Leukemia (2001) 15, 832–839
 2001 Nature Publishing Group All rights reserved 0887-6924/01 $15.00
www.nature.com/leu
Serum nm23-H1 protein as a prognostic factor for indolent non-Hodgkin’s lymphoma
N Niitsu1,2, M Okamoto3, J Okabe-Kado2, T Takagi4, T Yoshida5, S Aoki6, Y Honma2 and M Hirano3
1
Department of Internal Medicine, Kitasato University School of Medicine, Kanagawa; 3Department of Internal Medicine, Fujita Health
University School of Medicine, Toyoake; 2Research Institute, Saitama Cancer Center, Saitama; 4Hematology-Oncology Division, Chiba
Cancer Center Hospital, Chiba; 5Toyama Prefectural Central Hospital, Toyama; and 6First Department of Internal Medicine, Niigata
University School of Medicine, Niigata, Japan (Adult Lymphoma Treatment Study Group)
Standard chemotherapy has been ineffective for improving the
poor 10-year survival rate of patients with indolent lymphoma.
However, a wider choice of therapeutic modalities has become
recently available, including immunotherapy with monoclonal
antibodies and allogeneic peripheral blood stem cell transplantation. Accordingly, a sensitive prognostic indicator is required
to identify high-risk patients and to help design new therapeutic approaches for them. We previously reported that the
serum nm23-H1 protein level was an independent prognostic
factor for aggressive lymphoma. The present study was performed to assess the clinical implications of this protein on indolent lymphoma and whether it can be used to classify the
aggressiveness of the disease in order to assist in the individualization of therapy. A total of 130 patients with indolent lymphoma were enrolled in this multicenter study. The serum
nm23-H1 protein level was significantly higher in patients with
indolent lymphoma than in a normal control group. In addition,
indolent lymphoma patients with higher nm23-H1 levels had
worse overall and progression-free survival rate than those
with lower nm23-H1 levels. Therefore, nm23-H1 in serum may
be useful for identifying a distinct group of patients at high risk.
Leukemia (2001) 15, 832–839.
Keywords: nm23-H1 protein; indolent lymphoma; prognostic factor
(I-factor) purified from a differentiation-resistant mouse
myeloid leukemia cell line was identical to nm23 protein.6,7
In an immunohistochemical study of nm23-H1 in malignant
lymphoma, the expression of this protein was significantly
increased in Hodgkin’s disease and high-grade NHL as compared with that in low-grade NHL.8 Recently, we established
an enzyme-linked immunosorbent assay (ELISA) for determining the serum level of nm23-H1 protein.9,10 Using this assay,
we have already demonstrated that the serum nm23-H1 level
is significantly higher in patients with indolent and aggressive
NHL, and acute myelogenous leukemia (AML) than in normal
controls.9,10 (Table 1) This assay may be useful for determining
the therapeutic strategy for aggressive NHL, since the prognosis is worse with a high nm23-H1 level.9 In the present
multicenter study, the association between the serum nm23H1 protein level and other prognostic markers of NHL was
assessed. The serum level of nm23-H1 was elevated in
patients with indolent lymphoma, and the serum level was
significantly correlated with the clinical outcome, suggesting
that nm23-H1 may be a valuable prognostic factor for
predicting the outcome in indolent lymphoma.
Introduction
Indolent lymphoma is characterized by slow progression.
However, since standard chemotherapy achieves poor progression-free survival and overall survival after 10 years of follow-up,1 this disease is difficult to cure. The international
prognostic index (IPI)2 reported by Shipp in 1993 has been
accepted in many countries as a prognostic model that reasonably predicts the clinical outcome for aggressive lymphoma.
The IPI model is based on five dependent prognostic factors
(age, performance status, number of extranodal sites, Ann
Arbor stage, and serum LDH concentration) and it can identify
patients with non-Hodgkin’s lymphoma (NHL) in four different
risk groups (ie low (L), low-intermediate (L–I), high-intermediate (H–I), and high risk (H)). The model has been extensively
applied to identify aggressive lymphoma and indolent lymphoma with a poor prognosis. Recently, new therapies have
been used to treat indolent lymphoma patients with risk factors that might indicate a poor prognosis, eg immunotherapy
with monoclonal antibodies, autologous stem cell transplantation combined with high-dose chemotherapy, and allogeneic peripheral blood stem cell transplantation for younger
patients.3–5 A wide choice of modalities has recently become
available for the treatment of indolent lymphoma. Therefore,
it is now necessary to stratify patients based on their prognosis
and to individualize therapy.
