|Year : 2015 | Volume
| Issue : 1 | Page : 29-34
Evaluation of serum lactate dehydrogenase in oral squamous cell carcinoma, oral leukoplakia and oral submucous fibrosis
Atul Rathore1, Anil Kumar Nagarajappa2, Sreedevi2
1 Department of Oral Medicine and Radiology, Index Institute of Dental Science, Indore, Madhya Pradesh, India
2 Department of Oral Medicine and Radiology, Hitkarini Dental College and Hospital, Jabalpur, Madhya Pradesh, India
|Date of Submission||19-Feb-2015|
|Date of Acceptance||03-Jul-2015|
|Date of Web Publication||12-Oct-2015|
Department of Oral Medicine and Radiology, Index Institute of Dental Science, Indore - 452 009, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Enzyme lactate dehydrogenase (LDH) is found in cells of almost all body tissues. Lactate dehydrogenase activity in serum increases as a marker of cellular necrosis. Serum LDH levels have been used as an adjunct biochemical marker in diagnosis in various pre-cancer and cancers. Aims and Objectives: To evaluate role of LDH as a biochemical parameter in the diagnosis of oral squamous cell carcinoma (OSCC), oral leukoplakia (OL) and oral submucous fibrosis (OSMF), to assess the levels of serum LDH in OSCC, OL and OSMF and to compare the same with normal individuals. Materials and Methods: A total of 120 patients were recruited for the study including 30 patients of OSCC, 30 patients of OL, 30 patients of OSMF and 30 normal controls. All were divided into age groups (20-60 years) irrespective of sex. From five milliliters of blood drawn under aseptic conditions, the serum was separated. The sample was subjected to biochemical analysis for quantitative estimation of serum LDH by a semi auto-analyzer. Results: It was observed that serum LDH activity was significantly (P < 0.05) increased in patients with OSCC, OL and OSMF. Conclusion: Serum LDH estimation can prove to be a valuable tool as a biochemical marker as it is a simple, non-invasive procedure and is easily accepted by the patient.
Keywords: Lactate dehydrogenase, leukoplakia, oral squamous cell carcinoma, oral sub-mucous fibrosis, serum
|How to cite this article:|
Rathore A, Nagarajappa AK, Sreedevi. Evaluation of serum lactate dehydrogenase in oral squamous cell carcinoma, oral leukoplakia and oral submucous fibrosis. J Indian Acad Oral Med Radiol 2015;27:29-34
|How to cite this URL:|
Rathore A, Nagarajappa AK, Sreedevi. Evaluation of serum lactate dehydrogenase in oral squamous cell carcinoma, oral leukoplakia and oral submucous fibrosis. J Indian Acad Oral Med Radiol [serial online] 2015 [cited 2020 May 25];27:29-34. Available from: http://www.jiaomr.in/text.asp?2015/27/1/29/167071
| Introduction|| |
Cancer is one of the leading causes of adult deaths worldwide. Oral cancer is a serious problem in many countries. It accounts for significant mortality and is also responsible for extensive disfigurement, loss of function, behavioral changes, financial and sociologic hardship.  In India the incidence of oral cancer is about three to seven times more common as compared to developed countries. India tops in prevalence of oral cancer in the world and oral cancer remains the commonest cancer among male population. Oral cancer is the third-most common cancer in India after cervical and breast cancer among women. 
Classic features may include a white lesion, red lesion, mixed red/white lesion, lump, ulcer with fissuring or raised exophytic margins, pain or numbness, abnormal blood vessels supplying a lump, loose tooth, unhealing extraction socket, induration, fixation of a lesion to deeper tissues, lymph node enlargement, dysphagia and weight loss.  Premalignant lesions and conditions such as leukoplakia, erythroplakia, oral sub-mucous fibrosis (OSMF), and lichen planus are very common in the general population. These lesions are precursors of oral cancer. The role of dentist is very important in early detection and management of precancer.
