A STUDYOFTHE SERUMPHOSPHATASEIN BONEDISEASE

By H. Q. WOODARD,GRAYH. TWOMBLYAND BRADLEYL. COLEY

(From the Memorial Hospital, New York City)

(Received for publication November 30, 1935)

Since the development of satisfactory methodsof determining the phospholytic activity of theblood by Kay (1, 2) and by Bodansky and others(3, 4, 5, 6), there has been increasing interest inthe relation of blood phosphatase to various patho-logical conditions. It is now fairly well estab-lished that the major portion of the phosphatasein the blood is contained in the erythrocytes (1,7, 8, 9, 10). Of the phosphatase in the serum,a part may well originate in the bones, and a partin the liver, kidney, and intestinal mucosa (11,12), as these tissues are rich in phosphatase.The serum phosphatase of non-osseous origin israised by ingestion of carbohydrates, greatlyraised by obstructive jaundice, and lowered bystarvation and by the ingestion of proteins (13,14, 15, 16, 17). The serum phosphatase ofosseous origin is greatly increased in bone dis-eases associated with excessive bone and osteoidformation (1, 4, 18, 19, 20, 21).

The rise in serum phosphatase in some types ofbone tumors is apparently due to the productionof large quantities of the enzyme by the neoplastictissue or adjacent periosteum, and the removal ofpart of the enzyme by the blood stream. It hasbeen reported by Kay (1), Bodansky and Jaffe(4), Simmons and Franseen (20, 21) and othersthat this increase in serum phosphatase is of usein the diagnosis of bone cancer, and that serialdeterminations made during the course of treat-ment are important in prognosis. In the presentpaper further evidence on these questions is pre-sented.

METHOD

Wehave used Bodansky's modification of Kay'sprocedure with some changes (2, 3). Fifteencc. of blood were allowed to clot for ½to 1 hour,and centrifuged. The serum was then decantedand centrifuged again to remove all cells. Onecc. of serum was then added to 9 cc. of sodium-beta-glycerophosphate and sodium barbituratebuffer, and incubated for 20 minutes to 2 hours,the time depending on the phospholytic activity

anticipated. A sample was then withdrawn forpH determination, and 10 per cent trichloraceticacid was added to the remainder of the mixture.Meanwhile, 1.5 cc. of serum had been added to13.5 cc. of 5 per cent trichloracetic acid for in-organic phosphorus determination. The trichlora-cetic acid precipitates were removed by filtration,and the inorganic phosphorus in the filtrate de-termined colorimetrically by means of molybdicand sulphuric acid and stannous chloride, all de-terminations being run in duplicate.

Two modifications of Bodansky's procedurewere introduced. The first was made because wewere unable to obtain blank solutions of molybdicand sulphuric acids and stannous chloride whichwere free from color. Accordingly we prepared3 blanks, (B1) containing the color reagentsmolybdic and sulphuric acids and stannous chlo-ride in the concentration in which they appearedin the standard phosphate solution; (B2) contain-ing the color reagents, substrate, and trichlora-cetic acid in the same concentration as for thephosphatase determination; (B2) containing colorreagents and trichloracetic acid in the same con-centration as for the determination of inorganicphosphorus. The apparent phosphorus concen-trations of these blanks were then read againstthe standard and applied as correction to thestandard and unknown solutions. It was foundthat, when this was done, the deviation fromBeer's law in known standard phosphate solutionsof different concentrations was very much lessthan that reported by Bodansky. The correctionfor substrate plus trichloracetic acid was less thanBodansky's for low phosphorus concentrationsand greater for high concentrations. The correc-tion for trichloracetic acid alone was less thanBodansky's. Appropriate correction curves wereprepared, and those of Bodansky were not used.Calculations made by both Bodansky's correctionsand the present ones for a series of 67 phos-phatase determinations showed an average varia-tion of only 2 per cent, but, since the blanks for

193

H. Q. WOODARD,GRAY H. TWOMBLYAND BRADLEY L. COLEY

different solution lots varied considerably, thedifferences between the values for individual de-terminations calculated by the two methodsamounted to as much as 10 per cent.

