Background: Patients with non-small cell lung cancer (NSCLC) are at high risk of venous thromboembolism (VTE), especially during chemotherapy. Even though the contact system is implicated in the pathogenesis of thrombosis, limited data are available on the role of contact system activation in NSCLC-associated VTE. Objectives: In a prospective cohort of patients with NSCLC starting chemotherapy, contact system activation and thrombin generation biomarkers were assessed in relation to 6-month VTE occurrence and mortality. Methods: Prechemotherapy plasma samples of 719 newly diagnosed patients with NSCLC were tested for in vivo biomarkers of contact system activation (ie, kallikrein [pKa]:antithrombin [AT; PKa:AT], activated factor [F]XI:AT [FXIa:AT], FXIa:C1-esterase inhibitor C1Inh [FXIa:C1Inh], activated FIX:AT [FIXa:AT]), and thrombin generation (ie, prothrombin fragment 1+2 [F1+2] and thrombin-antithrombin complex [TAT]). Clinical data, VTE, and mortality were recorded prospectively. Results: The 6-month VTE and mortality cumulative incidences were 11% and 27%, respectively. Basal levels of FXIa:AT complexes, F1+2, and TAT were higher in patients who developed VTE than those in VTE-free patients. Differently, PKa:AT, FIXa:AT, and TAT were lower in survivors than those in nonsurvivors. The multivariable analysis identified FXIa:AT (subdistribution hazard ratio, 1.17; 95% CI, 1.00-1.37) and TAT (subdistribution hazard ratio, 1.28; 95% CI, 1.10-1.50) as VTE-independent risk factors during chemotherapy. A score based on these biomarkers was generated, which was able to discriminate patients at significantly higher rates of VTE and mortality. Conclusion: Elevated in vivo contact pathway activation and thrombin generation were observed in patients with NSCLC who developed VTE. Furthermore, a score based on both FXIa:AT and TAT levels was developed to identify those patients at higher risk of VTE and mortality.

INTRODUCTION:Membranoproliferative glomerulonephritis (MPGN) is currently stratified into complement C3 glomerulopathy (C3G) and immune complex-mediated MPGN (IC-MPGN). However, classification is subject to continued debate. METHODS:Here, we applied hierarchical clustering to a much larger cohort of patients with C3G/IC-MPGN (295 individuals), extensively characterized for genetic and autoimmune complement abnormalities, with the goal of unraveling specific disease patterns. We also designed a user-friendly web application that with input of data at diagnosis could make cluster classification clinically applicable. RESULTS:Five clusters with unique phenotypic and complement profiles were identified. Cluster 1 and 2 patients showed systemic complement activation until C5. Consistently, C5 nephritic factor and anti-factor B antibodies were prevalent in these clusters. Cluster 2 was distinguished from cluster 1 for classical pathway activation markers in biopsy. Cluster 3 showed C3-restricted systemic complement activation associated with the prevalence of C3 nephritic factor. Cluster 4 and 5 patients shared a normal complement profile and intense glomerular C3 staining, consistent with solid-phase complement activation, but cluster 5 distinguished for the higher prevalence of genetic abnormalities. Cluster 4 patients had the highest incidence of kidney failure during follow-up, while cluster 1 had the best kidney prognosis. However, clusters 1 and 2 showed a high risk of post-transplant recurrence. Through our web application, we could visually compare the predicted profile of new patients with those of patients included in clustering analysis and assign these patients to different clusters. The cluster-based classification allows etiologic diagnosis of C3G/IC-MPGN and had better prognostic value than current approaches. CONCLUSIONS:Our proposed strategy may possibly guide anti-complement treatment.

