Molecular Medicine

, Volume 23, Issue 1, pp 13–23 | Cite as

Dabigatran Potentiates Gemcitabine-Induced Growth Inhibition of Pancreatic Cancer in Mice

  • Kun Shi
  • Helene Damhofer
  • Joost Daalhuisen
  • Marieke ten Brink
  • Dick J. Richel
  • C. Arnold Spek
Research Article


Pancreatic cancer is one of the most lethal solid malignancies, with few treatment options. We have recently shown that expression of protease activated receptor (PAR)-1 in the tumor microenvironment drives the progression and induces the chemoresistance of pancreatic cancer. As thrombin is the prototypical PAR-1 agonist, here we address the effects of the direct thrombin inhibitor dabigatran on pancreatic cancer growth and drug resistance in an orthotropic pancreatic cancer model. We show that dabigatran treatment did not affect primary tumor growth, whereas it significantly increased tumor dissemination throughout the peritoneal cavity. Increased dissemination was accompanied by intratumoral bleeding and increased numbers of aberrant and/or collapsed blood vessels in the primary tumors. In combination with gemcitabine, dabigatran treatment limited primary tumor growth, did not induce bleeding complications and prevented tumor cell dissemination. Dabigatran was, however, not as efficient as genetic ablation of PAR-1 in our previous study, suggesting that thrombin is not the main PAR-1 agonist in the setting of pancreatic cancer. Overall, we show that dabigatran potentiates gemcitabine-induced growth inhibition of pancreatic cancer but does not affect primary tumor growth when used as monotherapy.



Dabigatran was kindly provided by Dr. Ashley Goss from the CardioMetabolic Disease Research department of Boehringer Ingelheim Pharmaceuticals. This study is supported by grants from the Dutch Cancer Foundation (2009–4324 and 2014–6782).

Supplementary material

10020_2017_2301013_MOESM1_ESM.pdf (109 kb)
Supplementary material, approximately 108 KB.


