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Mosca MJ, He Z, Ricarte FR, Le Henaff C, Partridge NC. Differential Effects of PTH (1-34), PTHrP (1-36), and Abaloparatide on the Murine Osteoblast Transcriptome. J Endocr Soc 2023; 8:bvad156. [PMID: 38155918 PMCID: PMC10753291 DOI: 10.1210/jendso/bvad156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Indexed: 12/30/2023] Open
Abstract
Teriparatide (PTH (1-34)), PTHrP (1-36), and abaloparatide (ABL) have been used for the treatment of osteoporosis, but their efficacy long term is significantly limited. The 3 peptides exert time- and dose-dependent differential responses in osteoblasts, leading us to hypothesize they may also differentially modulate the osteoblast transcriptome. Treatment of mouse calvarial osteoblasts with 1 nM of the peptides for 4 hours results in RNA sequencing data with PTH (1-34) regulating 367 genes, including 194 unique genes; PTHrP (1-36) regulating 117 genes, including 15 unique genes; and ABL regulating 179 genes, including 20 unique genes. There were 83 genes shared among all 3 peptides. Gene ontology analyses showed similarities in Wnt signaling, cAMP-mediated signaling, ossification, but differences in morphogenesis of a branching structure in biological processes; receptor ligand activity, transcription factor activity, and cytokine receptor/binding activity in molecular functions. The peptides increased Vdr, Cited1, and Pde10a messenger RNAs (mRNAs) in a pattern similar to Rankl, that is, PTH (1-34) greater than ABL greater than PTHrP (1-36). mRNA abundance of other genes, including Wnt4, Wnt7, Wnt11, Sfrp4, Dkk1, Kcnk10, Hdac4, Epn3, Tcf7, Crem, Fzd5, Ppp2r2a, and Dvl3, showed that some genes were regulated similarly by all 3 peptides; others were not. Finally, small interfering RNA knockdowns of SIK1/2/3 and CRTC1/2/3 in PTH (1-34)-treated cells revealed that Vdr and Wnt4 genes are regulated by salt-inducible kinases (SIKs) and CREB-regulated transcriptional coactivators (CRTCs), while others are not. Although many studies have examined PTH signaling in the osteoblast/osteocyte, ours is the first to compare the global effects of these peptides on the osteoblast transcriptome or to analyze the roles of the SIKs and CRTCs.
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Affiliation(s)
- Michael J Mosca
- Department of Molecular Pathobiology, New York University College of Dentistry, New York, NY 10010, USA
- Vilcek Institute of Graduate Biomedical Sciences, New York University School of Medicine, New York, NY 10016, USA
| | - Zhiming He
- Department of Molecular Pathobiology, New York University College of Dentistry, New York, NY 10010, USA
| | - Florante R Ricarte
- Department of Molecular Pathobiology, New York University College of Dentistry, New York, NY 10010, USA
| | - Carole Le Henaff
- Department of Molecular Pathobiology, New York University College of Dentistry, New York, NY 10010, USA
| | - Nicola C Partridge
- Department of Molecular Pathobiology, New York University College of Dentistry, New York, NY 10010, USA
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Mosca MJ, He Z, Ricarte FR, Le Henaff C, Partridge NC. Differential effects of PTH (1-34), PTHrP (1-36) and abaloparatide on the murine osteoblast transcriptome. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.01.11.523646. [PMID: 37645806 PMCID: PMC10461920 DOI: 10.1101/2023.01.11.523646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Teriparatide (PTH(1-34)) and its analogs, PTHrP(1-36) and abaloparatide (ABL) have been used for the treatment of osteoporosis, but their efficacy over long-term use is significantly limited. The 3 peptides exert time- and dose-dependent differential responses in osteoblasts, leading us to hypothesize that they may also differentially modulate the osteoblast transcriptome. We show that treatment of mouse calvarial osteoblasts with 1 nM of the 3 peptides for 4 h results in RNA-Seq data with PTH(1-34) regulating 367 genes, including 194 unique genes; PTHrP(1-36) regulating 117 genes, including 15 unique genes; and ABL regulating 179 genes, including 20 unique genes. There were 83 genes shared among all 3 peptides. Gene ontology analyses showed differences in Wnt signaling, cAMP-mediated signaling, bone mineralization, morphogenesis of a branching structure in biological processes; receptor ligand activity, transcription factor activity, cytokine receptor/binding activity and many other actions in molecular functions. The 3 peptides increased Vdr, Cited1 and Pde10a mRNAs in a pattern similar to Rankl , i.e., PTH(1-34) > ABL > PTHrP(1-36). mRNA abundance of other genes based on gene/pathway analyses, including Wnt4, Wnt7, Wnt11, Sfrp4, Dkk1, Kcnk10, Hdac4, Epha3, Tcf7, Crem, Fzd5, Pp2r2a , and Dvl3 showed that some genes were regulated similarly by all 3 peptides; others were not. Finally, siRNA knockdowns of SIK1/2/3 and CRTC1/2/3 in PTH(1-34)-treated cells revealed that Vdr and Wnt4 genes are regulated by SIKs and CRTCs, while others are not. Although many studies have examined PTH signaling in the osteoblast/osteocyte, ours is the first to examine the global effects of these peptides on the osteoblast transcriptome. Further delineation of which signaling events are attributable to PTH(1-34), PTHrP(1-36) or ABL exclusively and which are shared among all 3 will help improve our understanding of the effects these peptides have on the osteoblast and lead to the refinement of PTH-derived treatments for osteoporosis.
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Luparello C, Librizzi M. Parathyroid hormone-related protein (PTHrP)-dependent modulation of gene expression signatures in cancer cells. VITAMINS AND HORMONES 2022; 120:179-214. [PMID: 35953109 DOI: 10.1016/bs.vh.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
PTHrP is encoded by PTHLH gene which can generate by alternative promoter usage and splicing mechanisms at least three mature peptides of 139, 141 and 173 amino acids with distinct carboxy terminus. PTHrP may undergo proteolytic processing into smaller bioactive forms, comprising an amino terminus peptide, which is the mediator of the "classical" PTH-like effect, as well as midregion and carboxy terminus peptides that act as multifaceted critical regulator of proliferation, differentiation and apoptosis via the reprogramming of gene expression in normal and neoplastic cells. Moreover, a nuclear/nucleolar localization signal sequence is present in the [87-107] domain allowing PTHrP nuclear import and "intracrine" effect additional to the autocrine/paracrine one. Within the large number of data available in the literature on PTHrP bioactivities, the goal of this chapter is to pick up selected studies that report the detection of molecular signatures of cancer cell exposure to PTHrP, either as full-length protein or discrete peptides, demonstrated by individual gene or whole genome expression profiling, briefly recapitulating the biological implications associated with the specific gene activation or silencing.
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Affiliation(s)
- Claudio Luparello
- Dipartimento di Scienze e Tecnologie Biologiche, Chimiche e Farmaceutiche (STEBICEF), Università di Palermo, Palermo, Italia.
| | - Mariangela Librizzi
- Dipartimento di Scienze e Tecnologie Biologiche, Chimiche e Farmaceutiche (STEBICEF), Università di Palermo, Palermo, Italia
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Wang W, Liu X, Wu J, Kang X, Xie Q, Sheng J, Xu W, Liu D, Zheng W. Plasma metabolite profiling reveals potential biomarkers of giant cell tumor of bone by using NMR-based metabolic profiles: A cross-sectional study. Medicine (Baltimore) 2019; 98:e17445. [PMID: 31577769 PMCID: PMC6783185 DOI: 10.1097/md.0000000000017445] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Giant cell tumor (GCT) of bone is a locally aggressive bone tumor, which accounts for 4% to 5% of all primary bone tumors. At present, the early diagnosis and postoperative recurrence monitoring are still more difficult due to the lack of effective biomarkers in GCT. As an effective tool, metabolomics has played an essential role in the biomarkers research of many tumors. However, there has been no related study of the metabolomics of GCT up to now. The purpose of this study was to identify several key metabolites as potential biomarkers for GCT by using nuclear magnetic resonance (NMR)-based metabolic profiles.Patients with GCT in our hospital were recruited in this study and their plasma was collected as the research sample, and plasma collected from healthy subjects was considered as the control. NMR was then utilized to detect all samples. Furthermore, based on correlation coefficients, variable importance for the projection values and P values of metabolites obtained from multidimensional statistical analysis, the most critical metabolites were selected as potential biomarkers of GCT. Finally, relevant metabolic pathways involved in these potential biomarkers were determined by database retrieval, based on which the metabolic pathways were plotted.Finally, 28 GCT patients and 26 healthy volunteers agreed to participate in the study. In the multidimensional statistical analysis, all results showed that there was obvious difference between the GCT group and the control group. Ultimately, 18 metabolites with significant differences met the selection condition, which were identified as potential biomarkers. Through Kyoto Encyclopedia of Genes and Genomes (KEGG) and Human Metabolome Database (HMD) database searching and literature review, these metabolites were found to be mainly correlated with glucose metabolism, fat metabolism, amino acid metabolism, and intestinal microbial metabolism. These metabolic disorders might, in turn, reflect important pathological processes such as proliferation and migration of tumor cells and immune escape in GCT.Our work showed that these potential biomarkers identified appeared to have early diagnostic and relapse monitoring values for GCT, which deserve to be further investigated. In addition, it also suggested that metabolomics profiling approach is a promising screening tool for the diagnosis and relapse monitoring of GCT patients.
