Identification of bone and liver metastases from breast cancer by measurement of plasma alkaline phosphatase isoenzyme activity

Diagnostic value of alkaline phosphatase and bone-specific alkaline phosphatase for metastases in breast cancer: a systematic review and meta-analysis

PURPOSE

Numerous studies had reported the diagnostic value of alkaline phosphatase (ALP) and its bone-specific isoforms (BAP) in the metastases of breast cancer (BC). The purpose of this meta-analysis was to summarize the diagnostic value of serum ALP and BAP in metastatic BC, especially focused on bone metastases.

METHODS

We searched comprehensively in the PubMed, Cochrane Library, and EMBASE for studies to explore the diagnostic accuracy of serum ALP/BAP level for metastatic BC. Qualities of including studies were assessed and pooled sensitivity, specificity, and summary receiver operating characteristic curve were calculated. Publication bias was assessed and meta-regression was conducted.

RESULTS

We finally included 25 studies with a total of 12,155 BC patients (1681 metastatic cases and 10,474 controls). According to the QUADAS-2 tool to assessment the methodological quality, most of the included studies were judged as high risk of patient selection bias. High serum levels of ALP/BAP in bone metastatic BC patients could be found compared with non-metastatic BC patients. The pooled sensitivity and specificity of ALP for BC bone metastases were 0.62 and 0.86, and the area under the curve (AUC) was 0.80. The pooled sensitivity and specificity of ALP for all site metastases (mainly bone and liver) were 0.56 and 0.91, and the AUC was 0.90. The pooled sensitivity and specificity of BAP for BC bone metastases were 0.66 and 0.92, and the AUC was 0.89.

CONCLUSION

Although not promising, serum ALP and BAP could bring useful information for the early detection of BC metastases especially for the bone metastases.

The predictive value of liver tests for the presence of liver metastases

Aim

To analyze the predictive value of biochemical liver tests in patients with malignant melanoma, breast, colorectal or lung cancers at the time of diagnosis of liver metastases.

Methods

A retrospective review of patients with the above-mentioned solid tumors at MedStar Georgetown University Hospital from 2016-2020.

Results

The highest optimal cutoff according to sensitivity and specificity for the presence of liver metastases was for AST ≥1.5 × ULN for melanoma, lung, and breast cancers and ≥2 × ULN for colorectal cancer, ALT ≥1.25 × ULN for melanoma, breast and colorectal cancers and ≥1.5 × ULN for lung cancer, and ALP ≥1.5 × ULN for melanoma, breast and colorectal cancers.

Conclusion

Using thresholds of liver enzymes above the ULN may improve the diagnostic accuracy for the presence of liver metastases.

Reliability of Alkaline Phosphatase for Differentiating Flare Phenomenon from Disease Progression with Bone Scintigraphy

Simple Summary

Bone scintigraphy is the most widely used radionuclide technique to investigate bone metastasis, primarily due to its reasonable time and cost factor. However, it is important to recognize that bone scintigraphy to assess treatment response sometimes shows a “flare phenomenon”, which can be misinterpreted as disease progression. Distinction between flare phenomenon and disease progression could help in the decision to continue effective treatments in patients with flare phenomenon and to cease ineffective treatments and consider other salvage treatment plans in patients with disease progression. Despite many methods having been tried to answer this question, there was still no reliable way to differentiate between flare phenomenon and progression of bone metastases. Our results suggest that ALP is a useful serologic marker to differentiate flare phenomenon from disease progression on bone scintigraphy in breast or prostate cancer patients with bone metastasis.

Abstract

The flare phenomenon (FP) on bone scintigraphy after the initiation of systemic treatment seriously complicates evaluations of therapeutic response in patients with bone metastases. The aim of this study was to evaluate whether serum alkaline phosphatase (ALP) can differentiate FP from disease progression on bone scintigraphy in these patients. Breast or prostate cancer patients with bone metastases who newly underwent systemic therapy were reviewed. Pretreatment baseline and follow-up data, including age, pathologic factors, type of systemic therapy, radiologic and bone scintigraphy findings, and ALP levels, were obtained. Univariate and multivariate analyses of these factors were performed to predict FP. An increased extent and/or new lesions were found in 160 patients on follow-up bone scintigraphy after therapy. Among the 160 patients, 80 (50%) had an improvement on subsequent bone scintigraphy (BS), while subsequent scintigraphy also showed an increased uptake in 80 (50%, progression). Multiple regression analysis revealed that stable or decreased ALP was an independent predictor for FP (p < 0.0001). ALP was an independent predictor for FP on subgroup analysis for breast and prostate cancer (p = 0.001 and p = 0.0223, respectively). Results of the study suggest that ALP is a useful serologic marker to differentiate FP from disease progression on bone scintigraphy in patients with bone metastasis. Clinical interpretation for scintigraphic aggravation can be further improved by the ALP data and it may prevent fruitless changes of therapeutic modality by misdiagnosis of disease progression in cases of FP.