  1. 1.
    Stathis A, Moore MJ. (2010) Advanced pancreatic carcinoma: current treatment and future challenges. Nat. Rev. Clin. Oncol. 7:163–72.CrossRefGoogle Scholar
  2. 2.
    Gudjonsson B. (2002) Survival statistics gone awry: pancreatic cancer, a case in point. J. Clin. Gastroenterol. 35:180–84.CrossRefGoogle Scholar
  3. 3.
    Ghaneh P, Costello E, Neoptolemos JP. (2007) Biology and management of pancreatic cancer. Gut. 56:1134–52.CrossRefGoogle Scholar
  4. 4.
    Cardenes HR, Chiorean EG, Dewitt J, Schmidt M, Loehrer P. (2006) Locally advanced pancreatic cancer: current therapeutic approach. Oncologist. 11:612–23.CrossRefGoogle Scholar
  5. 5.
    Vu TK, Hung DT, Wheaton VI, Coughlin SR. (1991) Molecular cloning of a functional thrombin receptor reveals a novel proteolytic mechanism of receptor activation. Cell. 164:1057–68.CrossRefGoogle Scholar
  6. 6.
    Salah Z, et al. (2012) Regulation of human protease-activated receptor 1 (hPar1) gene expression in breast cancer by estrogen. FASEB J. 26:2031–42.CrossRefGoogle Scholar
  7. 7.
    Nierodzik ML, Karpatkin S. (2006) Thrombin induces tumor growth, metastasis, and angiogenesis: Evidence for a thrombin-regulated dormant tumor phenotype. Cancer Cell. 10:355–62.CrossRefGoogle Scholar
  8. 8.
    Cisowski J, et al. (2011) Targeting protease-activated receptor-1 with cell-penetrating pepducins in lung cancer. Am. J. Pathol. 179:513–23.CrossRefGoogle Scholar
  9. 9.
    Diaz J, et al. (2012) Progesterone promotes focal adhesion formation and migration in breast cancer cells through induction of protease-activated receptor-1. J. Endocrinol. 214:165–75.CrossRefGoogle Scholar
  10. 10.
    Zhu L, et al. (2012) Cooperation of protease-activated receptor 1 and integrin alphanubeta5 in thrombin-mediated lung cancer cell invasion. Oncol. Rep. 28:553–60.CrossRefGoogle Scholar
  11. 11.
    Queiroz KC, et al. (2014) Protease-activated receptor-1 drives pancreatic cancer progression and chemoresistance. Int. J. Cancer. 135:2294–304.CrossRefGoogle Scholar
  12. 12.
    Schmidlin F, Bunnett NW. (2001) Protease-activated receptors: how proteases signal to cells. Curr. Opin. Pharmacol. 1:575–82.CrossRefGoogle Scholar
  13. 13.
    Macfarlane SR, Seatter MJ, Kanke T, Hunter GD, Plevin R. (2001) Proteinase-activated receptors. Pharmacol. Rev. 53:245–82.PubMedGoogle Scholar
  14. 14.
    Rudroff C, Striegler S, Schilli M, Scheele J. (2001) Thrombin enhances adhesion in pancreatic cancer in vitro through the activation of the thrombin receptor PAR 1. Eur. J. Surg. Oncol. 27:472–76.CrossRefGoogle Scholar
  15. 15.
    Nutescu EA, Shapiro NL, Chevalier A. (2008) New anticoagulant agents: direct thrombin inhibitors. Cardiol. Clin. 26:169–87, v-vi.CrossRefGoogle Scholar
  16. 16.
    Mungall D. (2002) BIBR-1048 Boehringer Ingelheim. Curr. Opin. Investig. Drugs. 3:905–07.PubMedGoogle Scholar
  17. 17.
    Gustafsson D. (2003) Oral direct thrombin inhibitors in clinical development. J. Int. Med. 254:322–34.CrossRefGoogle Scholar
  18. 18.
    Hankey GJ, Eikelboom JW. (2011) Dabigatran etexilate: a new oral thrombin inhibitor. Circulation. 123:1436–50.CrossRefGoogle Scholar
  19. 19.
    Nagarakanti R, et al. (2011) Dabigatran versus warfarin in patients with atrial fibrillation: an analysis of patients undergoing cardioversion. Circulation. 123:131–36.CrossRefGoogle Scholar
  20. 20.
    Eckman MH, Singer DE, Rosand J, Greenberg SM. (2011) Moving the tipping point: the decision to anticoagulate patients with atrial fibrillation. Circ. Cardiovasc. Qual. Outcomes. 4:14–21.CrossRefGoogle Scholar
  21. 21.
    Ezekowitz MD, Aikens TH, Nagarakanti R, Shapiro T. (2011) Atrial fibrillation: outpatient presentation and management. Circulation. 124:95–99.CrossRefGoogle Scholar
  22. 22.
    Scott KA, Amirehsani KA. (2015) Dabigatran etexilate: An alternative to warfarin for patients with nonvalvular atrial fibrillation. J. Am. Assoc. Nurse Pract. 27:190–96.PubMedGoogle Scholar
  23. 23.
    Ziske C, et al. (2008) Real-time high-resolution compound imaging allows percutaneous initiation and surveillance in an orthotopic murine pancreatic cancer model. Pancreas. 36:146–52.CrossRefGoogle Scholar
  24. 24.
    Dineen SP, et al. (2010) Smac mimetic increases chemotherapy response and improves survival in mice with pancreatic cancer. Cancer Res. 70:2852–61.CrossRefGoogle Scholar
  25. 25.
    Alexander ET, Minton AR, Peters MC, van Ryn J, Gilmour SK. (2016) Thrombin inhibition and cisplatin block tumor progression in ovarian cancer by alleviating the immunosuppressive microenvironment. Oncotarget. 7:85291–305.CrossRefGoogle Scholar
  26. 26.