Recently, the role of tumor markers in management of head and neck cancer has received increased attention. Among all the body fluids, blood has been the media of choice for the study of the biochemical markers. Increased serum lactate dehydrogenase (LDH) activity is considered as a marker of cellular necrosis and serum LDH levels have been used as a biochemical marker in diagnosis in various cancers such as oral, laryngeal and breast cancer. Studies have also suggested that increased levels of LDH in serum are seen in patients with oral leukoplakia (OL), OSMF and oral squamous cell carcinoma (OSCC). ,, Lactate dehydrogenase activity is mainly due to genomic changes during malignant transformation. Increased LDH levels are due to increased mitotic index and more lactic acid production by tumor cells due to breakdown of glycoprotein. Value of LDH elevates in OSCC and potentially malignant disorders; this finding can be used for benefit of the patient in predicting prognosis. ,,,,,,,
| Materials and Methods|| |
This study was approved by the ethical committee and review board of the concerned institution. A total of 120 patients were recruited for the study viz, 30 patients of OSCC, 30 patients of OL, 30 patients of OSMF and 30 normal subjects as controls. Thirty OSCC patients were recruited from the Oncology Department of Netaji Subhash Chandra Bose Medical College and Hospital, Jabalpur, Madhya Pradesh (M.P.). All 30 patients were histopathologically diagnosed as OSCC. Thirty patients of OSMF, 30 patients of OL and 30 normal subjects were recruited from the out patients attending Hitkarini Dental College and Hospital, Jabalpur, M.P. The 30 OSMF patients and 30 OL patients were clinically examined and diagnosed. Later they were confirmed histopathologically following punch biopsy at the Department of Oral Medicine and Radiology and Department of Oral Pathology, Hitkarini Dental College and Hospital, Jabalpur, M.P. Duly signed informed consent was obtained from every individual participating in the study.
- Patient's willingness to participate.
- Subjects in the age group of 20-60 years irrespective of sex.
- Histopathologically diagnosed patients of OSCC, OL and OSMF.
- Patient not willing for participation in the study.
- Patients undergoing chemotherapy, radiotherapy or any surgical procedure for OSCC. 
- Patients with a history of heart failure (myocardial infarction) within past 2 weeks. 
- Patient taking procainamides and other drugs used to treat arrhythmia, pulmonary infarction and stroke. 
- Patients suffering from hepatitis, hypothyroidism, anemia (hemolytic or pernicious anemia), lung disease, liver disease, kidney disease, pancreatitis, muscle trauma, and muscular dystrophy. ,,
- Patients with history of consumption of aspirin, narcotics or alcohol, and recent anesthesia. 
Collection of blood sample
Collection of serum sample was done by the method recommended by National Institute of Health (NIH - Bethesda, MD, USA, 2009). Five milliliters of blood was drawn from the peripheral veins (Brachial or Anti-cubital Vein) under aseptic conditions. Collected blood sample was kept in test tubes at room temperature for 30-60 minutes to allow sedimentation of cellular fraction of blood. Later, the sedimented blood sample was centrifuged at 3000 rpm for 10-15 minutes. Supernatant serum was separated out with the help of a micro-pipette. The quantification of LDH procedure was carried out at the General Pathology Department, Jabalpur Hospital and Research Centre, Jabalpur on the same day that the blood was drawn.
Biochemical analysis was carried out with a semi-automated machine (Biochemistry Analyzer Prietest EXP made by Rich Industry Limited, Kolkata, India) and ENZOPAK (UV- Kinetic) reagent kit was used which was manufactured by Reckon Diagnostic Pvt. Ltd., Vadodara, India. The kit contained 1 LDH (Coenzyme) and 2 LDH (Buffered substrate). One tablet of 1 LDH with 1.1 ml of 2 LDH were mixed gently to dissolve their contents. They were used after 5 minutes. It works on the principle that LDH catalyzes the oxidation of lactate to pyruvate accompanied by the simultaneous reduction of NAD to NADH. LDH activity in serum is proportional to the increase in absorbance due to the reduction of NAD.
Now 1 ml of working reagent was mixed with 0.05 ml of the serum sample. Reading of first absorbance of the test was noted exactly at 1 minute and thereafter at 30, 60 and 90 seconds at 340 nm of light. Determination of mean change in absorbance per minute and calculation of test results in the semi-automated biochemistry analyzer was done and the results were obtained.
| Results|| |
The data obtained was analyzed using the SPSS software 18 for windows. Appropriate univariate and bivariate analysis were carried out using the Student 't' test for the continuous variable (age) and two-tailed Fisher exact test or chi-square (χ2 ) test for categorical variables. The comparisons of mean LDH levels between four groups were done using ANOVA followed by Bonferroni post-hoc test for multiple comparisons.
Age and sex-wise distribution of study groups and controls
In general, males were more commonly affected in all three study groups when compared with controls. Oral squamous cell carcinoma was most commonly seen between 4 th and 6 th decades, OL between 3 rd and 5 th decades and OSMF between 2 nd and 4 th decades.
