|Year : 2021 | Volume
| Issue : 4 | Page : 409-413
Estimation of serum creatine phosphokinase and serum lactate dehydrogenase levels in oral leukoplakia and oral cancers – A clinicopathological study
Harsha Bhayya1, Geetha Paramkusam2, Swetha Kardalkar3, ML Avinash Tejasvi4, Pavani Donempudi5, Namrata Patil6
1 Department of Oral Medicine and Radiology, H.K.D.E.T's Dental college, Hospital and Research Institute, Bidar, Karnataka, India
2 Department of Oral Medicine and Radiology, Hyderabad, Telangana, India
3 Department of Dentistry, Bidar Institute of Medical Sciences, Bidar, Karnataka, India
4 Department of Oral Medicine and Radiology, Kamineni Institute of Dental Sciences, Narketpally, Telangana, India
5 Private Practitioner, Hyderabad, Telangana, India
6 Department of Oral Medicine and Radiology, KLE VK Dental College, Belgaum, Karnataka, India
|Date of Submission||31-Jan-2021|
|Date of Decision||24-May-2021|
|Date of Acceptance||05-Jul-2021|
|Date of Web Publication||27-Dec-2021|
Dr. Harsha Bhayya
Department of Oral Medicine and Radiology, H.K.D.E.T's Dental college, Hospital and Research Institute, Humnabad, Bidar, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aims: Evaluation of total serum creatine phosphokinase and serum lactate dehydrogenase levels as a biochemical parameter in the diagnosis of oral cancer, oral leukoplakia by the case-control method. Settings and Design: A hospital-based, case-control study was conducted at the Department of Oral Medicine, Diagnosis, and Radiology. Materials and Methods: The study included clinically and histopathologically diagnosed oral leukoplakia and oral cancers with 20 patients in each group. The control group consisted of 20 healthy patients without lesions or tobacco-related habits or any systemic diseases. The blood samples were collected from the study and control groups, centrifuged, and serum was analyzed for serum creatine phosphokinase and serum lactate dehydrogenase (CK and LDH) levels using an autoanalyzer. Statistical Analysis: Comparison of three groups with respect to each biochemical parameter was done by one-way ANOVA. Comparison between the groups was done by Tukey's multiple post hoc test. Results: It was found that total serum CK levels were statistically significantly decreased in both oral leukoplakia and oral cancer when compared with that of the control group. Total serum LDH levels were statistically significantly increased in both oral leukoplakia and oral cancer when compared with that of the control group. Conclusion: Although the results of the present study showed increased levels of LDH in both oral leukoplakia and oral cancer, and CK levels statistically decreased but they were within normal limits. Further. studies with a greater number of samples, different grades of epithelial dysplasias, and assessment of individual isoenzymes has to be carried out to evaluate the exact role of CK and LDH in the etiopathogenesis of oral cancer.
Keywords: Creatine phosphokinase, lactate dehydrogenase, oral cancer, oral leukoplakia
|How to cite this article:|
Bhayya H, Paramkusam G, Kardalkar S, Avinash Tejasvi M L, Donempudi P, Patil N. Estimation of serum creatine phosphokinase and serum lactate dehydrogenase levels in oral leukoplakia and oral cancers – A clinicopathological study. J Indian Acad Oral Med Radiol 2021;33:409-13
|How to cite this URL:|
Bhayya H, Paramkusam G, Kardalkar S, Avinash Tejasvi M L, Donempudi P, Patil N. Estimation of serum creatine phosphokinase and serum lactate dehydrogenase levels in oral leukoplakia and oral cancers – A clinicopathological study. J Indian Acad Oral Med Radiol [serial online] 2021 [cited 2022 Jan 29];33:409-13. Available from: https://www.jiaomr.in/text.asp?2021/33/4/409/333873
| Introduction|| |
Head and neck squamous cell carcinomas (HNSCC) make up the vast majority (more than 90%) of head and neck cancers. They are a group of tumor entities that arise from squamous mucosal surfaces including nasal cavities, paranasal sinuses, oral cavity, nasopharynx, oropharynx, hypopharynx, and larynx.
