Bone scan flare predicts successful systemic therapy for bone metastases

Changes in osteoblast function, assessed by serial bone scans and serum alkaline phosphatase bone isoenzyme (ALP-Bl) and osteocalcin, have been studied in 53 patients receiving systemic therapy for bone metastases from advanced breast cancer. In 12/16 patients with healing of lytic disease on x-ray a paradoxical deterioration in the bone scan appearances after 3 mo treatment was seen. This was characterized by increased activity in baseline lesions and the appearance of new foci of tracer uptake; changes which are indistinguishable from progressive disease. After 6 mo successful treatment the bone scan improved with reduced tracer uptake and no new lesions since the 3-mo scan. New lesions appearing after 6 mo indicated progressive disease. These changes are attributed to a flare in osteoblast activity induced by successful systemic therapy and confirmed by a transient rise in osteocalcin and ALP-Bl. After 1 mo of treatment 15/16 responders showed a rise in both parameters compared with only 5/23 nonresponders (p = less than 0.001). The flare response is the rule rather than the exception after successful systemic therapy for bone metastases. The appearance of new lesions or increasing activity in known lesions during the first 3 mo is as likely to herald radiological response as disease progression.

Biochemical prediction of response of bone metastases to treatment

Assessment of response of skeletal metastases to systemic therapy is currently dependent on radiological evidence of bone healing. We have performed a prospective study of additional response criteria in patients with progressive bone metastases from breast cancer. Changes in these potential markers of response were correlated with the radiological response and the time to treatment failure (TTF). Successful systemic therapy typically led to a transient increase in osteoblast activity ('flare'), a reduction in osteoclast activity and symptomatic improvement. After 1 month a greater than 10% rise in serum osteocalcin (BGP) and alkaline phosphatase bone isoenzyme (ALP-BI) and a greater than 10% fall in urinary calcium excretion were seen in 14/16 patients with radiographic evidence of bone healing (UICC partial responders). In comparison similar biochemical changes at 1 month were seen in only 4/20 patients with progressive disease (P less than 0.001). The predictive value and diagnostic efficiency (DE) of changes at 1 month in biochemical measurements and symptom score has been calculated. The combination of a greater than 10% rise in ALPBI and BGP and a greater than 10% fall in urinary calcium excretion had a DE of 89% for discriminating response from progression, 88% for response from non-response (progressing + no change patients), and 76% for TTF of greater than 6 months from TTF of less than 6 months. Serum calcium, tartrate resistant acid phosphatase (TRP), urinary hydroxyproline excretion and bone scan changes were unhelpful in discriminating between patient groups. Independent confirmation is needed, but our results suggest there are reliable alternatives to plain radiography in the early assessment of response of bone metastases to treatment.

Osteocalcin: a potential marker of metastatic bone disease and response to treatment

Serum osteocalcin (BGP) is an osteoblast product that probably reflects the rate of bone formation. It is a potential marker of skeletal metastases and, to investigate this, BGP was measured by radioimmunoassay in the serum of normal subjects and patients with breast or prostate cancer. Significantly higher levels were found in patients with metastatic bone disease in comparison to both normal subjects (P less than 0.001) and patients with non-metastatic cancer (P less than 0.05 for breast cancer and less than 0.001 for prostate cancer). The range of values was wide. Levels were higher in sclerotic than lytic bone metastases (P less than 0.01) and lower in patients with hypercalcaemia (P less than 0.001). Serial measurements of BGP were made in 53 patients with skeletal metastases from breast cancer receiving systemic therapy. At 1 month BGP rose by greater than 0.5 ng/ml in 15/16 responding patients compared with 7/23 patients with progressive disease (P less than 0.01). Responding patients also showed a rise in the bone isoenzyme of alkaline phosphatase and a paradoxical deterioration in the bone scan appearance, both reflecting a flare in osteoblast activity. The early increase in responding patients was followed by a gradual decrease over subsequent months as the osteoblast reaction induced by systemic therapy subsided. We conclude that BGP measurements reflect a wide variability of bone formation rates in metastatic bone disease. Bone formation was usually increased, particularly when metastases were sclerotic in appearance, but in patients with hypercalcaemia the low BGP levels suggest uncoupling of bone resorption and formation. Serial measurements of BGP may be useful in monitoring response to treatment.