We previously found that a differentiation inhibitory factor
Correspondence: N Niitsu, Department of Hematology and Internal
Medicine, Kitasato University School of Medicine, Kitasato, Sagamihara-shi, Kanagawa, 228-8555, Japan; Fax: 81 42 778 9847
Received 9 August 2000; accepted 16 January 2001
Materials and methods
Patients
We measured nm23-H1 levels in consecutive 130 untreated
indolent type lymphoma patients who were managed by the
Adult Lymphoma Treatment Study Group (ALTSG) in Japan.
Indolent lymphoma was of the B cell lineage in all patients,
including 86 with follicular grade I, 42 with follicular grade
II, and two with small lymphocytic lymphoma according to
the REAL schema.11 Patients with mantle cell lymphoma were
excluded from this analysis since it is an independent disease
unit and the types of therapy applied to treat this disease differ
from those for other types of indolent lymphoma. All slides
were re-examined by two hematopathologists to confirm the
diagnosis of indolent lymphoma and for uniform cytologic
classification. The median age was 66 years (range: 18–80
years). Clinical staging was performed according to the Ann
Arbor classification system.11 Evaluation included a complete
history and physical examination: chest roentgenography;
bone marrow aspiration and biopsy; computed tomography
of the chest, abdomen and pelvis; hemogram and differential
counts; and routine biochemistry tests. The subjects were all
patients with stage II to IV, in whom chemotherapy was indicated. The IPI could be determined in NHL cases.2 Indolent
lymphoma was in most cases treated with single agent
(cyclophosphamide : 3 patients) or cyclophosphamide, vincristine, and prednisone (COP: 60 patients). In addition to
chemotherapy, 67 patients received megavoltage radiotherapy. Patients were followed up at intervals of several
months. Re-evaluation included physical examination, hemo-
Serum nm23-H1 protein and indolent non-Hodgkin’s lymphoma
N Niitsu et al
Table 1
833
Serum levels of nm23-H1 in normal control and hematologic malignancy
Diagnosis
Normal control
Indolent lymphoma
Aggressive lymphoma
Acute myelogenous leukemia
Acute lymphoblastic leukemia
No. of patients
Serum level of nm23-H1
(mean ± s.d.)(ng/ml)
P value
45
130
149
102
6
3.89 ± 4.06
19.31 ± 22.34
50.73 ± 66.0
61.8 ± 34.6
65.7 ± 40.2
—
0.00001
0.00001
0.00001
0.0003
gram and differential counts, biochemistry tests, and computed tomography of the chest, abdomen, and pelvis. The
median follow-up time was 61 months (range: 6 to 115
months). Serum samples were obtained from 45 healthy volunteers with a mean age of 57 years (range: 18–84 years) for
comparison of nm23-H1 levels. All patients gave informed
consent for both treatment and sample collection in accordance with institutional policy.
rank and generalized Wilcoxon’s tests.14 Differences between
groups were evaluated by the Mann–Whitney U-test
(nonparametric analysis),15 or Fisher’s exact test, and P ⬍ 0.05
was taken to indicate significance. A multivariate analysis of
the prognosis was performed using Cox’s proportional-hazards regression model.16 All calculations were performed with
SAS software (version 6.10, SAS Institute, Cary, NC, USA).
Results
Enzyme-linked immunosorbent assay (ELISA) for
human nm23-H1
We determined the serum level of nm23-H1 protein by ELISA,
as described previously.9,10 Measurements were performed at
the Department of Immunology, SRL Inc (Tokyo, Japan).