KEY POINTS:This retrospective study analyzed clinical, histological, and biochemical data from a large cohort of participants with biopsy-proven primary C3 glomerulopathy/immune complex-mediated membranoproliferative GN. C3 glomerulopathy and immune complex-mediated membranoproliferative GN subjects shared most baseline and longitudinal features; 10-year kidney survival did not differ across histological subtypes. Older age at onset and higher proteinuria levels at 1 year from biopsy were the strongest predictors of kidney failure. BACKGROUND:Membranoproliferative glomerulonephritides (MPGNs) are defined by a typical glomerular histopathological pattern including C3 glomerulopathy (C3G) and immune complex-mediated MPGN (IC-MPGN). The overall prognosis is poor and the treatment options remain limited. Outcome predictors and reliable surrogate endpoints are critically needed for interventional trials. Herein, we described the natural history and analyzed clinical, histological and biochemical data from a large cohort of patients with primary C3G/IC-MPGN. METHODS:This is a retrospective analysis of patients with biopsy-proven primary C3G or IC-MPGN from the Italian Registry of MPGN. Demographic, clinical and histopathological data, molecular complement profiles, treatment patterns, and outcomes were collected. We performed univariable and multivariable Cox regressions and Kaplan-Meier survival analyses to assess risk associations with kidney disease progression. The composite endpoint included ESKD (defined by either eGFR <15 ml/min per 1.73 m 2 , initiation of chronic dialysis or kidney transplantation), doubling of serum creatinine at the last available follow-up, or death by kidney-related causes. RESULTS:Of the 349 patients identified, 208 had C3G and 141 IC-MPGN. Females were 41%, and over half were younger than 18 years old at time of biopsy. C3G and IC-MPGN patients shared most baseline and longitudinal features, with IC-MPGN patients presenting with higher baseline proteinuria (median 4.0 versus 2.3 g/24 hours, P < 0.001). Median eGFR at presentation was 83 ml/min per 1.73 m 2 . Twenty-six percent of patients progressed to ESKD over a median follow-up of 5 years from diagnosis. Higher proteinuria levels at 1 year from biopsy, particularly ≥1 g/24 hours, were significantly associated with a higher risk of adverse kidney outcomes. Pediatric onset was associated with better kidney survival, whereas kidney survival at 10 years did not statistically differ across histological subtypes. Complement dysregulation and rare functional variants in complement genes were not associated with outcomes. CONCLUSIONS:Our findings from a large and well-characterized cohort of individuals with primary C3G/IC-MPGN identify age at onset and proteinuria levels as associations with kidney survival, a finding that should inform future interventional trials.

Introduction. Primary membranoproliferative glomerulonephritis (MPGN) is a rare kidney disease with poor prognosis and no specific therapies. The disease heterogeneity and the difficulty of performing repeated kidney biopsies poses big challenges. This study investigates the correlation between non-contrast enhanced magnetic resonance imaging (MRI) and histologic and clinical findings in patients with primary MPGN. Methods. Patients with primary MPGN underwent baseline and 1-year kidney MRI in addition to biopsy and laboratory testing as part of a prospective MRI subproject of a clinical trial (ClinicalTrials.gov identifier NCT03723512). Diffusion-weighted and phase-contrast MRI were used to investigate kidney diffusivity and perfusion. Peritubular interstitial volume and fibrosis were quantified on kidney biopsies. Results. Seven patients with primary MPGN (18[17-21] years, 43% females) were included. Kidney biopsies showed variable degree of global and segmental glomerular sclerosis ([5-30]% and [10-60]%), mild interstitial fibrosis (<10%), and increased peritubular interstitial volume ([19-40]%). MRI and laboratory parameters changed very differently from patient to patient over 1 year. Peritubular interstitial volume and glomerular sclerosis negatively associated with renal blood flow (RBF)(rho = -0.81 and -0.77), and positively with renal vascular resistance (RVR)(rho = 0.65 and 0.73). Urinary albumin to creatinine ratio (uACR) negatively associated with RBF and filtration fraction (FF)(rho = -0.86 and -0.6), while positively with RVR (rho = 0.88). uACR decrease was associated with kidney diffusivity increase (rho = -0.5). Measured glomerular filtration rate (GFR) positively associated with kidney diffusivity, RBF, and FF (rho = 0.87, 0.85 and 0.59), while negatively with RVR (rho = -0.89); GFR increase was associated with kidney diffusivity, RBF, and FF increase (rho = 0.77, 0.7, and 0.7) and RVR decrease (rho = -0.7). Discussion/Conclusion. The strong correlation found between MRI and histologic and clinical findings, despite the rather limited number of patients, highlights MRI potential to monitor disease progression in patients with rare kidney disease.