The place of reference materials in clinical enzymology

Standardization embraces two concepts: achievement of a uniform standard of practice, or comparison with a standard of known or defined properties. In clinical enzymology the former concept can be equated with the adoption of recommended standardized methodology, which has had noteworthy successes in improving comparability of results. The use of enzyme standards or calibrators has received relatively little attention so far, but is increasingly important with the introduction of analysers which cannot readily utilize recommended methods. The main factor in the use of calibrators is that of commutability of calibrators and patients' samples between methods, which must be the subject of thorough experimental tests.

Gamma glutamyl transferase activity in rat colon during experimental colonic carcinogenesis

Colonic gamma glutamyl transferase activity is raised in colonic malignancy. This study was undertaken to determine how early and how extensively this raised activity occurs during carcinogenesis. Sixty rats were given weekly injections of dimethylhydrazine for 16 weeks, and 20 rats acted as controls. Groups of treated and control rats were sacrificed at regular intervals during the pre-cancerous phase of carcinogenesis, and gamma glutamyl transferase activity was measured at several sites in the colon. Gamma glutamyl transferase activity was raised as early as 4 weeks after the first injection of dimethylhydrazine (p less than 0.05), and the elevation persisted until the development of overt tumours. The raised gamma glutamyl transferase activity was observed throughout both the proximal and distal colon long before the appearance of macroscopic tumours. We conclude that an early and widespread elevation of colonic gamma glutamyl transferase activity occurs during carcinogenesis. This may have useful applications in the early detection of colonic malignancy.

Effect of bromelain on alkaline phosphatases of intestinal and non-intestinal tissues and serum

Human alkaline phosphatases extracted with butanol from liver, kidney and placenta, and from foetal and adult small intestine each contain fragments with molecular masses within the range of approximately 8 kDa to 20 kDa which can be removed by digestion with bromelain. However, in the case of adult intestine, this fragment (which is presumed to represent a membrane-binding domain) can only be demonstrated in tissue extracted immediately after removal at operation. Similar fragments are also present in foetal intestinal phosphatase in amniotic fluid, and in liver and bone alkaline phosphatases recovered from serum. Again, however, adult intestinal phosphatase from serum differs in the absence of the bromelain-sensitive fragment. These observations indicate differences in the ways in which intestinal and non-intestinal alkaline phosphatases gain access to the circulation, and also have implications for structural studies on intestinal phosphatase extracted post mortem from adult tissue.

Antibodies to porcine uteroferrin used in measurement of human tartrate-resistant acid phosphatase

The immunological similarity between human tartrate-resistant acid phosphatase (EC 3.1.3.2) and porcine uteroferrin previously reported for the isoenzyme from spleens of patients with leukemic reticuloendotheliosis (Ketcham et al., J Biol Chem 1985;260:5768-76) has been confirmed for partly purified acid phosphatase found in the spleen of a patient with Gaucher's disease, and for the corresponding isoenzyme in other tissues and serum. Anti-uteroferrin antibodies raised in rabbits have been used to demonstrate the feasibility of their application in an immunoassay for tartrate-resistant acid phosphatase in serum.

Antibodies to porcine uteroferrin used in measurement of human tartrate-resistant acid phosphatase

The immunological similarity between human tartrate-resistant acid phosphatase (EC 3.1.3.2) and porcine uteroferrin previously reported for the isoenzyme from spleens of patients with leukemic reticuloendotheliosis (Ketcham et al., J Biol Chem 1985;260:5768-76) has been confirmed for partly purified acid phosphatase found in the spleen of a patient with Gaucher's disease, and for the corresponding isoenzyme in other tissues and serum. Anti-uteroferrin antibodies raised in rabbits have been used to demonstrate the feasibility of their application in an immunoassay for tartrate-resistant acid phosphatase in serum.

Diagnostic aspects of alkaline phosphatase and its isoenzymes

The changes in serum alkaline phosphatase that are of main diagnostic importance result from increased entry of enzyme into the circulation. This results from increased osteoblastic activity in bone disease, and increased synthesis of alkaline phosphatase by hepatocytes in hepatobiliary disease. The liver and bone forms of alkaline phosphatase are differently-glycosylated forms of a single gene product. The main value of their specific estimation is found in patients in whom bone and liver diseases co-exist, for example, as a result of cancer. Abnormal expression of genetically-distinct alkaline phosphatase isoenzymes is valuable in monitoring cancers, particularly germ-cell tumors. These isoenzymes include Regan and Nagao isoenzymes, which correspond respectively to normal placental and placental-like alkaline phosphatases, and the Kasahara isoenzyme which appears to result from re-expression of a fetal intestinal alkaline phosphatase gene.

