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ACID AND ALKALINE PHOSPHATASES IN THEIRRELATION TO MALIGNANT DISEASE

By E. J. KING, M.A., PH.D., D.Sc.Professor of Chem.'cal Pathology, Post Graduate Medical School, London

and

G..E. DELORY, M.Sc., PH.D.Biochemift R ival Infirmary, Preston, Lancashire

Phosphatases are enzymes capable of catalysingthe hydrolysis of phosphoric esters with liberation'of inorganic phosphate, they are found widelyspread throughout nature. The early work on thediscovery and properties of these enzymes has beenthoroughly reviewed by Kay (1932).Acid and Alkaline PhosphatasesThere are probably many different phos-

phatases present in living organisms and muchvaluable data is being accumulated on theiridentity and methods of differential estimation.In the present state of our knowledge, however,and from the aspect of clinical application, we canbest think of them in terms of two groups, the so-called' alkaline ' and' acid' phosphatases. Theseenzymes are distinguished by the fact that thefirst class are optimally active at an alkaline andthe second at an acid pH. The actual pH varieswith the particular substrate, but when phenylphosphate is used, the acid phosphatases have anoptimum pH of 4.9 and the alkaline phosphatasesare optimally active at pH 9.8. Since these pHvalues are sufficiently far apart, it is possible todetermine one of the two groups of phosphatase inthe presence of the other. It will be convenient inthe first place to consider the two groups ofphosphatases separately.Alkaline PhosphatasesThe foundation of our knowledge of the bio-

logical functions of the alkaline phosphatases waslaid by Robison (1923) when he found an enzymepresent in the ossifying cartilage of young ratsand rabbits which liberated inorganic phosphatefrom hexose phosphate. This enzyme was op.-timally active at a pH 9.--9.5 under the con-ditions used by him.

Robison suggested that alkaline phosphataseplayed a vital part in ossification, since enzymichydrolysis of the phosphoric esters present in thefluids bathing the bone or cartilage led to a local

increase in the concentration of inorganic phos-phate in solution and thus to deposition of bonesalt.

Following up this observation, Robison,Macleod and Rosenheim (1930) stated that theirresults ' set in sharp distinction two mechanismsin calcifying hypertrophic cartilage, (i) the phos-phatase mechanism which produces in the matrixfluid a condition of supersaturation with respectto bone salts, and (2) the inorganic mechanismwhich favours deposition of this salt from super-saturation.'

In the meantime, Martland, Hansman andRobison (1924) had demonstrated the presence ofalkaline phosphatase in blood plasma, and Kay(1929) found raised levels in patients sufferingfrom osteitis deformans (Paget's disease) andosteitis fibrosa cystica (Von Recklinghausen'sdisease). Kay suggested that raised plasmaphosphatase levels might be due to leakage fromthe bones, where the enzyme had been produced inexcess to compensate for the bone lesion, or mightresult from the bending of the weakened boneswhich squeezed out some of the cellular contents.Increased plasma alkaline phosphatase levels werealso found in rickets (Demuth, 1925), cancermetastases in the bones (Coryn, 1934) and injaundice (Roberts, 1930). Later workers haveconfirmed and extended these findings, and theclinical value and limitations of plasma alkalinephosphatase estimations are now fairly wellestablished. Critical reviews of this subject deal-ing fully with work up to the respective dates ofpublication have been presented by Morris andPeden (1937), by Franseen, Simmons and Maclean(I939) and by Sunderman (I942). These papersshould be consulted for a more comprehensive listof references.The plasma alkaline phosphatase is increased in

a very large number of bone diseases, and attentionhas been concentrated on the elucidation of thecommon factors leading to this increase.

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Kay's hypothesis to account for enhancedplasma phosphatase values in bone disease has beenextended by Bodansky and Jaffe (1934). Theysuggest that the level of alkaline phosphatase in theplasma is a reflection of bone cell activity, and thatone of the factors controlling this activity may bedeveloped in the process of normal bone forma-tion. Thus, in active rickets, normal bone forma-tion does not take place, the normal inhibitoryfactor will not appear or will only appear in in-adequate amount, and the increased cellularactivity will be paralleled by an increased plasmaphosphatase level. On treatment, normal bonebegins to form, the normal controls come into play,the cellular activity is controlled at progressivelylower levels and the plasma alkaline phosphataselevel falls. The nature of these controlling factorsand their mode of operation is still obscure.