It has been well established by researchers that virtually all oral cancers are preceded by visible clinical changes in the oral mucosa usually in the form of a white or red patch (two-step process of cancer development). Classic features may include a white lesion, red lesion, mixed red/white lesion, lump, ulcer with fissuring or raised margins, pain or numbness, loose tooth, unhealed extraction socket, induration, fixation of a lesion to deeper tissues, lymph node enlargement, dysphagia, and weight loss. Prevention or early detection of such potentially malignant disorders (PMD) has the benefit of not only decreasing the incidence but also improving the survival of those who develop oral cancer. Despite advances in detection and treatments over recent decades, the survival rate has not improved significantly over the last 30 years due to a lack of reliable early diagnostic biomarkers and a limited number of molecularly targeted therapeutic strategies.
Many tumor markers and enzyme analyses have been used earlier to aid in the diagnosis of malignancies and premalignant lesions. Blood has become the media of choice for the study of the biochemical markers among all the body fluids. Markers such as carcinoembryonic antigen (CEA), lactate dehydrogenase (LDH), and phosphohexose isomerase (PHI) have been found to be elevated in certain malignancies like in large gut malignancies, hemangiopericytoma, and adenocarcinoma. The enzyme creatine phosphokinase (CK) has been hypothesized as a marker for many cancers like lung, colon, and liver carcinomas.,
The aim of this study was to evaluate total serum CK and serum LDH levels in patients with oral cancer, oral leukoplakia. The objective of the present study was to assess whether quantification of serum LDH and serum CK levels would be considered as a biochemical marker in the early detection of oral leukoplakia and oral cancer.
| Materials and Methods|| |
The present study was conducted in the department of Oral Medicine, Diagnosis and Radiology of a Dental college. The study was approved by the Institutional ethical committee (KIDS / IEC/ OMR/11-20) and followed the principles of Helsinki declaration, proposed in 1964 and modified in 2000. Informed written consent was taken from the study subjects after explaining the purpose, nature, and objective of the study in their own language, and confidentiality was assured.
Convenient sampling was used as part of non-probability sampling and patients attending the OPD were enrolled for the study. Sample size was determined by considering a confidence level of 95% and an error rate of ±5%, determining the need to include 60 participants in the study. Hence sample size was taken as 60 patients, of which 20 patients with oral cancer, and 20 patients with oral leukoplakia were assigned as Group II and Group III, respectively. After obtaining informed consent from the patients, a biopsy was done and subjected to histopathological evaluation and after confirming the clinical as well as histopathological diagnosis, such patients were included in the study group. 20 normal healthy individuals without any of the above lesions with no deleterious habits like tobacco usage in any form and without any systemic diseases were also included in the study and taken as a control group and were assigned as Group I. Complete blood count, liver and kidney function tests, and lipid profile, were performed to rule out any systemic disorders in all the three groups.
The inclusion criteria for the patients were
- All patients above 15 years to 60 years of age of both sexes with oral leukoplakia based on Van der Waal criteria were included.
- All patients above 15 years to 60 years of age of both sexes with oral cancer based on the American Joint Committee on Cancer (AJCC) criteria 8th edition were included.
The exclusion criteria for the study were the patients who had any systemic diseases like cardiac disease, diabetes, renal disease, etc., and patients on long-term use of medications.
Collection of Sample: Five mL of venous blood was collected from the antecubital vein of study participants and was then centrifuged at 3000 rpm for 10 min to separate the serum. The serum, thus obtained was utilized for biochemical estimation of serum CK and LDH levels using Siemens autoanalyzer. The results were tabulated and analyzed.