Briefly, 96-well plates (Corning, Corning, NY, USA) were
coated with a monoclonal anti-nm23-H1 antibody
(Seikagakukougyo, Tokyo, Japan), washed four times with
phosphate-buffered saline (PBS), and incubated with 25%
Block Ace (Dainihon Seiyaku, Osaka, Japan). Serum samples
were diluted two-fold with PBS, and then 50 ␮l aliquots were
added to the wells. After incubation at room temperature for
1 h, the wells were washed four times with PBS containing
0.05% Tween 20 (T-PBS). Samples were then incubated at
room temperature for 1 h with a polyclonal anti-nm23-H1
antibody (Santa Cruz Biotechnologies, Santa Cruz, CA, USA),
washed four times with T-PBS, and incubated with alkaline
phosphatase-conjugated anti-rabbit IgG (BioRad, Richmond,
CA, USA). After washing four times with T-PBS, alkaline phosphatase activity was detected using diethanolamine as a substrate and an alkaline phosphatase-detecting kit (BioRad). The
reaction was stopped by addition of 50 ␮l of 0.4 N NaOH.
Absorbance was measured at 405–415 nm with a correction
wavelength of 620–630 nm using a Microplate reader.
Soluble interleukin-2 receptor (IL-2R) was measured with a
sandwich ELISA12 and soluble CD44 was measured by sandwich ELISA using a sCD44std ELISA kit (Bender MedSystems,
Vienna, Austria).
Statistical analysis
The patients’ characteristics were compared using the chisquare test. Overall survival (OS) was defined as the interval
from initiation of therapy to the time of death or last followup. Progression was defined as a 25% increase in the product
of the two largest tumor diameters. Progression-free survival
(PFS) was calculated from the date of entry to the date of the
first physical or radiographic evidence of disease progression,
death or the last follow-up visit. Survival analysis was performed using the Kaplan–Meier method.13 The statistical significance of differences in survival was determined by the log-
Correlations between the nm23-H1 level and other
serum markers in indolent lymphoma
The serum level of nm23-H1 was significantly elevated in the
patients with indolent lymphoma (n = 130, mean ± s.d.;
19.31 ± 22.34 ng/ml) compared with that in the healthy controls. (n = 45, 3.89 ± 4.06 ng/ml; P = 0.00001). Furthermore,
this level was higher in follicular grade I (n = 86,
20.92 ± 24.12 ng/ml; P = 0.00001), follicular grade II (n = 42,
18.47 ± 32.41 ng/ml; P = 0.046), and small lymphocytic
(n = 2, 11.36 ± 8.56 ng/ml; P = 0.025) than in the healthy controls, without any significant difference among the three histological types. When the correlation between nm23-H1 and
other known serum markers of NHL, as well as correlations
among the known serum markers were assessed, there was a
weak correlation between serum nm23-H1 protein and sIL-2R
(r = 0.2424, P = 0.0055), but not between the nm23-H1 level
and LDH, beta2-microglobulin (MG), or sCD44. There was a
correlation between sIL-2R and LDH (r = 0.3628, P = 0.0002),
and between sIL-2R and beta2-MG (r = 0.4647, P = 0.0001),
while beta2-MG was also correlated with sCD44 (r = 0.3452,
P = 0.0069) (Table 2).
Relationship between serum nm23-H1 protein and
clinicopathological features of indolent lymphoma
Table 3 shows the clinicopathological features of the 130
patients. The cut-off value of LDH was the upper limit of the
normal range at each institution. An increased LDH level was
correlated with the nm23-H1 protein level (P = 0.0016). In
addition, the nm23-H1 protein level increased as the disease
stage increased (P = 0.043). With respect to the IPI classification, the nm23-H1 level was higher in the H–I + H risk
group than in the L + L–I risk group (P = 0.007), although there
was no significant difference between lymphomas with different histology (P = 0.1971). The nm23-H1 protein level was
independent on the response to therapy (CR vs non-CR). These
results suggest that the nm23-H1 protein level is associated
with the tumor mass and the IPI, but not with the response
to therapy.
