Pretreatment Serum Lactate Dehydrogenase Predicting Metastatic Spread in Ewing's Sarcoma HARMAR D. BRERETON, M.D., RICHARD SIMON, Ph.D., and THOMAS C. POMEROY, M.D., Bethesda, Maryland
We measured serum lactate dehydrogenase levels in 36 patients with localized Ewing's sarcoma before treatment. The results were evaluated to determine if the levels served as a prognostic indicator for metastatic spread. After adjusting for primary site of disease and adjuvant chemotherapy, the pretreatment serum lactate dehydrogenase proved an extremely good predictor of which patients would ultimately develop metastatic disease. The median serum lactate dehydrogenase of the total group was between 2 0 1 and 214 IU/litre. Three of 18 patients presenting with serum levels of this enzyme of < 201 lU/litre ultimately developed metastases, while 16 of 18 patients who presented with serum levels of > 214 IU/litre developed metastases (P < 0.001).
LACTATE DEHYDROGENASE is an enzyme capable of rever-
sibly converting pyruvate to lactate and is operative particularly in anaerobic glycolysis, where the end product of glucose metabolism is lactate. Since the early 1960s when laboratory analysis of lactate dehydrogenase became possible on a mass scale by automation of the test, measurements of this enzyme have been made in patients with various neoplasms. Elevated levels of this enzyme have been reported in Burkitt's lymphoma ( 1 ) , carcinoma of the ovary ( 2 ) , lung ( 3 ) , lymphomas and leukemias ( 4 ) , and others ( 5 ) ; however, the prognostic implications of this enzyme elevation are not generally appreciated. Materials and Methods
Since 1964, 66 consecutive patients with Ewing's sarcoma have been evaluated and treated in our department. Evaluation for metastatic disease included a radiographic bone survey, chest X-ray and whole lung tomography, radioisotopic bone and brain scans, bone marrow aspirate and biopsy, and spinal fluid examination. Treatment consisted of a 5000 rad tumor dose to the primary site, delivered during 5 weeks. Prophylactic whole brain irradiation and chemotherapy were administered as summarized in Table 1. Forty-nine patients had serum lactate dehydrogenase levels measured before any therapy. Thirtysix of these 49 patients presented with localized disease. Lactate dehydrogenase was measured by the kinetic reaction mode using the forward reaction described by Wacker and associates (6). This method was automated in our institution in 1972, and all measurements made before that time have been • From the Radiation Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
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converted to the range now used, so that serum levels of this enzyme measured before that time may be compared with levels measured since that time. Serum lactate dehydrogenase levels were also obtained in normal volunteers (32 men and 31 women) to serve as control levels. Results
The range of serum lactate dehydrogenase in normal volunteers was a mean of 161 IU/litre ± 5 3 (two standard deviations), with a median of 156 IU/litre. Thirty-six patients who had pretreatment serum enzyme levels measured presented with localized disease. Nineteen of these 36 patients ultimately developed metastases, and the time interval between the onset of therapy and detection of metastases (Table 2) ranged from 4 to 61 months (mean, 12 months; median, 9 months). Seventeen patients have not developed metastases, and follow-up intervals after initiating treatment have ranged from 12 to 69 months (mean, 34 months; median, 32 months; Table 2 ) . The mean serum lactate dehydrogenase of those who developed metastases was 331 IU/litre ± 161 (one standard deviation) and of those who did not develop metastases was 166 IU/litre ± 38 (one standard deviation). This difference was significant P < 0.0001. This analysis, however, does not take into consideration the effect of primary site or adjuvant therapy, both of which would be expected to affect the ultimate development of metastases. Table 2 relates the time interval between the onset of therapy and the detection of metastatic disease with the initial serum lactate dehydrogenase, primary site, and adjuvant therapy. The median serum lactate dehydrogenase of patients presenting without metastases is between 201 and 214 I U / litre, and this median is used for presenting the data in Table 2. Eighteen patients had an initial serum level of this enzyme no greater than 201 IU/litre, and only 3 of these patients developed metastatic disease, whereas 16 of the 18 patients with initial serum level of this enzyme greater than 214 IU/litre developed metastases ( P < 0.001). Patients with axial primary tumors have a significantly higher risk of developing metastatic disease than those with nonaxial primaries ( P < 0.025), and those patients who received adjuvant therapy S4 (Table 1) had a significantly lower risk of developing metastatic disease than the other patients (P < 0.05). Because initial serum lactate dehydrogenase is correlated with primary site and Annals of Internal Medicine 83:352-354, 1975
Table 1. National 1 Cancer Institute's Ewing's Sarcoma Adjuvant Therapy Program Protocol
Starting Date
Adjuvant, Dose, and Schedule*
SI
1964
S2
1968
S3
1969
S4
1971
Cyclophosphamide, Single dose (20 to 30 mg/kg body weight) versus several weekly courses of 15 mg/kg body weight • week Cyclophosphamide, Four courses (40 mg/kg body weight) at 6-week intervals; plus vincristine, ten courses (0.025 mg/kg body weight) at 2-week intervals Cyclophosphamide, four courses (40 mg/kg body weight) during months 1, 2, 4, and 6; plus vincristine, four courses (0.04 mg/kg body weight) during months 1, 2, 4, and 6; plus D-actinomycin, two courses (10 to 15 jug/kg body weight • day for 5 consecutive days) on months 3 and 5; plus Central nervous system prophylaxis, 2000 rads whole brain X-ray and one intrathecal dose of methotrexate (10 to 15 mg) Central nervous system prophylaxis, same as protocol S3; plus four drug cycles at intervals of 7 weeks using adriamycin, 75 mg/m 2 body surface in a single dose on day 1 of cycle; cyclophosphamide, same as protocol S3 on day 21 of the cycle; vincristine, same as protocol S3 on day 21 of the cycle
* Given in combination with irradiation of the primary site, as described in the text.