Introduction: Lysinuric protein intolerance (LPI) is a multisystemic inborn error of metabolism with a variable clinical expressivity that usually begins in childhood with growth failure and gastroenterological/neurological problems related to the altered urea cycle and, later, with complications involving the renal, pulmonary, and immunohematological systems. Case Report: We present the case of a 40-year-old woman suffering from chronic kidney disease in the context of a LPI, whose diagnosis was challenging because the signs of the disease were always blurred and the patient never manifested critical episodes typical of this multisystemic disease. In addition to renal disease, splenomegaly, thrombocytopenia, elevated lactate dehydrogenase (LDH), hyperferritinemia, and hypertriglyceridemia were also present. A thorough investigation of the patient's food preferences revealed her spontaneous aversion to protein-containing foods and excessive drowsiness during the occurrence of infectious episodes or on the rare occasions of excessive protein intake, although without ever coming to medical attention. These nuanced signs led us to suspect an impairment of the urea cycle and ultimately allowed us to narrow down the diagnosis to LPI through biochemical and genetic investigations. Conclusion: Nephrologists should consider LPI in the differential diagnosis, whenever a patient presents with mixed proteinuria, tubular dysfunction, and/or chronic kidney disease of unknown origin. In these circumstances, we suggest looking for other signs such as growth failure, signs and symptoms ascribed to urea-cycle impairment, pulmonary involvement, hepatosplenomegaly, and laboratory alterations such as pancytopenia, hyperferritinemia, lipid abnormalities, and elevated LDH.

Membranoproliferative glomerulonephritis (MPGN) is a rare chronic nephropathy, affecting predominantly children and young adults and defined by a typical glomerular histopathological pattern of mesangial hypercellularity, endocapillary proliferation and duplication of the glomerular basement membrane. While clinical presentation and outcome are variable, the overall prognosis is poor, with progression to end-stage renal disease (ESRD) in about 40% of cases.

Background: In hospitalized patients, the SARS-CoV2 infection induces a thromboinflammatory state characterized by endothelial cell dysfunction, platelet activation, and hypercoagulability, leading to an increased risk of thrombosis. In ACS patients with concomitant SARS-CoV2 infection, a higher in-hospital mortality rate is reported; however, no information on the impact of this infection on the thromboinflammatory profile of patients presenting with ACS is currently available. Similarly, no role of hemostatic biomarkers in predicting in-hospital or long-term mortality risk has been established in this population. Aim: In a prospective cohort of ACS patients, we aimed to 1) characterize the contribution of concomitant SARS-CoV2 infection to the thromboinflammatory status by measuring a panel of hemostatic and inflammatory biomarkers; and 2) assess the role of these biomarkers in predicting in-hospital and/or two-year mortality. Methods: Consecutive patients admitted to interventional cardiology for ACS (i.e., ST-elevation myocardial infarction [STEMI], non-STEMI [NSTEMI], or unstable angina [UA]) during the first wave of the pandemic in Bergamo, Italy, from March to May 2020, were enrolled and followed-up for 2 years. Coronary angiography and percutaneous coronary intervention (PCI) data were collected. At admission, patients underwent complete blood cell count and an extensive coagulation profiling, including biomarkers of endothelial-cell activation (von Willebrand factor [vWF] antigen and activity, and ADAMTS13); hypercoagulation (prothrombin fragment 1+2 [F1+2], and D-dimer); and fibrinolytic proteins (tissue plasminogen activator [t-PA], and inhibitor [PAI-1]). In addition, the inflammatory biomarkers fibrinogen, factor VIII (FVIII), neutrophil extracellular traps (NETs), and C reactive protein (CRP) were tested. The occurrence of in-hospital and two-year mortality was prospectively recorded. Results: A total of 99 (76M/23F, median age 67 years) ACS patients (56 STEMI, 34 NSTEMI, 9 UA) were