We also analyzed the serum nm23-H1 level in relation to
Leukemia
Serum nm23-H1 protein and indolent non-Hodgkin’s lymphoma
N Niitsu et al
834
Table 2
Correlation of nm23-H1 levels to other serum markers in indolent lymphoma patients
nm23-H1
LDH
sIL-2R
␤2-MG
sCD44
—
0.13996ⴱ
P = 0.1122
0.24240
P = 0.0055
0.08477
P = 0.3376
0.15331
P = 0.2422
LDH
0.13996
P = 0.1122
—
0.36278
P = 0.0002
0.14269
P = 0.1485
0.08280
P = 0.5294
sIL-2R
0.24240
P = 0.0055
0.36278
P = 0.0002
—
0.46467
P = 0.0001
0.13630
P = 0.2991
␤2-MG
0.08477
P = 0.3376
0.14269
P = 0.1485
0.46467
P = 0.0001
—
0.34520
P = 0.0069
sCD44
0.15331
P = 0.2422
0.08280
P = 0.5294
0.13630
P = 0.2991
0.34520
P = 0.0069
—
nm23-H1
ⴱSpearman’s correlation coefficients.
Table 3
Association between the pretreatment nm23-H1 levels and clinicopathological factors in indolent non-Hodgkin’s lymphoma
Factors
No. of patients
nm23-H1 leveld (%)
⭐25 ng/ml
⬎25 ng/ml
U testa
F testc
Age at diagnosis (years)
⭐60
⬎60
65
65
73.9
76.9
26.1
23.1
0.687
0.712
Gender
Male
Female
76
54
76.3
74.1
23.7
25.9
0.773
0.688
111
19
77.5
63.2
22.5
36.8
0.184
0.199
Serum LDH level
Normal
⬎Normal
72
58
86.1
62.1
13.9
37.9
0.002
0.001
Ann Arbor stage
II
III
IV
46
35
49
84.3
68.6
69.4
15.7
31.4
30.6
0.043b
0.038
Histology
Follicular grade I
Follicular grade II
Small lymphocytic
86
42
2
71.8
84.4
100
28.2
15.6
0
0.197
0.221
Extranodal sites
0–1
⬎1
117
13
76.9
61.5
23.1
38.5
0.539
0.714
B symptoms
Absent
Present
104
26
77.9
65.4
22.1
34.6
0.189
0.198
Bulky disease
Absent
Present
115
15
75.7
73.3
24.3
26.7
0.845
0.762
54
36
32
8
85.2
77.8
59.4
62.5
14.8
22.2
40.6
37.5
0.007
0.006
101
29
76.2
72.4
23.8
27.6
0.677
0.694
WHO performance status
0–1
2–4
International prognostic index
Low
Low–intermediate
High–intermediate
High
Response
CR
non CR
LDH, lactate dehydrogenase; CR, complete remission.
a
Mann–Whitney test; bKruskal–Wallis test; cFisher’s exact test; dnm23-H1: cut-off line: 3/4 point concentration.
Leukemia
P value
Serum nm23-H1 protein and indolent non-Hodgkin’s lymphoma
N Niitsu et al
835
histological subgroups (Figure 1a). The results showed that
when the LDH level (normal/elevated) (Figure 1b) was high
and the risk assessed by IPI (Figure 1c) was greater, the serum
nm23-H1 level also tended to be higher.
Correlation of nm23-H1 and other prognostic features
with survival
For the entire 130 patients, the 9-year overall survival rate was
36.5% and the 7-year progression free survival (PFS) rate was
15.7%. The patients were divided into two groups with different serum nm23-H1 levels using various cut-off values over
12.01 ng/ml, which was the upper limit in the controls
(3.89 + 2 s.d.). The cut-off values tested were as follows:
12.01 ng/ml (⭐12.01, n = 66 vs ⬎12.01, n = 64), 20.2 ng/ml
(2/3 point; ⭐32.5, n = 87 vs ⬎32.5, n = 43), and 25.0 ng/ml
(3/4 point; ⭐25.0, n = 98 vs ⬎25.0, n = 32). Only two groups
based on a cut-off at the 3/4 value differed significantly from
each other with respect to overall survival (Wilcoxon test,
P = 0.0358, log-rank test, P = 0.0486) and PFS (Wilcoxon test,
P = 0.0144, log-rank test, P = 0.0245) (Figure 2, Table 4). This
indicated that the prognosis of indolent lymphoma was poor
when the nm23-H1 protein level was 25.0 ng/ml or higher.
