In many tumor types serum lactate dehydrogenase (LDH) levels is an indirect marker of tumor hypoxia, neo-angiogenesis and worse prognosis. However data about hepatocellular carcinoma (HCC) are lacking in the clinical setting of patients undergoing transarterial-chemoembolization (TACE) in whom hypoxia and neo-angiogenesis may represent a molecular key to treatment failure. Aim of our analysis was to evaluate the role of LDH pre-treatment levels in determining clinical outcome for patients with HCC receiving TACE. One hundred and fourteen patients were available for our analysis. For all patients LDH values were collected within one month before the procedure. We divided our patients into two groups, according to LDH serum concentration registered before TACE (first: LDH≤450 U/l 84 patients; second: LDH>450 U/l 30 patients). Patients were classified according to the variation in LDH serum levels pre- and post-treatment (increased: 62 patients vs. decreased 52 patients). No statistically significant differences were found between the groups for all clinical characteristics analyzed (gender, median age, performance status ECOG, staging systems). In patients with LDH values below 450 U/l median time to progression (TTP) was 16.3 months, whereas it was of 10.1 months in patients above the cut-off (p = 0.0085). Accordingly median overall survival (OS) was 22.4 months and 11.7 months (p = 0.0049). In patients with decreased LDH values after treatment median TTP was 12.4 months, and median OS was 22.1 months, whereas TTP was 9.1 months and OS was 9.5 in patients with increased LDH levels (TTP: p = 0.0087; OS: p<0.0001). In our experience, LDH seemed able to predict clinical outcome for HCC patients undergoing TACE. Given the correlation between LDH levels and tumor angiogenesis we can speculate that patients with high LDH pretreatment levels may be optimal candidates for clinical trial exploring a multimodality treatment approach with TACE and anti-VEGF inhibitors in order to improve TTP and OS.
Citation: Scartozzi M, Faloppi L, Bianconi M, Giampieri R, Maccaroni E, Bittoni A, et al. (2012) The Role of LDH Serum Levels in Predicting Global Outcome in HCC Patients Undergoing TACE: Implications for Clinical Management. PLoS ONE 7(3): e32653. https://doi.org/10.1371/journal.pone.0032653
Editor: Yihai Cao, Karolinska Institutet, Sweden
Received: August 9, 2011; Accepted: January 28, 2012; Published: March 26, 2012
Copyright: © 2012 Scartozzi et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: The authors have no support or funding to report.
Competing interests: The authors have declared that no competing interests exist.
Hepatocellular carcinoma (HCC) represents the commonest primary cancer of the liver. Incidence is increasing and HCC has risen to become the 5th commonest malignancy worldwide and the third leading cause of cancer related death, exceeded only by cancers of the lung and stomach , . HCC prevalence is higher in sub-Saharan Africa, central and Southeast Asia.
Surgery is the only potentially curative treatment for HCC. In carefully selected patients, resection and transplantation in fact, allow a 5 years survival ranging from 60 to 70%, and should be considered as a first treatment option in this setting .
Unfortunately most patients in Western countries present with an intermediate or advanced HCC at diagnosis with the consequent inability to use curative treatments. These patients are therefore candidates to palliative therapies such as arterial embolization, chemoembolization (TACE) and systemic treatment . Only recently the molecular targeted drug, Sorafenib, has been introduced among the therapeutic options for these patients –.
TACE represents a crucial treatment option for HCC, however comparing clinical findings resulted often hampered by the considerable variability in patients selection criteria and modalities of execution of therapy –. However, global results for TACE are still unsatisfactory, with only a small proportion of patients benefiting from these procedures. The molecular mechanism that accounts for treatment failure is not clear , . It is possible that some adaptive responses to hypoxia may represent a key factor for resistance. Induction of tumor hypoxia combined with chemotherapy by transcatheter arterial chemoembolization has been widely used in treating unresectable HCC.
Hypoxia represents a clinical biological mechanism for treatment resistance in cancer cells via the formation of new blood vessels. Furthermore, a growing body of evidence indicates that hypoxia might actually promote cancer development.
There are significant differences between energy metabolism of cancer cells and that of normal tissues. Cancer cells maintain high aerobic glycolytic rates and produce high levels of lactate and pyruvate, a phenomenon known historically as the Warburg effect .
