The relationship between the coagulation and inflammatory phases of wound healing in early breast cancer

Abstract

Introduction: Cancer is likened to a non-healing wound. Markers of coagulation (TF, thrombin, PAR1 and PAR2), the fi rst phase of wound healing, have increased stromal fi broblast expression in poor prognosis breast cancer (estrogen receptor (ER) negative, Her2 positive, high Ki67/grade). We hypothesised that markers of infl ammation, the second phase of wound healing, (CD68, macrophage marker; Heme oxygenase 1 (HO-1), macrophage and cancer cell marker; fi broblast activation protein (FAP), fi broblast marker) would correlate with coagulation markers and predict poor prognosis in early breast cancer. Aim: To assess the relationship between coagulation and infl ammatory markers in early breast cancer. To assess the prognostic value of CD68, HO-1 and FAP infl ammatory markers using clinicopathological variables. Materials and Methods: The prospective cohort study CHAMPion (Cancer induced Hypercoagulability as a Marker of Prognosis) recruited patients with ductal carcinoma in situ(DCIS) and invasive breast cancer. In tissue microarrays of 201 invasive tumours, 58 DCIS tumours and matched normal breast tissue distant from disease, CD68+ tumour associated macrophage(TAM)/CD68+ normal macrophage (normal tissue), epithelial HO-1 and fi broblast FAP expression, quantifi ed by immunohistochemistry(dichotomised: high/present vs low/absent), was correlated with tumour factors (grade, proliferation (Ki67), ER, HER2); demographics, behavioural factors (smoking, alcohol) and survival (disease-free survival (DFS), overall survival (OS)). Correlation between coagulation and infl ammatory markers was assessed using Cramer’s V correlation test (p<0.05). Results: High CD68+ macrophage expression was more commonly seen in invasive breast cancer, compared to DCIS, and normal tissue (59%, 41% and 6%, respectively; p<0.001). In invasive cancer, CD68+ TAM expression was increased with increasing tumour grade (Grade 1: 42%, Grade 2: 58%, Grade 3: 72%; p=0.006), high Ki67 (71% vs 47%; p=0.004), ER negativity (79.4% vs 55.4%; p=0.01) and HER2 (HER2 positive 81.8% vs HER2 negative 56.3%; p=0.03). CD68+ TAM expression was higher in high grade compared to low/ intermediate grade DCIS (44% vs 31%, p=0.52). CD68+ TAM expression was increased patients who self-reported alcohol intake (non-drinker 43% vs drinker 62%; p=0.01). Positive HO-1 and FAP expression was not associated with poor prognosis subgroups however cancer cell expression of HO-1 was associated with shorter DFS (HR 3.22, p=0.027) and OS (HR 2.86, p=0.029). Cancer-associated fi broblast (CAF) and tissue factor (TF) expression weakly correlated with high CD68+ TAM expression (CV 0.12, p=0.09), cancer cell HO-1 expression (CV 0.14, p=0.04) and CAF FAP expression (CV 0.15, p=0.03). In CAFs, PAR2 and FAP expression correlated (CV 0.14, p=0.04). Conclusions: Tumour infl ammation, as assessed by high CD68+ TAM expression is increased in poor prognosis breast cancer sub-types. The association reported here between CD68 and alcohol is suggestive of a mechanism for alcohol as a breast cancer risk factor. The correlation between stromal coagulation (fi broblast TF) and infl ammation highlights wound healing as potentially mechanistic in breast cancer growth.