Since the nm23-H1 level for indolent lymphoma was lower
than that for AML and aggressive lymphoma, the cut-off point
would have been relatively high. Hence, the cut-off point was
set at 25 ng/ml. In the group with a low nm23-H1 level (less
than 25 ng/ml) (n = 98), there were 48 patients who
underwent COP therapy, 48 patients who underwent
COP/radiation therapy, and 2 patients who underwent cyclophosphamide therapy, and in the group with a high nm23-H1
level (higher than 25 ng/ml) (n = 32), there were 12 patients
who underwent COP therapy, 19 patients who underwent
COP/radiation therapy, and 1 patient who underwent cyclophosphamide therapy. Hence, there were no differences with
respect to therapy methods. We also calculated the overall
survival and PFS for patients with normal or increased LDH
levels. The 5-year overall survival rates for patients with normal and increased LDH levels, were 70.5% and 62.9%,
respectively (Wilcoxon and log-rank tests showed no significant differences), and the 5-year PFS was 40.9% and 13.9%,
respectively, (Wilcoxon and log-rank tests showed no signifi-
Figure 2
Overall survival (a) and progression-free survival (b)
curves of patients with indolent lymphoma. High nm23-H1
(⬎25 ng/ml) patients (n = 32) had a worse prognosis than low nm23H1 (⭐25 ng/ml) patients (n = 98).
cant differences) (Figure 3). Furthermore, the 5-year overall
survival rate was 72.8% for the L + L–I risk group and 54.0%
for the H–I + H risk group (Wilcoxon test, P = 0.0234, log-rank
test, P = 0.0068), and the 5-year PFS was 30.6% for the L + L–
I risk group and 13.4% for the H–I + H risk group (Wilcoxon
test, P = 0.0024, log-rank test, P = 0.0071) (Figure 4).
Univariate analysis was performed to assess the predictive
power of nm23-H1 and other prognostic factors. Overall survival was significantly worse for patients who had a WHO
PS of 2–4, more than one extranodal site, B symptoms, bulky
disease, an IPI classification of H–I + H risk, an sIL-2R of
858.0 U/ml or higher, or an nm23-H1 level of 25.0 ng/ml or
higher. The PFS rate was significantly lower in patients with
a PS of 2–4, Ann Arbor stage III/IV, more than one extranodal
site, an IPI classification of H–I + H risk, an sIL-2R of
858.0 U/ml or higher, or nm23-H1 level of 25.0 ng/ml or
higher (Table 4). In contrast, classification of the patients
based on serum LDH or beta2-MG levels failed to produce
any significant difference in either overall survival or PFS. An
additional multivariate analysis revealed that the five prognostic factors used to calculate the IPI score and the serum nm23H1 level were associated with OS (Table 5). These results indicate that the nm23-H1 level is an independent prognostic factor which may predict both the OS. This was also true for
ascertaining the OS in patients with indolent lymphoma.
Discussion
Figure 1
Serum levels of nm23-H1 protein in patients with indolent lymphoma classified according to the histology, LDH level, or
international prognostic index.