analyzed. Based on nasal swabs, 24 positive and 75 negative SARS-CoV-2 patients were identified. At admission, all patients showed significantly (p<0.05) higher levels of thromboinflammatory biomarkers compared to normal range values. Furthermore, ACS SARS-CoV-2-positive patients displayed significantly (p< 0.05) higher levels of fibrinogen, FVIII, D-dimer, vWF, t-PA, PAI-1, CRP, and NETs, together with significantly (p<0.05) lower levels of lymphocytes, hemoglobin, platelets, and ADAMTS-13 as compared to negative patients. The STEMI SARS-CoV2-positive group exhibited the highest values of the biomarkers. When performed, PCI ended more frequently with partial coronary reperfusion (TIMI grade flow <3) in SARS-CoV2-positive compared to negative patients (p= 0.004). The cumulative incidence of in-hospital mortality was 10%. The univariable analysis identified SARS-CoV-2 positivity as the strongest independent risk factor for mortality (HR 5.9 [95%CI 1.2-31.1]). Regarding the other clinical and laboratory parameters, the multivariable analysis identified dyspnea at presentation, vWF antigen, and leukocytes as independent risk factors for in-hospital mortality. These variables were used to develop a continuous score. Based on this score, the cumulative incidence of mortality was 0 % in the low-risk group, 19% in the intermediate-risk group (95% CI 6.1- 48.2%), and 71% in the high-risk group (95% CI 28.2-113.2%). After a 2-year observation, the mortality rate was 8%. Age was the sole independent risk factor for a 2-year mortality, with a HR of 1.2 (95% CI 1.04-1.3), regardless of the initial SARS-CoV2 status. Conclusions: For the first time, our study demonstrates that SARS-CoV2 infection worsens the thromboinflammatory state of ACS patients. This harmful effect might explain the observed heightened mortality rate among ACS patients concomitantly infected with SARS-CoV-2, which in our study was six times higher than in non-infected ACS patients. Additionally, the proposed scoring system, based on thromboinflammatory biomarkers, has proven effective in identifying ACS patients with elevated risks of in-hospital mortality. The potential role of this scoring system in identifying high-risk patients may possibly extend beyond our study to other highly inflammatory settings.

Introduction: Breast cancer is the most prevalent malignancy among women worldwide and is the cancer type in which the thrombogenic effect of anti-cancer drugs was first recognized (Levine et al, NEJM 1988). The occurrence of VTE in patients with metastatic breast cancer upon commencing anticancer treatment significantly affects disease burden, quality of life, and healthcare expenditure. Consequently, it is essential to accurately discern patients with a significant risk of developing thrombosis, thereby warranting medical prophylaxis. However, the stratification of outpatients on chemotherapy for metastatic breast cancer initiating an anticancer treatment by validated risk assessment models (RAMs) remains an unmet clinical need. In a prospective, observational cohort study of newly diagnosed metastatic breast cancer patients beginning chemotherapy, we aim to evaluate the incidence of VTE and the role of hypercoagulation biomarkers in predicting VTE and mortality within a 12-month follow-up. Methods: Newly diagnosed, metastatic breast cancer patients were enrolled and prospectively followed for VTE and mortality (HYPERCAN study, ClinicalTrials.gov ID#NCT02622815). Blood samples were collected at enrolment, before starting chemotherapy, and tested for biomarkers of blood clotting activation (i.e. D-dimer, fibrinogen, prothrombin-fragment 1+2 [F1+2]). Univariable and multivariable analyses were performed using the Cox proportional hazard model to identify statistically significant prognostic factors (SPSS Statistics, version 21.0). Fine and Gray competing risk analysis was also performed (Stata Corp, version 16). Results: A prospective cohort of 189 metastatic breast cancer patients with a median age of 59 years (range 32-91 years) was analyzed. Ductal carcinoma was diagnosed in 80% of patients. The most represented molecular subtypes were Luminal B HER2-neg (32.3%) > Luminal B HER2-pos (24.3%) > Luminal A (13.2%) > triple negative (TN, 9.5%) > HER2-pos (9%). Within 1 year of enrollment, 13 patients experienced VTE in a median time of 173 days (IQR: 52-258), resulting in a VTE cumulative incidence of 7.0% (95% CI 3.7-11.5). During the same follow-up period, the cumulative incidence of mortality was 12% (95% CI 7.4-17), within a median time to death of 212 days (IQR 106-306). Patients who experienced VTE had significantly higher baseline levels of D-dimer and fibrinogen than those who remained VTE-free during the same follow-up period (p<0.02). No significant differences were found in F1+2 levels between the two groups. In the Fine and Gray competing univariable analysis, D-dimer [HR 1.02 (95% CI 1.00-1.04), p=0.008] and Fibrinogen (HR 1.06 (95% CI 1.03-1.10), p<0.001), considered as continuous variables, emerged as significant predictors of VTE. Following correction for clinical variables (age, BMI, cardiovascular risk factors, and tumor histological characteristics), both biomarkers retained their independent associations with VTE occurrence. To establish specific cut-off values for each biomarker, D-dimer and fibrinogen levels were categorized into quartiles based on their distribution within the cohort. The results showed that D-dimer values greater than 533 ng/mL (2nd quartile) [HR 3.8 (95% CI 1.7 - 8.7), p=0.032] or fibrinogen values exceeding 428 mg/dL (3rd quartile) [HR 2.6 (95% CI 1.03-6.4), p=0.042] were significantly associated with an increased risk of VTE. Subsequently, the patients were categorized into two risk groups based on whether their biomarker values were above or below the identified thresholds. Specifically, analysis using Kaplan-Meier curves based on the D-dimer threshold revealed a VTE incidence of 3.3% versus 11% (p=0.029) in the low- and high-risk groups, respectively. Similarly, stratification by the fibrinogen threshold demonstrated a VTE incidence of 3.0% versus 18% (p<0.001) in the low- and high-risk groups. In this cohort, the occurrence of VTE did not affect the mortality rate, which was 64% in patients with VTE versus 51% in patients with no VTE (p=ns). Conclusion: Our data indicated that pre-chemotherapy D-dimer and fibrinogen levels are effective in identifying metastatic breast cancer patients at higher risk of VTE. These findings highlight the potential of these biomarkers in enhancing risk stratification and guiding personalized treatment strategies for breast cancer patients.

Patients with chronic Myeloproliferative Neoplasms (MPN) including polycythemia vera (PV) and essential thrombocythemia (ET) exhibit unique clinical features, such as a tendency toward thrombosis and hemorrhage, and risk of disease progression to secondary bone marrow fibrosis and/or acute leukemia. Although an increase in blood cell lineage counts (quantitative features) contribute to these morbid sequelae, the significant qualitative abnormalities of myeloid cells that contribute to vascular risk are not well understood. Here, we address this critical knowledge gap via a comprehensive and untargeted profiling of the platelet proteome in a large (n= 140) cohort of patients (from two independent sites) with an established diagnosis of PV and ET (and complement prior work on the MPN platelet transcriptome from a third site). We discover distinct MPN platelet protein expression and confirm key molecular impairments associated with proteostasis and thrombosis mechanisms of potential relevance to MPN pathology. Specifically, we validate expression of high-priority candidate markers from the platelet transcriptome at the platelet proteome (e.g., calreticulin (CALR), Fc gamma receptor (FcγRIIA) and galectin-1 (LGALS1) pointing to their likely significance in the proinflammatory, prothrombotic and profibrotic phenotypes in patients with MPN. Together, our proteo-transcriptomic study identifies the peripherally-derived platelet molecular profile as a potential window into MPN pathophysiology and demonstrates the value of integrative multi-omic approaches in gaining a better understanding of the complex molecular dynamics of disease. Highlights MPN patient platelet proteome identifies key pathobiological mediators of thrombosis and proteostasis. The MPN platelet proteomic profile validates our prior findings from the platelet transcriptome.