Lactic dehydrogenase (LDH), which is a glycolytic enzyme, composed of four polypeptide chains, each one encoded by separate gene (M and H), exists in various types of human tissue and neoplasms. LDH is a key enzyme in the conversion of pyruvate to lactate under anaerobic conditions . Five isoforms of LDH have been identified as a result of the five different combinations of polypeptide subunits . In preclinical models up-regulation of LDH has been suggested to ensure both an efficient anaerobic/glycolytic metabolism and a reduced dependence on oxygen under hypoxic conditions in tumor cells. Altered serum levels of LDH has also been reported in patients with HCC.
The biological link between hypoxia, LDH levels and the tumor-driven angiogenesis pathway through the abnormal activation of the hypoxia inducible factor 1 (HIF-1) is well established. The biological activity of HIF-1 is determined by the expression and activity of the HIF-1α subunit . HIF-1α is an essential factor that upregulates a series of genes involved in glycolytic energy metabolism, angiogenesis, erythropoiesis and cell survival . Hypoxia in the tumor microenvironment is sufficient to activate HIF-dependent expression of several downregulated genes . These include genes encoding for vascular endothelial growth factor, erythropoietin and many enzymes involved in glucose, iron, and nucleotide metabolism .
Although links among these factors are well known, their translation into clinical practice is still poorly investigated. The aim of our analysis is to assess the prognostic role of LDH in a population of HCC patients, treated with TACE.
We retrospectively analyzed a population of HCC patients, treated with TACE (lipiodol or drug-eluting microspheres) from 2002 to 2010, at our institution. The study included all patients consecutively treated with TACE (in our institution, patients were treated with TACE with lipiodol from 2002 until 2006 and with TACE with microspheres from 2007 to 2010). Patients were classified according to ECOG PS (Eastern Cooperative Oncology Group performance status) and were staged using different staging systems: Child-Pugh, BCLC (Barcelona Clinic Liver Cancer), Okuda, MELD (Model for End-Stage Liver Disease), MELD-Na (Model for End-Stage Liver Disease – Sodium).
We recorded LDH serum levels pre- (within 1 month prior to treatment) and post-treatment (within one month after). LDH serum levels were determined according to IFCC (International Federation of Clinical Chemistry and Laboratory Medicine) method. The assay has been conducted in Our Institution Laboratory certified for Quality control according to the present rules in Europe (ISO 9001:2008). Patients were divided into two groups, according to LDH serum concentration registered before TACE. First group included patients with pretreatment LDH≤450 U/l, whereas the other group included patients with pretreatment LDH>450 U/l. LDH serum levels cut-off has been set to 450 U/l, because it is the upper limit of normality in blood specimens in our Institution. Patients were, also, classified according to any variation in LDH serum levels pre- and post-treatment (increased vs. decreased).
The A.O.U. “Ospedali Riuniti” of Ancona Ethical Committee approved the analysis. Patients gave written consent for their clinical information to be anonymously stored in the hospital database and used for research.
Clinical outcome evaluation and statistical analysis
Treatment response was assessed through computed tomography (CT) and magnetic resonance imaging (MRI), alpha-fetoprotein (α-FP) assay, performed after one month of treatment and then every 3 months, according to the new RECIST criteria (New Response Evaluation Criteria in Solid Tumors 1.1). Radiological images were reviewed in double-blind by two radiologists.
The distribution curves of survival and time to progression were estimated using the Kaplan-Meier method. Overall survival (OS) was calculated as the time interval between the date of the procedure and the date of death or last follow-up. The time to progression (TTP) was calculated as the time interval between the date of the procedure and the date of progression or last follow-up.
The clinical variables analyzed were: gender (male vs. female), age (≤69 years vs. >69 years), ECOG PS (0–1 vs. 2–3), the Child-Pugh score (A vs. B), BCLC stage (A vs. B–C), Okuda stage (I vs. II vs. III), the MELD score (≤10 vs. 11–15 vs. >15), the MELD-Na score (≤10 vs. 11–15 vs. >15), the type of TACE (TACE or precision TACE; Lipiodol or drug eluting microspheres).
The association between variables was estimated using the chi-square test. Any differences between the groups were considered significant if the significance level was less than 0.05.