    de Boer JD, et al. (2015) Effect of the oral thrombin inhibitor dabigatran on allergic lung inflammation induced by repeated house dust mite administration in mice. Am. J. Physiol. Lung Cell Mol. Physiol. 309:L768–75.CrossRefGoogle Scholar
  27. 27.
    Kopec AK, et al. (2014) Thrombin inhibition with dabigatran protects against high-fat-diet-induced fatty liver disease in mice. J. Pharmacol. Exp. Ther. 351:288–97.CrossRefGoogle Scholar
  28. 28.
    Marangoni MN, et al. (2016) Differential effects on glial activation by a direct versus an indirect thrombin inhibitor. J. Neuroimmunol. 297:159–68.CrossRefGoogle Scholar
  29. 29.
    Borensztajn K, et al. (2010) Protease-activated receptor-2 induces myofibroblast differentiation and tissue factor up-regulation during bleomycin-induced lung injury: potential role in pulmonary fibrosis. Am. J. Pathol. 177:2753–64.CrossRefGoogle Scholar
  30. 30.
    Duitman J, et al. (2012) CCAAT/enhancer-binding protein delta facilitates bacterial dissemination during pneumococcal pneumonia in a platelet-activating factor receptor-dependent manner. Proc. Natl. Acad. Sci. USA. 109:9113–18.CrossRefGoogle Scholar
  31. 31.
    Shi K, Queiroz KC, Stap J, Richel DJ, Spek CA. (2013) Protease-activated receptor-2 induces migration of pancreatic cancer cells in an extracellular ATP-dependent manner. J. Thromb. Haemost. 11:1892–902.PubMedGoogle Scholar
  32. 32.
    Cunningham D, et al. (2009) Phase III randomized comparison of gemcitabine versus gemcitabine plus capecitabine in patients with advanced pancreatic cancer. J. Clin. Oncol. 27:5513–18.CrossRefGoogle Scholar
  33. 33.
    Whatcott CJ, Posner RG, Von Hoff DD, Han H. (2012) Desmoplasia and chemoresistance in pancreatic cancer. In: Pancreatic Cancer and Tumor Microenvironment. Grippo PJ, Munshi HG (eds.). Transworld Research Network, Trivandrum, India. Chapter 8 ( Scholar
  34. 34.
    Hwang RF, et al. (2008) Cancer-associated stromal fibroblasts promote pancreatic tumor progression. Cancer Res. 68:918–26.CrossRefGoogle Scholar
  35. 35.
    Chambers RC, Leoni P, Blanc-Brude OP, Wembridge DE, Laurent GJ. (2000) Thrombin is a potent inducer of connective tissue growth factor production via proteolytic activation of protease-activated receptor-1. J. Biol. Chem. 275:35584–91.CrossRefGoogle Scholar
  36. 36.
    Goerge T, et al. (2006) Tumor-derived matrix metalloproteinase-1 targets endothelial proteinase-activated receptor 1 promoting endothelial cell activation. Cancer Res. 66:7766–74.CrossRefGoogle Scholar
  37. 37.
    Zhang Y, Wang Y, Xiang Y, Lee W. (2012) Prohibitins are involved in protease-activated receptor 1-mediated platelet aggregation. J. Thromb. Haemost. 10:411–18.CrossRefGoogle Scholar
  38. 38.
    Cooper DM, Pechkovsky DV, Hackett TL, Knight DA, Granville DJ. (2011) Granzyme K activates protease-activated receptor-1. PLoS One. 6:e21484.CrossRefGoogle Scholar
  39. 39.
    Ramsay AJ, et al. (2008) Kallikrein-related peptidase 4 (KLK4) initiates intracellular signaling via protease-activated receptors (PARs). KLK4 and PAR-2 are co-expressed during prostate cancer progression. J. Biol. Chem. 283:12293–304.CrossRefGoogle Scholar
  40. 40.
    Knecht W, et al. (2007) Trypsin IV or mesotrypsin and p23 cleave protease-activated receptors 1 and 2 to induce inflammation and hyperalgesia. J. Biol. Chem. 282:26089–100.CrossRefGoogle Scholar
  41. 41.
    Jiang G, et al. (2010) PRSS3 promotes tumour growth and metastasis of human pancreatic cancer. Gut. 59:1535–44.CrossRefGoogle Scholar
  42. 42.
    Neesse A, et al. (2011) Stromal biology and therapy in pancreatic cancer. Gut. 60:861–68.CrossRefGoogle Scholar
  43. 43.
    Borensztajn KS, Spek CA. (2008) Protease-activated receptors, apoptosis and tumor growth. Pathophysiol. Haemost. Thromb. 36:137–47.CrossRefGoogle Scholar
  44. 44.
    Tsopanoglou NE, Maragoudakis ME. (2009) Thrombin’s central role in angiogenesis and pathophysiological processes. Eur. Cytokine Netw. 20:171–79.PubMedGoogle Scholar
  45. 45.
    Battinelli EM, et al. (2014) Anticoagulation inhibits tumor cell-mediated release of platelet angiogenic proteins and diminishes platelet angiogenic response. Blood. 123:101–02.CrossRefGoogle Scholar
  46. 46.
    Haralabopoulos GC, Grant DS, Kleinman HK, Maragoudakis ME. (1997) Thrombin promotes endothelial cell alignment in Matrigel in vitro and angiogenesis in vivo. Am. J. Physiol. 273: C239–45.CrossRefGoogle Scholar
  47. 47.
    Wang B, Pearson T, Manning G, Donnelly R. (2010) In vitro study of thrombin on tubule formation and regulators of angiogenesis. Clin. Appl. Thromb. Hemost. 16:674–78.CrossRefGoogle Scholar
  48. 48.