Subtle hyperthyroidism presenting as suspected hepatobiliary disease

Three patients, each with a nonspecific clinical history and raised serum alkaline phosphatase levels, were referred for investigation of hepatobiliary disorders. Isoenzyme analysis showed both hepatic and bony isoenzymes to be elevated, and eventually hyperthyroidism was diagnosed in each patient. Hyperthyroidism can be difficult to recognize clinically, and isolated elevation of serum alkaline phosphatase levels may be a useful clue.

Association of alkaline phosphatase with an autoantigen recognised by circulating anti-neutrophil antibodies in systemic vasculitis

A solid phase radioimmunoassay has been developed to detect circulating autoantibodies to neutrophil cytoplasmic antigens in systemic vasculitis. After fractionation of these antigens by size, with gel filtration high performance liquid chromatography, sera from patients with clinically different forms of systemic vasculitis, Wegener's granulomatosis (WG) and microscopic polyarteritis (MP), showed contrasting specificities of binding. WG sera bound to 100, 6.2, and 1.8 kD components, whereas MP sera bound only to the 100 kD component, allowing immunological distinction between the syndromes. The 100 kD component recognised by both WG and MP sera also showed alkaline phosphatase activity. Further evidence for this association was obtained by direct binding experiments between systemic vasculitis sera and calf-intestinal or human neutrophil alkaline phosphatase and by the cross-reactivity of W8, a monoclonal antibody raised to a neutrophil cytoplasmic autoantigen, with various preparations of the enzyme.

The physical characteristics and enzymatic modification of fetal intestinal alkaline phosphatase in amniotic fluid

The predominant form of alkaline phosphatase in amniotic fluid at 16 to 18 weeks gestation has the inhibition characteristics of the isoenzymes from adult and fetal small intestine. These characteristics are shared by an alkaline phosphatase of presumed intestinal origin occasionally found in the sera of premature neonates. However, in contrast to the rapid anodal migration of the latter enzyme, amniotic fluid phosphatase is of low electrophoretic mobility in polyacrylamide gel, and it has a high molecular weight. Digestion of amniotic fluid with bromelain produces a rapidly-migrating active enzyme form, with a molecular weight of about 135,000, compared with 145,000 for the fetal intestinal phosphatase in serum. The bromelain-treated amniotic fluid phosphatase is similar in size to a Kasahara isoenzyme in the serum of a cancer patient, which is itself thought to result from re-expression of a fetal intestinal phosphatase gene.

The value of cross-sectional echocardiography in detecting perioperative myocardial infarction following coronary artery bypass graft surgery

Detection of perioperative myocardial infarction following coronary artery bypass graft surgery may be difficult. To assess the value of cross-sectional echocardiography in detecting perioperative infarction, 45 patients were studied by this technique to assess left ventricular regional wall motion before and eight to ten days after cardiac surgery. Deterioration in septal, antero-lateral, apical, inferior and posterior segments was correlated with Q-wave change in the ECG and with CK-MB taken at pre, 4, 7, 21, 48 and 72 hours post surgery. Echocardiographic regional wall motion was assessed semiquantitatively by a point score system (3 = normal, 2 = hypokinetic, 1 = akinetic, 0 = dyskinetic). Sixteen patients showed deterioration in regional wall motion greater than or equal to 1 point. Eleven of these patients had new hypokinetic abnormalities of 1 point in the previously normal septal segment, but no ECG infarction. Three of the 11 had raised CK-MB and only one fulfilled the CK-MB criteria for perioperative infarction. Four other patients showed new akinetic segments (deterioration of two points). All four had CK-MB criteria for perioperative infarction and three had new ECG Q-wave. Three other patients showed ECG infarction without echo or CK-MB changes. Thus the development of a new akinetic segment on cross-sectional echocardiographic analysis of regional wall motion is a good marker of perioperative myocardial infarction. However, the great majority of new septal hypokinetic segments do not result from this operative complication.

Electrophoresis of human alkaline and acid phosphatases

Zone electrophoresis has played an important part in understanding the inter- and intratissue heterogeneity of acid and alkaline phosphatases. Electrophoresis of alkaline phosphatase in serum is of practical diagnostic value in deciding between liver and bone as alternative, or coexisting, sources of a raised total activity and, more rarely, in helping to define the contributions of other alkaline phosphatase isoenzymes. Certain tissue-specific patterns of acid phosphatase zones are also diagnostically useful in confirming the identity of isoenzymes in serum indicated by other techniques.