Prognostic Value of Pretreatment Albumin-to-Alkaline Phosphatase Ratio in Extensive-Disease Small-Cell Lung Cancer: A Retrospective Cohort Study

PURPOSE

Evidence regarding the relationship between albumin-to-alkaline phosphatase ratio (AAPR) and overall survival (OS) in extensive-disease small-cell lung cancer (ED-SCLC) patients is limited. This study aimed to investigate whether AAPR was independently related to OS in ED-SCLC patients after adjusting for potential covariates.

PATIENTS AND METHODS

This was a retrospective cohort study of 224 patients with ED-SCLC. The target independent and dependent variables were pretreatment AAPR and OS, respectively. Covariates included age; sex; Eastern Cooperative Oncology performance status score; smoking history; existence of metastasis to organs such as the bone, lung, liver, brain, malignant plural effusion and others; sum of organ metastasis (≤3, >3), evaluation of first-line treatment; and sum of treatment lines (<2, ≥2). Student's t test or chi-squared test was used to analyze the associations between AAPR and clinical characteristics. Kaplan-Meier survival analysis and Cox's proportional hazards regression model were used to assess the prognostic value of AAPR for OS.

RESULTS

The average patient age was 60.51±8.73 years, and 87.95% were men. A non-linear relationship between AAPR and OS was detected, with an inflection point of 0.35. The hazard ratios (HRs) of the left (AAPR <0.35) and right sides (AAPR ≥0.35) of inflection point were 0.04 (95% CI=0.00-0.70, p=0.0268) and 0.52 (95% CI=0.16-1.64, p=0.2659), respectively. Kaplan-Meier analysis showed a median OS of 9.73 months (95% CI=8.6-12.33) for AAPR <0.35 and 13.7 months (95% CI=11.43-16.37) for AAPR ≥0.35 (log-rank p<0.0001). The Cox proportional hazards model showed that AAPR <0.35 increased the risk of death after adjusting for potential confounders (HR=1.65, 95% CI=1.11-2.46). In subgroup analysis, the trends of HRs were increased across all subgroups with AAPR <0.35 after stratification.

CONCLUSION

Pretreatment AAPR might be served as an independent prognostic indicator in ED-SCLC patients. Our findings should be further validated in large-scale and prospective clinical trials.

Three gold indicators for breast cancer prognosis: a case-control study with ROC analysis for novel ratios related to CBC with (ALP and LDH)

Science is still unable to develop a specific strategy for predicting breast cancer in humans. Several attempts are done to obtain the best and closest prognostic predictive biomarkers for breast cancer. The present study aimed to evaluate the impact of novel ratios calculated between the blood indices with CA15.3, alkaline phosphatase and lactate dehydrogenase as prognostic biomarkers in breast cancer. This study was conducted on two groups (Breast cancer Patients group in comparison to a control group who has no tumor family history). All the volunteers are subjected to the routine analysis included liver and kidney function tests, complete blood count with blood indices, tumor markers (CA15.3) assessment, alkaline phosphatase, and lactate dehydrogenase analysis. Thirty different ratios were calculated in the present research between blood indices and three inexpensive serum biomarkers; CA15.3, alkaline phosphatase and lactate dehydrogenase. Fifteen ratios of them were significant in breast cancer group than the control group. Three ratios (PDW/lymphocytes, MPV/lymphocytes, and ALP/RDW) of them gave a sensitivity of 100% with high specificity as indicators for breast cancer incidence. The correlation between significant ratios was very interesting. The more interesting was in the results of subgroup analysis which showed that the ALP/RDW ratio is more specific for pre-menopause while PDW/lymphocytes ratio is more specific for post-menopause. The ratios PDW/lymphocytes, MPV/lymphocytes, and ALP/RDW can be used as prognostic biomarkers in breast cancer patients. The interesting advantage in the results depends on the availability of these indicators in routine blood analysis and will not increase the cost of the diagnostic plan.