Franseen, et al. (I939) have classified the groupsof bone lesions in which raised alkaline phos-phatase values are found as follows: (i) abnormalor neoplastic proliferation of bone; (2) frustratedattempts at osteogenesis with the production ofosteoid tissue; and (3) reparative processes ac-companying or following inflammatory, traumaticor neoplastic destruction of the architecture orcontinuity of bone.Thus raised plasma alkaline phosphatase levels,

so far as bone disease is concerned, are invariablyassociated witli osteoblastic activity. In cancerwith metastases in the bones, X-ray examinationmay show the lesion to be purely destructive,nevertheless histological examination invariablyshows some attempt at repair. The plasmaalkaline phosphatase level will, therefore, dependon the nature and extent of the lesion. Wherethere is a single lesion of the type mentioned theplasma enzyme content may not be raised, butwith many lesions an enhanced value is alwaysfound. Where osteoplastic lesions occur, ex-tremely high values have been recorded; whilein conditions such as myelomatosis where thelesion is purely destructive as seen by histologicalexamination, the plasma alkaline phosphatase isnormal or at most only slightly raised.Although we are not concerned here with

jaundice, it should be mentioned in passing thatthe high blood alkaline phosphatase values foundin this condition are probably due to absorptioninto the blood stream of bile which is a rich sourceof this enzyme (Armstrong, King and Harris,I934).

Further reference to alkaline phosphatase ismade in a later section.

Normal Values for Alkaline Phosphatasein PlasmaMethods for the estimation of alkaline phos-

phatase depend on the estimation of either (i) theamount of inorganic phosphate liberated by theenzyme from sodium 3-glycero phosphate (Jennerand Kay, I932) (Bodansky, 1933) or (2) theamount of phenol liberated from phenyl phosphate(King and Armstrong, 1934). In each case, thehydrolysis is allowed to proceed at 37° for a statedtime at a stated pH and the results expressed inarbitrary units. As a consequence, the normalvalues will depend on the method employed. Forthree of the methods which have been mostcommonly employed the normal values are givenas Bodansky: 1-4, Jenner and Kay: 3-8 andKing and Armstrong: 3-13. All values areexpressed as units per Ioo ml.

It is not easy to convert the value for onemethod to that for another by means of a factor,because of the differing behaviour of the enzymeunder the various conditions, and each publishedresult has to be considered in terms of the normalfinding for the method employed. As a roughyardstick, however, the King and Armstrong andthe Jenner and Kay units are approximately equaland values obtained by these methods are about2.5 times the corresponding Bodansky value.

Acid PhosphataseOur awareness of the clinical importance of

acid phosphatase determinations has been builtmainly on the valuable work of Kurtscher and hiscolleagues in Germany and the two Americanschools; those of Gutman and of Huggins.

Studying the source of the enzyme whichDemuth (I925) had found to be present in humanurine, Kurtscher and Wolbergs (I935) showed thepresence of large amounts of acid phosphatase inprostatic tissue and made a careful study of itsproperties.

In a series of publications from 1936 onwards,the Gutmans reported investigations which con-firmed and extended Kurtscher's observations, andrecorded important advances in our knowledge ofprostatic phosphatase. The concentration of theenzyme in the human prostate gland is between500 and 2,500 units per gm. ofwet tissue, and in theseminal fluid it is present in concentrations varyingfrom 700 to 3,700 units per ml. It is absent fromor only present in very small amount beforepuberty, but it can be produced precociously inthe immature Rhesus monkey by injection oftestosterone propionate.Gutman and Gutman (1938) noted that this

phosphatase was also present at the site of bonemetastases secondary to prostatic carcinoma andthat the plasma enzyme level was raised, oftenmarkedly, in the serum of patients suffering frommetastasizing prostatic carcinoma. This observa-tion has proved to be one of the most fruitful of

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our time, and a considerable number of publica-tions have testified to its clinical importance.Gomori (1939, I941) has developed histological

techniques for the demonstration of the phos-phatases, and has shown that acid phosphataseoccurs in the cells of the prostatic epithelium whereit is apparently produced.