Patients with indolent lymphoma rarely achieve a cure with
conventional therapy and many of them eventually die of the
Leukemia
Serum nm23-H1 protein and indolent non-Hodgkin’s lymphoma
N Niitsu et al
836
Table 4
Prognostic factors in a univariate analysis
Factors
International Index
L + L–I
H–I + H
No. of
patients
5-year
survival (%)
Wilcoxon
test
Log-rank
test
5-year
PFS
(%)
P value
Wilcoxon
test
Log-rank
test
90
40
72.8
54.0
0.0234
0.0068
30.6
13.4
0.0024
0.0071
111
19
69.4
62.4
0.0130
0.0646
27.1
35.3
0.0001
0.0004
Serum LDH level
Normal
⬎Normal
72
58
70.5
62.9
0.4256
0.1651
40.9
13.9
0.1325
0.1085
Ann Arbor stage
II
III, IV
46
84
70.4
75.6
0.0960
0.1471
27.4
23.5
0.0177
0.0927
Extranodal sites
0–1
⬎1
117
13
69.7
52.8
0.0002
0.0008
41.7
26.0
0.0061
0.0152
B symptoms
absent
present
104
26
72.0
42.1
0.0016
0.0073
25.8
20.1
0.2038
0.7135
Bulky disease
absent
present
115
15
68.9
54.9
0.0486
0.1490
58.3
31.2
0.1546
0.9375
Age at diagnosis (years)
⭐60
⬎60
65
65
70.0
69.9
0.9793
0.8969
44.9
22.3
0.1545
0.0997
Gender
Male
Female
76
54
64.3
70.4
0.1803
0.5917
23.5
28.4
0.1319
0.5022
Treatment parameters
COP
COP/radiation
Cyclophosphamide
60
67
3
61.3
68.2
60.4
0.5412
0.3041
38.6
40.4
34.6
0.0946
0.1472
30
100
62.4
68.4
0.4250
0.7099
16.4
27.6
0.6832
0.3054
66
64
87
43
98
32
69.4
65.5
69.9
62.8
72.0
50.0
0.3558
0.1449
0.0669
0.0787
0.2250
0.1530
0.0821
0.1473
0.0358
0.0486
48.6
44.2
45.3
43.5
58.6
29.7
0.0144
0.0245
49
81
74.4
62.1
0.0119
0.0096
17.5
26.7
0.0073
0.0663
WHO performance status
0–1
2–4
␤2-MG (mg/l)
control + 2 s.d.
⬎0.9
⭐0.9
nm23-H1 level (ng/ml)a
control + 2 s.d. ⭐12.01
⬎12.01
2/3 point
⭐20.2
⬎20.2
3/4 point
⭐25.0
⬎25.0
sIL-2R (U/ml)
control + 2 s.d. ⭐858.0
⬎858.0
a
2/3 point, one third higher; 3/4 point, one fourth higher.
disease.17 It has been reported that the best therapy for indolent lymphoma is to watch and wait unless it becomes symptomatic: the 5- and 10-year actuarial survival rates of untreated
patients are 82% and 73%, respectively, under this ‘watch and
wait’ policy. In patients who are initially monitored without
treatment; chemotherapy is started after a median of 3 years.18
Patients who receive intensive chemotherapy may achieve
CR, but their survival fails to reach a plateau, indicating that
more curative therapy is needed. A mouse–human chimera
monoclonal to CD20, IDEC-C2B8 (rituximab), was recently
introduced to treat indolent B-lymphoma. When used alone,
it has a 50–70% efficacy rate19 and when used in combination
Leukemia
P value
with CHOP therapy, it achieves a high efficacy of 90–100%.3
However, the improvement of survival still remains unknown
due to the need for long-term observation. Therefore, in young
patients with chemotherapy-resistant recurrence, the application of allogeneic stem cell transplantation is being investigated. To select candidates for such intensive therapy, a
reliable prognostic classification of indolent lymphoma would
be useful. As in aggressive NHL, the IPI is used to identify
indolent lymphoma patients with a poor prognosis.20 Many
prognostic studies of indolent lymphoma have been performed, and the following parameters were found to be associated with a poor prognosis: older age, poor performance status,
Serum nm23-H1 protein and indolent non-Hodgkin’s lymphoma
N Niitsu et al
Table 5
Multivariate analysis by Cox’s proportional hazards
model on indolent lymphoma
Category
nm23-H1 (⬍25/⭓25 ng/ml)
Age (⬍60/⭓60 years)
Stage (I, II/III, IV)
Performance status (0, 1/2–4)
Extranodal sites (0, 1/⬎1)
LDH (normal/⬎normal)
Figure 3
Overall survival (a) and progression-free survival (b)
curves of patients with indolent lymphoma based on the serum
LDH level.
Figure 4
Overall survival (a) and progression-free survival (b)
curves of patients with indolent lymphoma based on the international
prognostic index.
Hazards ratio
P value
2.827
1.423
1.294
1.944
1.728
1.303
0.0055
0.1911
0.4092
0.0144
0.2582
0.3098
837
advanced stage, B symptoms, bulky disease, bone marrow
involvement, increased serum LDH, and high serum beta2MG levels.20–24
The biological prognostic factors for aggressive lymphoma
have been extensively studied in recent years, but only a few
studies have been performed on the prognostic indicators for
indolent lymphoma. In patients with indolent lymphoma,
prognostic factors have been previously used to choose from
among three therapeutic options: the ‘watch and wait’
method, single-agent chemotherapy, and the COP regimen.
