Bone marrow acid phosphatase: another look

Grossly elevated serum prostatic acid phosphatase in a patient with carcinoid

We report a case of carcinoid, diagnosed histochemically and biochemically, which was associated with grossly elevated serum prostatic acid phosphatase and normal serum prostate specific antigen.

Bone marrow prostatic specific antigen and prostatic acid phosphatase levels: are they helpful in staging prostatic cancer?

We analyzed serum and bone marrow levels of prostatic specific antigen and prostatic acid phosphatase quantified by double antibody radioimmunoassay in 70 patients. Of the patients 36 had prostatic cancer, including 23 with metastatic disease. There was a significant correlation between the serum and bone marrow levels of prostatic specific antigen and prostatic acid phosphatase independently of the metastases (p less than 0.001). No patient with prostatic cancer and positive bone marrow prostatic specific antigen or prostatic acid phosphatase levels had normal serum levels. Quantification of bone marrow prostatic specific antigen and prostatic acid phosphatase does not provide more information than does serum determination.

Tumor markers: value and limitations in the management of cancer patients

Sixteen tumor markers are reviewed, and measured to the ideal: produced by the tumor cell alone absent in health and in benign disease present in all patients with a given malignancy level in the blood representative of tumor mass detectable in occult disease. The only marker that approaches the ideal is human chorionic gonadotropin (HCG) in gestational trophoblastic tumors. In this malignancy, the HCG level suggests the diagnosis and stage, confirms response to therapy, and predicts relapse. The three most widely used and intensely studied tumor markers are carcinoembryonic antigen (CEA), alphafetoprotein (AFP), and HCG. CEA cannot be used in screening for cancer, but in carcinoma of the colon its elevation preoperatively increases the likelihood of advanced disease and postoperative recurrence. Postoperatively, elevated titers are often but not invariably associated with recurrent disease. AFP and HCG are useful in the management of nonseminomatous germ cell testicular tumors. Like CEA, they cannot be used for screening. They are more likely to be increased with advancing stage, and after therapy rising levels almost always mean recurrent disease. Some markers are valuable in specific circumstances, such as calcitonin in screening for familial medullary carcinoma of the thyroid. In multiple myeloma, immunoglobulins are useful in determining the tumor mass and response to therapy. In neuroblastoma, catecholamine metabolites are useful primarily in making the diagnosis. In some malignancies, the absence of effective therapy lowers the value of the marker, as for AFP in hepatoma. The remaining markers are too unreliable or too little studied to be useful in the management of an individual patient with cancer. The purpose of this paper is to provide the clinician with an understanding of the limitations of the present tumor markers that will lead to wiser use of the tests, and to provide standards to which future tumor markers should be measured.

Acid phosphatase in prostatic tissue homogenates from patients with benign prostatic hyperplasia and prostatic carcinoma

Acid phosphatase activity biochemically in the primary tumor of 20 patients with prostatic carcinoma, was studied in an attempt to understand the basis for a correlation or lack of correlation between serum and/or bone marrow acid phosphatase levels and the presence and/or clinical behavior of prostatic carcinoma. The enzyme activity was similarly measured in 19 patients with benign prostatic hyperplasia as controls. On the average, enzyme activities were lower (P less than 0.002) in the tissues from patients with carcinoma. There was no correlation of enzyme activity in tumor with the age of the patient, stage of disease, degree of differentiation of the tumor, or serum acid phosphatase activity.

Bone marrow and acid phosphatase by counterimmune electrophoresis: pre-treatment and post-treatment correlations

The value of bone marrow acid phosphatase in the staging of prostatic cancer has been a controversial issue. A number of investigators have concluded that the enzymatic determinations of bone marrow acid phosphatase are inaccurate because of lack of specificity. The introduction of the immune methods for measuring acid phosphatase has revived interest in the role of immune bone marrow acid phosphatase in pre-treatment staging. Fifty-five patients underwent determination of simultaneous immune bone marrow and serum acid phosphatase before any treatment. While positive values did predict a risk for initial and subsequent metastasis they could not be used to dictate against definitive therapy. Positive bone marrow values were paralleled by positive serum values and provided no additional staging information.

Biologic markers in cancer diagnosis and treatment

We have reviewed several tumor markers that our advocates feel are now clinically useful, involve current assay technology, and are based on already available information. These include, in selected instances, estrogen receptors for breast cancer, thyrocalcitonin for medullary cancer of the thyroid, prostatic acid phosphatase for cancer of the prostate, alpha-fetoprotein for hepatocellular cancer, and carcinoembryonic antigen for monitoring colon cancer. We have considered the potential use of measurement of serum proteases and protein degradation products due to their activity as possible future areas of development, and we have explored measurement of tissue aryl hydrocarbon hydroxylase to identify populations at risk of cancer resulting from chemical carcinogenesis. It is clear that the study of tumor markers is already improving patient care in some specific areas and offers exciting potential for the future.