Using Gomori's technique, and also followingplasma acid and alkaline phosphatase levels inprostatic cancer, Huggins, Stevens and Hodges(194I) concluded that' prostatic carcinoma is oftencomposed of epithelial cells of a mature type,which in common with all other types of adultprostatic epithelium is responsive to depression ofthe levels of androgenic hormones in the organism.'The significance of these observations will be

discussed in a subsequent section.

Normal Values for Acid PhosphataseMost of the acid phosphatase determinations

given in the literature have been determined bymethods which are modifications of the King andArmstrong procedure, in which a buffer solutionof pH 5 is used, instead of that of pH io used inthe alkaline phosphatase procedure. Unfor-tunately, however, all workers have not used thesame hydrolysis time. The acid phosphatase levelof normal plasma is so low, and consequently theamount of phenol liberated is so small, that theGutmans have used hydrolysis periods of three tofive hours and calculated the enzyme value bydividing by the number of hours hydrolysis.

Such long periods of hydrolysis are, however,very inconvenient, especially in routine work, andconsequently some workers have made use ofshorter incubation times, for example, one hour.Since, however, there is not a straight line re-lationship between the time of hydrolysis and theamount of phenol liberated, the values for a onehour period will be greater than those obtainedwhen a longer time is used and the one hourfigure obtained by calculation. Huggins andHodges (1941) have used a 30 minute period ofhydrolysis. .In passing it may be mentioned thatthe objection to the one hour method, namelythe difficulty of measuring the small amount ofphenol liberated, may be met to some extent byusing a good photoelectric colorimeter (or aPulfrich photometer), and taking precautions tokeep the blank contributed by the reagents downto a minimum.The normal values thus depend on the standard

time adopted, and are given as follows:-Time of Units per

incubation 1oo ml.3-5 hours up to 3 Sullivan, Gutman and Gutman

(1942).I , I-5 Watkinson, Delory, King and

Haddow (I944).--5 Herbert (1946).

30 minutes 3.25 ± 1.37 Huggins and Hodges (I94I).

Effect of Castration and the Administra-tion of Androgens and Oestrogens on thePhosphatases in Prostatic CarcinomaHuggins and Hodges (1941) studied the effect

of castration and the administration of androgensand oestrogens on the plasma phosphatases inpatients with metastatic carcinoma of the prostate.They chose patients who showed a markedlyraised serum acid phosphatase, and found thatthe acid phosphatase level fell rapidly after bilateralorchidectomy, usually reaching or approachingnormal values within I2 days. The alkalinephosphatase on the other hand rose at first butlater fell. Similar results were found afteradministration of stilboestrol. The fall in theacid phosphatase level was usually accompanied byclinical improvement. This aspect has been re-viewed by Haddow (I943).

After administration of testosterone propionate,however, the serum acid phosphatase level rose.When the injections were stopped there was a fallto the pre-injection level. No changes were de-tected in the alkaline phosphatase concentrationduring treatment, but on cessation of the ad-ministration it tended to rise.The effect of castration was confirmed by

Sullivan, Gutman and Gutman (I942) who madea careful study of 33 patients, 3I of whom hadpre-operative serum acid phosphatase levels rang-ing from 4.2 to 520 units per 0oo ml. In everycase except one (one of two patients who had beencastrated by a different technique in which thetunica was left in situ after removal of the contents)an immediate fall in acid phosphatase took placewhich was usually demonstrable within 24 hours.The serum acid phosphatase continued to fall,the decline being on the average 55 per cent. ofthe pre-operative level on the second, and 64 percent. on the fourth post-operative day. One weekafter castration the mean fall was 70 per cent. ofthe original value and after two weeks 73 per cent.At about the third week there was a slighttransitory rise, but after this time, the declinecontinued until at the end of 2-3 months it reachedan equilibrium value, which was usually 5 unitsor less when the original level was not greater than30 units per Ioo ml. Where the original level wasvery high, however, the equilibrium value wasoften still markedly raised.The effect of castration on the serum alkaline

phosphatase was found by these workers to bemore variable. During the first few days followingcastration, there was either no significant change,or erratic fluctuations below or above the initialvalue. About the second or third week, thealkaline phosphatase concentration usually rose,sometimes to more than twice the pre-operativelevel. Thereafter, the level fell slowly until