The reproducibility of the method was studiedby finding the average difference between dupli-cate determinations on the same trichloracetic acidfiltrate or standard phosphate solution. Theaverage differences between duplicates for 100unselected solutions in each series were:

AverageSolution difference

per cent

Standard P ... ......... 1.3Serum inorganic P.1.7

Phosphatase-same dilution of filtrate .. 2.9Phosphatase-different dilution of filtrate 3.8

Rangeper cent

Oto 5.5Oto 5.6Oto 10.7Oto 13.5

The last includes determinations made at thelimits of concentration at which the method can

be used.For duplicate determinations made on different

samples of the same serum, the average differ-ences for 30 sera were

Averagedifferenceper cent

Phosphatase ........ ...... 5.6Phosphorus ...... ........ 3.6

Rangeper cent

Oto 190 to 14

The experimental error of the method is thusnot large enough to affect the clinical significanceof the results.

The second modification of Bodansky's methodwhich was employed consisted in the determina-tion of the pH of the serum-substrate mixture atthe end of each incubation. Preliminary workshowed that the buffering action of different sera

varied so much that, when two sera were mixedwith the same substrate at the same concentration,the pH of the mixture differed by as much as

0.15 pH. Further, it was found very difficult toprevent the absorption by the substrate of CO2in sufficient amounts to change the pH markedly.Accordingly 2 substrates were prepared, one con-

taining HCI and the other NaOH in sufficientamounts so that, when the substrates were mixedwith serum in the proportion of 9: 1, the pH ofthe resulting mixtures would be approximately8.2 and 8.7. The phospholytic activity was thendetermined at these two pH values, and the ac-

tivity at pH 8.6 was found by interpolation. Theactivity at pH 8.7 was usually about twice thatat pH 8.2.

The pH was determined by means of thymolblue in a Myers bicolorimeter at room tempera-ture with a precision of ± 0.02 pH. The thirdwedge in the colorimeter was filled with potas-sium dichromate solution and was adjusted tomatch the color of each serum-substrate mixture.Preliminary work was also done with phenol-phthalein and cresol red as indicators. The pHvalues with different indicators were not the same,there evidently being an unknown error due tosubstrate, serum proteins, or both. As we didnot have facilities for checking the pH poten-tiometrically the pH readings reported here, whileconsistent with themselves, may contain a sys-tematic error.

The pH of the serum-substrate mixture wasfound to fall somewhat during incubation, pre-sumably owing to the liberation of phosphoricacid by the phosphatase. For 33 determinationsthe average pH change was - 0.09 pH. The pHchange was greater the higher the initial pH andthe greater the phospholytic activity, but thechanges observed were too near the experimentalerror of the method for exact study of these re-lationships.

Bodansky (22) has reported that the phos-pholytic activity of sera increases about 10 percent in 24 hours at ice box temperature, and 15to 20 per cent in 4 to 6 hours at 37° C. Wehavefound that a part of this change in phospholyticactivity is due to a change in the pH of the serum,since when a portion of a fresh serum sample ismixed with a given substrate, and another of theserum which has been kept for 24 hours at roomtemperature is mixed with the same substrate, thepH of the second mixture is significantly higherthan the first. The pH of the substrate itselfdoes not change appreciably in 24 hours. Whenproper correction for pH was made, the phos-pholytic activity of 30 sera increased an averageof only 10 per cent after 24 hours at room tem-perature. In some cases a decrease was noted.The changes observed did not appear to be cor-related with the magnitude of the initial phos-pholytic activity nor with diagnosis, were notmuch greater than the experimental error, andwere not large enough to be of clinical signifi-cance. An average increase in inorganic phos-phorus of 0.15 mgm. per 100 cc. or 4 per cent was

194

SERUMPHOSPHATASEIN BONEDISEASE

observed in sera that had stood for 24 hours atroom temperature.