One hundred and fourteen patients were available for our analysis: 98 (86%) males and 16 (14%) females. Median age was 69 years (range 49–89) (Table 1). Eighty-four patients (74%) showed pretreatment LDH serum levels below the cut-off, while 30 (26%) were found above the chosen cut-off. Sixty-two patients (54%) showed decreased LDH serum levels after treatment, while in 52 (46%) this value increased.
No statistically significant differences were found between the groups of patients for all clinical characteristics analyzed (gender, median age, performance status ECOG, staging systems) (Table 1). Moreover, among the same groups, no significant differences were found in terms of objective responses (Table 2) and according with the type of TACE performed (lipiodol or drug-eluting microspheres).
In patients with LDH values below 450 U/l median time to progression (TTP) was 16.3 months, whereas it was of 10.1 months in patients above the cut-off. This difference was found to be statistically significant (p = 0.0085) (Figure 1, panel 1). Accordingly median overall survival (OS) was 22.4 months and 11.7 months in group A and B respectively (p = 0.0049) (Figure 1, panel 2). In patients with decreased LDH values after treatment median TTP was 12.4 months, and median OS was 22.1 months, whereas TTP was 9.1 months and OS was 9.5 in patients with increased LDH levels (TTP: p = 0.0087 Figure 1, panel 3; OS: p<0.0001 Figure 1, panel 4).
Panel 1) Median time to progression (TTP) according to LDH serum levels: LDH≤450 U/l (–––), LDH>450 U/l (--------) (p = 0.0085). Panel 2) Median overall survival (OS) according to LDH serum levels: LDH≤450 U/l (–––), LDH>450 U/l (--------) (p = 0.0049). Panel 3) Median TTP according to the LDH serum levels variations pre- and post-treatment: LDH decreased post-treatment (–––), LDH increased post-treatment (--------) (p = 0.0087). Panel 4) Median OS according to the LDH serum levels variations pre- and post-treatment: LDH decreased post-treatment (–––), LDH increased post-treatment (--------) (p<0.0001).
The clinical management of HCC is becoming increasingly challenging along with the growing availability of therapeutic options. Moreover the typical HCC patient has, in most cases, two different diseases, cancer and the underlying liver disease, both heavily influencing patients clinical outcome. In this setting patients stratification may represent a crucial factor for the choice of the appropriate treatment strategy for the appropriate patient. In fact, although many staging systems have been proposed, a relevant degree of heterogeneity can still be seen in the same sub-group of patients making treatment selection highly demanding.
In our experience, LDH serum levels seemed able to predict clinical outcome in terms of TTP and OS for HCC patients undergoing TACE. Globally our data indicated that LDH levels might identify patients with distinctive prognosis within the same staging group.
These findings are in accordance with previously published analyses suggesting a relationship between LDH levels and a worse outcome in different tumor types.
In colorectal cancer patients LDH up-regulation was in fact associated with an increased risk of nodal and distant metastases and high LDH serum levels have been shown to correlate with a decreased median overall survival , .
A strong association has also been demonstrated between the expression of LDH, in particular the LDH-5 isoform and an aggressive phenotype in gastric cancer .
This apparently enhanced tumor aggressiveness often determining worse prognosis in cancer patients showing high LDH levels has been traditionally correlated with molecular mechanism underlying tumor hypoxia and angiogenesis.
The possible link between LDH levels and tumor angiogenesis has been indicated in 2 different clinical trials (the CONFIRM 1 & 2 trials) investigating PTK/ZK (vatalanib), an oral inhibitor of VEGF (vascular endothelial growth factor) receptors, in first and second-line therapy of advanced colorectal cancer. Results from subsequent analyses from these trials in fact evidenced an improved median PFS with the use of PTK/ZK in patients with high serum LDH levels, thus suggesting that tumor angiogenesis represent a key crucial event in presence of high LDH levels , .
Increased levels of VEGF have been associated with tumor grade and with an inferior overall survival in HCC, apparently indicating that angiogenesis may represent a key-factor also for these patients , .