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after many months it reached a steady level, whichwas usually nearer normal than the pre-operativevalue.As Huggins and Hodges (1941) point out, these

findings are in keeping with the idea that the twogroups of phosphatase are the result of the activityof two different types of cells, prostatic epitheliumand osteoblasts, the former being controlled, atleast in part, by the action of the androgens presentin the body. Following castration, androgenproduction falls, and consequently the serum acidphosphatase level decreases rapidly. The raisedserum alkaline phosphatase levels, on the otherhand, are due to increased osteoblastic activity ofthe bone and show no consistent early response tocastration. After a latent period, however, furtherincreased osteoblastic activity begins to occur, andthe alkaline phosphatase increases still further.This, as Sullivan, et al. (I942) point out, isassociated with increased osteoblastic healing ofskeletal metastases, often seen as increased densityof X-ray films 2-3 months after operation. As theextra bone formation lessens, the serum alkalinephosphatase level falls. These findings have beenconfirmed in all essentials by many workers, e.g.,Kahle, Ogden and Getzoff (I942) and Watkinson,Delory, King and Haddow (I944). The latterworkers also reported one case treated with tri-phenylchlorethylene in which the serum acidphosphatase level rose from 20 units per Ioo ml.to between 40 and 50 at 5 months, after whichit dropped to reach a normal level at about 8months after the beginning of treatment.

Separate Estimation of Enzymes in theAcid Phosphatase GroupAs indicated in the introduction to this article,

there are probably several enzymes in the bloodwhich are estimated by the ordinary acid phos-phatase procedures.Our knowledge of the identity of the various

enzymes is increasing rapidly at the present time,and the following account must therefore be re-garded as subject to considerable change in thenext few years.

It is evident that there are at least two acidphosphatases in the blood other than that comingfrom the prostate gland. One of these is to befound in the red cells, and it is for this reason thathaemolysed blood should not be used for prostaticacid phosphatase estimations by the ordinary pro-cedures. Another non-prostatic enzyme occursnormally in the serum, not only of men, but alsoof women.Methods have, therefore, been devised which

attempt to estimate the prostatic enzymeseparately in the presence of the other acid phos-phatases. Such methods depend on the use of

substances which will inactivate one or other o'the enzymes.

Herbert (I946) has employed incubation with40 per cent. alcohol at room temperature for 30minutes to inactivate the prostatic component andthus to determine it indirectly. Thus, prostaticphosphatase is represented by the difference be-tween the values for the untreated and the alcohol-treated samples. Herbert has also studied amethod which depended on inactivation ofprostatic phosphatase by incubation of the serumalone at 37°. This second method, however,proved not to be entirely specific.Another approach to this question of the

estimation of prostatic, in the presence of other,acid phosphatases has been made possible by theobservation of Abul-Fadl and King (I947) that0.5 per cent. formaldehyde completely inactivatesred cell acid phosphatase and destroys most of thenormal'serum enzyme, but has no effect on theprostatic enzyme.Serum Phosphatase Levels in DiseaseTable i, adapted from Sunderman, indicates

the level of acid and alkaline phosphatase to beexpected in disease. As already mentioned, araised alkaline serum phosphatase value in boneconditions is invariably associated with increasedosteoblastic activity, rather than a specific bonedisease, whereas an increase in the serum acidphosphatase is usually associated with meta-stasizing carcinoma of the prostate. It is not sur-prising, therefore, that all workers have failed todetect any correlation between the concentrationof the two enzymes in the serum in this condition,for, although both the acid and the alkalinephosphatase levels may be raised, each of theenzymes is elaborated by a different type of cell.

It is not so easy, however, to see why, in con-ditions such as Paget's disease, where a markedincrease in alkaline phosphatase occurs, there mayalso be an increase in acid phosphatase. The firsthypothesis to be investigated was that the alkalineenzyme was not completely inactivated at pH 4.9,and that consequently some hydrolysis could takeplace at this pH. Such hydrolysis, although due tothe activity of the alkaline enzyme, would, ofcourse, be recorded as due to a different enzyme,namely acid phosphatase. This was found byGutman, Gutman and Robinson (1940) not to bethe case, a view with which all subsequent in-vestigators agree. Abul-Fadl and King (1947)have suggested that the bones of actual cases ofPaget's disease may contain an acid phosphatasenot present in normal bone, although they did nothave an opportunity of testing this point.

Although all workers have confirmed the Gut-mans' important observation that the serum acid

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June 1948 KING & DELORY : Acid and Alkaline Phosphatases in their Relation to Malignant Disease 303

DISEASE

Prostatic cancer:(a) with bone meta-

stases.(b) without bone

metastases.Other diseases ofpros-state.

Osteitis deformans.

Osteitis fibrosa cystica.Osteogenic sarcoma.Myelomatosis.Other bone tumours.Cancer of organs(other than prostate)with bonemetastases.

Rickets.Osteomalacia.Senile osteoporosis.Osteogenesis imper-fecta.

Jaundice.

PHOSPHATASE

ALKALINE ACID

Normal orslightly raised.Normal.

Normal.

Markedly raised.

Markedly raised.

Raised.Normal.Normal or raised.Normal or raised.

Raised.Raised.Normal.Normal or raised.

Markedly raisedin obstructive,less so in toxic,and normal inhaemolyticjaundice.

Usually markedlyraised.Most frequently nor-mal.Normal.

Normal or slightlyraised.Normal or slightlyraised.

Usually normal.Normal.Usually normal.Usually normal.

May be slightly raised.

phosphatase is most frequently raised in metastaticprostatic carcinoma, there seem to be occasionalapparent exceptions. For this reason, and becausemuch of the work has been carried out quiterecently, the question of serum acid phosphataselevels in disease will be reviewed in some detail.

Table 2 shows the number of cases of prostaticcancer, with and without bone metastases, inwhich various workers have reported raised serumacid phosphatase values. The particular authors'own normal value has been adopted in decidingwhether a given value is raised or not. Thistable also includes, for convenience, results ofanalyses in which attempts were made to dis-tinguish the prostatic from the other acid phos-phatases by means of alcohol and formalin. Theseobservations will be discussed later on.

All workers agree that the serum acid phos-phatase level is raised in most, but not all, cases ofprostatic cancer, and that such rises are morelikely to be found when bone metastases aredemonstrable. The higher the value, the morelikely are bone metastases to be present. Toillustrate this point, among Sullivan's, et al. 130cases with bone metastases, 25 per cent. gaveresults between 5 (upper limit of normal 3) and9.9 units per 0oo ml., 48 per cent. gave higherfigures still, while 4 per cent. gave values morethan I,ooo units per Ioo ml. On the other hand,among their cases without bone metastases, theconcentration was never greater than 4.9 unitsper Ioo ml.

In Table 3, the findings of three groups of

TABLE ISFRUM ACID AND ALKALINEIPHOSPHATASE IN DISEASE.

Adapted from Sunderman (1942).

workers-Sullivan, et al., Herbert, and Abul-Fadl and King have been collated to illustrate thefrequency with which they obtained high valuesin disease other than prostatic cancer. All theworkers do not classify their results in exactly thesame way. For example, Herbert has included 21cases of cancer of organs (other than the prostate)without bone metastases in the general miscel-laneous group. Similarly, the miscellaneous groupof Sullivan, et al., described as including 'avariety of infections, degenerative diseases, meta-bolic disorders, blood dyscrasias, etc.,' may wellinclude kidney conditions classified separately bythe other workers. Nevertheless, the Table givesa fair picture of the distribution of enhancedserum acid phosphatase values.

It is interesting to note that in the three cases inthe general miscellaneous group of Sullivan, et al.,giving raised values, one (a case of Hodgkin'sdisease involving the liver and probably bones)showed a result of 4.2 units per Ioo ml. Thesecond, of uncertain diagnosis, gave a figure of3.2 units per Ioo ml., while the third was a patientwith sickle-cell anaemia in haemolytic crisis. Inthis patient, the serum acid phosphatase levelsrose from 2.7 to 6.9 and then to I4.6 units perioo ml as the red cell count fell. The highfigures here were attributed to liberation of redcell phosphatase as a result of haemolysis in vivo.Among the cases of prostatic cancer without

demonstrable metastases, no results greater than4.9 units per Ioo ml. were recorded.Two of Herbert's cases of benign prostatic

hyperplasia gave abnormal figures for serum acidphosphatase. In one of them, the increase wasvery slight-5.4 (upper limit of normal 5.0) unitsper Ioo ml., while in the other case, three estima-tions, made within four days, gave the followingresults: first day-3.5, second day-8.8, andfourth day-5.2 units per Ioo ml.Employing the alcohol technique to which