    Lange S, et al. (2014) Independent anti-angiogenic capacities of coagulation factors X and Xa. J. Cell Physiol. 229:1673–80.CrossRefGoogle Scholar
  49. 49.
    Ruffell B, Affara NI, Coussens LM. (2012) Differential macrophage programming in the tumor microenvironment. Trends Immunol. 33:119–26.CrossRefGoogle Scholar
  50. 50.
    Fischer C, et al. (2007) Anti-PLGF inhibits growth of VEGF(R)-inhibitor-resistant tumors without affecting healthy vessels. Cell. 131:463–75.CrossRefGoogle Scholar
  51. 51.
    Zhang W, et al. (2010) Depletion of tumor-associated macrophages enhances the effect of sorafenib in metastatic liver cancer models by antimetastatic and antiangiogenic effects. Clin. Cancer Res. 16:3420–30.CrossRefGoogle Scholar
  52. 52.
    Zeuner A, et al. (2014) Elimination of quiescent/slow-proliferating cancer stem cells by Bcl-XL inhibition in non-small-cell lung cancer. Cell Death Differ. 21:1877–88.CrossRefGoogle Scholar
  53. 53.
    Icli F, et al. (2007) Low molecular weight heparin (LMWH) increases the efficacy of cisplatinum plus gemcitabine combination in advanced pancreatic cancer. J. Surg. Oncol. 95:507–12.CrossRefGoogle Scholar
  54. 54.
    von Delius S, et al. (2007) Effect of low-molecular-weight heparin on survival in patients with advanced pancreatic adenocarcinoma. Thromb. Haemost. 98:434–39.CrossRefGoogle Scholar
  55. 55.
    van Doormaal FF, et al. (2011) Randomized trial of the effect of the low molecular weight heparin nadroparin on survival in patients with cancer. J. Clin. Oncol. 29:2071–76.CrossRefGoogle Scholar
  56. 56.
    Qiu W, Su GH. (2013) Development of orthotopic pancreatic tumor mouse models. Methods Mol. Biol. 980:215–23.CrossRefGoogle Scholar
  57. 57.
    Partecke LI, et al. (2011) A syngeneic orthotopic murine model of pancreatic adenocarcinoma in the C57/BL6 mouse using the Panc02 and 6606PDA cell lines. Eur. Surg. Res. 47:98–107.CrossRefGoogle Scholar
  58. 58.
    Hwang CI, Boj SF, Clevers H, Tuveson DA. (2016) Preclinical models of pancreatic ductal adenocarcinoma. J. Pathol. 238:197–204.CrossRefGoogle Scholar
  59. 59.
    Daley D, et al. (2016) yS T Cells Support Pancreatic Oncogenesis by Restraining αβ T Cell Activation. 166:1485–99, e15.Google Scholar
  60. 60.
    Inman KS, Francis AA, Murray NR. (2014) Complex role for the immune system in initiation and progression of pancreatic cancer. World J. Gastroenterol. 20:11160–81.CrossRefGoogle Scholar
  61. 61.
    De Monte L, et al. (2011) Intratumor T helper type 2 cell infiltrate correlates with cancer-associated fibroblast thymic stromal lymphopoietin production and reduced survival in pancreatic cancer. J. Exp. Med. 208:469–78.CrossRefGoogle Scholar
  62. 62.
    Fukunaga A, et al. (2004) CD8+ tumor-infiltrating lymphocytes together with CD4+ tumor-infiltrating lymphocytes and dendritic cells improve the prognosis of patients with pancreatic adenocarcinoma. Pancreas. 28:e26–e31.CrossRefGoogle Scholar
  63. 63.
    Pylayeva-Gupta Y, Lee KE, Hajdu CH, Miller G, Bar-Sagi D. (2012) Oncogenic Kras-induced GM-CSF production promotes the development of pancreatic neoplasia. Cancer Cell. 21:836–47.CrossRefGoogle Scholar
  64. 64.
    Ochi A, et al. (2012) MyD88 inhibition amplifies dendritic cell capacity to promote pancreatic carcinogenesis via Th2 cells. J. Exp. Med. 209:1671–87.CrossRefGoogle Scholar
  65. 65.
    Frese KK, Tuveson DA. (2007) Maximizing mouse cancer models. Nat. Rev. Cancer 7:645–58.CrossRefGoogle Scholar
  66. 66.
    Petersen LC, et al. (2005) Characterization of recombinant murine factor VIIa and recombinant murine tissue factor: a human-murine species compatibility study. Thromb. Res. 116:75–85.CrossRefGoogle Scholar

Copyright information

© The Author(s) 2017

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, and provide a link to the Creative Commons license. You do not have permission under this license to share adapted material derived from this article or parts of it.

The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.

To view a copy of this license, visit (

Authors and Affiliations

  • Kun Shi
    • 1
  • Helene Damhofer
    • 2
  • Joost Daalhuisen
    • 1
  • Marieke ten Brink
    • 1
  • Dick J. Richel
    • 3
  • C. Arnold Spek
    • 1
  1. 1.Center for Experimental and Molecular Medicine, H2-215, Academic Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
  2. 2.Laboratory for Experimental Oncology and Radiobiology, Center for Experimental Molecular Medicine, Academic Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
  3. 3.Department of Medical Oncology, Academic Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands

Personalised recommendations