RESULTS

Since liver and biliary tract disease associatedwith obstruction raise the serum phosphatase, andcachexia lowers it, we have not studied patientsshowing liver involvement nor patients in poor

general condition. The icteric index was de-termined on all sera in the course of the measure-

ments of pH, so cases with mild jaundice couldbe detected and excluded. As most cases studiedwere from the out-patient department it was ingeneral not possible to obtain fasting blood.Nearly all samples were drawn 2 to 3 hours afterbreakfast, so that the food factor was approxi-mately constant. Since Bodansky and Jaffe foundno difference in the average phosphatase levels intwo otherwise comparable groups of blood sam-

ples, one drawn 2 to 4 hours after breakfast andthe other fasting, the error from this source isprobably not of clinical significance (4).

Kay ( 1 ) has reported that the variation inserum phosphatase in the normal individual issmall. Wehave studied this further by makingserial determinations on 4 healthy individuals freefrom bone abnormalities. The results confirmKay's report that the normal adult variation inserum phosphatase is small. It is not likely toexceed 1 unit even when observed over longperiods during which the individual's conditionwith respect to food, exercise and fatigue under-goes considerable change. The data for 2 cases

are shown in Figures 1 and 2. In women, the

menstrual cycle does not appear to influence theserum phosphatase. The effect of various thera-peutic agents will be considered later.

Belfanti et al. (23) have found that the phos-phatase of rabbit liver and kidney is at its maxi-mumactivity at pH 4.5, while the phosphataseof bone is at its maximum at pH 9.0. Roche (9,10) and Kay (1) report that the pH of maximumactivity for the phosphatase of serum and ofleukocytes is about 9.0, and that of erythrocytesabout 6.0. Since the phosphatase of serum prob-ably originates from several sources, and since thework of Franseen et al. (20, 21) and the earlywork of Kay (1) was done at pH 7.6, while thatof Bodansky and coworkers (3, 4, 11, 13, 14,

22) and of the present authors was done at pH8.6, the question arose whether the different in-vestigators have been studying the same enzyme.It also seemed possible that the different phos-phatase fractions in the serum might be distin-

M M AM Mlo #3/

a X S10

X-x

A~~~~~~~~p x I,

20 40 60 80 100 120 NO1O160 SDAY5

FIG. 1. NORMALMALE CONTROLFIG. 2. NORMALFEMALECONTROLSHOWINGLACK OF

VARIATION IN PHOSPHATASEWITH MENSTRUATION.FIG. 3. RETROPERITONEALSARCOMAINVADING ILIUM;

NORMAL PHOSPHATASE UNCHANGED BY ROENTGENTHERAPY.

FIG. 4. OSTEOCHONDROSARCOMAOF FIBULA; NORMALPHOSPHATASENOT SIGNIFICANTLY CHANGEDBY RE-PEATED LOCAL EXCISIONS.

See legend to Figure 11 for abbreviations.

guished by their pH of maximum activity. Asall our determinations have been done at two dif-ferent pH values, we have examined the ratios ofphosphatase activity over the limited pH rangestudied to see if any evidence could be obtainedon these questions.

195

H. Q. WOODARD,GRAY H. TWOMBLYAND BRADLEY L. COLEY

Wefirst determined the phospholytic activity of13 sera at 3 or more pH values between pH 8.1and 8.8, and found that the curve obtained byplotting phosphatase units against the pH was astraight line within the experimental error overthis pH range. Wethen found the ratio of phos-pholytic activity at pH 8.7 to that at pH 8.2 for87 sera on which two phosphatase determinationshad been made, one having been made be-tween pH 8.10 and 8.30 and the other betweenpH 8.60 and 8.80, the difference between the twopH values being at least 0.50 pH in each case.The average value of the ratio for 59 sera forwhich the phospholytic activity at pH 8.6 wasnormal (equal to or less than 4.0 units) was 2.2;the average value of the ratio for 52 sera havingmore than 4.0 units of phosphatase at pH 8.6 wasalso 2.2. There was considerable variation in theratios in both groups. There was not, however,any evidence that the sera with high phospholyticactivity contained an enzyme having an optimumat a different pH from the sera of low phospho-lytic activity. Investigation over a wider pH rangemight, of course, show such a difference, butthis seems unlikely since the degree of elevationof serum phosphatase in disease, which has beenreported by investigators working at pH 7.6 andthose working at pH 8.6, has been about the same.

