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Lee E, Park YJ, Lindroth AM. H3.3-G34W in giant cell tumor of bone functionally aligns with the exon choice repressor hnRNPA1L2. Cancer Gene Ther 2024:10.1038/s41417-024-00776-6. [PMID: 38811797 DOI: 10.1038/s41417-024-00776-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/14/2024] [Accepted: 04/17/2024] [Indexed: 05/31/2024]
Abstract
RNA processing is an essential post-transcriptional phenomenon that provides the necessary complexity of transcript diversity prior to translation. Aberrations in this process could contribute to tumourigenesis, and we have previously reported increased splicing alterations in giant cell tumor of bone (GCTB), which carries mutations in the histone variant H3.3 encoding glycine 34 substituted for tryptophan (H3.3-G34W). G34W interacts with several splicing factors, most notably the trans-acting splicing factor hnRNPA1L2. To gain a deeper understanding of RNA processing in GCTB and isogenic HeLa cells with H3.3-G34W, we generated RNA-immunoprecipitation sequencing data from hnRNPA1L2 and H3.3-G34W associated RNAs, which showed that 80% overlapped across genic regions and were frequently annotated as E2F transcription factor binding sites. Splicing aberrations in both GCTB and HeLa cells with H3.3-G34W were significantly enriched for known hnRNPA1L2 binding motifs (p value < 0.01). This splicing aberration differed from hnRNPA1L2 knockouts, which showed alterations independent of H3.3-G34W. Of functional significance, hnRNPA1L2 was redistributed to closely match the H3.3 pattern, likely driven by G34W, and to loci not occupied in normal parental cells. Taken together, our data reveal a functional overlap between hnRNPA1L2 and H3.3-G34W with likely significant consequences for RNA processing during GCTB pathogenesis. This provides novel opportunities for therapeutic intervention in future modus operandi.
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Affiliation(s)
- Eunbi Lee
- Graduate School of Cancer Science and Policy, Cancer Biomedical Science, National Cancer Center, Goyang-si, Republic of Korea
- Department of Nutritional Science and Food Management, Ewha Womans University, Seoul, Republic of Korea
- Graduate Program in System Health Science and Engineering, Ewha Womans University, Seoul, Republic of Korea
| | - Yoon Jung Park
- Department of Nutritional Science and Food Management, Ewha Womans University, Seoul, Republic of Korea
- Graduate Program in System Health Science and Engineering, Ewha Womans University, Seoul, Republic of Korea
| | - Anders M Lindroth
- Graduate School of Cancer Science and Policy, Cancer Biomedical Science, National Cancer Center, Goyang-si, Republic of Korea.
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2
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Kimura A, Toda Y, Matsumoto Y, Yamamoto H, Yahiro K, Shimada E, Kanahori M, Oyama R, Fukushima S, Nakagawa M, Setsu N, Endo M, Fujiwara T, Matsunobu T, Oda Y, Nakashima Y. Nuclear β-catenin translocation plays a key role in osteoblast differentiation of giant cell tumor of bone. Sci Rep 2022; 12:13438. [PMID: 35927428 PMCID: PMC9352730 DOI: 10.1038/s41598-022-17728-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 07/29/2022] [Indexed: 12/02/2022] Open
Abstract
Denosumab is a game-changing drug for giant cell tumor of bone (GCTB); however, its clinical biomarker regarding tumor ossification of GCTB has not been elucidated. In this study, we investigated the relationship between Wnt/β-catenin signaling and the ossification of GCTB and evaluated whether endogenous nuclear β-catenin expression predicted denosumab-induced bone formation in GCTB. Genuine patient-derived primary GCTB tumor stromal cells exhibited osteoblastic characteristics. Identified osteoblastic markers and nuclear β-catenin translocation were significantly upregulated via differentiation induction and were inhibited by treating with Wnt signaling inhibitor, GGTI-286, or selective Rac1-LEF inhibitor, NSC23766. Furthermore, we reviewed the endogenous ossification and nuclear β-catenin translocation of 86 GCTB clinical samples and elucidated that intra-tumoral ossification was significantly associated with the nuclear translocation. Three-dimensional quantitative analyses (n = 13) of tumoral CT images have revealed that the nuclear β-catenin translocation of naïve GCTB samples was significantly involved with the denosumab-induced tumor ossification. Our findings suggest a close relationship between the nuclear β-catenin translocation and the osteoblastic differentiation of GCTB. Investigations of the nuclear β-catenin in naïve GCTB samples may provide a promising biomarker for predicting the ossification of GCTB following denosumab treatment.
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Affiliation(s)
- Atsushi Kimura
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka City, 812-8582, Japan
| | - Yu Toda
- Department of Anatomic Pathology, Pathological Sciences, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshihiro Matsumoto
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka City, 812-8582, Japan.
| | - Hidetaka Yamamoto
- Department of Anatomic Pathology, Pathological Sciences, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kenichiro Yahiro
- Department of Orthopedic Surgery, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Eijiro Shimada
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka City, 812-8582, Japan
| | - Masaya Kanahori
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka City, 812-8582, Japan
| | - Ryunosuke Oyama
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka City, 812-8582, Japan
| | - Suguru Fukushima
- Department of Musculoskeletal Oncology and Rehabilitation, National Cancer Center, Tokyo, Japan
| | - Makoto Nakagawa
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka City, 812-8582, Japan
| | - Nokitaka Setsu
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka City, 812-8582, Japan
| | - Makoto Endo
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka City, 812-8582, Japan
| | - Toshifumi Fujiwara
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka City, 812-8582, Japan
| | - Tomoya Matsunobu
- Department of Orthopaedic Surgery, Kyushu Rosai Hospital, