CLINICAL PHARMACODYNAMICS Clln. Drug Invest. 11 (2): 108-113.1996 1173-2563/96/0002-0108/$03.00/0

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Lactate Dehydrogenase (LDH) Changes During Chemotherapy Supported by Recombinant Granulocyte Colony-Stimulating Factor (rG-CSF) in Malignant Lymphoma Kohichi Isobe, Kazuo Hatano, Hiroshi Yoshida, Shigeo Yasuda, Kimiichi Uno and Noboru Arimizu Department of Radiology, Chiba University Hospital, Chiba, Japan

Summary Lactate dehydrogenase (LDH) levels sometimes act as a good index of response to the treatment of malignant lymphoma. The cause of increases in LDH levels during chemotherapy with recombinant granulocyte colony-stimulating factor (rG-CSF) is not always clear, i.e. whether or not these increases are because of the disease activity or are a side effect of rG-CSF therapy. In this study we evaluated the changes in LDH levels during chemotherapy supported by rG-CSF in patients with malignant lymphoma. A total of 128 courses of rG-CSF chemo­therapy were administered to 42 patients with malignant lymphoma. 87 (66%) of these treatment courses were associated with abnormalities in LDH levels, white blood cell count (WBC) and/or alkaline phosphatase (ALP) levels. We found significant correlations between the dose of rG-CSF and the frequency of ALP and WBC, but not LDH, abnormalities. Increases in LDH levels during chemo­therapy were more frequently seen in patients who had elevated pretreatment LDH levels. Although increases in LDH levels may be a side effect of rG-CSF therapy, we must be aware of the probability that they may represent the activity of malignant lymphoma, especially in patients with increased pretreatment LDH levels.

The effectiveness of recombinant human granulocyte colony-stimulating factor (rG-CSF) in chemotherapy for malignant disorders such as ovarian cancer, testicular cancer, lung cancer, and malignant lymphoma, has been well established. Employment of rG-CSF allows the use of an in­creased dose intensity of anticancer agents by de­creasing the duration of myelosuppression and pyrexia, and may improve treatment outcome.

creases in lactate dehydrogenase (LDH) and alka­line phosphatase (ALP) levels with elevation of white blood cell counts (WBC) during the course of chemotherapy for non-Hodgkin's lymphoma[ll and testicular cancerPl However, we have seen some cases in which there were increases in LDH levels in the absence of increases in ALP levels and WBC in the course of chemotherapy for malignant lymphoma, a condition in which LDH activity is sometimes an index of response to treatment. The LDH level is one of the most important prognostic factors in patients with malignant lymphoma, and

Adverse effects of rG-CSF therapy, such as minor biochemical abnormalities and bone pain, are rarely reported. Some authors have reported in-

LDH and rG-CSF in Malignant Lymphoma

increases in this parameter during treatment, espe­cially during courses of chemotherapy, can be con­fusing as the cause is not clear - the increase could be related to disease activity or could be a side effect of G-CSF therapy. Therefore, it is important to clarify whether or not the increases in LDH lev­els during treatment represent relapse of malignant lymphoma. This issue is discussed here.

Materials and Methods

Patients

From April 1992 to December 1993, 42 patients with primary or recurrent malignant lymphoma were treated with combination chemotherapy, in conjunction with rG-CSF (Lenograstim®) therapy, and radiation therapy at the Department of Radiol­ogy, Chiba University Hospital.

Patient characteristics are shown in table I. The mean age of the patients at the time of treatment was 58 years, and 20 of the patients were men. 22 patients had primary disease and 20 had recurrent tumours.

Table I. Patient characteristics

No. of patients (%)

Age(y)

Range 18-80

Mean 58

Gender

Male 20(48)

Female 22(52)

Disease status

Primary 22 (52)

Recurrent 20(48)

Disease stage

"" 22(52)

II "IV 20(48)

Histology

Intermediate grade 36(86)

High grade 5(12)

Hodgkin's disease 1 (2)

Pretreatment LDH level

Elevated 16 (38)

Normal 26 (62)

Abbreviation: LDH = lactate dehydrogenase.

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109

Pretreatment evaluations included careful his­tory and physical examination, complete blood counts with biochemistry, liver and kidney func­tion tests, standard posteroanterior and lateral chest x-rays, garium scintigraphs, computed tomo­graphy imaging of the neck, chest, abdomen and pelvis, bilateral bone marrow needle biopsy/ aspiration from the iliac crests, lumbar puncture with cerebrospinal fluid examination, and upper and lower gastrointestinal barium contrast study. Liver biopsy and bipedallymphangiographs were performed on some patients.

All the patients were staged according to the Ann-Arbor classification systemP] 22 had early stage (stage I or II) and 20 had advanced stage (stage III or IV) disease. Histological diagnoses were confirmed by an experienced haematopathol­ogist, and 41 patients with non-Hodgkin's lym­phoma were classified according to the Working Formulation criteria: [4] 36 were classified with in­termediate grade and 5 with high grade histological disease. One patient with Hodgkin's disease was diagnosed as having mixed cellular type disease.

Treatment

Except for those with low grade malignant lym­phoma or with diffuse small cleaved cell lym­phoma with B cell phenotype, patients in our insti­tution are generally treated with a combination of chemotherapy and radiation therapy. Radiation therapy is administered after completion of chemo­therapy.

The following chemotherapy regimens were ad­ministered to patients in the present study: BACOD-E (bleomycinldoxorubicin [adriamycin]/ cyclophosphamide/vincristine/dexamethasone/ etoposide [VP-16])[5] was given to 16 patients; CHOP[6] (cyclophosphamide/doxorubicin [adria­mycin]/vincristine/prednisone) and CHOP-like regimens were given to 20 patients; the remaining 6 patients received other chemotherapy regimens.

Subcutaneous injection of rG-CSF 100 Ilg/body (absolute) was started when the absolute WBC was below 2000/111, and was continued until the WBC reached 10 000/111. In principle, routine laboratory

Clin. Drug Invest, 11 (2) 1996

110

Table II. Patterns of increases in LDH, ALP and WBC during chemotherapy supported by rG-CSF

Courses (%)

None 41 (32)

LDH only 14 (11)

ALP only 22 (17)

WBConly 9(7)

ALP+LDH 5(4)

ALP + WBC 2 (2)

LDH+WBC 20(16)

ALP + LDH + WBC 14 (11)

Total 128

Abbreviations: ALP = alkaline phosphatase; LDH = lactate dehy­drogenase; WBC = white blood cell count.

studies, including complete blood counts and bio­chemistry, were performed at the beginning of the day (before administration of anticancer agents) on day 1 of each course of chemotherapy, 3 times a week during the period of rG-CSF therapy, and if indicated at any other time.

Results

A total of 128 evaluable courses of chemo­therapy with rG-CSF were administered to the 42 patients. The median dose of rG-CSF was 700~g per course (range: 100 to 1600~g); 1 to 5 courses of chemotherapy were administered, with a median of 3 courses. Each chemotherapy regimen was repeated every 3 weeks. Only 411128 treatment courses were not associated with increases in WBC, LDH and ALP levels. Various patterns of

Isobe et al.

abnormalities of these parameters were observed and, even in an individual patient, each course of chemotherapy displayed different patterns of kinetics. The abnormalities observed are listed in table II. The patterns of abnormalities as a function of administered rG-CSF dose are listed in tables III and IV. Although there was no statistically signifi­cant difference between the dose of rG-CSF and the pattern of abnormalities (p = 0.08 by X2 test), there was a clear relationship between the frequency of ALP and WBC abnormalities and increasing doses of rG-CSF (p = 0.007 and 0.05, respectively). We compared patients in whom an increase in LDH level was noted with those whose LDH levels de­creased or remained normal during treatment (table V). There was a significant relationship be­tween the presence of an elevated pretreatment LDH level and an increase in LDH level during rG-CSF therapy (p < 0.01). 15 of 16 (94%) patients who had elevated pretreatment LDH levels had in­creases in their LDH levels during rG-CSF therapy, despite the fact that LDH levels returned to the nor­mal range after administration of chemotherapy.

Among the 14 treatment courses (in 11 patients) associated with an increase in LDH levels only, it was not clear whether these increases indicated tumour relapse or the influence of rG-CSF therapy in 2 patients, one with bone marrow involvement only and the other with persistent bulky cervical lymph nodes. Both of these patients showed pre­treatment LDH increments. In the other 9 patients,

Table III. Number of courses of chemotherapy associated with observed patterns of increases in LDH, ALP and WBC as a function of rG-CSFdose

Pattern of increases Dose of rG-CSF per course (~g)

100-400 (n = 36 courses) 500-800 (n = 53) 900-1600 (n = 39)

None 18 16 7

LDH only 6 5 3

ALP only 4 8 10

WBConly 5 3

ALP+LDH 2 2

ALP + WBC 0 0 3

LDH+WBC 5 9 6

ALP + LDH + WBC 8 5

Abbreviations: ALP = alkaline phosphatase; LDH = lactate dehydrogenase; rG-CSF = recombinant granulocyte colony-stimulating factor; WBC = white blood cell count.

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LDH and rG-CSF in Malignant Lymphoma 111

Table IV. Number of courses of chemotherapy associated with ALP, LDH and WBC increases as a function of rG-CSF dose

Abnormality Dose of rG-CSF per course (l1g) p value

100-400 (n = 36 courses) 500-800 (n = 53) 900-1600 (n = 39)

LDH

Yes 13 24 16

No 23 29 23 0.688

ALP

Yes 6 18 20

No 30 35 19 0.007

WBC

Yes 7 22 17

No 29 31 22 0.051

Abbreviations: ALP = alkaline phosphatase; LDH = lactate dehydrogenase; WBC = white blood celi count.

Table V. Comparison of patients' characteristics as a function of the presence or absence of increased LDH levels during treatment

No. of patients

Gender

Male/female

Age (y)

Range (mean)

Disease status

Primary/recurrent

Disease stage

HI/III-IV

Histology

Intermediate/high

Elevated pretreatment LDH level

Yes/no

a p values were calculated using the X2 test or Student's t-test.

Abbreviations: LDH = lactate dehydrogenase; NS = not significant.

the increase in LDH levels was the result of rG-CSF therapy.

The correlation coefficients of the kinetics of WBC and LDH, and WBC and ALP, were 0.28 and 0.08, respectively. In the 16 patients with elevated pretreatment LDH levels, the respective correla­tion coefficients were 0.27 and 0.29, and in the remaining 26 patients they were 0.44 and -0.05, respectively. There seem to be no conclusive cor­relations among the kinetics of each parameter.

LDH isoenzyme examinations were performed at an appropriate time during 5 treatment courses only. This was because of the difficulty in predict­ing precisely when the increases in LDH and WBC occur (our routine laboratory studies did not in-

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LDH abnormality p value"

yes no

29 13

13/16 7/6 NS

18-80 (58) 38-78 (59) NS

17/12 5/8 NS

14/15 8/5 NS

25/3 11/2 NS

15/14 1/12 0.007

clude LDH isoenzyme evaluation). Our data re­vealed various patterns of LDH isoenzyme incre­ments: normal pattern in 2 treatment courses, LDH2 and LDH3 dominant in 1, and other types in 2. However, we could not reach any conclusions about whether LDH isoenzyme examination can be helpful for differentiating the cause of increase in LDH level.

There was no significant relationship between other adverse effects observed during chemother­apy, such as febrile episodes and mucositis, and the kinetics of ALP, LDH and WBC (data not shown).

Although there was no confirmation, except for laboratory data and routine chest x-rays, another severe complication that might have been related

Clin, Drug Invest, 11 (2) 1996

112

to rG-CSF therapy was interstitial pneumonitis. This occurred in 2 of the patients whose WBC and LDH levels showed marked increases without an increase in ALP levels - one patient with WBC 22 800/J.,l1, LDH 719 lUlL (216 "" 450 lUlL normal range) and ALP 130 lUlL (72 "" 206 lUlL normal range), and the other with WBC l2700/J.,l1, LDH 1278 lUlL, and ALP 187 lUlL. They were success­fully treated with methylprednisolone 1000 mg/day for 3 consecutive days, or infusion of urinastatin 25 OOOU for 2 days.

Discussion

rG-CSF aids in the removal of maturated neu­trophils from bone marrow to peripheral blood flow and stimulates neutrophil growth and matura­tion, causing production of neutrophil ALP. Data from preclinical studies in rats revealed increases in ALP and y-glutamyl transpeptidase, but not LDH, activities in association with rG-CSF admin­istration. [7]

It was concluded that the increase in ALP levels was the result of neutrophil growth and progress in maturation.

A case of a 52-year-old woman with stage III diffuse centroblastic-centrocytic non-Hodgkin's lymphoma who had been treated with M-BACOD (methotrexatelbleomycinldoxorubicin [adriamycin]/ cyclophosphamide/vincristine/dexamethasone) has been reported.D] She experienced increases in LDH levels only during rG-CSF therapy and this closely paralleled increases in peripheral blood leucocyte counts. The authors reported similar in­creases in LDH levels in 15 other patients, but did not reach any significant conclusion.

Examination of LDH isoenzymes revealed a normal pattern and did not provide any further in­formation on their study. However, while isoenzy­mal examination revealed various patterns in our study (although only examined during 5 courses), we also concluded that LDH isoenzyme examina­tion does not provide meaningful information that would allow differentiation between relapse of lymphoma and adverse effects of rG-CSF as the cause of the increase in LDH levels. The increase

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Isobe et a/.

in LDH isoenzymes that is usually observed in patients with malignant lymphoma has an LDH2 and LDH3 dominant pattern. Increases in LDH levels during the rG-CSF injection may be similar to that seen in active malignant lymphoma, since many haematological disorders that induce LDH to increase show LDH2 and LDH3 abnormalities.

Five patients with high-risk testicular cancer treated with combined chemotherapy plus rG-CSF have been reportedJ2] These patients developed ALP elevation with leucocytosis and there was a significant correlation between the two (r = 0.78, P < 0.01). They also developed transient increases in LDH levels, but the relationship between the LDH and WBC kinetics was less close than that between ALP and WBC. It was speculated that LDH was influenced by disease-related LDH in­creases in individual patients, and the authors con­cluded that 'it is important to be aware of these transient changes of ALP and LDH which may be interpreted as an expression of disease activity'.

Although these 2 previous reports[1,2] have noted a close relationship between WBC and ALP and/or LDH kinetics, we could not find any signif­icant correlations between these parameters [r = 0.08 (WBC and ALP) and 0.28 (WBC and LDH), respectively. There must be some individual differ­ence regarding the response to rG-CSF injection; however, we do not know why these differences occurred. There were no comments regarding the dose and duration of rG-CSF in the previous re­portS.[1,2] In our institution, injection of 100 J.,lglbody (absolute) of rG-CSF was started when the absolute WBC was below 2000/J.,l1, and contin­ued until the WBC reached 10 OOO/J.,ll. We found statistically significant correlations between the in­jected dose of rG-CSF and the frequency of ALP and WBC, but not LDH, abnormalities. This sug­gests ALP and WBC kinetics are more susceptible to rG-CSF than LDH.

Increases in LDH levels are usually observed during the second half of each course of chemo­therapy. During this period, leucopenia is usually found and tumour relapse is also likely to occur. When the next course of anticancer agents is ad-

Clln. Drug Invest, 11 (2) 1996

LDH and rG-CSF in Malignant Lymphoma

ministered, LDH derived from the tumour itself decreases in response to chemotherapy. Of course, at that stage rG-CSF injection will have already been discontinued, so LDH affected by rG-CSF re­turns to normal. Therefore, understanding the cause of the increase in LDH levels by only con­sidering biochemical data may be confusing, un­less these increases are seen in the last course of planned chemotherapy. It might be possible to be given some indication regarding relapse or influ­ence of rG-CSF if LDH, ALP and WBC kinetics can be monitored between termination of rG-CSF and the administration of the next course of chemo­therapy. However, this is difficult in a planned course of chemotherapy as treatment delay might decrease the chance of cure.

Patients with elevated pretreatment LDH levels are more likely to have a bulky disease site, and tumour relapses are likely to occur locally in most of these patients. When local disease progression is identified physically or radiologically during the course of chemotherapy with rG-CSF support, the increase in LDH levels may have been derived from the tumour cell itself, but the effect of rG-CSF cannot be excluded, and it is difficult to evaluate patients who only show bone marrow involvement. The only available methods are bone marrow aspi­ration or biopsy, but these are not convincing meth­ods for deciding whether or not the increase in LDH levels is caused by relapse.

We believe that there are no definitive biochem­ical tests to differentiate between increases in LDH levels caused by tumour relapse of malignant lym­phoma and that caused by the influence of rG-CSF therapy. One possible method of differentiation is to monitor tumour markers of malignant lym­phoma, such as soluble interleukin-2 (IL-2) recep-

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113

tor, ~2-microglobulin, thymidine kinase, copper and so on, that may not be affected by rG-CSF therapy.

Often the increase in LDH levels observed in the course of rG-CSF therapy may be a side effect of rG-CSF, and tumour relapse during chemother­apy may be very rare. However, as other investiga­tors have mentioned,[l] we must be aware of the probability that the increase in LDH levels may represent the activity of malignant lymphoma, es­pecially in patients with elevated pretreatment LDH levels.

Acknowledgements

We thank Chugai Co. for their advice on the statistical analysis.

References 1. Maiche AG, Muhonen T, Porkka K. Lactate dehydrogenase

changes during granulocyte colony-stimulating factor treat­ment. Lancet 1992; 340: 853

2. Fossa SO, Poulsen JP, Aaserud A. Alkaline phosphatase and lactate dehydrogenase changes during leucocytosis induced by G-CSF in testicular cancer. Lancet 1992; 340: 1544

3. Lukes RJ, Craver LF, Hall TC, et al. Report of the committee on Hodgkin's disease staging. Cancer Res 1971; 31: 1860-1

4. Sponsored study of classification of Non-Hodgkin's lympho­mas. Summary and description of a working formulation for clinical usage. Cancer 1982; 49: 2112-35

5. ltami J, Nemoto K, Shigeo Y, et al. BACOO-E for the patients with non-Hodgkin's lymphoma (in Japanese). J Jpn Soc Can­cer Ther 1991; 26: 2410-9

6. McKelvey EM, Gottlieb JA, Wilson HE, et al. Hydroxy­daunomycin (adriamycin) combination chemotherapy in ma­lignant lymphoma. Cancer 1976; 38: 1484-93

7. Masuda K, Noguchi N, Sugimoto T, et al. Four week intrave­nous toxicity study of recombinant human G-CSF (rG-CSF) in rats [in Japanese]. Yakuri to Chiryo 1990; Suppl. 18: 2267-98

Correspondence and reprints: Dr Kohichi Isobe, 1-8-1 Inohana, Chuoh-ku, Chiba-shi, Chiba 260, Japan.

Clin. Drug Invest. 11 (2) 1996