The degree of activation of the enzyme wasalso studied by the addition of magnesium asmagnesium chloride to a final concentration of0.005 M. It was found that the activity of theserum phosphatase was increased an average of22 per cent in 34 determinations. This is inharmony with the findings of Kay and others (1,24). The effect of magnesium was slightlygreater in the higher pH range, but there wasno significant difference between normal andpathological sera. Thus the effect of magnesiumdoes not seem to be of diagnostic significance.

The diagnostic value of phosphatase determina-tion. The results of phosphatase determinationsmade for diagnostic purposes are summarized inthe accompanying tables. Figures for serum cal-cium and inorganic phosphorus were normal in allcases except those of generalized osteitis fibrosacystica, and hence are omitted except in thosecases. Table I shows the figures for serum phos-phatase in normal individuals, in cases of malig-

TABLE I

Serum phosphatase with and uithoWt bone involvement

Ca Sex Serumnum- and Diagnosis phospha- Remarks

ber age tase

Bodanskyyears units

per 100 cc.A Normals, average of 23 2.9 Range, 1.7 to 5.0

B Tumors without bone involvement

1 F 66 Myosarcoma, stomach 4.72 F 42 Fibroid, uterus 2.63 F 57 Carcinoma, breast 3.64 F 64 Carcinoma, breast 3.85 F 47 Carcinoma, breast 4.06 M53 Adenosarcoma, kidney 3.27 F 47 Carcinoma, breast 1.68 F 44 Carcinoma, breast 4.19 M63 Carcinoma, prostate 3.7

10 M73 Carcinoma, prostate 3.811 M45 Carcinoma, prostate 3.012 M55 Carcinoma, prostate 3.813 M70 Carcinoma, prostate 3.0

Average 3.5 Range, 1.6 to 4.7

C Benign bone tumors and alied benign lesions of bone

1 M60 Osteomyelitis, tibia 2.22 M65 Osteomyelitis, tibia 4.43 F 50 Osteomyelitis 3.74 M13 Osteitis 5.4 Normalforage5 M17 Osteochondroma, humerus 4.86 M35 Oseochondroma, finger 3.07 M21 Ostooma, Ilium 2.48 F 12 Osteochondroma, humerus 8.6 Normal for age!9 M10 Osochondroma, humerus 8.1 Normal for age'

10 M15 Osteochondroma, humerus 7.3 Normal for age!11 M12 Enchondromatosis 8.5 Normal for age,12 F 48 Myositis osificans 3.713 F 29 Calcifiednodules 2.014 F 22 Multiple exostoses 3.215 M20 Leontiasis ossium 5.116 F 19 Osteomyelitis 2.417 F 17 Epiphysealchondromatousglantoell

tumor 1.518 F 30 Apgresvegiantcelltumor, femur 3.819 M30 Giant cell tumor, tibia 5.220 F 28 Aggrewive osteoplastic giant cel tu-

mor 8.1

Averageforadults (OmittingCases 4, 8, 9, 10 and 11) 3.7 Range, 1.5 to 8.1

nant disease not involving bone, and in cases ofnon-malignant bone disease.

In the normal group the average phosphatasefor 23 adults was 2.9 units with a range of 1.7to 5.0. These figures are slightly higher thanthose of Bodansky and Jaffe (4). Another casenot included in the table was a woman in goodhealth without bone abnormalities or jaundice, butwith a high gastric acidity, whose serum phos-phatase values on two occasions were 6.6 and 5.3units, with normal calcium and phosphorus.Eight months later the serum phosphatase hadfallen to 3.5 units. This case suggests the needfor caution in interpreting the presence of a highphosphatase in cases of suspected bone disease.

196

SERUMPHOSPHATASEIN BONEDISEASE

The 13 cases of neoplastic disease not primaryin bone and without involvement of bone or liverhad serum phosphatase values within the normalrange. This is in harmony with the findings ofBodansky and Jaffe (4) that malignant diseaseper se does not influence the serum phosphatase.

