Sudan Journal of Medical Sciences Volume 17, Issue no. 1, DOI 10.18502/sjms.v17i1.10686 Production and Hosting by Knowledge E Original Article Recent Update on Serum Alkaline and Acid Phosphatases in Pre- and Postoperative Breast Cancer Patients Stalinjit Singh1,2, Sudershan Kapoor3, Mukesh Chander4, and Prabhjot Kaur Gill5* 1PhD Scholar, Centre for Interdisciplinary Biomedical Research, Adesh University, Bathinda, Punjab, India 2Assistant Professor, Department of Medical Lab Sciences, Khalsa College Amritsar, Punjab, India 3Professor & Head, Department of Surgery, Government Medical College & Hospital, Amritsar, Punjab, India 4Assistant Professor, Department of Biotechnology, Khalsa College, Amritsar, Punjab, India 5Professor, Biomedical Research, Sri Guru Ram Das University of Health Sciences, Amritsar, India ORCID: Prabhjot Gill: https://orcid.org/0000-0003-1598-8448 Abstract Background: Breast carcinoma in females is an ever-growing malaise with significant mortality and morbidity. In resource-poor settings, the need for a cost-effective and reliable diagnostic tool is of utmost importance. Methods: In the present study, 54 histopathologically proven breast cancer patients were investigated for their pre- and postoperative serum ALP and ACP levels. Results: A total of 34 cases (belonging to the age interval of 40–60 years) exhibited a significant drop in serum ALP level after surgery (P = 0.002). Although the serum ACP also showed a postoperative decline, it was not as significant as that of serum ALP. Conclusion: The role of serum ALP and ACP in the diagnosis, prognosis, and monitoring/surveillance of breast carcinoma cannot be underestimated particularly in third-world countries lacking in medical infrastructure or resource-poor settings. Keywords: alkaline phosphatase, acid phosphatase, breast cancer, malignancy 1. Introduction Alkaline phosphatase (ALP) and acid phosphatase (ACP) are hydrolase enzymes that are active under alkaline and acidic conditions, respectively. They chemically remove the phosphate group from the nucleotides and proteins [1]. Growing children have a comparatively higher levels of serum ALP due to active bone formation and growth. Similarly, males have higher serum ALP level as compared to females, while the dif- ference is neutralized after the age of 60. In females, the serum ALP is elevated during puberty, pregnancy, lactation, and menopause, which is purely physiological [2]. Whereas, ACP is prominently synthesized by the liver, bone marrow, prostate, and How to cite this article: Stalinjit Singh, Sudershan Kapoor, Mukesh Chander, and Prabhjot Kaur Gill* (2022) “Recent Update on Serum Alkaline and Acid Phosphatases in Pre- and Postoperative Breast Cancer Patients,” Sudan Journal of Medical Sciences, vol. 17, Issue no. 1, pages 70–78. DOI 10.18502/sjms.v17i1.10686 Page 70 Corresponding Author: Prabhjot Kaur Gill; email: pjkgill@rediffmail.com Received 17 January 2021 Accepted 07 March 2022 Published 31 March 2022 Production and Hosting by Knowledge E Stalinjit Singh et al.. This article is distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use and redistribution provided that the original author and source are credited. Editor-in-Chief: Prof. Mohammad A. M. Ibnouf http://www.knowledgee.com mailto:pjkgill@rediffmail.com https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ Sudan Journal of Medical Sciences Stalinjit Singh et al. spleen. However, at the same time, the pathological basis of serum ALP elevation also cannot be ruled out, which can be indicative of multi-factorial etiology involving infection of the bone (osteomyelitis), autoimmune disorders (rheumatoid arthritis), CKD (chronic kidney disease), and malignancy [3]. The pathological basis of elevated serum ALP and ACP levels can be associated with infection, inflammation, and infiltration. Serum ALP is the most reliable tumor marker among others like serum ACP, lactose dehydrogenase (LDH), calcium, and serum amyloid-A protein (SAA) in breast carcinoma [4]. Serum ALP estimation is a cost-effective and reliable diagnostic tool in breast cancer, particularly in third-world countries that lack the infrastructure for the modern-day diag- nosis of breast cancer [4]. The serum ALP level is known to rise proportionally with the advancing stage in breast cancer [5]. Breast carcinoma, like