Sex-wise comparison of LDH levels between study population and controls
In the control group subjects, the mean value of LDH was 162.44 IU/L ± 37.05 for males, 146.70 ± 18.80 IU/L for females and total of 161.39 ± 36.14 IU/L. In the OSCC subjects mean value of LDH was 323.18 IU/L ± 49.49 for males, 327.04 ± 34.16 IU/L for females and total of 323.83 ± 46.80 IU/L. In the OL subjects mean value of LDH was 277.91 ± 33.34 IU/L for males and total of 277.91 IU/L ± 33.34. In the OSMF subjects mean value of LDH was 247.57 ± 47.58 IU/L for males, 263.40 ± 10.74 IU/L for females and total of 249.68 ± 44.65 IU/L [Table 1] and [Graph 1 [Additional file 1] ].
|Table 1: Sex-wise comparison of LDH levels between study population and controls|
Click here to view
Inter-group comparison for mean value of LDH levels for male subjects in OSCC was significantly higher than control, OL and OSMF groups (P < 0.0001). The mean value of LDH levels in male subjects of OL and OSMF were significantly higher when compared to mean LDH levels of control group subjects. When value of LDH levels of male subjects of OL group were compared with male subjects of OSMF group, mean LDH levels of OL group was significantly increased (P < 0.01). Similarly mean value of LDH levels for female subjects between OSCC group subjects and control and OSMF group subjects showed significantly very high levels of LDH (P < 0.0001). Mean LDH levels in OSMF subjects were also higher from control group (P < 0.0001). The OL group did not have any female subjects.
Overall comparison of mean LDH levels
Mean LDH level in control group, OSCC group, OL group and OSMF group subjects was 161.39 ± 36.14 IU/L, 323.83 ± 46.80 IU/L, 277.91 ± 33.34 IU/L and 249.68 ± 44.65 IU/L, respectively [Table 2] and [Table 3], and [Graph 2 [Additional file 2] ]. ANOVA results showed a significant F ratio (F = 85.046; P < 0.0001) and individual group comparison using Bonferroni post hoc tests showed a significantly very high mean LDH levels with OSCC subjects and very low levels in controls. Mean LDH levels of OSCC subjects were significantly higher than OL and OSMF group subjects. Mean levels of LDH of OL and OSMF group subjects were also found significantly different. Results clearly suggest that mean levels of LDH were significantly higher in OL and OSMF group subjects compared to the control subjects.
| Discussion|| |
Oral cancer often presents a clinical diagnostic challenge to the dental practitioner, particularly in its early stage of development. Typically, they tend to be preceded by a premalignant state for a long time. , It is believed that the etiology is multi-factorial and the process is multiple stepwise one. The role of carcinogens such as tobacco and alcohol has been well established.  Tumor markers present in serum, tissue and other body fluids during neoplastic process are of clinical value in the management of patients with various body cancers.  One of the key enzymes involved in glycolysis, the muscle isoform of lactate dehydrogenase is overexpressed by metastatic cancer cells and is linked to the vitality of tumors in hypoxia.
Lactate dehydrogenase is a hydrogen transfer enzyme and is involved in the final step in the metabolic chain of anerobic glycolysis. Lactate dehydrogenase catalyzes the oxidation of L-lactate to pyruvate with Nicotinamide-Adenine Dinucleotide (NAD + ) as the hydrogen acceptor. The enzyme is composed of four peptide chains of two types: M (Muscle) and H (Heart), each under separate genetic control. Lactate dehydrogenase, a cytoplasmic enzyme is present essentially in all major organ systems. The extracellular appearance of LDH is used to detect cell damage or cell death.
Results of our study suggested that males were more commonly affected than females in all groups. Mean age of occurrence in OSCC group was highest when compared with OL, OSMF and control group. Mean age in OL group was higher than OSMF and control. Similar observations were made in studies conducted by Cunmigaiper et al. (1998), Narang et al. (2001) and Sciubba (1995). ,, Individual group comparison using Bonferroni post-hoc tests showed a significantly very high mean LDH levels with OSCC subjects and very low levels in controls. Mean LDH levels of OSCC subjects were significantly higher than OL and OSMF group subjects. These findings are supported by the studies conducted by other investigators. ,,,,, Mean levels of LDH of OL and OSMF group subjects were also found significantly different. Results clearly suggest that mean levels of LDH were significantly higher in OL and OSMF group subjects compared to control subjects. Similar observations were made in studies conducted by various other investigators. ,,, Significant elevated mean LDH levels were found in serum of patients indulging in various kinds of adverse habits i.e., betel nut , and smoking. 