Of the 20 cases with benign bone tumors andosteomyelitis, only one (Case 20) showed anelevated serum phosphatase. This was an aggres-sive giant cell tumor which was laying down bone.This suggests that the bone forming characteris-tics of a tumor are of more importance than itsmalignancy in determining whether its presencewill give rise to an elevated serum phosphatase.

TABLE II

Osteitis deformans and generalised osteitis fibrosa cystica

Case Sex Serum Po-Clnum- and Diagnosis phospha- Phos Cal-ber age tase phorus cium

Bodansky mgm. mgm.units per per

per 100 cc. 100 cc. 100 cc.1 M75 Osteitis deformans 30.32 M39 Osteitis deformans 6.43 F 59 Osteitis deformans 11.54 F 66 Osteitis deformans 10.65 M64 Osteitis deformans 18.86 M61 Osteitis deformans 13.57 M63 Osteitis deformans 31.58 F 63 Osteitis deformans 13.79 F 49 Generalized osteitis 15.8 1.8 15.3

fibrosa cystica10 M38 Generalized osteitis 9.4 1.4 10.2

fibrosa cystica

Table II shows figures for 8 cases of osteitisdeformans and 2 cases of generalized osteitisfibrosa cystica. The serum phosphatase was highin all the cases of osteitis deformans, as has previ-ously been noted by other observers (28). Oneof the cases of generalized osteitis fibrosa cysticashowed the high serum calcium, low serum phos-phorus, and high serum phosphatase usually re-

corded. The second case, which was clinicallymuch more severe, had normal serum calcium,with low serum phosphorus and high serum phos-phatase. The significance of this finding couldnot be determined without further metabolicstudies on his calcium balance. Such a blood pic-

ture is not uncommon in this disease, however(Gutman, Swenson and Parsons (25)).

Table III shows the phosphatase figures for 14cases of malignant disease not primary in bone

TABLEIII

Tumors not primary in bone but with bone involvement

Cas S Srumnum- and Diagnosis Type of bone reaction phospha-

ber age tase

Bodanslcyyears units

per 100 cc.1 M83 Undiosed tumor originaly

osteolic, but osteoplastic attime of detenation. Pa-tient died 6 months later ofliver metastases 12.0

2 F 39 Carcinoma, breast Small osteolytic 2.93 M63 Carcinoma, prostate Severe osteoplastic 15.54 F 26 Retroperitoneal sar- Osteoltic 2.2

coma5 M47 Carcinoma, prostate Early osteoplastio 5.66 M63 Carcinoma, prostate Osteoplastic 27.47 M30 Hemangioma invad- Osteoplasticbutslowgrowing 2.4

ing tibia8 M68 Carcinoma, prostate Osteoplastio 45.59 F 23 Carcinoma, ovary 26.0

10 F 67 Mycosisfungoidesin- Osteolytic 2.3vadingelavicle

11 M63 Carcinoma, prostate 3.512 M56 Carcinoma prostate Osteoytic 8.913 F 60 Carcinoma, beast Osteoytic 6.614 M44 Neurogenic sarcoma Mixedosteoytic and osteoplas 2.7

invading tibia tic

but metastatic to or invading bone. The serumphosphatase ranged from normal to 45.5 units,the highest figures being in metastatic carcinomaof the prostate. The radiographs of the patientsin this group were reviewed without reference tothe blood findings in order to determine whetherthe lesions were chiefly osteolytic or osteoplastic.The radiographic appearance was then comparedwith the chemical findings, and, as can be seenfrom the table, there is a close correlation betweenthe two. When the bone lesion was small, veryslowly progressive or chiefly osteolytic the serumphosphatase was low; widespread osteoplasticlesions on the other hand were associated withhigh serum phosphatase.