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Affiliation(s)
| | | | - Juan Wu
- Department of Pharmacy, General Hospital of Western Theater Command, Chengdu city, Sichuan Province, People's Republic of China
| | | | | | | | - Wei Xu
- Department of Orthopedics
| | - Da Liu
- Department of Orthopedics
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Martínez-López FJ, Bañuelos-Hernández AE, Becerra-Martínez E, Santini-Araujo E, Amaya-Zepeda RA, Pérez-Hernández E, Pérez-Hernández N. 1H NMR metabolomic signatures related to giant cell tumor of the bone. RSC Adv 2017. [DOI: 10.1039/c7ra07138h] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
1H NMR metabolomic profiling for giant cell tumor of the bone.
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Affiliation(s)
| | | | - Elvia Becerra-Martínez
- Centro de Nanociencias y Micro y Nanotecnologías
- Instituto Politécnico Nacional
- Ciudad de México
- Mexico
| | - Eduardo Santini-Araujo
- UMAE de Traumatología, Ortopedia y Rehabilitación “Dr. Victorio de la Fuente Narváez”
- Instituto Mexicano del Seguro Social (IMSS)
- Ciudad de México
- Mexico
| | - Ruben A. Amaya-Zepeda
- Departamento de Patología
- Escuela de Medicina y Escuela de Odontología
- Universidad de Buenos Aires
- Argentina
| | - Elizabeth Pérez-Hernández
- Departamento de Patología
- Escuela de Medicina y Escuela de Odontología
- Universidad de Buenos Aires
- Argentina
| | - Nury Pérez-Hernández
- Escuela Nacional de Medicina y Homeopatía
- Instituto Politécnico Nacional
- Ciudad de México
- Mexico
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Mak IW, Singh S, Turcotte R, Ghert M. The Epigenetic Regulation of SOX9 by miR-145 in Human Chondrosarcoma. J Cell Biochem 2014; 116:37-44. [DOI: 10.1002/jcb.24940] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 08/15/2014] [Indexed: 02/01/2023]
Affiliation(s)
- Isabella W.Y. Mak
- Department of Surgery; McMaster University; Hamilton Ontario Canada
- Department of Surgery; Juravinski Cancer Centre; Hamilton Health Sciences; Hamilton Ontario Canada
| | - Shalini Singh
- Department of Surgery; McMaster University; Hamilton Ontario Canada
| | - Robert Turcotte
- Department of Orthopaedic Surgery; McGill University Health Centre; Montreal Quebec Canada
| | - Michelle Ghert
- Department of Surgery; McMaster University; Hamilton Ontario Canada
- Department of Surgery; Juravinski Cancer Centre; Hamilton Health Sciences; Hamilton Ontario Canada
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Zhou W, Yin H, Wang T, Liu T, Li Z, Yan W, Song D, Chen H, Chen J, Xu W, Yang X, Wu Z, Xiao J. MiR-126-5p regulates osteolysis formation and stromal cell proliferation in giant cell tumor through inhibition of PTHrP. Bone 2014; 66:267-76. [PMID: 24973691 DOI: 10.1016/j.bone.2014.06.021] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 06/03/2014] [Accepted: 06/17/2014] [Indexed: 12/15/2022]
Abstract
Parathyroid hormone-related protein (PTHrP) has been identified to play a crucial role in osteolysis formation and stromal cell (GCTSC) proliferation in giant cell tumor (GCT). MiR-126-5p is an intronic miRNA identified as tumor suppressor in many tumors, but its role in GCT is poorly understood. We found that miR-126-5p was decreased in GCT and could directly regulate PTHrP expression. Furthermore, miR-126-5p could control osteoclast (OC) differentiation, GCTSC proliferation and osteolysis formation in GCT through negative regulation of PTHrP. Thus, these results suggest that miR-126-5p could directly target PTHrP and have a tumor suppressor function in GCT.