Albumin-to-alkaline phosphatase ratio: A novel prognostic index of overall survival in cholangiocarcinoma patients after surgery

AIM

To clarify the prognostic significance of preoperative albumin-to-alkaline phosphatase ratio (AAPR) in cholangiocarcinoma (CCA) subjects receiving surgery.

METHODS

In this retrospective study, we included 303 CCA patients receiving surgery without preoperative therapy between 2002 and 2014. Clinicopathological characteristics (including AAPR) were analyzed to determine predictors of post-operative overall survival and recurrence-free survival (RFS). In addition, univariate and multivariate Cox proportional hazards models were conducted, followed by application of time-dependent receiver operating curves to identify the optimal cut-off.

RESULTS

Univariate and multivariate analyses revealed both decreased overall survival [hazard ratio (HR): 2.88, 95%CI: 1.19-5.78] and recurrence-free survival (HR: 2.31, 95%CI: 1.40–3.29) in patients with AAPR < 0.41 compared to those with AAPR ≥ 0.41. The optimal cut-off of AAPR was 0.41. Of the 303 subjects, 253 (83.5%) had an AAPR over 0.41. The overall 1-, 3- and 5-year survival rates were 70.2%, 38.0% and 16.5%, respectively in the low (< 0.41) AAPR group, which were significantly lower than those in the high (≥ 0.41) AAPR group (81.7%, 53.9%, and 33.4%, respectively) (P < 0.0001). Large tumor size, multiple tumors, and advanced clinical stage were also identified as significant predictors of poor prognosis.

CONCLUSION

Our outcomes showed that AAPR was a potential valuable prognostic indicator in CCA patients undergoing surgery, which should be further confirmed by prospective studies. Moreover, it is necessary to investigate the mechanisms concerning the correlation of low AAPR with poor post-operative survival in CCA patients.

Usefulness of Bone Formation Markers in Breast Cancer

The skeleton is the main site affected by metastases and breast cancer is the most frequent tumor to invade bone. The assessment of bone metastases is difficult and biochemical markers of bone formation (BFMs) could be a promising alternative. Although the essential role of osteoblasts in the metastatic process of bone destruction is now well established, little attention has been paid to BFMs. We conducted a Medline search for studies about BFMs in breast cancer. Our review allows us to conclude that BFMs have high specificity but low sensitivity for the diagnosis of bone metastases. The available biochemical markers cannot replace imaging techniques for the diagnosis of bone metastases. Several studies indicate that BFM serum levels reflect total tumor burden in the skeleton. BFM levels are higher in patients with blastic lesions compared to those with lytic lesions. Serial measurements of BFMs could be useful for the clinical assessment of response to antineoplastic treatment or to bisphosphonate therapy. Besides markers of bone resorption, biochemical markers of bone formation are a promising alternative for the assessment of metastatic bone disease, but large prospective studies are needed to address this important issue.

Sacral insufficiency fractures: a case of mistaken identity

Introduction

Sacral insufficiency fractures are an important cause of lower back pain in the elderly. Clinically and radiologically, they must be distinguished from osseous metastases, which frequently coexist. To date, no case report has comprehensively explored the full range of diagnostic hurdles and potential pitfalls.

Case presentation

We report the case of a 70-year-old Caucasian female who presented to our services with a short history of progressive back pain without any history of trauma. A prior history of breast cancer was noted. Bone scintigraphy was initially reported as consistent with metastatic sacral deposits. Further characterization with magnetic resonance imaging and computed tomography revealed bilateral insufficiency fractures of the sacral alar. The patient responded well to conservative management.

Conclusion

To avoid misdiagnosis, particularly in those who are also at risk of osseous metastases, sacral insufficiency fractures must always be considered as a cause of lower back pain.

Secondary osteosarcoma arising after treatment for childhood hematologic malignancies

Secondary osteosarcoma arising after the treatment of hematologic malignancies other than Hodgkin's lymphoma is rare. We report two cases of secondary osteosarcoma arising after treatment for childhood hematologic malignancies (non-Hodgkin's lymphoma and lymphoblastic leukemia). A 10-year-old boy, at the age of 3, was diagnosed with non-Hodgkin's lymphoma. He received chemotherapy, radiation, and bone-marrow transplantation and then was in complete remission. At 6 years, he complained of increasing pain of the right thigh and was diagnosed with osteoblastic osteosarcoma. A 26-year-old man, at the age of 6, was diagnosed as having acute lymphoblastic leukemia (ALL). He received chemotherapy, radiation, and peripheral blood stem cell transplantation (PBSCT). At 11 years after PBSCT, he visited with the complaint of left lumbar swelling. He was diagnosed with chondroblastic osteosarcoma. In both cases alkaline phosphatase (ALP) had already increased prior to the onset of the symptom. We should rule out secondary osteosarcoma at the abnormal elevation of ALP during clinical follow-up of patients after treatment of childhood hematologic malignancies.