Joshi et al. (2012) found increased serum and salivary LDH levels in all cases in OL and OSCC groups in comparison with the control group, but the increase in LDH levels was less in saliva as compared to serum in group II OL patients. The increase in LDH levels was consistent in saliva and serum of OSCC patients.  Shklar (1966) conducted a study on epidermoid carcinoma of oral mucosa which showed a notable increase in LDH activity.  Masahiro et al. (1971) correlated clinical and experimental activity of serum LDH and its isoenzymes in oral cancer and noted increased levels.  Ninomiya et al. (1985) stated that neoplastic cells showed morphologic and enzymatic changes indicating incomplete cellular destruction; dilatation of capillary vessels was also found. LDH isozyme pattern displayed a high level of LDH 5 in the non-treated OSCC, and following cryosurgery, it decreased and revealed an approximately normal LDH 5 pattern.  Gorogh et al. (1990) studied serum LDH isoenzymes in OSCC. They concluded that the percentage distribution of serum LDH isoenzymes may represent a useful parameter of disease activity in patients with OSCC.  Dreyfuss et al. (1992) in their study found that LDH and carcino-embryonic antigen (CEA) elevations correlated primarily with the presence of distant metastases.  Mody et al. (1994) found that there was a significant correlation between the degree of differentiation of OSCC and serum LDH.  Liaw et al. (1997) estimated serum LDH values in patients with nasopharyngeal carcinoma. The results showed higher serum LDH values in patients with metastatic disease. They concluded that serum LDH levels correlate with the clinical responsiveness to systemic chemotherapy.  Narang et al. (2001) found that of all the three parameters they studied which were raised irrespective of the site and the character of the tumor, only LDH was significantly raised in the metastatic group compared to the non-metastatic group.  Hong et al. (2010) in their study observed reactivity of Hypoxia-induced Factor 1 a (HIF-1a), PDK 1 (pyruvate dehydrogenase kinase 1) and LDH 5 in 29, 32 and 54 patients, respectively, and found that the expression levels of the three biomarkers were significantly correlated.  Rajendran (1994) confirmed a positive relation between OSMF and serum LDH isoenzyme pattern.  Anuradha et al. (1998) in their study found that the activity of LDH in the serum of OSMF patients was significantly higher than the normal patients.  Kamath et al. (2013) in their study found that tissue breakdown releases LDH; and therefore, LDH can be measured as a surrogate for tissue breakdown, e.g., hemolysis. Elevated levels were seen in OSMF patients indicating evidence of tissue breakdown.  The results of our study suggest that elevation of LDH above baseline is a specific marker for OSCC, OL and OSMF.
| Conclusion|| |
Based on our study results it can be concluded that the activities of LDH enzyme was significantly increased in potentially malignant disorders (like OL, OSMF) and OSCC patients. Therefore, quantification of serum LDH can be used as a biochemical marker, as it is simple and easily accepted by the patient. An attempt should be made to integrate the simultaneous testing of different serum molecular markers in order to raise the possibility of an accurate diagnosis by simply using micro- and nano-electrical-mechanical systems biosensors.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Wood NK, Goaz PW. Differential Diagnosis of Oral and Maxillofacial Lesions. 5 th
ed. St. Louis, Missouri: Elsevier; 2006. p. 587.
Khan Z. An overview of oral cancer in indian subcontinent and recommendations to decrease its incidence. p. 1-29. Available from: http://www.webmedcentral.com/article_view/3626. [Last accessed on 2015 Aug 06].
Scully C, Bagan JV, Hopper C, Epstein JB. Oral cancer: Current and future diagnostic techniques. Am J Dent 2008;21:199-209.
Joshi PS, Chougule M, Dudanakar M, Golgire S. Comparison between salivary and serum lactate dehydrogenase levels in patients with oral leukoplakia and oral squamous cell carcinoma - A pilot study. Int J Oral Maxillofac Pathol 2012;3:07-12.
Anuradha CD, Devi CS. Studies on enzymes of clinical significance in oral sub mucous fibrosis. J Clin Biochem Nutr 1998;24:45-52.
Kamath VV, Satelur K, Komali Y. Biochemical markers in oral sub mucous fibrosis: A review and update. Dent Res J (Isfahan) 2013;10:576-84.
T-Tomity I, Takács O. Investigations on the distribution of serum LDH isoenzymes of patients with carcinoma laryngis. Laryngo Rhino Otol (Stuttg) 1979;58:916-9.
Giannoulaki EE, Kalpaxis DL, Tentas C, Fessas P. Lactate dehydrogenase isoenzyme pattern in sera of patients with malignant diseases. Clin Chem 1989;35:396-9.
Shklar G. Enzyme histochemistry of human oral carcinoma. Oral Surg Oral Med Oral Pathol 1966;21:764-9.