other types of malignancies, is a cumulative outcome of multiple predisposing factors which interactively initiate carcinogenesis. The prevalence of breast carcinoma increases with advancing age, particularly post-menopausal females are more prone to malignancy. Cessation of a menstrual cycle is followed by altered biochemistry of female sex hormones and hence increased risk of breast carcinoma [6]. The clinical presentation of breast cancer includes multiple symptoms, which are often ignored by patients leading to the delay in medical intervention which resulted in mortality and morbidity related to the disease [7]. In the absence of metastatic spread, the surgical resection of the tumor can normalize the elevated serum ALP level in breast cancer patients, thereby indicating a good prognosis [8]. There are numerous missing links in the studies regarding variation in the level of serum ALP and ACP in breast carcinoma. The underlying cause of elevated ALP and ACP levels needs to be investigated thoroughly to diagnose the malignancy in its early stage. The real-time use of serum ALP and ACP as a diagnostic and prognostic tool is possible only if the knowledge gaps and missing links are well understood and worked upon. Therefore, the present study investigates the role of serum ALP and ACP pre and post operative surgery in breast cancer patients. 2. Materials And Methods All protocols, procedures, and instrumentation were standardized according to the setting in the Department of Medical Laboratory Sciences, Khalsa College of Pharmacy and Technology, Amritsar. DOI 10.18502/sjms.v17i1.10686 Page 71 Sudan Journal of Medical Sciences Stalinjit Singh et al. 2.1. Permission The study was approved by the Doctoral Advisory Committee, Institutional Research Committee, and Institutional Ethics Committee of Adesh University, Bathinda. Permission was granted by the competent authority of Government Medical College and Hospital (GMC&H), Amritsar for the collection of blood samples of breast cancer patients from July 2017 to July 2018. The inclusion criteria for this study were: female patients with histopathologically proven malignancy breast cancer, patients with diverse demography (rural/urban) and socioeconomic status, nonpregnant female subjects, patients without autoimmune dis- orders (rheumatoid arthritis) and bone infections (osteomyelitis), aged >20 years, having no liver disease (cirrhosis), chronic kidney disease and hemodialysis, and mentally fit to provide informed consent and relevant information related to the disease. 2.2. Sample collection Fasting 2 ml of blood was drawn by venipuncture under aseptic conditions before and after the surgery (pre and postoperatively) after written informed consent was obtained from the breast cancer patients. The needles and syringes were discarded according to the protocol for biomedical waste management. 2.3. Transportation Blood samples were immediately transported (with 4ºC temperature maintained in a cool box) to the clinical laboratory for further processing. 2.4. Enzyme assay Blood samples were centrifuged at 2500 rpm for 15 min to obtain serum. P-Nitrophenyl phosphate kits for serum ALP and serum ACP were used to measure serum ALP and ACP on a semi-automated analyzer (Erba Chem 5 Plus V2). Absorbance readings were taken at 405 nm wavelength with temperature maintained at 37ºC. The manufacturer’s guidelines were followed throughout the procedure. Readings were reported in IU/L. DOI 10.18502/sjms.v17i1.10686 Page 72 Sudan Journal of Medical Sciences Stalinjit Singh et al. 2.5. Statistical analysis All necessary analysis was done using MS-Excel 2007. The means or frequencies of patient demographics were interpreted. The variation between pre and postoperative values of both serum ALP and ACP was analyzed by using unpaired t-test. P-value ≤ 0.05 was considered statistically significant. 