We also demonstrated that LDH serum levels variations (pre- and post-treatment) might correlate with clinical outcome in HCC patients. These findings seem to suggest that the biological phenomenon underlying LDH serum levels is a dynamic one and may be influenced by medical treatment. Recently Kohles et al. showed a possible prognostic role of pretreatment LDH serum levels in HCC patients undergoing TACE , confirming our hypothesis. We can then speculate that patients with high LDH pretreatment levels may be optimal candidates for clinical trial exploring a multimodality treatment approach including TACE and VEGF inhibitors.
After confirmation in larger analyses we believe that LDH should be considered as a relevant clinical variable to be included in the prognostic classification of HCC patients, with the aim to better define the most appropriate therapeutic strategy and to better stratify patients included in clinical trials.
Further studies testing the molecular and biological correlation between serum LDH levels and tumor angiogenesis are needed in both basic science and clinical arenas.
Conceived and designed the experiments: MS LF MB GSB SC. Performed the experiments: MS LF MB RG EM. Analyzed the data: MS LF MB AB MDP. Contributed reagents/materials/analysis tools: MS LF MB CL LB. Wrote the paper: MS LF MB.
- 1. Parkin DM, Bray F, Ferlay J, Pisani P (2005) Global cancer statistics, 2002. Ca Cancer J Clin 55: 74–108.
- 2. Montalto G, Cervello M, Giannitrapani L, Dantona F, Terranova A, et al. (2002) Epidemiology, risk factors and natural history of hepatocellular carcinoma. Ann N Y Acad Sci 963: 13–20.
- 3. Bruix J, Sherman M (2005) Management of Hepatocellular carcinoma. AASLD Practice Guideline. Hepatology 42: 1208–1236.
- 4. Okada S (1998) Chemotherapy in hepatocellular carcinoma. Hepatogastroenterology 45: suppl 31259–1263.
- 5. Faloppi L, Scartozzi M, Maccaroni E, Di Pietro Paolo M, Berardi R, et al. (2011) Evolving strategies for the treatment of hepatocellular carcinoma: from clinical-guided to molecularly-tailored therapeutic options. Cancer Treat Rev May; 37(3): 169–77. Epub 2010 Aug 25. Review.
- 6. Abou-Alfa GK, Schwartz L, Ricci S, Amadori D, Santoro A, et al. (2006) Phase II study of sorafenib in patients with advanced hepatocellular carcinoma. J Clin Oncol 24: 4293–4300.
- 7. Llovet J, Ricci S, Mazzaferro V, Hilgard P, Gane E, et al. (2007) SHARP Investigators. Sorafenib improves survival in advanced Hepatocellular Carcinoma. N Engl J Med Jul 24; 359(4): 378–90.
- 8. Llovet JM, Di Bisceglie AM, Bruix J, Kramer BS, Lencioni R, et al. (2008) Design and Endpoints of Clinical Trials in Hepatocellular Carcinoma. J Nat Cancer Inst 100: 698–711.
- 9. Groupe d'Etude et de Traitement du Carcinome Hepatocellulaire (1995) A comparison of lipiodol chemoembolization and conservative treatment for unresectable hepatocellular carcinoma. N Engl J Med 332: 1256–61.
- 10. Bruix J, Llovet JM, Castells A, Montañá X, Brú C, et al. (1998) Transarterial embolization versus symptomatic treatment in patients with advanced hepatocellular carcinoma: results of a randomized controlled trial in a single institution. Hepatology 27: 1578–83.
- 11. Pelletier G, Ducreux M, Gay F, Luboinski M, Hagège H, et al. (1998) Treatment of unresectable hepatocellular carcinoma with lipiodol chemoembolization: a multicenter randomized trial. J Hepatol 29: 129–34.
- 12. Scartozzi M, Svegliati Baroni G, Faloppi L, Di Pietro Paolo M, Pierantoni C, et al. (2010) Trans-arterial chemo-embolization (TACE), with either lipiodol (traditional TACE) or drug-eluting microspheres (precision TACE, pTACE) in the treatment of hepatocellular carcinoma: efficacy and safety results from a large mono-institutional analysis. J Exp Clin Cancer Res Dec 15: 29: 164.
- 13. Lo CM, Ngan H, Tso WK, Liu CL, Lam CM, et al. (2002) Randomized controlled trial of transarterial lipiodol chemoembolization for unresectable hepatocellular carcinoma. Hepatology 35: 1164–71.