Our chief interest in this study was with caseshaving primary bone tumors, since Franseen et al.(20, 21) has suggested that serum phosphatasedeterminations are of value for diagnosis andprognosis in such cases. Our observations aresummarized in Table IV. In the osteoplastic typeof osteogenic sarcoma the serum phosphatase isusually elevated, while in the osteolytic type ofosteogenic sarcoma, in chondrosarcoma, and inendothelial myeloma the serum phosphatase isnormal or only slightly raised. The correlationbetween phosphatase figures and either the histo-logical or radiographic type of the tumor is notclose, and the phosphatase findings can only be

197

H. Q. WOODARD,GRAY H. TWOMBLYAND BRADLEY L. COLEY

TABLE IV

Malignant tumors primary in bone

Case Sex Serumnum- and Diagnods Type of bone reaction phospha-

ber ap tase

Bodanityears unil.

per 100 cc.1 M40 Chondrosarcoma, Chiefly osteoplastc 7.5

femur2* F 26 Osteogencarcoma 9.83 M28 Osteogenlosarcoma, Otoplastc 13.2

tibia4 M23 Osteogenisaroma, Osteolytic 5.6

humerus5 M18 Osteogenicsarcoma, Osteoplastlc 13.7

femur6B M24 Odseognesarcoma, Osteoytic 6.7

humerus7 M88 Odwegenisarcoma, Small osteolytic 2.9

sygoma8 M73 Osteogenisarcoma, Osteolytic 3.1

scapula9 M12 Osteogenlcearcoma, Osteoplastic. Phosphatasehigh 17.9

femur for age10 F 11 Odeogeniucarcoma Mixedosteoplastic and osteolytic. 3.8

Phosphataselowforage11 k-dF teogemiesarcmm, O"teobti 4.1clavilel

12 M30 Lowgradeosteo- Osteoplastic 2.6ohondrosrcoma,fibula-frommy-ositisoslficans

13 M27 Osteochondrosar- Smallmixedosteoplasticandos- 3.9ooma, rib teoytie. Slowly growing

14 M45 Ostochondrosar- Chiefly osteoplasio 4.2ooms, sernum

15 F 55 Chondromyxosar- Osteolytio 2.4ooma, ribs

16 MU3 Atypicalgnt Ootic 4.3tumor, um

17 M21 Endothllalmye- Chiefly osteolytic, very slow 4.0loma,sacrum growth

18 F 19 Endothelialmye- Slow osteoplasia 3.7loma

19 F 16 Endothelialmye Oseoly, with osteoplastic callus 5.0loma femur formation

20 M48 Endotiielalmye- Osteoytic 6.0loms ulna

21 F 37 EndoLelIalmye- Osteolytic 2.7loma femur

22 F 8 Endotelialmye- Osteolytic. Phosphatasenormal 6.7loma, rib forage

* Diagnosis by radiographs only, no biopsy.

considered as suggestive, rather than definitelydiagnostic of the type of tumor studied.

The prognzostic significance of phosphatase de-terminations. In theory, when a tumor such as

osteogenic sarcoma is present and is pouring largequantities of phosphatase into the blood stream,the removal of the tumor by operation, or its in-activation by radiation or toxins should result ina fall in serum phosphatase. The extent andconstancy of the drop should be an indication ofthe effectiveness of the treatment, a late rise inphosphatase indicating the presence of recurrence

or metastases. Franseen and coworkers have re-

ported this to be the case (20, 21). On the otherhand, if the tumor present is one such as endo-thelial myeloma, which is not a source of exces-sive phosphatase, its removal should not affect

the serum phosphatase. Wehave studied a num-ber of cases during therapy in the hope that serialphosphatase determinations would prove to be areliable guide in prognosis.

It was necessary first to determine whether thetherapeutic procedures, operation, irradiation, andthe administration of Coley's toxins, would inthemselves influence the serum phosphatase. Ac-cordingly we made serial determinations on fifteenpatients whose initial serum phosphatase wasnormal or only slightly raised. The observationsfor two typical cases are shown in Figures 3 and4. The phosphatase was not significantly raisedin any case following irradiation alone. Theslight drop in phosphatase observed in two casesfollowing irradiation may have been due to treat-ment, but was too small to be of much significance.Irradiation alone, therefore, appears to be with-out effect on normal phosphatase. In one casein this series where operation was followed by theadministration of toxins, and in one case whereirradiation was followed by the administration oftoxins, there was a marked rise in phosphatase.In the cases with a high initial reading, which arediscussed more fully later, there was a markedrise in phosphatase in two cases following opera-tion and the administration of toxins and in twocases following irradiation and injection oftoxins. It seems probable, though the rise inphosphatase during toxin therapy is not constant,that phosphatase determinations made during acourse of toxins are without significance in prog-nosis.

The effect of operation is difficult to evaluate.Bodansky and Jaffe (4) have reported a drop inserum phosphatase following operations not in-volving bone, but this may have been due to poornutrition during the postoperative period. Sincewe have observed a slight rise in serum phos-phatase on 3 occasions following bone operations,and since Hunsberger and Ferguson (26) andSmith and Maizels (18) have shown that thereis a rise in serum phosphatase during the healingof fractures, it is likely that the serum phos-phatase may be somewhat elevated following anyoperative procedure involving considerable bonetrauma.

The second series of charts, Figures 5 to 11inclusive, shows the changes during treatment in

198

SERUMPHOSPHATASEIN BONEDISEASE

I I I I I IT

/01

AMP. MET. A x A

I I 1

I5 -

.~-t x HNED METAMP

EXCI51ON # 7

I I I

DAY5FIG. 5. OSTEOGENICSARCOMAOF FEMUR; MODERATELYHIGH INITIAL PHOSPHATASE

REMAINING ELEVATED DURING TREATMENTBY RADIUM, AMPUTATION AND TOXINS, BUTLATER FALLING TO NORMALIN SPITE OF INCREASINGLY EXTENSIVE PULMONARYMETASTASES.

FIG. 6. OSTEOGENICSARCOMAOF FEMUR; HIGH INITIAL PHOSPHATASEFALLING UNDERROENTGENTHERAPY, BECOMINGNORMALAFTER AMPUTATIONIN SPITE OF TOXIN THERAPY,AND THEN RISING SLOWLYPROBABLYBECAUSEOF THE ONSETOF PUBERTY.

FIG. 7. OSTEOGENICSARCOMAOF TIBIA; HIGH PHOSPHATASEFALLING AFTER ROENTGENTHERAPYRESULTING IN ROENTGENNECROSIS OF THE TUMOR, WITH FURTHERFALL AFTER

LOCAL EXcISION.See legend to Figure 11 for abbreviations.

5 patients with osteogenic sarcoma, one with an

endothelial myeloma, and one with an aggressivegiant cell tumor, all of whom had a high initialserum phosphatase. These are chosen as typicalexamples from a series of 12 such cases. In two(Figures 6 and 9) there was a prompt drop fol-lowing amputation, which was maintained during a

subsequent course of toxins. One of these cases

(aged 12½ years) subsequently showed a markedrise in phosphatase coincident with an increase inthe rate of body growth. Four months later heshowed evidence of lung metastases. On theother hand, in two cases (Figures 5 and 8) therewas a more or less marked rise in phosphataseduring treatment. In both, the phosphatase laterfell to high normal levels, but one has remainedfree of disease and the other now has advancedlung metastases. A third case which has beenfollowed for only five weeks had a similar risein phosphatase during therapy. In addition tothese cases who developed lung metastases whileunder observation, we have seen two other cases

who already had lung metastases at the time ofour first phosphatase determinations. In one theprimary tumor had been removed by amputation,in the other the primary had recurred in the ad-jacent soft parts after temporary inactivation byirradiation. In both, the serum phosphatase was

within normal limits. It seems from these chartsthat the serum phosphatase is so variable duringthe course of treatment, especially by toxins, thatdeterminations made at such times are withoutvalue in prognosis, and that, even in the absenceof other factors, the serum phosphatase can notbe relied upon to detect early metastases. Wefeel therefore that, at present, no reliance can beplaced on phosphatase determinations as an aidin prognosis.