3. Results and Discussion The present study reported 54 breast cancer patients registered at Government Medical College and Hospital (GMC&H), Amritsar. According to the age interval, the participants were divided into different age groups (Table 1). Among them, the most affected age group was 40–49 years (37%) followed by 50–59 years (26%). Similar results were reported by the American Cancer Society, Indian Cancer Society, and NCBI. Whereas, Anders et al [9] reported the incidence of early onset of breast cancer in females. In the current study, early onset of malignancy (12.96%) related to the age interval of 30– 39 years had been reported. Data reported by NCBI and NIH (2019) reveals that 11% of breast cancer cases occur in women <40 years of age. The early onset of breast carcinoma among young females is alarming and ever-increasing. Predisposing risk factors are prolonged use of oral contraceptives, high animal fat intake, and low BMI in premenopausal females [10], whereas non-modifiable risk factors include familial predisposition and gene mutations [11]. In the present study, familial predisposition cases (7.4%) belonged to the age interval of 50–59 years (Table 1). Rural and urban distribution of patients in the current study was found to be 64.82% and 35.18%, respectively. According to the World Bank collection of development indicators (2018), 65.97% of the Indian population resides in the rural belt. Also, it is the rural population which owing to their low socioeconomic status visits exclusively government hospitals for treatment. In total, 54 cases were confirmed for the malignancy (malignant breast lesions) as supported by FNAC findings. Of them, 19 subjects were confirmed with stage II, whereas the remaining 35 had stage-III presentation. Furthermore, all of the stage-III patients were identified with axillary lymphadenopathy (Table 2). Out of the 54 confirmed malignant cases, 44 had a painless lump (81.48%), while 10 had a painful lump (18.51%). A painless lump is a more common clinical feature among breast carcinoma patients [12]. Further, in the current study, ulceration of skin over the lump (18.51%) was also reported. Breast cancer with skin ulceration is considered a locally advanced disease [13]. The finding of skin ulceration as a symptom of locally advanced DOI 10.18502/sjms.v17i1.10686 Page 73 Sudan Journal of Medical Sciences Stalinjit Singh et al. Table 1: Demographics of breast carcinoma patients. Age interval (yr) N = 54 Percentage 30–39 07 12.96% 40–49 20 37.03% 50–59 14 25.92% 60–69 07 12.96% 70–79 06 11.11% Rural 35 64.82 % Urban 19 35.18% Familial predisposition 04 7.40% Table 2: Distribution of breast cancer patients according to their symptoms. Clinical symptoms No. of patients Percentage Stage (TNM) II 19 35.18% III 35 64.81% Axillary Lymphadenopathy 35 64.81% Lump Painless 44 81.48% Painful 10 18.51% Ulceration of skin over lump 10 18.51% Skin changes (skin texture changes) of the breast involved 09 16.66% Nipple discharge 08 14.81% Weight loss 05 09.25% Anorexia 07 12.96% Malignant lesions 54 90.0% Benign lesions 06 10.0% Malignant + benign lesions 60 100% 0 50 100 150 200 250 300 350 400 30 35 39 39 40 43 44 44 45 45 45 47 48 49 50 50 50 51 54 55 57 62 65 66 70 72 75 S e r u m A L P I U / L Age(years) PRE OPERATIVE POST OPERATRIVE Figure 1: Pre- and postoperative serum alkaline phosphatase levels in different age groups of breast carcinoma. breast carcinoma and inflammatory breast cancer is a deciding factor for early diagnosis and the choice of treatment and its outcome. The breast skin changes were observed in 16.66% of cases whereas 14.81% of patients reported nipple discharge after skin changes in the breast. As reported earlier, nipple discharge is a characteristic feature of ductal carcinoma in situ ranging from 2% to 13% in clinical presentation [14]. The typical symptoms of breast carcinoma like a lump, ulceration, and pigmentation of skin over DOI 10.18502/sjms.v17i1.10686 Page 74 Sudan Journal of Medical Sciences Stalinjit Singh et al. Table 3: Comparison of pre and postoperative levels of serum ALP and ACP in different age groups of breast carcinoma. Breast carcinoma ALP IU/L ACP IU/L Age (yr) No. of cases Mean ± SD P-value No. of cases Mean ± SD P- value 30–39 Preoperative 07 202.02 ± 66.16 0.0841 07 0.70 ± 0.07 0.1064 Postoperative 147.71 ± 37.97 0.62 ± 0.07 40–49 Preoperative 20 207.24 ± 63.61 0.0029 20 0.72 ± 0.13 0.0812 Postoperative 151.79 ± 44.98 0.65 ± 0.11 50–59 Preoperative 14 201.46 ± 50.36 0.002 14 0.72 ±0.11 0.2249 Postoperative 145.81 ± 34.02 0.67 ± 0.10 60–69 Preoperative 07 184.32 ± 50.57 0.091 07 0.76 ± 0.32 0.620 Postoperative 142.17 ± 33.61 0.69 ± 0.21 70–79 Preoperative 06 174.22 ± 74.46 0.4868 06 0.66 ± 0.12 0.6577 Postoperative 148.0 ± 48.72 0.62 ± 0.12 