Purpose: Lactate dehydrogenase (LDH) levels in blood of patients with melanoma have proven to be an accurate predictor of prognosis and response to some treatments. Exclusion of patients with high LDH levels from many trials of new treatments has created a need for treatments aimed at patients with high LDH levels. This article reviews the metabolic basis for the association of LDH with prognosis and the treatment initiatives that may be successful in this patient group. Experimental Design: Review of current literature on the topic. The growth rates and sites of spread of metastatic melanoma vary widely between patients. In some instances, the disease shows indolent growth rates and limited spread to skin, lymph nodes, or lungs. In other patients, the disease has rapid growth rates and early spread to multiple sites, including internal organs. Several studies have identified lactate dehydrogenase (LDH) levels as the most reliable marker of the more rapidly growing highly metastatic forms of the disease (1, 2). LDH levels also identify melanoma that are resistant to certain forms of treatment (3) and is widely used by sponsors to exclude patients with unfavorable prognosis from clinical trials of new agents. Data from the Genasense study (3) suggest that approximately one third of patients are excluded from trials if a cutoff of >1.2 upper limit of normal is taken as an entry criteria.LDH is coded for by two genes, LDH-A (M-muscle type) and LDH-B (H-heart type), which code for two polypeptide chains that form five isoenzymes depending on the combinations of the two chains. LDH-5 is composed of four M subunits, whereas LDH-1 is composed of four H subunits (4). LDH-5 is the most efficient isotype in catalyzing conversion of pyruvate to lactate (5). LDH-5 expression is readily detected in histologic sections of melanoma and was shown to be a strong correlate of prognosis in primary melanoma. It was not an independent predictor and correlated with the other prognostic determinants of thickness and mitotic rate. Increased levels of LDH within the cell are believed to be due largely to upregulation by the transcription factor hypoxiainducible factor 1α (HIF-1α). The latter is normally degraded by the E3 ligase von Hippel-Lindau protein under normal oxygen levels but not under hypoxic conditions, leading to posttranslational increases in HIF-1α (6). Hypoxia also activates the endoplasmic reticulum (ER) stress response, which indirectly upregulates mRNA for HIF-1α (7) through the transcription factor XBP-1 and Akt activation (8); however, this needs to be confirmed. Hypoglycemia and other factors resulting from the demands of the malignant process also contribute to ER stress and the resultant unfolded protein response (9-11).One of the consequences of ER stress is a change in metabolism of the cell due to activation of HIF-1α and activation of the Akt pathway. These changes are believed to result in reduced mitochondrial-dependent oxidation of glucose by cancer cells referred to as the Warburg effect (12). As ...