Bone marrow acid phosphatase by radioimmunoassay: 3 years of experience

Clinical followup of 112 patients staged by the immunochemical determination of prostatic acid phosphatase from bone marrow aspirates is presented. This represents a 94 per cent (112 of 118) retrieval rate of a group studied more than 2 years previously. Of the 11 patients judged to be at high risk 4 (36 per cent) have suffered bony metastases, whereas only 3 of 86 patients (3 per cent) with normal bone marrow acid phosphatase by radioimmunoassay have done so. An additional 184 patients with carcinoma and 77 controls have been studied. Although radioimmunoassay greatly improves specificity in bone marrow aspirates a few falsely positive results can occur. This finding may be secondary to cross reaction from leukocyte acid phosphatase and/or interference from lipid.

Radical retropubic prostatectomy and pelvic lymphadenectomy for high-stage cancer of the prostate

A series of 340 patients with adenocarcinoma of the prostate treated by bilateral pelvic lymphadenectomy and radical retropubic prostatectomy was reviewed to determine the factors that influence survival and time to progression of disease. Follow-up ranged from 1-12 1/2 years. Factors evaluated were grade, stage, and bulk of tumor; influence of seminal vesical involvement and number of pelvic nodes involved; age of patient; and year of surgery. Tumor grade was the only factor related significantly to patient survival. However, grade, stage, and bulk of tumor were all significantly associated with interval between surgery and disease progression. Furthermore, in Stage C disease, seminal vesical involvement (C+) was an adverse factor for disease progression, particularly among patients with low-grade tumor. This is in contrast to the finding that, among patients with Stage D1 disease, those with seminal vesical involvement experienced more favorable survival times and times to progression of disease when compared with patients without seminal vesical involvement. Overall, patient survival compared favorably with an age-matched control group for all stages, A through D1. Patients with few pelvic nodes involved had a survival experience nearly comparable with that of an age-matched control group. This suggests that pelvic lymphadenectomy might have a therapeutic value and that patients with pelvic nodal disease only, without evidence for metastatic disease, should not be denied radical surgery. The influence of concomitant hormonal manipulation or radiotherapy (or both) on patient survival and disease progression is not conclusively answered in this report.

Bone marrow acid phosphatase in prostate cancer: an assessment by immunoassay and biochemical methods

Comparisons of the bone marrow and serum acid phosphatase values obtained by counter-immunelectrophoresis and the Roy biochemical test were made in 72 patients with and in 13 patients without prostatic cancer. The counter-immunoelectophoresis test, when positive at more than 1 international unit per liter, showed only 4.4 per cent falsely positive results. The Roy biochemical test, which used sodium thymolphthalein monophosphate as the substrate, had 65 per cent falsely positive bone marrow acid phosphatase levels. Conflicting reports regarding the value of bone marrow acid phosphatase determinations in patients with prostatic cancer result from the use of non-specific substrates in biochemical methods for measurement and from the trauma incidental to bone marrow aspiration, which releases many non-prostatic acid phosphatase enzymes. The use of immunoassay such as counter-immunoelectrophoresis minimizes this source of error.

Radioimmunoassay of bone marrow prostatic acid phosphatase

The clinical value of prostate acid phosphatase (PAP) measurements in the bone marrow aspirate of patients with prostatic adenocarcinoma has been unclear. Using a radioimmunoassay (RIA) to measure PAP, we have evaluated this potential indicator of occult metastases in 127 controls and in 300 patients with prostatic adenocarcinoma. Elevations of the tumor marker were found in 9%, 10%, 19%, and 82% of patients with stages B, C, D1, and D2 adenocarcinoma respectively. Clinical follow-up ranging from 7 to 43 months (average 23 months) was available for 97 patients without any initial indication of metastasis by bone scan. In this group 11 patients had elevated levels of bone marrow acid phosphatase (BMAP) by RIA and four developed radiological evidence of bone metastasis 21-25 months following initial staging. However, only three of the 86 patients with normal BMAP levels have developed bone metastasis. Our results indicate that measurement of bone marrow PAP by immunological methods has prognostic significance. Dilution of the bone marrow aspirate by peripheral blood, however, may limit the application of this technique.

Clinical significance of serum and bone marrow acid phosphatase

Currently available immunochemical assays for the determination of serum prostatic acid phosphatase have improved the reliability of this biological marker in carcinoma of the prostate. Although the value of such methods for screening the general population is questionable, a certain percentage of elevated serum levels is observed in patients with localized disease. The significance of such findings is unclear at the present time. Recent evidence suggests that in elevated bone marrow acid phosphatase, using these methods is of predictive value in the future development of metastatic disease.

Carcinoma of gallbladder simulating metastatic prostatic cancer

This is a case of carcinoma of the gallbladder, which clinically, chemically, and radiographically simulated metastatic prostate cancer. Other causes of elevated serum and bone marrow acid phosphatase and axial skeletal osteoblastic metastases are reviewed.

