH-modified surfaces. It was found that coagulation occurred at a slower rate on the ATH-modified surfaces compared to unmodified PDMS, and the resulting clot was mechanically weaker. By creating a surface with bioinert and bioactive properties, non-specific protein adsorption was reduced and anticoagulation at the surface through specific protein binding was promoted. This dual PEO/ATH modification strategy may therefore offer an improved approach for the minimization of thrombosis on PDMS and biomaterial surfaces more generally.</p> / Master of Applied Science (MASc)

<p>Unfractionated heparin (UFH) is used as an adjunct during thrombolytic therapy. However, its use is associated with many clinical limitations, such as the inability to inhibit fibrin-bound coagulation factors, increasing the potential for sustained procoagulant activity. We have developed a covalent conjugate of antithrombin (AT) and heparin (ATH) with superior anticoagulant properties to those of UFH. Some advantages of ATH include enhanced inhibition of surface-bound enzymes and its ability to reduce the overall size and mass of clots <em>in vivo</em>. However, the potential interactions of UFH or ATH with the components of the fibrinolytic pathway are not well understood. Therefore, our study utilized discontinuous second order rate constant (<em>k₂</em>) assays to determine rates of inhibition of plasmin (Pn) in the presence or absence of fibrin by AT+UFH <em>vs.</em> ATH. In addition, we monitored the rates of Pn generation in a system comprised of preformed fibrin clots with the aim of evaluating the inhibitory effect of AT+UFH or ATH in this more native system. The <em>k₂</em>values for the inhibition of Pn without fibrin were 5.74x10⁶±0.278x10⁶ and 6.39x10⁶±0.588x10⁶ for AT+UFH and ATH, respectively (p=0.36). In the presence of fibrin, the <em>k₂</em>values decreased to 1.45x10⁶±0.0971x10⁶ for AT+UFH and 3.07x10⁶±0.192x10⁶for ATH (<em>p</em></p> / Master of Science (MS)

<p>The management of thrombosis in the presence of thrombocytopenia is challenging because the inherent risk of bleeding associated with anticoagulant use may increase due to low platelet counts. Guidelines regarding anticoagulant use in this situation are based mainly on expert opinions and anecdotal data. We developed an <em>in-vitro</em> model to study the effect of anticoagulants on plasma clot formation in the presence of low platelet counts. We used thromboelastography (TEG) to measure global viscoelastic properties of clot formation and scanning electron microscopy (SEM) to observe and quantify changes in the fibrin clot structure. Experiments were conducted in plasma with varying platelet concentrations from <10 >– 150 × 10⁹/L. Clotting was activated with tissue factor (TF) and calcium, in the presence of factor XIIa inhibitor, corn trypsin inhibitor. One of the following anticoagulants at therapeutic concentration was added to the mixture: unfractionated heparin (UFH), dalteparin, fondaparinux, rivaroxaban or dabigatran. We found clotting had different sensitivity to TF concentration depending on the anticoagulant present. Effects on TEG parameters varied at a fixed TF concentration with each anticoagulant. UFH had the greatest influence, delaying clotting significantly at low platelet counts. The factor-specific anticoagulants had the least impact on TEG parameters. SEM revealed that UFH had the greatest impact on clot structure. UFH caused significant increase in porosity and fibrin widths and had significantly less fibers when platelets decreased. In conclusion, this study may provide fundamental data to understand clot formation in the presence of anticoagulants at low platelet counts. At low platelets the anticoagulants can jeopardize clot formation, especially UFH. The mechanism of each anticoagulant may contribute to the variation in response to TF initiated clotting. AT-dependent anticoagulants compromised plasma clotting more than the newer factor specific anticoagulants, possibly related to the multiple, non-specific inhibition of coagulation factors.</p> / Master of Science (MSc)