The statistical analysis was performed by using statistical package for social sciences (SPSS) 19.0 version software for the assessment of levels of total serum LDH and total serum CK levels. Comparison of three groups with respect to each biochemical parameter was done by one-way ANOVA. Comparison between the groups was done by Tukey's multiple post hoc test. P value was determined and expressed as
- P = 0.001 represents statistically highly significant.
- P = 0.05 represents statistically significant.
- P >0.05 represents statistically not significant.
| Results|| |
The present study was a case-control study, consisting of study and control groups. The study group involved mainly two subgroups of patients, with oral cancer (17 males and 3 females) and leukoplakia (17 males and 3 females). The control group consisted of 20 (10 males and 10 females) healthy individuals.
The mean serum levels of total serum CK and total serum LDH were assessed in the present study. The mean value of total serum CK for the control group, oral cancer group and oral leukoplakia were 102.50 IU/L (±27.21), 69.20 IU/L (±31.11), 75.40 IU/L (±36.08) respectively. Similarly the mean value of total serum LDH for the control group, oral cancer group and oral leukoplakia group were 139.50 IU/L (±30.46), 318.40 IU/L (±105.19), 296.10 IU/L (±112.118).
Comparison of the levels of total serum CK and LDH among the three groups was done by one way ANOVA, and it was found that the mean value between groups was significantly different; hence, there was a significant decrease of CK (P = 0.004) and significant increase of LDH between groups (P = 0.000) as shown in [Table 1].
Comparison between the three groups was done by Tukey's multiple post hoc test. There were statistically significant decreased levels of total serum CK in both oral leukoplakia (P = 0.009) and oral cancer (P = 0.002) when compared with the control group. However, there was no statistically significant change of total serum CK between patients with oral cancer and oral leukoplakia (P = 0.538). Similarly, there were a statistically significant increased levels of total serum LDH in both oral leukoplakia (P = 0.000) and oral cancer (P = 0.000) when compared with the control group. However, there was no statistically significant change of total serum LDH in patients with oral cancer and oral leukoplakia (P = 0.439) as shown in [Table 2].
| Discussion|| |
CK is an intracellular enzyme present in the greatest amounts in skeletal muscle, myocardium, and brain; smaller amounts occur in other visceral tissues. It occurs in large amounts in the serum primarily as three isoenzymes: CK-BB, which is found in large amounts in the brain, gastrointestinal tract, and genitourinary tract; CK-MM, which is found in skeletal and cardiac muscle; and the hybrid CK-MB, which is found primarily in cardiac muscle. It has hence become an important clinical marker for muscle damage. The serum CK level in healthy individuals depends on age, race, lean body mass, and physical activity. Serum CK levels vary with physiological and pathological states, the estimation of serum CK is an established clinical biochemical investigation, which is used in the assessment of muscle disorders. Disruption of cell membranes due to hypoxia or other injury releases CK from the cellular cytosol into the systemic circulation. On this basis, elevated serum levels of CK have been used as a sensitive but nonspecific test for myocardial infarction. Serum CK enzymes have been reported to have potential value as a tumor marker for patients with prostatic carcinoma, breast cancer, lung cancer, colorectal carcinoma, lymphoma, and various other malignancies. However, the percentage of patients showing abnormal CK-BB concentrations in serum in these malignancies varies considerably from one laboratory to the next.
LDH is an NAD+-dependent enzyme that catalyzes the interconversion of pyruvate and lactate. LDH is present in all cells in the body although the main concentrations are found in the liver, heart, kidneys, skeletal muscle, and erythrocytes. Cell death or cell damage may lead to the appearance of extracellular LDH.
Serum LDH has a widespread distribution in the body and due to its extracellular appearance, it is used as a parameter in the determination of cell damage/cell death. LDH is released into peripheral blood due to any pathologic or physiologic changes or injuries, which could be ischemia, excess heat or cold, starvation, dehydration, injury, exposure to bacterial toxins, after ingestion of certain drugs, and from chemical poisonings. Therefore, the total serum LDH is a highly sensitive, but nonspecific test. The exact reason for the enzyme release from the tissue remains obscure. However, the mechanism of focal nature of the muscle fiber damage may provide an anatomic basis for understanding enzyme release. It is stated that enzyme efflux may take place from a reversibly injured portion of the cell and may not imply irreversible cell injury or cell death.