Görögh T, Eickbohm JE, Ewers R, Lippert B. Lactate dehydrogenase isoenzymes in squamous cell carcinomas of the oral cavity. J Oral Pathol Med 1990;19:56-9.
Dreyfuss AI, Clark JR, Andersen JW. Lipid-associated sialic acid, squamous cell carcinoma antigen, carcinoembryonic antigen, and lactic dehydrogenase levels as tumor markers in squamous cell carcinoma of the head and neck. Cancer 1992;70:2499-503.
Liaw CC, Wang CH, Huang JS, Kiu MC, Chen JS, Chang HK. Serum lactate dehydrogenase level in patients with nasopharyngeal carcinoma. Acta Oncol 1997;36:159-64.
Hong SH, Roh SY, Ko YH, Won HS, Lee MA, Woo IS, et al
. Prognostic significance of glycolytic metabolic change related to HIF-1alpha in oral squamous cell carcinomas. Korean J Pathol 2010;44:360-9.
Huijgen HJ, Sanders GT, Koster RW, Vreeken J, Bossuyt PM. The clinical value of lactate dehydrogenase in serum: A quantitative review. Eur J Clin Chem Clin Biochem 1997;35:569-79.
Bethes LT, Gold JA. Serum enzymes in bronchogenic carcinoma and other pulmonary diseases. Bethesda, Maryland: P. 64-7. Available from: http://intlxhestjournal.chestpubs.org/. [Last accessed on 2013 Sep 09].
Nagler RM, Lischinsky S, Diamond E, Klein I, Reznick AZ. New insights into salivary lactate dehydrogenase of human subjects. J Lab Clin Med 2001;137:363-9.
Granchi C, Roy S, Giacomelli C, Macchia M, Tuccinardi T, Martinelli A, et al
. Discovery of N-hydroxyindole-based inhibitors of human lactate dehydrogenase isoform A (LDH-A) as starvation agents against cancer cells. J Med Chem 2011;54: 1599-612.
William BM, Bongu NR, Bast M, Bociek RG, Bierman PJ, Vose JM, et al
. The utility of lactate dehydrogenase in the follow up of patients with diffuse large B-cell lymphoma. Rev Bras Hematol Hemoter 2013;35:189-91.
Nair DR, Pruthy R, Pawar U, Chaturvedi P. Oral cancer: Premalignant conditions and screening--An update. J Cancer Res Ther 2012;8(Suppl 1):S57-66.
Macdonald RP, Simpson JR, Nossal E. Serum lactic dehydrogenase; a diagnostic aid in myocardial infarction. JAMA 1957;165:35-40.
Narang AP, Greval RS, Chopra H, Kalra CS. The role of two enzymes (LDH and PHI) and a tumor marker (CEA) in the prognostic evaluation of head and neck malignancy. Indian J Otolaryngol Head Neck Surg 2001;53:76-80.
Sciubba JJ. Oral leukoplakia. Crit Rev Oral Biol Med 1995;6: 147-60.
Masahiro D. Clinical and experimental studies of serum LDH activity and LDH Isoenzymes of patients with oral cancer. The Journal of Kyunshu Dental Society 1971;24:821-46.
Ninomiya T, Mori M. Histologic and histochemical changes in experimental carcinomas following cryosurgery. Int J Oral Surg 1985;14:362-70.
Mody RN, Indurkar AD. Lactate dehydrogenase in the diagnosis of oral squamous cell carcinoma. The Journal of Israel Dental Association 1994;11:34-6.
Schwartz MA, Walsh WS, West M, Zimmerman HJ. Serum enzymes in disease. X. Glycolytic and oxidative enzymes and transaminases in patients with carcinoma of the head, neck, and esophagus. Cancer 1962;15:927-30.
Jeng JH, Ho YS, Chan CP, Wang YJ, Hahn LJ, Lei D, et al
. Areca nut extract up-regulates prostaglandin production, cyclooxygenase-2 mRNA and protein expression of human oral keratinocytes. Carcinogenesis 2000;21:1365-70.
Chiang SL, Jiang SS, Wang YJ, Chiang HC, Chen PH, Tu HP, et al
. Characterization of arecoline-induced effects on cytotoxicity in normal human gingival fibroblasts by global gene expression profiling. Toxicol Sci 2007;100:66-74.
Mahapatra SK, Das S, Dey SK, Roy S. Smoking induced oxidative stress in serum and neutrophil of the university students. Al Ameen J Med Sci 2008;1:20-31.
Rajendran R. Oral sub mucous fibrosis: Etiology, pathogenesis, and future research. Bull World Health Organ 1994;72:985-96.
[Table 1], [Table 2], [Table 3]