Total Serum Alkaline Phosphatase Activity in Dogs with Mammary Neoplasms: a Prospective Study on 79 Natural Cases

Increased total alkaline phosphatase (TALP) activity in the serum, long noticed in canine mammary tumours among other neoplasms, has not been yet associated with malignancy, osseous transformation of neoplastic tissue or histopathological typing. Therefore, the purpose of this study was to correlate this biochemical abnormality with the above-mentioned parameters, in 79 adult to elderly female dogs with mammary neoplasms, without evidence of metastatic or any other disease. Histopathology disclosed that 64 (81%) of these neoplasms were malignant and 15 (19%) benign, belonging to various histological types. Radiology and histopathology revealed the presence of osseous tissue in 18 (22.8%) cases. The malignant neoplasms were subsequently allocated into group A including 46 (74.2%) of epithelial origin and group B with 16 (25.8%) neoplasms of both epithelial and mesenchymal origin ('malignant mixed' tumours). In addition, their benign counterparts were divided into group C (adenomas, fibroadenomas) and group D (benign mixed tumours) that included seven (46.7%) and eight (53.3%) tumours, respectively. Almost 55% of the dogs with malignant and 47% with benign tumours had increased serum-TALP activity. However, no significant difference in serum-TALP activity was found between the dogs with malignant (mean +/- SE: 243.7 +/- 37.4 U/l) and benign (167.9 +/- 38.4 U/l) neoplasms, with (238.9 +/- 45.3 U/l) and without (226.5 +/- 38.3 U/l) osseous transformation, with (298.5 +/- 85.6 U/l) or without (201.2 +/- 30.5 U/l) myoepithelial cell proliferation and with different tumour size (T1/T2: 175.1 +/- 34.9 and T3: 254.5 +/- 42.5 U/l). In histopathological typing, the only difference noticed involved the malignant neoplasms of group A (190.5 +/- 25.5 U/l) compared with group B (378 +/- 124.6 U/l) dogs. The higher increase of serum-TALP activity in 'malignant mixed' tumours could not be attributed to osseous transformation or new ALP isoenzyme production by myoepithelial cells. Increased serum-TALP activity is of no apparent diagnostic (as to tumour type) or prognostic value.

Prevalence of Metastases in Hepatocellular Carcinoma: Risk Factors and Impact on Survival

The purpose of this study was to determine the prevalence and risk factors of metastases in hepatocellular carcinoma (HCC) patients and analyze the effects of different locations of metastases on survival. Retrospective analysis was performed on 347 HCC patients who received a metastatic workup including bone scan and computed tomography scans of chest, abdomen, and pelvis. Clinical and tumor characteristics were evaluated as risk factors for metastasis by univariate and multivariate methods. Survival was analyzed by Kaplan-Meier and Cox regression methods. One hundred forty-five patients had metastases: 71 had thoracic, 57 had abdominal, and 34 had bone metastases. Significant differences were noted with weight loss, hepatitis C, tumor grade, tumor multifocality, size, and alkaline phosphatase levels between the metastases group and the nonmetastases group by univariate analysis. Poor differentiation, multilobar spread, and size (≥5 cm) were strongest predictors of metastatic disease by logistic regression. Patients with thoracic metastases had significantly poorer survival. HCC metastasis is prevalent on initial presentation. Evaluation for liver transplantation or curative resection requires a full metastatic workup. Poor differentiation, larger tumors, and those with multilobar spread have increased risk for metastasis. Patients with thoracic spread have poor prognosis as compared to other locations of metastasis.

New and traditional serum markers of bone metabolism in the detection of skeletal metastases

OBJECTIVES

The evaluation of "new" and "traditional" markers of osteoblastic and osteoclastic activity, in patients with bone metastases.

DESIGN AND METHODS

Our series consist of 40 patients with clinical, radiological, and scintigraphic evidence of bone metastases, and 40 age-matched healthy subjects. In all samples, traditional markers were evaluated by measuring total alkaline phosphatase (ALP), tartrate-resistant acid phosphatase (TrACP) activity, and osteocalcin (BGP) concentration. To assess new biochemical bone markers, bone isoenzyme of alkaline phosphatase (ALP-B) activity, carboxyterminal propeptide of type I procollagen (PICP), and carboxyterminal telopeptide of type I collagen (ICTP) concentrations were measured.