type of adjuvant therapy, evaluation of the prognostic importance of initial serum levels of this enzyme must be adjusted for the effects of the other two variables. This evaluation was done for the development of metastases using Cox's nonparametric life-table regression test ( 7 ) . This method assumes that serum lactate dehydrogenase, primary site (axial skeleton or other), and adjuvant therapy SI and S2, S3 or S4 (Table 1), have a linear effect on the hazard function governing the time to development of metastases. Advantages of this test are that actual serum enzyme values are used, rather than merely specifying a level above or below some arbitrary figure. The test also takes into consideration variable follow-up times. The hypothesis that presenting serum lactate dehydrogenase had no effect on the development of metastases after adjusting for primary site and adjuvant therapy was tested and rejected with P = 0.001. As a confirmatory statistical evaluation, the Mantel-Haenszel actuarial chi-square test (8) was applied to the data, with serum lactate dehydrogenase categorized as above or below the median (Table 2 ) . After adjusting for primary site and adjuvant treatment, the hypothesis of no lactate dehydrogenase effect on the time until development of metastases was rejected with P < 0.02. Discussion
Since Warburg's initial observations (9) that neoplastic cells may metabolize glucose anaerobically, there have Table 2. The Recurrence-Free Therapy Site
Adjuvant Therapy *
Interval Dated
from the Onset of
L D H f < 201
Axial
Other
SI + S2 S3 S4 SI + S2 S3 S4
L D H > 214
months -
61 12J, 32J, 33J 631 69| 8, 441, 581 9, 12 J, 1 5 | , 19J, 25J 251, 261, 291, 32 J
ACKNOWLEDGMENTS: Received 23 January 1975; revision accepted 18 April 1975. • Requests for reprints should be addressed to Harmar D. Brereton, M.D., Clinical Center, Bldg. 10, Room B3B38, National Institutes of Health, Bethesda, MD 20014.
Time
We measured serum lactate dehydrogenase levels in 36 patients with localized Ewing's sarcoma before treatment. The results were evaluated to determine if the levels served as a prognostic indicator for metastatic spread. After adjusting for primary site of disease and adjuvant chemotherapy, the pretreatment serum lactate dehydrogenase proved an extremely good predictor of which patients would ultimately develop metastatic disease. The median serum lactate dehydrogenase of the total group was between 2 0 1 and 214 IU/litre. Three of 18 patients presenting with serum levels of this enzyme of < 201 lU/litre ultimately developed metastases, while 16 of 18 patients who presented with serum levels of > 214 IU/litre developed metastases (P < 0.001).
LACTATE DEHYDROGENASE is an enzyme capable of rever-
sibly converting pyruvate to lactate and is operative particularly in anaerobic glycolysis, where the end product of glucose metabolism is lactate. Since the early 1960s when laboratory analysis of lactate dehydrogenase became possible on a mass scale by automation of the test, measurements of this enzyme have been made in patients with various neoplasms. Elevated levels of this enzyme have been reported in Burkitt's lymphoma ( 1 ) , carcinoma of the ovary ( 2 ) , lung ( 3 ) , lymphomas and leukemias ( 4 ) , and others ( 5 ) ; however, the prognostic implications of this enzyme elevation are not generally appreciated. Materials and Methods
Since 1964, 66 consecutive patients with Ewing's sarcoma have been evaluated and treated in our department. Evaluation for metastatic disease included a radiographic bone survey, chest X-ray and whole lung tomography, radioisotopic bone and brain scans, bone marrow aspirate and biopsy, and spinal fluid examination. Treatment consisted of a 5000 rad tumor dose to the primary site, delivered during 5 weeks. Prophylactic whole brain irradiation and chemotherapy were administered as summarized in Table 1. Forty-nine patients had serum lactate dehydrogenase levels measured before any therapy. Thirtysix of these 49 patients presented with localized disease. Lactate dehydrogenase was measured by the kinetic reaction mode using the forward reaction described by Wacker and associates (6). This method was automated in our institution in 1972, and all measurements made before that time have been • From the Radiation Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
352
Downloaded from https://annals.org by Karolinska Institute user on 01/24/2019
converted to the range now used, so that serum levels of this enzyme measured before that time may be compared with levels measured since that time. Serum lactate dehydrogenase levels were also obtained in normal volunteers (32 men and 31 women) to serve as control levels. Results