Introduction: Given the great variability of the individual response to SARS-CoV2 infection, it is important to understand whether and how biological and genetic factors might predispose to the infection and to the degree of severity, including the development of systemic coagulopathy and thrombosis. In this study, we evaluated the frequency of prothrombotic allelic variants (AVs) in coagulation genes in a population of COVID-19 patients, to verify whether these polymorphisms, alone or in combination, are associated to an increased susceptibility to develop COVID-19 and/or a greater severity. Methods: A cohort of 358 patients (257M/101F; median age: 55 years) from the Bergamo area with two different degrees of COVID-19 severity, i.e., severe disease (hospitalized, n=212) or mild disease (non-hospitalized, n=146), was enrolled from April 2020 to June 2021 and followed-up for disease outcome and thrombosis. A cohort of 377 healthy subjects (177M/200F; median age: 49 years) from the same area without COVID-19 acted as a control group. DNA was analyzed for a panel of prothrombotic/inflammatory single nucleotide polymorphisms (SNPs) including FII rs1799963, FV rs6025, FV rs118203907, FXIIIA1 rs5985, FGB rs1800790, MTHFR rs1801131 and MTHFR rs1801133 as well as two SNPs located in the coding region of angiotensin-converting enzyme (ACE2) gene, namely ACE2 rs140312271 and ACE2 rs41303171. Statistical analysis was performed using SPSS statistical software. Results: Among the AVs analyzed, the rs6025 polymorphism of FV gene (FV Leiden) was more frequent in COVID-19 patients than in the control group. By a logistic regression corrected for age and gender, FV Leiden was associated with a 3-fold risk of developing COVID-19 (OR: 3.2 [95% CI 1.02-10]). In contrast, the rs41303171 polymorphism of the ACE2 gene was more frequent in the control group and was a protective factor for COVID-19 (OR: 0.12 [95% CI 0.02-0.99]) even after correction for age and gender. No significant differences appeared in the frequency of the other SNPs alone or in combination. Within the COVID-19 patient cohort, the rs1801131 SNP of MTHFR gene was associated with less severe COVID-19 disease. In the hospitalized severe cohort, 17 (8%) patients developed an overt venous thromboembolic event, and 7 COVID-19-related deaths (4%) were recorded. No significant associations were found between any of the AVs analyzed and the outcomes of thrombosis and death. However, the analyses of circulating biomarkers of clotting (i.e. D-dimer, FVIII, fibrinogen, prothrombin fragment 1+2 [F1+2], and FXIII), fibrinolysis (i.e. tissue plasminogen activator [tPA], and plasminogen activator inhibitor-1 [PAI-1]) and endothelial cell activation (i.e. thrombomodulin [TM], and von Willebrand Factor [vWF]), and the neutrophil-to-lymphocyte ratio (NLR) as an inflammatory biomarker revealed thathaving fibrinogen (OR: 4.9 [95% CI 1.04-23.1]), vWF:Ag (OR: 11.8 [95% CI 2.1-66.9]) and NLR (OR: 26.1 [95% CI 2.9-237] levels above the 75th percentile was significantly associated with death. Of interest, in the same hospitalized patient group, but not in the control group, the presence of FXIII SNPs was significantly associated with high levels of F1+2. Conclusions: Our study shows that the FV Leiden polymorphism predisposes to COVID-19 infection, while the rs41303171 ACE2 polymorphism has a protective role. In addition, the rs1801131 SNP of gene MTHFR correlates with a milder COVID-19 disease. In patients with severe COVID-19, the inflammatory marker NLR, and the circulating hemostatic proteins vWF and fibrinogen are associated with mortality.

