Preoperative elevated peripheral blood platelet count predicts poor prognosis in a variety of human cancers [17] among them also gastric cancer [18].Thrombocytes and Lymphatics in Esophageal CancerIn esophageal cancer (SCC and AC), an increase in platelet count after en bloc resection has been reported to be associated with better prognosis in one study [19], and in a study from Pakistan, low preoperative platelet counts were associated with poor prognosis [20]. In contrast, another study found that preoperative thrombocytosis indicated poor prognosis in esophageal SCC [20]. Nevertheless, it is not completely clear if elevated platelet counts are induced by a more aggressive phenotype of tumors, or contribute themselves to clinical behavior of tumors. Most probably tumors may induce thrombopoesis directly e.g. via factor like IL-6 [21]. Platelets seem also to promote metastasis, but the exact mechanisms are still unclear [22,23]. Platelets play also a role in tumor angiogenesis after activation, e.g. in response to endothelial damage [24]. This effect seems to be induced not only by platelet factor secretion, but also by direct stimulation of angiogenesis [25]. It is well known that peripheral human platelets are able to secrete To treatment, even among patients treated during the acute phase [4]. Since pro-lymphangiogenic factors like VEGF-C and PDGFR-B, which are released during platelet activation [26]. In addition, platelets play an important role in the embryonic development of the lymphatic Title Loaded From File system [7]. So they have been reported to inhibit proliferation and migration of lymphatic endothelial cells during embryonic development upon activation by interaction of CLEC2 and podoplanin, which is expressed on lymphatic endothelial cells [27]. In malignant disease, the interaction between platelets and podoplanin via CLEC-2 induces a number of pathways involved in tumor cell migration and growth [28]. Surprisingly, to our knowledge no data on the role of platelets in lymphangiogenesis in human malignant disease do exist so far. In our present study, we investigated in a large series of esophageal cancers the association of PBPC with platelets in tumor vessels, within the tumor stroma and with lymphangiogenesis. Perioperative PBPC were associated with the presence of platelets within tumor tissue, and platelets within the tumor tissue was associated with increased lymphangiogenesis. While no direct association of STC or VTC with LVI of tumor cells was seen, PBPC and VTC influenced LVI in regression analysis.This indicates that a complex interaction between PBPC, VTC and STC promotes LVI of tumor cells. To investigate our findings in detail in vitro, we performed cell culture experiments, showing that platelets promote growth of LECs in a dose- and time-dependent manner. This induction ofLEC growth seems to be induced by secretion of pro-lymphangiogenic factors like VEGF-C and PDGF-BB. So our findings might be a possible explanation why increased preoperative PBPC are associated with diminished prognosis in a variety of human cancers, although this was not evident in our study. Although podoplanin interacts with platelets during development, an interaction between lymphatic endothelial cells and platelets has not been described previously. This might be explained by the fact that thrombocytes are not found within the lymphatic vascular system. Nevertheless, platelets facilitate extravasation by the release of matrix metalloproteinases and by stimulation of tumor and endothelial cells [28]. As evident in our study,.Preoperative elevated peripheral blood platelet count predicts poor prognosis in a variety of human cancers [17] among them also gastric cancer [18].Thrombocytes and Lymphatics in Esophageal CancerIn esophageal cancer (SCC and AC), an increase in platelet count after en bloc resection has been reported to be associated with better prognosis in one study [19], and in a study from Pakistan, low preoperative platelet counts were associated with poor prognosis [20]. In contrast, another study found that preoperative thrombocytosis indicated poor prognosis in esophageal SCC [20]. Nevertheless, it is not completely clear if elevated platelet counts are induced by a more aggressive phenotype of tumors, or contribute themselves to clinical behavior of tumors. Most probably tumors may induce thrombopoesis directly e.g. via factor like IL-6 [21]. Platelets seem also to promote metastasis, but the exact mechanisms are still unclear [22,23]. Platelets play also a role in tumor angiogenesis after activation, e.g. in response to endothelial damage [24]. This effect seems to be induced not only by platelet factor secretion, but also by direct stimulation of angiogenesis [25]. It is well known that peripheral human platelets are able to secrete pro-lymphangiogenic factors like VEGF-C and PDGFR-B, which are released during platelet activation [26]. In addition, platelets play an important role in the embryonic development of the lymphatic system [7]. So they have been reported to inhibit proliferation and migration of lymphatic endothelial cells during embryonic development upon activation by interaction of CLEC2 and podoplanin, which is expressed on lymphatic endothelial cells [27]. In malignant disease, the interaction between platelets and podoplanin via CLEC-2 induces a number of pathways involved in tumor cell migration and growth [28]. Surprisingly, to our knowledge no data on the role of platelets in lymphangiogenesis in human malignant disease do exist so far. In our present study, we investigated in a large series of esophageal cancers the association of PBPC with platelets in tumor vessels, within the tumor stroma and with lymphangiogenesis. Perioperative PBPC were associated with the presence of platelets within tumor tissue, and platelets within the tumor tissue was associated with increased lymphangiogenesis. While no direct association of STC or VTC with LVI of tumor cells was seen, PBPC and VTC influenced LVI in regression analysis.This indicates that a complex interaction between PBPC, VTC and STC promotes LVI of tumor cells. To investigate our findings in detail in vitro, we performed cell culture experiments, showing that platelets promote growth of LECs in a dose- and time-dependent manner. This induction ofLEC growth seems to be induced by secretion of pro-lymphangiogenic factors like VEGF-C and PDGF-BB. So our findings might be a possible explanation why increased preoperative PBPC are associated with diminished prognosis in a variety of human cancers, although this was not evident in our study. Although podoplanin interacts with platelets during development, an interaction between lymphatic endothelial cells and platelets has not been described previously. This might be explained by the fact that thrombocytes are not found within the lymphatic vascular system. Nevertheless, platelets facilitate extravasation by the release of matrix metalloproteinases and by stimulation of tumor and endothelial cells [28]. As evident in our study,.