However, a wider choice of therapies is becoming available
and it is hoped that a curative therapy will eventually be
established. Therefore, it seems to be necessary to establish
prognostic factors that enable us to identify patients who
should be treated differently. The serum nm23-H1 protein
level was previously reported as a prognostic factor for
aggressive NHL, so the present study was designed to determine whether this protein was also an indicator for indolent
lymphoma. We found that the outcome of indolent lymphoma
was poor when the nm23-H1 level was high.
The nm23 gene seems to be involved in the suppression of
tumor metastasis, since its expression is decreased in cancer
with a propensity for metastasis.25 The product of this gene is
identical to nucleoside diphosphate kinase (NDPK).26
Decreased expression of nm23-H1 has been associated with
an aggressive clinical course in several human tumor cohorts,
such as primary breast, primary hepatocellular, ovarian and
gastric carcinomas, as well as melanoma. However, the
relationship between nm23 expression and tumor metastatic
potential is somewhat controversial. In other tumors, such as
childhood neuroblastoma and pancreatic carcinoma,
increased expression of nm23 is positively correlated with
tumor aggressiveness.27 We previously investigated the relative levels of nm23-H1 and nm23-H2 transcripts in bone marrow and peripheral blood samples from patients with AML,
determined the correlation between the expression of nm23
gene and clinical data, and evaluated the importance of nm23
expression as a prognostic factor in AML.28,29 We also used
ELISA to measure serum nm23-H1 protein levels in 102 AML
patients, and found that nm23-H1 protein levels were higher
in AML patients than in controls and that patients with high
nm23-H1 levels had a poor prognosis.10
The serum nm23-H1 protein level in malignant lymphoma
patients was significantly higher than that in normal controls.
In patients with aggressive lymphoma, a high nm23-H1 level
was associated with a poor prognosis and seemed to be an
independent prognostic indicator of the need for more intensive therapy. The level of this protein can be easily measured
using a small quantity of blood prior to therapy.9 Serum nm23H1 protein levels in patients with indolent lymphoma in the
present study were significantly higher than that of normal
controls, but lower than that of patients with either aggressive
Leukemia
Serum nm23-H1 protein and indolent non-Hodgkin’s lymphoma
N Niitsu et al
838
NHL9 or AML.10 In AML patients, the nm23-H1 protein level
was closely related to the product of the number of tumor
cells and the level of cellular nm23-H1 expression.10 These
results suggest that the more rapid proliferative potential and
greater nm23-H1 production in aggressive lymphoma cells
account for the higher nm23-H1 protein level than in indolent
lymphoma. Also, the tendency was that the more advanced
the disease state, the higher the nm23-H1 level, suggesting
that this prognostic factor correlates with tumor volume.
There have been only a few studies on the biological prognostic factors for indolent lymphoma. Litam et al30 reported
that a beta2-MG level of 3.0 mg/l or higher was associated
with a low complete remission rate and early treatment failure. A high serum IL-6 level is also reported to be associated
with a short duration of failure-free survival.31 In the present
study, the overall survival and PFS were significantly lower in
the patients with serum nm23-H1 protein levels ⬎25.0 ng/ml,
suggesting that this protein can serve as a new prognostic indicator for indolent lymphoma. Low-risk patients can be treated
by immunotherapy with monoclonal antibodies alone or in
combination with the CHOP regimen, whereas other therapeutic approaches (including allogeneic bone marrow
transplantation) should be considered for the treatment of
high-risk patients. The nm23-H1 protein level may be useful
for the management of indolent lymphoma in the future,
although the value of nm23-H1 protein as a prognostic factor
needs to be verified in large-scale prospective studies. It is
expected that the prognostic value of nm23-H1 would be
increased by using it in combination with other prognostic
factors. We are planning to assess such combinations to
predict the outcome more accurately than with nm23-H1
protein alone.
Acknowledgements
We thank the Department of Immunology, SRL Inc (Tokyo,
Japan) for measuring the serum nm23-H1 protein levels.
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