External quality assessment of serum enzyme activity assays and the effect of calibration on interlaboratory concordance

The design and results of a UK external quality assessment scheme for six enzymes are described, from 21 surveys over a period of 7 years. Improvements in interlaboratory agreement and the adoption of reliable methods are documented. The potential of enzyme calibration materials in further improving numerical concordance between laboratories using different assay conditions, including temperature, is demonstrated and discussed.

Comparison of a tumour-derived form of intestinal alkaline phosphatase with foetal and adult intestinal alkaline phosphatases

An intestinal alkaline phosphatase-like (Kasahara) isoenzyme has been isolated from the serum of a patient with lung cancer and compared with foetal intestinal alkaline phosphatase from the serum of a premature infant and with adult intestinal phosphatase isolated from serum in the same way. Although the ligand-binding sites of the three enzymes were indistinguishable, the foetal intestinal and Kasahara isoenzymes differed slightly from the adult isoenzyme in heat stability and markedly in electrophoretic mobility and neuraminidase-sensitivity, while themselves being similar in these respects. Neither the Kasahara isoenzyme nor foetal phosphatase reacted with anti-placental phosphatase monoclonal antibodies. These results suggest that the Kasahara isoenzyme corresponds to the reappearance of foetal intestinal alkaline phosphatase, rather than to modification of the adult intestinal isoenzyme.

Measurement of high molecular weight forms of enzymes in serum in the detection of hepatic metastases of colorectal cancer

Total gamma-glutamyl transferase and alkaline phosphatase, liver-specific alkaline phosphatase and high molecular weight forms of the two enzymes were measured in the sera of 42 patients with colorectal cancer, of whom 26 were apparently metastases-free and 16 had palpable liver metastases. The average levels of all enzymes were significantly higher in the group with metastases, but there was considerable overlap between the groups. The predictive values of positive results were of the order of 50-75%; predictive values of negative results were more than 70% for all tests, with high molecular weight alkaline phosphatase (87%) performing best in this respect. However, measurement of high molecular weight enzymes does not offer marked advantages over more conventional enzyme tests in the detection of hepatic metastases of colorectal cancer.

An enzyme-amplified monoclonal immunoenzymometric assay for prostatic acid phosphatase

An immunoassay for prostatic acid phosphatase is described in which a high degree of specificity for the prostatic isoenzyme, obtained by the use of monoclonal antibodies, is combined with great sensitivity, made possible by enzyme-amplified measurement of the combination of the isoenzyme with its antibody. The increase in sensitivity thus achieved is of the order of 170 times that of conventional methods of measurement. The advantages of the enzyme-amplified method have been shown to be particularly useful in detecting and monitoring small abnormalities of prostatic acid phosphatase levels in patients with prostatic cancer.

Role of transient ischaemia and perioperative myocardial infarction in the genesis of new septal wall motion abnormalities after coronary bypass surgery

To evaluate the role of ischaemia in the genesis of new septal wall motion abnormalities after coronary artery bypass surgery 45 patients were studied by cross sectional echocardiography before and 8-10 days after operation. Regional left ventricular wall motion was classified as normal, hypokinetic, akinetic, or dyskinetic. Septal wall motion abnormalities were correlated with electrocardiographic Q wave changes and serial serum MB creatine kinase measured before and 4, 7, 21, 48, and 72 hours after operation. Of the 14 patients who developed new septal wall motion abnormalities after operation two developed septal akinesis (both had perioperative infarction) and one new dyskinesis in the previously akinetic septal segment. Of the 11 patients with new septal hypokinesis, eight had normal serial creatine kinase MB values, two had raised values peaking four and seven hours after operation, with a return to normal values at 21 hours indicating transient ischaemia, and one had enzymatic criteria for perioperative infarction. Most new echocardiographic septal wall motion abnormalities after coronary artery bypass grafting are not caused by transient ischaemia, perioperative infarction, or generalised cell necrosis.

Inhibition of human alkaline phosphatase isoenzymes by the affinity reagent reactive yellow 13

The dye Reactive Yellow 13, an affinity reagent for intestinal alkaline phosphatase, inhibits intestinal and other human alkaline phosphatases in solution. The inhibition depends markedly on the presence of a phosphate acceptor such as diethanolamine. The dye is an uncompetitive inhibitor with respect to both substrate and phosphate acceptor in the case of non-intestinal phosphatases. However, in the case of intestinal alkaline phosphatase, the inhibition is noncompetitive with respect to the substrate and competitive with respect to the phosphate acceptor. These observations account for the specific binding of intestinal phosphatase when the dye is used as a ligand in affinity chromatography.