In the present study, total CK levels were assessed, and found that the mean value between groups was statistically significant, and hence there was a significant decrease of CK (P = 0.004). These results were not consistent with the study conducted by N Zarghami et al., as they concluded that creatine kinase BB (CK-BB) is elevated in many tumors including those of the breast and is associated with more aggressive tumors, but its value as a prognostic indicator is limited.
High CK activity in cancers had been noticed for years. J Joseph et al., compared the levels of creatine kinase activity and the distribution of CK isoenzymes determined by agarose gel electrophoresis in normal colon, liver and lung tissues, and in colon, liver and lung in adenocarcinomas, lung squamous cell carcinomas, and lung carcinoids. In addition, it was found that colon and lung adenocarcinomas, and squamous cell carcinomas presented lower CK activity than the normal tissues which was consistent with the results of the present study, and no differences were found between hepatocarcinoma and normal liver tissue. In contrast, lung carcinoids had higher CK activity than normal lung tissue.
Spoorthi Banavar Ravi et al., assessed mean serum CK among the control group (group I), different grades of oral epithelial dysplasia (mild- group II; moderate- group III; severe - group IV), and found that mean serum CK was significantly increased in Group III and Group IV when compared to Group I and Group II. Mean serum CK between Group I and Group II was statistically not significant. Whereas, between groups I and group III, and group I and group IV differed significantly.
Rupakar P et al. in their study compared serum CK level between control and different grades of oral squamous cell carcinoma of well, moderate, and poorly differentiated carcinoma. It was found that serum CK level did not show a significant result when compared between Group I (control) and Group II. When compared between Group I (control) and Group III and between Group I (control) and Group IV, it showed significant results. Between different grades of oral cancer (between Group II, Group III, Group IV) serum CK level showed changes, but statistically it was nonsignificant.
Joseph BB et al compared CK levels between leukoplakia and normal subjects and found no significant correlation between CK, leukoplakia and age.
In the present study, assessment of total serum CK levels among controls, oral leukoplakia, and oral cancer was done, which showed statistically significant decreased levels of serum CK in oral leukoplakia and oral cancer when compared to controls (P = 0.004). The mean serum levels of CK among all the three groups showed statistically significant decreased levels, though the values were found to be within the normal limits clinically.
Swei H. Tsung measured total creatine kinase (CK; EC 188.8.131.52) activity and isoenzyme pattern in normal and neoplastic tissues. Found that CK activity was detected in all the examined tissue and concluded that total CK activity was very low in most tumor tissues, which was consistent with the results of the present study, where total CK activity was reduced. According to Patra S et al., CK activity gradually decreased progressively in the muscle with the progression of malignancy and even undetectable in the final stage of dedifferentiation.
Alteration of cellular enzyme levels in the blood is a reflection of the presence of some abnormality in the disease tissue or organ. This abnormality may be due to an altered amount of the enzyme-forming tissue, an altered rate of synthesis of these enzymes within the tissue of origin, or an alteration in the permeability of the cell membrane brought about by the pathological condition. When disease or injury affects tissues containing LDH, the cells release LDH into the bloodstream, where it is identified in higher than normal levels. Cancers can also elevate the LDH level. The increased activity of serum LDH in cancer patients is attributed to the release of enzymes from malignant cells.
In the present study, significant elevation of mean LDG levels was found in Leukoplakia and oral cancer groups (P = 0.000). Priya Shirish Joshi et al., concluded that serum and salivary LDH levels increased in all cases of OL and OSCC groups in comparison to the control group which was consistent with the results of the present study. C-C. Liaw et al., found higher serum LDH levels in nasopharyngeal carcinoma, and more cases with elevated values were seen in patients with metastatic disease. In a study conducted by Visnja Bog danovic et al., it was found that serum LDH levels were elevated in patients with breast cancer, which could be an indicator of a prognostic sign of disease progression.
Subramanian N et al., in his study concluded that LDH isoenzyme acts as an important biochemical marker in cervical carcinoma. It also helps in assessing grades of malignancy. Muralidhar M et al., also reported a definite rise of serum LDH in premalignant and malignant cases which was consistent with the results of the present study. Serum LDH isoenzymes in squamous cell carcinoma of the oral cavity were studied by T Gorogh et al. It was found that the percentage of distribution of serum LDH isoenzymes may act as important inference in the activity of the disease in a patient with Oral squamous cell carcinoma (OSCC).
Sharma et al. carried out a study to evaluate the role of serum lactate dehydrogenase (LDH) as a biochemical parameter in the oral premalignant and malignant and normal subjects. It was found that an increased level of LDH was found in the serum in patients with oral premalignant and malignant lesions. They also found that the raised level of LDH had a positive correlation with the histologic grading and concluded that poorly differentiated lesions recorded the highest value followed by moderately and well-differentiated lesions. Gholizadeh et al. concluded that patients with OSCC and oral lichenoid reactions (OLRs) had higher serum levels of LDH than oral lichen planus (OLP) and control groups.
Forkasiewicz et al. in their study concluded that the increased rate of glycolysis in rapidly growing tumor cells is expressed by changes in LDH total activity and/or the LDH isoform composition. But because of the low specificity and sensitivity of these changes, LDH cannot be recommended as a specific marker in cancer diagnosis.
Limitations and Future Prospects
Although the results of the present study showed increased levels of LDH in both oral leukoplakia and oral cancer, and CK levels within the normal limits, further prospective longitudinal studies with a greater number of samples, different grades of epithelial dysplasia, and assessment of individual isoenzymes has to be carried out to evaluate the exact role of CK and LDH in the etiopathogenesis of cancer.
| Conclusion|| |
The present study conducted on oral cancer and oral leukoplakia for the assessment of total serum CK and total serum LDH levels showed statistically significant results. Quantification of serum LDH and CK can be potentially used as a biochemical marker, as it is a simple, noninvasive procedure and easily accepted by the patient. With the recent advancements in newer techniques and methods for the evaluation of enzymes, we can better understand the role of LDH and CK as markers of carcinogenesis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Parkin DM. Global cancer statistics in the year 2000. Lancet Oncol 2001;2:533-43.
Sturgis EM, Cinciripini PM. Trends in head and neck cancer incidence in relation to smoking prevalence: An emerging epidemic of human papilloma virus-associated cancers?. Cancer 2007;110:1429-35.
Reibel J. Prognosis of oral pre-malignant lesions: Significance of clinical, histopathological, and molecular biological characteristics. Crit Rev Oral Biol Med 2003;14:47-62.
Fedele S. Diagnostic aids in the screening of oral cancer. Head Neck Oncol 2009;1:5-11.
Agada FO, Patmore H, Al Hamarneh O, Stafford ND, Greenman J. Genetic profile of head and neck squamous cell carcinoma: Clinical implications. J LaryngolOtol 2009;123:266-72.
Narang AP, Greval RN. Chopra H, Kalra CS. 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.
Joseph J, Cardesa A, Carreras J. Creatine kinase activity and isoenzymes in lung, colon and liver carcinomas. Br J Cancer 1997;76:600-5.
Neri B, Bartalucci S, Gemellic MT, Tommasi M, Bacalli S. Creatine kinase isoenzyme BB: A lung cancer associated marker. Int J Biol Markers 1988;3:19-22.
Waal van der I, Schepman KP, Meij van der EH. A modified classification and staging system for oral leukoplakia. Oral Oncol 2000;36:264-6.