reference has already been made, Herbert foundthat the addition of alcohol to sera in the non-prostatic diseases usually led to no significantchange in the serum acid phosphatase concentra-tion, although sometimes it caused a definite rise,and sometimes a slight fall. From 0o2 cases ofnon-prostatic disease, there were only two ex-ceptions to the rule that alcohol treatment doesnot cause a fall of more than one unit in the enzymelevel. All the 14 cases of non-prostatic diseasefound to have total serum acid phosphatase con-centrations greater than 5 units per ioo ml. con-formed to this rule. In five of the cases of prostaticcancer in which bone metastases were not demon-strated, or where there was no radiological ex-amination, a significant fall occurred after alcoholtreatment, despite the fact that the total acid

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304 POST GRADUATE MEDICAL JOURNAL June 1948

TABLE 2

SERUM ACID PHOSPHATASE IN PROSTATIC CARCINOMA.Adapted and extended from Herbert, I946.

All cases Cases with Cases withoutbone metastases. bone metastases.

No. with No. with No. withTotal high Total high Total highNo. values No. values. No. values.

Huggins and Hodges (1941) .. .. .. .. 47 21 25 19 20 IHuggins, Stevens and Hodges (I941) 1.. .. .. 4 7 -Sullivan, Gutman and Gutman (1942) .. .. .. 200 II8 130 II0 70 8Watkinson, Delory, King and Haddow (I945).. I 0 6 7 6 3 0Herger and Sauer (194I) .. .. .. .. 31 22Herger and Sauer (I945) .. .. .. .. - - 59 52Smith and Maclean (I943) .. .. .. .. 10 7 5 3 5 4Woodard and Dean (1I947) .. .. .. .. 127 70 71 5 1 56 I9Herbert (1946):

(a) Total phosphatase .. .. .. .. 87 42 35 29 47 12(b) Alcohol procedure .. .. .. .. 56 32 24 20 26 8

Abul-Fadl and King (1948):(a) Total phosphatase .. .. .. .. 44 28 22 i6 22 12(b) Alcohol procedure .. .. .. .. 31 21 i8 1 5 1 3 6(c) Formalin procedure .. .. .. .. 44 21 22 I6 22 5

phosphatase was within normal limits. On theother hand, in every case where the presence ofmetastases was established, and the serum acidphosphatase content was originally raised, it fellon treatment with alcohol, usually, although notalways, to the normal level.The findings of Abul-Fadl and King agree, in

general, with those of the other workers, althoughthey find a greater proportion of raised values inconditions other than metastasizing prostaticcancer. Some of their figures for these conditionsshow very significant increases over the normal(5 units per ioo ml.), the two highest figures inthe general miscellaneous group being 25 (in acase of myeloid leukaemia) and 24 units per ioo ml.(in a case of bronchopneumonia).

These workers found that their formalin pro-cedure, despite occasional failures, was of clinicalhelp in distinguishing between prostatic cancerand other diseases. In the high figure for broncho-pneumonia quoted above, for example, the valueafter treatment with formalin was only i.8 unitsper ioo ml., thus indicating that the high serumphosphatase value found originally was due toacid phosphatases other than that from theprostate. In the figures given in Table 2 andTable 3 for the formalin procedure, the upperlimit of normal is taken as 4 units per ioo ml.Only seven out of 57 cases in Abul-Fadl andKing's general miscellaneous group gave resultsgreater than 3 units per ioo ml. after treatmentwith formalin; the highest figure (6.6 units perIOO ml.) being found in a case of steatorrhoea withtotal acid phosphatase I2 units and associated

raised serum alkaline phosphatase (48 King-Armstrong units per ioo ml.). Of the seven raisedserum formalin resistant acid phosphatase values,only five were greater than 4.0 units per ioo ml.

In the 22 cases of prostatic cancer with demon-strable metastases i6 (that is all the cases withoriginal high total acid phosphatase) showedserum formalin resistant enzyme greater than 4units per ioo ml.The value of formalin, in distinguishing raised

serum acid phosphatase due to the prostatic en-zyme from those where the enzyme originateselsewhere, has been confirmed independently byone of us (G.E.D.) in a series not yet sufficientlycomprehensive for publication.