Large GWAS indicated that genetic factors influence the response to SARS-CoV-2. However, sex, age, concomitant diseases, differences in ancestry, and uneven exposure to the virus impacted the interpretation of data. We aimed to perform a GWAS of COVID-19 outcome in a homogeneous population who experienced a high exposure to the virus and with a known infection status. We recruited inhabitants of Bergamo province-that in spring 2020 was the epicenter of the SARS-Cov-2 pandemic in Europe-via an online questionnaire followed by personal interviews. Cases and controls were matched by age, sex and risk factors. We genotyped 1195 individuals and replicated the association at the 3p21.31 locus with severity, but with a stronger effect size that further increased in gravely ill patients. Transcriptome-wide association study highlighted eQTLs for LZTFL1 and CCR9. We also identified 17 loci not previously reported, suggestive for an association with either COVID-19 severity or susceptibility.

Introduction: Hemostatic biomarkers have been widely explored in different cancer types as possible predictors of specific cancer outcomes, including survival, malignant disease recurrence, and progression. Results from many small and single-center studies are promising, stimulating confirmatory data from large, prospective studies. In a large cohort of high-risk breast cancer patients enrolled in the prospective, observational, multicenter HYPERCAN study, we aim to establish whether prechemotherapy hemostatic levels can predict disease recurrence (DR). Methods: TheHYPERCAN study (ClinicalTrials.gov ID#NCT02622815) is a prospective, observational, multicenter study, specifically designed to evaluate the role of hemostatic biomarkers in relation to disease recurrence, disease progression, mortality response to therapy and thrombosis. Patients with surgically resected high-risk breast cancer enrolled between 2012 and 2019, from the HYPERCAN study were analyzed. Blood samples collected at enrollment, before starting anticancer treatment, were tested for thrombin generation (TG) by both the ST-Genesia system (STG-ThromboScreen reagent, with and without thrombomodulin) and the calibrated automated thrombogram (CAT) at 5 pM TF. D-dimer, fibrinogen, prothrombin fragment 1+2 (F1+2), and proteins C and free protein S (FPS) were also measured. Outcome analyzed was early-DR (E-DR) within 2 years. Results: A total of 1,059 patients (15M/1,044F), mean age 53 years (SD±11) were analyzed. Breast conserving-resection was performed in 53% and mastectomy in 47% of patients. HER-2 expression was positive in 26% of tumor specimens. The most frequent molecular subtype was Luminal B HER2 negative (32%), followed by Luminal A (22%), Luminal B HER2 positive (19%), Triple negative (13%) and HER2 positive (8%). The largest proportion of tumors were classified as invasive ductal carcinoma, diagnosed in 86% of subjects. All patients were eligible for systemic adjuvant chemotherapy, and for receiving trastuzumab in case of HER-2 positivity. Within 2 years from enrollment, 53 (5.5 %) patients experienced an E-DR, 8 died, while 92 were lost at follow-up. E-DR patients were characterized by worse stage (IIIC), more frequently triple-negative, and less often Luminal-B/HER2-positive molecular subtypes (p<0.05). In addition, E-DR subjects were characterized by increased pre-chemotherapy levels of D-dimer (p=0.004), and peak of TG performed by both Genesia (p=0.001), with and without thrombomodulin, and by CAT (p<0.001) assays. The remaining coagulation parameters were not significantly different between the two groups. The competitive multivariable proportional hazard regression model, corrected for age and surgery status, identified D-dimer and TG peak (by both methods) as independent risk factors for E-DR. This model was internally validated by 1,000-bootstrapping resampling correction. A continuous risk score was therefore generated including D-dimer and TG, which provided a ROC AUC of 0.652 (p<0.001). By this score the patients were significantly stratified in a high- vs low-risk for E-DR (HR 23 vs 0%: Log-rank <0.001). Conclusions: In this large prospective cohort of surgically resected breast cancer patients at high-risk of DR, we could generate and internally validate a risk assessment model based on pre-treatment values of TG and D-dimer, able to identify those subjects at higher risk of DR in the first 2 years after tumor resection. This score, if externally validated, may help the clinical surveillance and serve as treatment guidance in patients with primary breast cancer that are at high risk of recurrence, avoiding overtreatment in those at low risk.