Lactate and cancer: spinal metastases and potential therapeutic targets (part 2)

Metastatic spine disease is a heterogeneous clinical condition commonly requiring surgical intervention. Despite this heterogeneity, all cases share the common theme of altered tumor metabolism, characterized by aerobic glycolysis and high lactate production. Here we review the existing literature on lactate metabolism as it pertains to tumor progression, metastasis, and the formation of painful bone lesions. We included articles from the English literature addressing the role of lactate metabolism in the following: (I) primary tumor aggressiveness, (II) local tissue invasion, (III) metastasis formation, and (IV) generation of oncologic pain. We also report current investigations into restoring normal lactate metabolism as a means of impeding tumor growth and the formation of bony metastases. Both in vivo and in vitro experiments suggest that high lactate levels may be necessary for tumor cell growth, as small molecules inhibitors of lactate dehydrogenase (LDH5/LDHA) decrease both the rate of tumor growth and formation of metastases. Additionally, in vitro evidence strongly implicates lactate in tumor cell migration by driving the amoeboid movements of these cells. Acidification of the local bony tissue by excess lactate production activates CGRP⁺ neurons in the bone marrow and periosteum to generate oncologic bone pain. High lactate may also increase expression of acid sensing receptors in these neurons to generate the neuropathic pain seen in some patients with metastatic disease. Lastly, investigation into lactate-directed therapeutics is still early in development. Initial preclinical trials looking at LDH5/LDHA inhibitors as well as inhibitors of lactate transporters (MCT1) have demonstrated promise, but clinical work has been restricted to a single phase I trial. Lactate appears to play a crucial role in the pathogenesis of metastatic spine disease. Efforts are ongoing to identify small molecules inhibitors of targets in the lactogenic pathway capable of preventing the formation of osseous metastatic disease.