RESULTS

Our findings showed that the best diagnostic efficiency is provided by ICTP (0.94) followed by total ALP (0.90), ALP-B (0.80), and TrACP (0.76). The efficiency of BGP and PICP was, instead, very low (0.64 and 0.60, respectively).

CONCLUSION

Our results confirm the utility of the new serum markers such as ALP-B and ICTP assays in detecting bone metastases.

Bone-origin alkaline phosphatase in plasma by wheat-germ lectin methods in bone disease

Bone-origin ALP in plasma may be readily quantified by WG-lectin methods and such measurements (reflecting osteoblastic activity) are useful in a wide variety of bone disorders. The studies summarized here have confirmed that ALP isoenzyme examination by these methods adds tissue specificity and diagnostic sensitivity to total ALP measurement.

Monitoring skeletal cancer metastases with the bone isoenzyme of tissue unspecific alkaline phosphatase

The efficacy of bone alkaline phosphatase (ALP) isoenzyme measurement using lectin precipitation in confirming metastatic bone lesions was compared with total ALP and osteocalcin assay in serum. Sixty-five patients with cancer and metastases to bone (n = 44), liver (n = 15) or lymph nodes (n = 6) as well as 33 healthy adults were studied. Assay of bone ALP is as sensitive but more specific than assay of total ALP in the identification of bone metastases. On the other hand, bone ALP did not correlate with osteocalcin, as is the case in other bone diseases. In the serial monitoring of nine patients with skeletal metastases, bone ALP correlated well with the presence of pain and the progression or regression of metastatic spread.

Interpretation and clinical significance of alkaline phosphatase isoenzyme patterns

Alkaline phosphatase (ALP, EC 3.1.3.1) is a membrane-bound metalloenzyme that consists of a group of true isoenzymes, all glycoproteins, encoded for by at least four different gene loci: tissue-nonspecific, intestinal, placental, and germ-cell ALP. Through posttranslational modifications of the tissue-nonspecific gene, for example, through differences in carbohydrate composition, bone and liver ALP are formed. Nowadays, most commercially available methods for separating or measuring ALP isoenzymes are easy to perform and sensitive and allow for reproducible and quantitative results. As more isoenzymes and isoforms have been characterized, confusion has arisen due to the many different names they were given. For the sake of simplicity and because of structural analogies, we propose an alternative nomenclature for the ALP isoenzymes and isoforms based on their structural characteristics: soluble, dimeric (Sol), anchor-bearing (Anch), and membrane-bound (Mem) liver, bone, intestinal, and placental ALP. Together with lipoprotein-bound liver ALP and immunoglobulin-bound ALP, these names largely fit the many forms of ALP one can encounter in human serum and tissues. The clinically relevant isoenzymes are sol-liver, Mem-liver, lipoprotein-bound liver, and Sol-intestinal ALP in liver diseases, and Sol-bone and Anch-bone ALP in bone diseases. Many different isoenzyme patterns can be found in malignancies and renal diseases. This test provides the clinician with valuable information for diagnostic purposes as well as for follow-up of patients and monitoring of treatment. However, ALP isoenzyme determination will only provide clinically useful information if the patterns are correctly interpreted. In this respect, care should be taken to use the proper reference ranges, taking into account the age and sex of the patient. A normal total ALP activity does not rule out the presence of an abnormal isoenzyme pattern, particularly in children. Separating ALP into its isoenzymes adds considerable value to the mere assay of total ALP activity.

Lectin affinity electrophoresis of alkaline phosphatase for the differentiation of bone and hepatobiliary disease

An affinity electrophoresis procedure is described for the separation and quantification of the bone- and liver-derived fractions of alkaline phosphatase in plasma. Separation is carried out on cellulose acetate membrane pre-soaked with buffer containing wheat germ lectin. The electrophoretic mobility of the bone enzyme is preferentially retarded by the lectin and this fraction is well separated from the liver fraction. After separation, enzyme activity is demonstrated by staining using an indigogenic alkaline phosphatase substrate incorporated in agar gel, and the stained fractions quantified by densitometry. The procedure has low imprecision, good linearity, and the activities of the bone and liver fractions correlate well with values obtained using nonelectrophoretic quantification methods. The procedure is especially suitable for use in the diagnostic laboratory.