Combined serum and bone marrow radioimmunoassays for prostatic acid phosphatase

Combined serum and bone marrow radioimmunoassays for prostatic acid phosphatase provide a unique means for the early diagnosis and more accurate clinical staging of prostatic cancer. The combined screening technique appears to be helpful, particularly in providing a clinical assessment of the presence or absence of early, subclinical lymphatic and bone marrow metastases. Low titer elevations of bone marrow prostatic acid phosphatase by radioimmunoassay have been observed commonly in clinically understaged C prostatic cancer with normal technetium bone scans, indicating the presence of unrecognized stage D disease with bone metastases. The combined screening method also is of distinct clinical value in the early diagnosis of prostatic cancer and in monitoring the effects of specific therapy. In therapeutically responsive patients marked suppression of serum and bone marrow prostatic acid phosphatase is observed regularly with the radioimmunochemical method under study.

Reliability of bone marrow acid phosphatase as a parameter of metastatic prostatic cancer

The reliability of bone marrow acid phosphatase determination by a spectrophotometric assay and 2 immunochemical methods was evaluated in 40 patients: 20 men with known prostatic carcinoma and 20 men of comparable age without clinical evidence of prostatic cancer. The large percentage of falsely positive results obtained by the colorimetric assay invalidates this method as the sole parameter of metastatic prostatic carcinoma.

Prostatic acid phosphatase by radioimmunoassay tumor marker in bone marrow

Bone marrow acid phosphatase was determined by radioimmunoassay and enzymatic analysis in 95 patients with benign prostatic hypertrophy, 50 patients with disseminated prostatic carcinoma and 36 patients with non-prostatic malignancy. The results indicate superior specificity of the radioimmunoassay. A brief review of the topic and the clinical implications are discussed.

Bone marrow acid phosphatase in staging of prostatic cancer: how reliable is it?

To evaluate the reliability of bone marrow acid phosphatase in the staging of prostatic carcinoma we analyzed 50 bone marrow samples collected at random from the hematology service at this hospital. The samples were assayed for acid phosphatase content by a colorimetric method using sodium thymolphthalein monophosphate as a substrate and by 2 immunochemical assays developed at our laboratory (counter immunoelectrophoresis and radioimmunoassay). We found a high percentage (61 per cent) of falsely positive results in patients with various hematological diseases without evidence of prostatic carcinoma by the colorimetric evaluation. All of these patients except 1 had negative immunochemical assay. Until a specific assay for prostatic acid phosphatase is developed for clinical use we caution the use of a single elevation of bone marrow acid phosphatase as a parameter of metastatic disease.

Bone marrow acid phosphatase by radioimmunoassay

A double-antibody radioimmunoassay was developed and utilized to measure prostatic acid phosphatase in bone marrow aspirates. One hundred-eighteen patients with carcinoma of the prostate in various clinical stages, and fifty with benign prostatic hyperplasia were studied. In patients with carcinoma, levels of prostatic acid phosphatase in bone marrow aspirates were found to correlate well with increasing clinical stage of the disease. Determination of bone marrow prostatic acid phosphatase by radioimmunoassay may be a valuable adjunct to clinicopathologic staging of prostatic carcinoma.

The significance of bone marrow acid phosphatase in patients with prostatic carcinoma

The levels of total and l-tartrate labile acid phosphatase were studied in 49 patients with prostatic carcinoma. The results were compared with the results from a control group. The acid phosphatase levels from the bone marrow were above the upper normal limit of serum acid phosphatase both in the control group and in patients with prostatic carcinoma. This may be due to acid phosphatase released from blood cells during haemolysis. There was a positive correlation between serum and bone marrow acid phosphatase levels in patients with prostatic carcinoma. Significantly raised levels of bone marrow acid phosphatase (above the upper limit of the normal range from the control group) were observed only in advanced stage IV patients with significantly increased serum levels. The levels of bone marrow acid phosphatase gave no supplementary diagnostic information in any of the patients with prostatic carcinoma. Doubt is expressed concerning the hypothesis that raised levels of bone marrow acid phosphatase are diagnostic of early metastases from prostatic carcinoma.

Radioimmunochemical measurement of bone marrow prostatic acid phosphatase

Human acid phosphatases are ubiquitous phosphohydrolases that are present in most respiring tissues and cells. Specifically, human prostatic acid phosphatase is a unique enzyme within a vast family of acid phosphatases concerned with catabolic processes in cellular metabolism. The majority of serum and bone marrow acid phosphatases are of non-prostatic origin and are present chiefly in erythrocytes, leukocytes, platelets and other maturing cells in the bone marrow. The specific concentration of prostatic acid phosphatase in serum and bone marrow is normally relatively low compared to non-prostatic acid phosphatases. Many falsely positive assays for total serum acid phosphatases and bone marrow acid phosphatases have been reported, particularly after traumatic marrow biopsy procedures and mishandling of blood samples in the clinical laboratory and in hematologic disease states. The disruption and lysis of whole blood and marrow cells can liberate non-specific acid phosphatases into the serum. Since standard enzymatic assays do not discriminate accurately prostatic acid phosphatase from non-prostatic acid phosphatase present in the serum spurious results can be realized. A preliminary experience with a promising radioimmunoassay for the specific measurement of prostatic acid phosphatase in bone marrow and serum is presented.