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Affiliation(s)
- Wang Zhou
- Department of Bone Tumor Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Huabin Yin
- Department of Bone Tumor Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Ting Wang
- Department of Bone Tumor Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Tielong Liu
- Department of Bone Tumor Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Zhenxi Li
- Department of Bone Tumor Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Wangjun Yan
- Department of Bone Tumor Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Dianwen Song
- Department of Bone Tumor Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Haiyan Chen
- Division of Rheumatology, Zhongda Hospital, Dongnan University, Nanjing, China
| | - Jia Chen
- Department of Bone Tumor Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Wei Xu
- Department of Bone Tumor Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Xinghai Yang
- Department of Bone Tumor Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, China.
| | - Zhipeng Wu
- Department of Bone Tumor Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, China.
| | - Jianru Xiao
- Department of Bone Tumor Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, China.
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Mak IWY, Evaniew N, Popovic S, Tozer R, Ghert M. A Translational Study of the Neoplastic Cells of Giant Cell Tumor of Bone Following Neoadjuvant Denosumab. J Bone Joint Surg Am 2014; 96:e127. [PMID: 25100780 DOI: 10.2106/jbjs.m.01332] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Giant cell tumor of bone is a primary bone tumor that is treated surgically and is associated with high morbidity in many cases. This tumor consists of giant cells expressing RANK (receptor activator of nuclear factor-κB) and mesenchymal spindle-like stromal cells expressing RANKL (RANK ligand); the interaction of these cells leads to bone resorption. Denosumab is a monoclonal antibody that binds RANKL and directly inhibits osteoclastogenesis. Clinical studies have suggested clinical and histological improvement when denosumab was administered to patients with a giant cell tumor. However, no studies have yet examined the viability and functional characteristics of tumor cells following denosumab treatment. METHODS Specimens were obtained from six patients with a histologically confirmed giant cell tumor. Two of the patients had been treated with denosumab for six months. Primary cultures of stromal cells from fresh tumor tissue were established. Cell proliferation was measured over a two-day time course. The expression of RANKL and osteoprotegerin was analyzed with use of real-time PCR (polymerase chain reaction). RESULTS Histological specimens from both patients who had completed denosumab treatment showed the absence of giant cells but persistence of stromal cells. Cell proliferation studies indicated that proliferation of stromal cells cultured from clinical specimens following denosumab treatment was approximately 50% slower than that of specimens from untreated patients. The expression of RANKL in the specimens from the treated patients was almost completely eliminated. CONCLUSIONS Once the giant cell tumor tissue was no longer exposed to denosumab, the stromal cells continued to proliferate in vitro, albeit to a lesser degree. However, they also showed almost complete loss of RANKL expression. CLINICAL RELEVANCE It is clear that treatment with denosumab only partially addresses the therapeutic need of patients with a giant cell tumor by wiping out the osteoclasts but leaving the neoplastic stromal cells proliferative.