Amin MB, Edge SB, Greene FL Compton CC, Gershenwald JE, Brookland RK, et al
. editors. American Joint Committee on Cancer Staging Manual. 8th
ed. New York: Springer; 2017.
Lee TH, Goldman L. Serum enzyme assays in the diagnosis of acute myocardial infarction. Recommendations based on a quantitative analysis. Ann Intern Med 1986;105:221-33.
Wong SS, Wu AH, Fritsche HA. Reassessment of creatine kinase BB as a marker for cancer of the prostate, breast, and lung. Clin Chem 1987;33:809-11.
Drent M, Cobben NA, Henderson RF, Wouters EF, van Dieijen-Visser M. Usefulness of lactate dehydrogenase and its isoenzymes as indicators of lung damage or inflammation. Eur Respir J 1996;9:1736-42.
Zarghami N, Yu H, Diamandis EP, Sutherland DJ. Quantification of creatine kinase BB isoenzyme in tumor cytosol and serum with an ultrasensitive time-resolved immunofluorometric technique. Clin Biochem 1995;28:243-53.
Ravi SB, M V, C P, D'souz ND. Serum creatinine phosphokinase: A potential diagnostic tool for oral premalignant lesions ?- A histopathological biochemical study. Indian J Stomatol 2011;2:86-90.
Rupakar P, Patel H, Shah S, Patel T, Shah M. Study of serum creatine phosphokinase level in oral squamous cell carcinoma. J Adv Med Dent Scie Res 2016;4:10-3.
Joseph BB, George S. Level of serum creatine phosphokinase in leukoplakia-A biochemical Study. Int J Recent Sci Res 2016;7:10660-3.
Tsung SH. Creatine kinase activity and isoenzyme pattern in various normal tissues and neoplasms. Clin Chem 1983;29:2040-3.
Patra S, Bera S, Sinharoy S, Ghoshal S, Ray S, Basu A, et al
. Progressive decrease of Phosphocreatine, creatine and creatine kinase in skeletal muscle upon transformation to sarcoma. FEBS J 2008;275:3236-47.
Merza KS, Alaaraji SB, Abdullah BH. Comparative study on lactate dehydrogenase, alkaline phosphatase and immunoglobulins in serum and saliva of acute leukemia and oral squamous cell carcinoma patients. Iraqi J Sci 2010;51:262-70.
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;3:7-12.
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.
Visnja BD, Turshijan S. Activity of lactate dehydrogenase and superoxide dismutase in the circulation of patients with breast carcinoma. Arch Oncol 2008;16:39-41.
Subramanian N, Krishnan HM, Venkatachalam P, Kamatchi PA. A study of lactate dehydrogenase (LDH) isoenzyme is a biochemical tumour marker in cervical carcinoma patients. Int J Hum Genet 2009;9:5-12.
Muralidhar M, Raghavan MR, Bailoor DN, Kamath VV. Evaluation of serum lactate dehydrogenase (LDH) in oral premalignant and malignant lesions. Ann Dent 1998;42:11-5.
Gorogh T, Eickbohm JE, Ewers R, Lippert B. Lactate dehydrogenase isoenzymes in squamous cell carcinomas of the oral eavity. J Oral Pathol Med 1990;19:56-9.
Sharma G, Sharma P, Kumar P, Kumar R. Study on serum lactate dehydrogenase level in precancerous, cancerous, and healthy subjects. Asian J Pharm Clin Res 2016;9:328-30.
Gholizadeh N, Ramandi MA, Langroudi MM, Jafari M, Sharouny H, Sheykhbahaei N. Serum and salivary levels of lactate dehydrogenase in oral squamous cell carcinoma, oral lichen planus and oral lichenoid reaction. BMC Oral Health 2020;20:314.
Forkasiewicz A, Dorociak M, Stach K, Szelachowski P, Tabola R, Augoff K, et al
. The usefulness of lactate dehydrogenase measurements in current oncological practice. Cell Mol Biol Lett 2020;25:35.
[Table 1], [Table 2]