Abul-Fadl and King also tried Herbert'salcohol procedure in a large number of their cases.Their findings showed that falls in serum acidphosphatase concentration after alcohol treatmentoccurred more frequently, and to a greater degreein prostatic cancer than in other conditions. Thefall in these other conditions was, however, veryoften much greater than i.o units per ioo ml. (thefigure given by Herbert) and occasionally greaterthan 2.0 units per ioo ml.

In the I5 cases of untreated prostatic cancerwith bone metastases studied by the alcoholtechnique, and where the serum total acid phos-phatase level was raised, the fall on alcohol treat-ment was greater than 7 units per ioo ml. in 14cases, while in the other case it was I.4 units perI00 ml. Among the cases of this condition, whenthe serum acid phosphatase was not originallyraised, the fall was 3.8 and i.i respectively in two

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June I948 KING & DELORY Acid and Alkaline Phosphatases in their Relation to Malignant Disease 305

TABLE 3

SERUM ACID PHOSPHATASE IN DISEASES OTHER THAN PROSTATIC CANCER.

SULLIVAN, et al. (1942) HERBERT (1946) ABUL-FADL AND KING(I1948)

No. of No. with No. of No. with No. of No. withcases high values cases high values cases high values

Normal subjects .. .. .. 30 0 * * - * *Non-malignant prostatic disease. .. 85 0 95 2 23 (23) I4 I0 (7) 8Paget's disease .. .. .. .. 96 20 22 2 I5 (I5) II 6 (I) 3Hyperparathyroidism .. .. 9 3 3 IMiscellaneous bone diseases .. .. 72 4 23 INephritis i.. .. .. .. .. - - 6 2 I6 (I6) I5 5 (2) 4Obstructive jaundice .. .. - 4 I I8 (I8) I8 I3 (8) IoOther liver disease .. .. . - I9 7 20 (20) I9 8 (3) 9Neoplasia other than of prostate:"(a) with skeletal metastases .. 99 20 - -

(b) with liver involvement .. 46 I - - 24 (24) i6 I4 (0) 5(c) no definite bone or liver metastases 64 4 ,(d) primary bone tumours . . 31 33

Miscellaneous general diseases .. .. 53 3 66 0 57 (57) 38 I7 (5) IO

*Figures in brackets show the number of cases investigated bv the formalin method and the number giving valuesgreater than 4 units per I00 ml.

Figures in italics show the number of cases investigated by the alcohol method and the number where the fall aftertreatment was greater than i unit per IOO ml.

of the six cases studied, and less than I.O in theothers.

Clinical Value of Phosphatase Determina-tions(a) Alkaline phosphataseSo far as the value of serum alkaline phosphatase

estimations in the differential diagnosis. QfLeo-plasia is concerned, little can bie added to reviewsalready published (e.g., Morris and Peden, 1937,and Sunderman, I942). The following is a briefsummary of the position. In malignant disease,where there is no involvement of bone or liver,the serum alkaline phosphatase is normal, butwhere bone metastases are present, raised valuesare usually recorded. Such raised values areassociated with increased osteoblastic activity andare, therefore, found in so many bone conditionsthat, by itself, alkaline phosphatase estimation isof little value in differential diagnosis, although itmay be of help when considered in relation toclinical, radiological and other biochemical find-ings. It is claimed that it may be of value in thediagnosis of multiple myelomata in the earlystages, since the serum alkaline phosphatase isnormal, or only slightly raised in this condition incontra-distinction to Paget's and Von Reckling-hausen's disease where very high values are oftenfound.

(b) Acid phosphataseIn assessing the value of acid phosphatase

estimations in prostatic cancer, two things must

be established. Firstly, the constancy with whichraised values are encountered in prostatic cancer,and secondly, the frequency with which suchvalues are found in other conditions. These twoquestions will be considered separately. It isgenerally agreed that raised serum acid phos-.phatase values are found in m-isb`Wifitall, casesof carcinoma of the prostate with bone metastases.As Sullivan, et al. point out, excluding thepossibility of errors in diagnosis or in the chemicalestimation, there are three other possible causesof failure which have to be considered, (i) theextent of the invasion of blood and lymph channelsin a particular case may not be sufficiently great toallow large amounts of the prostatic enzyme topass into the blood stream, (2) the neoplasticprostate tissue, in some patients, may producesmall quantities of acid phosphatase and (3) theserum enzyme level may have been lowered bytreatment.