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Affiliation(s)
- Isabella W Y Mak
- Departments of Surgery (I.W.Y.M., N.E., and M.G.), Pathology and Molecular Science (S.P.), and Oncology (R.T.), McMaster University, 711 Concession Street, Hamilton, ON L8V 1C3, Canada. E-mail addresses for I.W.Y. Mak: ; . E-mail address for N. Evaniew: . E-mail address for S. Popovic: . E-mail address for R. Tozer: . E-mail address for M. Ghert:
| | - Nathan Evaniew
- Departments of Surgery (I.W.Y.M., N.E., and M.G.), Pathology and Molecular Science (S.P.), and Oncology (R.T.), McMaster University, 711 Concession Street, Hamilton, ON L8V 1C3, Canada. E-mail addresses for I.W.Y. Mak: ; . E-mail address for N. Evaniew: . E-mail address for S. Popovic: . E-mail address for R. Tozer: . E-mail address for M. Ghert:
| | - Snezana Popovic
- Departments of Surgery (I.W.Y.M., N.E., and M.G.), Pathology and Molecular Science (S.P.), and Oncology (R.T.), McMaster University, 711 Concession Street, Hamilton, ON L8V 1C3, Canada. E-mail addresses for I.W.Y. Mak: ; . E-mail address for N. Evaniew: . E-mail address for S. Popovic: . E-mail address for R. Tozer: . E-mail address for M. Ghert:
| | - Richard Tozer
- Departments of Surgery (I.W.Y.M., N.E., and M.G.), Pathology and Molecular Science (S.P.), and Oncology (R.T.), McMaster University, 711 Concession Street, Hamilton, ON L8V 1C3, Canada. E-mail addresses for I.W.Y. Mak: ; . E-mail address for N. Evaniew: . E-mail address for S. Popovic: . E-mail address for R. Tozer: . E-mail address for M. Ghert:
| | - Michelle Ghert
- Departments of Surgery (I.W.Y.M., N.E., and M.G.), Pathology and Molecular Science (S.P.), and Oncology (R.T.), McMaster University, 711 Concession Street, Hamilton, ON L8V 1C3, Canada. E-mail addresses for I.W.Y. Mak: ; . E-mail address for N. Evaniew: . E-mail address for S. Popovic: . E-mail address for R. Tozer: . E-mail address for M. Ghert:
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Mak IWY, Turcotte RE, Ghert M. Parathyroid hormone-related protein (PTHrP) modulates adhesion, migration and invasion in bone tumor cells. Bone 2013; 55:198-207. [PMID: 23466453 DOI: 10.1016/j.bone.2013.02.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Revised: 02/11/2013] [Accepted: 02/15/2013] [Indexed: 12/22/2022]
Abstract
Parathyroid-hormone-related protein (PTHrP) has been shown to be an important factor in osteolysis in the setting of metastatic carcinoma to the bone. However, PTHrP may also be central in the setting of primary bone tumors. Giant cell tumor of bone (GCT) is an aggressive osteolytic bone tumor characterized by osteoclast-like giant cells that are recruited by osteoblast-like stromal cells. The stromal cells of GCT are well established as the only neoplastic element of the tumor, and we have previously shown that PTHrP is highly expressed by these cells both in vitro and in vivo. We have also found that the stromal cells exposed to a monoclonal antibody to PTHrP exhibited rapid plate detachment and quickly died in vitro. Therefore, PTHrP may serve in an autocrine manner to increase cell proliferation and promote invasive properties in GCT. The purpose of this study was to use transcriptomic microarrays and functional assays to examine the effects of PTHrP neutralization on cell adhesion, migration and invasion. Microarray and proteomics data identified genes that were differentially expressed in GCT stromal cells under various PTHrP treatment conditions. Treatment of GCT stromal cells with anti-PTHrP antibodies showed a change in the expression of 13 genes from the integrin family relative to the IgG control. Neutralization of PTHrP reduced cell migration and invasion as evidenced by functional assays. Adhesion and anoikis assays demonstrated that although PTHrP neutralization inhibits cell adhesion properties, cell detachment related to PTHrP neutralization did not result in associated cell death, as expected in mesenchymal stromal cells. Based on the data presented herein, we conclude that PTHrP excreted by GCT stromal cells increases bone tumor cell local invasiveness and migration.
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Affiliation(s)
- Isabella W Y Mak
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada.
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Hsu SHC, Zhang X, Cheng S, Wunder JS, Hui CC, Alman BA. Suppressor of fused (Sufu) mediates the effect of parathyroid hormone-like hormone (Pthlh) on chondrocyte differentiation in the growth plate. J Biol Chem 2012; 287:36222-8. [PMID: 22930757 DOI: 10.1074/jbc.m112.382275] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Growth plate chondrocytes undergo a coordinated process of differentiation, regulating long bone growth. Parathyroid hormone-like hormone (Pthlh) inhibits hypertrophic differentiation in the growth plate chondrocytes and reduces Hedgehog (Hh) signaling. In mice lacking the Hh mediator Suppressor of fused (Sufu), Pthlh treatment resulted in the up-regulation of Hh activity and an increased number of hypertrophic chondrocytes. Furthermore, Pthlh increased Sufu protein levels, and in chondrocytes lacking Sufu, it was unable to process Hh-regulated Gli transcription factors. Pthlh regulates chondrocyte differentiation and Gli activity in a Sufu-dependent manner, with Sufu acting as a molecular switch in its regulation of differentiation.
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Affiliation(s)
- Shu-Hsuan C Hsu
- Program in Developmental and Stem Cell Biology, Hospital for Sick Children, Toronto, Ontario M5G 1L7, Canada
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