- 14. O'Suilleabhain CB, Poon RT, Yong JL, Ooi GC, Tso WK, et al. (2003) Factors predictive of 5-year survival after transarterial chemoembolization for inoperable hepatocellular carcinoma. Br J Surg 90: 325–31.
- 15. Warburg O (1965) On the origin of cancer cells. Science 123: 309–14.
- 16. Holbrook JJ, Liljas A, Steindel SJ (1975) Lactate dehydrogenase. In: Boyer PD, editor. The enzymes, 3rd edition, vol. XI, part A. New York: Academic Press. pp. 191–2.
- 17. Markert CL (1963) Lactate dehydrogenase isozymes: dissociation and recombination of subunits. Science 140: 1329–30.
- 18. Semenza G (2002) Signal transduction to hypoxia-inducible factor 1. Biochem Pharmacol 64: 993–8.
- 19. Semenza GL (2000) HIF-1: mediator of physiological and pathophysiological responses to hypoxia. J Appl Physiol 88: 1474–80.
- 20. Maxwell PH, Dachs GU, Gleadle JM, Nicholls LG, Harris AL, et al. (1997) Hypoxia-inducible factor-1 modulates gene expression in solid tumors and influences both angiogenesis and tumor growth. Proc Natl Acad Sci USA 94: 8104–9.
- 21. Semenza GL (1999) Regulation of mammalian O2 homeostasis by hypoxia-inducible factor 1. Annu Rev Cell Dev Biol 15: 551–78.
- 22. Koukourakis MI, Giatromanolaki A, Sivridis E, Gatter KC, Trarbach T, et al. (2011) Prognostic and Predictive Role of Lactate Dehydrogenase 5 Expression in Colorectal Cancer Patients Treated with PTK787/ZK 222584 (Vatalanib) Antiangiogenic Therapy. Clin Cancer Res; Clin Cancer Res Jul 15; 17(14): 4892–900. Epub 2011 Jun 1.
- 23. Wu XZ, Ma F, Wang XL (2010) Serological diagnostic factors for liver metastasis in patients with colorectal cancer. World J Gastroenterol Aug 28; 16(32): 4084–8.
- 24. Kolev Y, Uetake H, Takagi Y, Sugihara K (2008) Lactate dehydrogenase-5 (LDH-5) expression in human gastric cancer: association with hypoxia-inducible factor (HIF-1alpha) pathway, angiogenic factors production and poor prognosis. Ann Surg Oncol Aug; 15(8): 2336–44. Epub 2008 Jun 3.
- 25. Van Cutsem E, Bajetta E, Valle J, Köhne CH, Hecht JR, et al. (2011) Randomized, placebo-controlled, phase III study of oxaliplatin, fluorouracil, and leucovorin with or without PTK787/ZK 222584 in patients with previously treated metastatic colorectal adenocarcinoma. J Clin Oncol May 20; 29(15): 2004–10. Epub 2011 Apr 4.
- 26. Hecht JR, Trarbach T, Hainsworth JD, Major P, Jäger E, et al. (2011) Randomized, Placebo-Controlled, Phase III Study of First-Line Oxaliplatin-Based Chemotherapy Plus PTK787/ZK222584, an Oral Vascular Endothelial Growth Factor Receptor Inhibitor, in Patients With Metastatic Colorectal Adenocarcinoma. J Clin Oncol 20 May; 29(15): 1997–2003. Epub 2011 Apr 4.
- 27. Chao Y, Li CP, Chau GY, Chen CP, King KL, et al. (2003) Prognostic significance of vascular endothelial growth factor, basic fibroblast growth factor, and angiogenin in patients with resectable hepatocellular carcinoma after surgery. Ann Surg Oncol 55–62.
- 28. Poon RT, Ho JW, Tong CS, Lau C, Ng IO, et al. (2004) Prognostic significance of serum vascular endothelial growth factor and endostatin in patients with hepatocellular carcinoma. Br J Surg 91: 1354–60.
- 29. Kohles N, Nagel D, Jungst D, Durner J, Stieber P, et al. (2012) Prognostic relevance of oncological serum biomarkers in liver cancer patients undergoing chemoembolization therapy. Tumour Biol Feb; 33(1): 33–40. Epub 2011 Sep 20.