0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 30 35 39 39 40 43 44 44 45 45 45 47 48 49 50 50 50 51 54 55 57 62 65 66 70 72 75 S e r u m A C P I U / L Age(years) PRE OPERATIVE Figure 2: Pre- and postoperative serum acid phosphatase levels in different age groups of breast carcinoma. the lump, nipple discharge, and lymphadenopathy (axillary or generalized) have been reported in many studies related to breast cancer with minor variation in their distribution (NCBI, American Cancer Society). Henceforth, weight loss in breast carcinoma can be attributed to the stage of cancer, (as the stage advances, the nutritional demand of cancer cells increases as is the cancer load) and the psychological stress related to malignancy and anorexia. Therefore, the current study reported five cases with significant weight loss (>10% of body weight) accounting for 9.25% of breast cancer patients (Table 2). In addition, loss of appetite (anorexia) was reported in seven patients (12.96%). Both weight loss and anorexia resulted to be the outcome of psychological DOI 10.18502/sjms.v17i1.10686 Page 75 Sudan Journal of Medical Sciences Stalinjit Singh et al. stress related to cancer, altered biochemistry, the nutritional burden of caner load, and diminished taste and smell perceptions [15]. Comparison of pre and postoperative levels of serum ALP and ACP was undertaken statistically to find any significant variation. The age group 40–49 years (n = 20) exhibited a statistically significant drop (postoperatively) in the level of serum ALP from 207.24 ± 63.61 to 151.79 ± 44.98 (p = 0.002) (Table 3, Figure 1). However, the drop for serum ACP was from 0.729 ± 0.137 to 0.657 ± 0.117 (Table 3, Figure 2). The age group 50–59 years (n = 14) also exhibited a statistically significant difference (p = 0.002) for the decline in postoperative serum ALP level from 201.46 ± 50.36 to 145.81 ± 34.02, thus reinforcing the use of serum ALP as a cost-effective tumor marker in breast carcinoma in poor resource settings [16]. Serum ACP levels in pre and postoperative cases in age groups 40–49 and 50–59 years showed a statistically insignificant drop from 0.72 to 0.65–0.67 IU/l with p-values 0.081 and 0.224, respectively (Table 3). The maximum number of patients (20 + 14 = 34) showing a significant drop in serum ALP levels postoperatively belonged to the age group 40–60 years, which had the largest number of cases. Similarly, a significant drop in serum ALP postoperatively in all stages has been reported earlier [8]. 4. Conclusion The most common symptom of breast cancer is a lump or mass in the breast, which in most cases is painless. Other findings are axillary lymphadenopathy, nipple dis- charge, ulceration of skin over the lump, and changes in the skin texture of the breast involved. The role of serum ALP and ACP as tumor markers has its advantages in resource-poor settings. Furthermore, the high prevalence of breast carcinoma among females of developing countries reinforces the use of serum ALP and ACP as cancer markers in resource-poor settings. Therefore, studies will be required to establish the value of serum ALP to predict the prognosis, diagnosis, and monitoring of breast cancer. Acknowledgements Nil. DOI 10.18502/sjms.v17i1.10686 Page 76 Sudan Journal of Medical Sciences Stalinjit Singh et al. Ethical Considerations The current study was approved by the institutional ethics committee of the Government Medical College, Amritsar (Code no. GMCIEC00104). Competing Interests There are no conflicts of interest. Availability of Data and Material All relevant data of this study are available to any interested researchers upon reason- able request to the corresponding author. Funding There is no funding source. References [1] Buchet, R., Millán, J. L., and Magne, D. (2013). Multisystemic functions of alkaline phosphatases. In Phosphatase modulators (pp. 27–51). Totowa, NJ: Humana Press. [2] Yulia, A. and Wijesiriwardana, A. (2012). Extremely high isolated maternal alkaline phosphatase serum concentration–2 case reports and literature review. Archives of Disease in Childhood-Fetal and Neonatal Edition, vol. 97, no. 1, pp. A65–A66. [3] Sharma, U., Pal, D., and Prasad, R. (2014). Alkaline phosphatase: an overview. Indian Journal of Clinical Biochemistry, vol. 29, no. 3, pp. 269–278. 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