DISCUSSION

On examination of the above data we are

brought to the conclusion that serum phosphataseactivity is a measure of the amount of new boneformation taking place in the body, or of an at-tempt on the part of the body to form new bone,

199

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5i

o

(0)I0

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H. Q. WOODARD,GRAY H. TWOMBLYAND BRADLEY L. COLEY

15

10

5j

10

o

54

I0

Is

/0

20 Li bU60 ysto 1 U140 It) ISDAYS

FIG. 8. OSTEOGENICSARCOMAOF HUMERUS;SLIGHTLYELEVATED INITIAL PHOSPHATASESHOWINGSLIGHT RISEAFTER AMPUTATION, MARKEDRISE DURING TOXIN THER-APY, WITH A SUBSEQUENTDROPTO HIGH NORMALLEVEL.

FIG. 9. OSTOGENICSARCOMAOF FEMUR; HIGH INI-TIAL PHOSPHATASEWITH PROMPT DROP TO NORMALAFTER AMPUTATIONAND No CHANGEAFTER APPENDEC-TOMYAND TOXIN THERAPY.

FIG. 10. ENDOTHELIAL MYELOMAOF ULNA; SLIGHTLYRAISED INITIAL PHOSPHATASESHOWINGLITTLE CHANGEFOLLOWINGLOCAL EXCISION AND ROENTGENAND TOXINTHERAPY.

FIG. 11. AGGRESSIVE GIANT CELL TUMOst OF FEMUR;HIGH INITIAL PHOSPHATASEWITH PROGRESSIVE FALLFOLLOWINGROENTGENTHERAPY.

Abbreviations used in Figures

X-Roentgen therapy.e- Radium therapy.T-Coley's toxins therapy.OP-Excision or curettage.AMP-Amputation.NED-No evidence of disease.MET-Pulmonary metastases.

and is in no sense a unique and characteristic in-dication of the presence of any one type of bonetumor. It is possible that phosphatase readingsare high in generalized osteitis fibrosa cystica andosteitis deformans because the body is attemptingto repair defects due to metabolic disorder. Theyare often high in osteogenic sarcoma because thistumor frequently forms new bone, but they may

be low because the particular tumor is not form-ing bone. Lung metastases are usually not osteo-plastic in character although Brunschwig andHarmon (27) believe osteoplastic metastases oc-

cur more frequently than is generally supposed.None of our four cases with lung metastases fromosteogenic sarcoma showed any radiographicevidence of bone formation in the lungs, however.This probably explains why three of the cases hadnormal serum phosphatase values, while thefourth showed only a high normal for an activelygrowing boy of his age.

Although the figures for serum phosphatase are

not definitely characteristic for any type of tumor,we feel that they are of diagnostic significance.For instance they may differentiate a growing

tumor with a high rate of osteoplastic activitysuch as osteogenic sarcoma, a less actively ossify-ing tumor such as chondrosarcoma, or a very

slowly changing or stationary bony abnormalitysuch as an osteoma or an old myositis ossificans,tumors which may show almost indistinguishableroentgenological pictures. In interpreting thephosphatase findings it must be remembered thatcallus formation around a healing pathologicalfracture through the site of an osteolytic tumormay cause an elevation in the serum phosphatase,even though the tumor itself may not producemuch phosphatase.

SUMMARY

Determinations of serum phosphatase have beenmade by a modification of Bodansky's method on

normal individuals and on cases of neoplastic dis-ease of the bone.

The phosphatase of normal serum did not ap-

pear to differ from that of pathological serum indegree of activation as measured by the activat-

M (Chart No. 2) -Menstruation.A (Chart No. 9)-Appendectomy.P-ase-Serum phosphatase in Bodansky units.

T 7

AMP #

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AMP A

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| T_

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200

SERUMPHOSPHATASEIN BONEDISEASE

ing effect of magesium or in pH of optimum ac-tivity.

The serum phosphatase was found to be normalor very slightly raised in chronic osteitis, osteo-myelitis, benign bone tumors, endothelial myeloma,and chondrosarcoma, and high in osteitis de-formans, generalized osteitis fibrosa cystica,osteoplastic metastatic disease, and some cases ofosteogenic sarcoma, particularly those in whichthere is radiographic evidence of considerablebone production.

Serum phosphatase determinations were notfound to be of value in detecting pulmonarymetastases.

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