Sullivan found that some (but not all) of thecases in which normal serum acid phosphatasevalues were found were in patients with markedlyanaplastic tumours, and in one case, the tumouritself was found to show very little enzyme activity.Herbert also found the tumour to be anaplasticin one of her cases with bone metastases, inwhich a normal serum acid phosphatase value wasobtained.

So far as the serum acid phosphatase concentra-tion in diseases other than prostatic cancer withmetastases is concerned, the work of Abul-Fadland King suggests that marked increases may be

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306 POST GRADUATE MEDICAL JOURNAL June I948

found more frequently than has been thoughthitherto. Such increases are, however, often dueto an acid phosphatase'which may be distinguishedfrom prostatic phosphatase by the use of sub-stances which inactiyate the various enzymes ina different degree. The stimulus which the intro-duction of alcohol and formalin has given will,undoubtedly, lead to further advances in ourknowledge of this subject. Apart from inactivationexperiments, clinical findings may also be of valuein deciding whether an increased serum acidphosphatase concentration is from a non-prostaticsource.

All workers are agreed with the statements ofSullivan, et al. on the place of serum acid phos-phatase estimations in the diagnosis of metastasizingprostatic cancer. The main value is in thosepatients suspected on clinical grounds, and fromX-ray evidence, of metastasizing prostatic cancer,and where confirmation is sought. When theX-ray findings are inconclusive, the diagnosis maybe established by the phosphatase estimation, andit is often possible to anticipate the X-ray demon-stration of bone metastases by several months.Conversely, where the presence of metastases isdefinitely established, evidence may be obtainedfor or against the possibility that the primarytumour is in the prostate where this is in doubt.The estimation is also helpful in following thecourse of therapy.

(c) Acid and alkaline phosphataseTable i, already mentioned, indicates the

typical findings for serum acid and alkalinephosphatase in various conditions.The simultaneous estimation has proved of

especial value in distinguishing prostatic cancerwith osteoplastic bone metastases from' localizedPaget's disease. In Paget's disease the serum

alkaline phosphatase is markedly increased whilethe acid phosphatase is normal or only slightlyincreased, except when there is such extensiveinvolvement that both phosphatases becomefurther increased, in which case Paget's disease iseasily recognized by its very 'high alkalinephosphatase values.

BIBLIOGRAPHY...ABUL-FADL, M. A. M., and KING, E. J. (1947), Biochem. J.,

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Canad. Med. Ass. Y., 31, 14.BODANSKY, A. (I933), J. Biol. Chem., 101, 93.BODANSKY, A., andJAFFE, H. L. (1934), Arch. Int. Med., 54, 88.CORYN, G. (J934), J. de Chir. et Ann. de la Soc. Belge de Chir..

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80, I 28.HUGGINS, C., and HODGES, C.V. (194I), Cancer Res., 1, 293.HUGGINS, C., STEVENS, R. E., and HODGES, C. V. (1941),

Arch. Strg., 43, 409.JENNER, H. D., and KAY, H. D. (I932), Brit. -. Exp. Path., 13, 22.KAHLE, P. J., OGDEN, H. D., and GETZOFF, P. L. (1942),1 . Urol., 48, 83.KAY, H. D. (1929), Brit. j. Exp. Path., 10, 253.KAY, H. D. (i932), Physiol. Rev., 12, 384.KING, E. J., and ARMSTRONG, A. R;. (193.4), Canad. Med. Ass.

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(I1942), Y. Urol., 48, 426.SUNDERMAN, F. W. (I942), Am. 7. Clin. Path., 12, 404.<WATKINSON. J. M., DELORY, G. E., KING, E. J., and HAD-f DOW, A. (I944), Brit. Med..7., 2, 492.WOODARD, H. Q., and DEAN, A. L. (I947),.7. Urol., 57, IS8.

A Clinic for the diagnosis and treatment of Internal Diseases (except Mental or Infectious Diseases). TheClinic is provided with a staff of doctors, technicians and nurses.

The surroundings are beautiful. The climate is mild. There is central heating throughout. The annualrainfall is 30.5 inches, that is, less than the average for England.

The Fees are inclusive and vary according to the room occupied.

For particulars apply to THE SECRETARY, Ruthin Castle, North Wales.Telegrams: Castle, Ruthin. Telephone: Ruthin 66

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