The range of serum lactate dehydrogenase in normal volunteers was a mean of 161 IU/litre ± 5 3 (two standard deviations), with a median of 156 IU/litre. Thirty-six patients who had pretreatment serum enzyme levels measured presented with localized disease. Nineteen of these 36 patients ultimately developed metastases, and the time interval between the onset of therapy and detection of metastases (Table 2) ranged from 4 to 61 months (mean, 12 months; median, 9 months). Seventeen patients have not developed metastases, and follow-up intervals after initiating treatment have ranged from 12 to 69 months (mean, 34 months; median, 32 months; Table 2 ) . The mean serum lactate dehydrogenase of those who developed metastases was 331 IU/litre ± 161 (one standard deviation) and of those who did not develop metastases was 166 IU/litre ± 38 (one standard deviation). This difference was significant P < 0.0001. This analysis, however, does not take into consideration the effect of primary site or adjuvant therapy, both of which would be expected to affect the ultimate development of metastases. Table 2 relates the time interval between the onset of therapy and the detection of metastatic disease with the initial serum lactate dehydrogenase, primary site, and adjuvant therapy. The median serum lactate dehydrogenase of patients presenting without metastases is between 201 and 214 I U / litre, and this median is used for presenting the data in Table 2. Eighteen patients had an initial serum level of this enzyme no greater than 201 IU/litre, and only 3 of these patients developed metastatic disease, whereas 16 of the 18 patients with initial serum level of this enzyme greater than 214 IU/litre developed metastases ( P < 0.001). Patients with axial primary tumors have a significantly higher risk of developing metastatic disease than those with nonaxial primaries ( P < 0.025), and those patients who received adjuvant therapy S4 (Table 1) had a significantly lower risk of developing metastatic disease than the other patients (P < 0.05). Because initial serum lactate dehydrogenase is correlated with primary site and Annals of Internal Medicine 83:352-354, 1975
Table 1. National 1 Cancer Institute's Ewing's Sarcoma Adjuvant Therapy Program Protocol
Starting Date
Adjuvant, Dose, and Schedule*
SI
1964
S2
1968
S3
1969
S4
1971
Cyclophosphamide, Single dose (20 to 30 mg/kg body weight) versus several weekly courses of 15 mg/kg body weight • week Cyclophosphamide, Four courses (40 mg/kg body weight) at 6-week intervals; plus vincristine, ten courses (0.025 mg/kg body weight) at 2-week intervals Cyclophosphamide, four courses (40 mg/kg body weight) during months 1, 2, 4, and 6; plus vincristine, four courses (0.04 mg/kg body weight) during months 1, 2, 4, and 6; plus D-actinomycin, two courses (10 to 15 jug/kg body weight • day for 5 consecutive days) on months 3 and 5; plus Central nervous system prophylaxis, 2000 rads whole brain X-ray and one intrathecal dose of methotrexate (10 to 15 mg) Central nervous system prophylaxis, same as protocol S3; plus four drug cycles at intervals of 7 weeks using adriamycin, 75 mg/m 2 body surface in a single dose on day 1 of cycle; cyclophosphamide, same as protocol S3 on day 21 of the cycle; vincristine, same as protocol S3 on day 21 of the cycle
* Given in combination with irradiation of the primary site, as described in the text.
type of adjuvant therapy, evaluation of the prognostic importance of initial serum levels of this enzyme must be adjusted for the effects of the other two variables. This evaluation was done for the development of metastases using Cox's nonparametric life-table regression test ( 7 ) . This method assumes that serum lactate dehydrogenase, primary site (axial skeleton or other), and adjuvant therapy SI and S2, S3 or S4 (Table 1), have a linear effect on the hazard function governing the time to development of metastases. Advantages of this test are that actual serum enzyme values are used, rather than merely specifying a level above or below some arbitrary figure. The test also takes into consideration variable follow-up times. The hypothesis that presenting serum lactate dehydrogenase had no effect on the development of metastases after adjusting for primary site and adjuvant therapy was tested and rejected with P = 0.001. As a confirmatory statistical evaluation, the Mantel-Haenszel actuarial chi-square test (8) was applied to the data, with serum lactate dehydrogenase categorized as above or below the median (Table 2 ) . After adjusting for primary site and adjuvant treatment, the hypothesis of no lactate dehydrogenase effect on the time until development of metastases was rejected with P < 0.02. Discussion
Since Warburg's initial observations (9) that neoplastic cells may metabolize glucose anaerobically, there have Table 2. The Recurrence-Free Therapy Site
Adjuvant Therapy *
Interval Dated
from the Onset of
L D H f < 201
Axial
Other
SI + S2 S3 S4 SI + S2 S3 S4
L D H > 214
months -
61 12J, 32J, 33J 631 69| 8, 441, 581 9, 12 J, 1 5 | , 19J, 25J 251, 261, 291, 32 J
ACKNOWLEDGMENTS: Received 23 January 1975; revision accepted 18 April 1975. • Requests for reprints should be addressed to Harmar D. Brereton, M.D., Clinical Center, Bldg. 10, Room B3B38, National Institutes of Health, Bethesda, MD 20014.
Time
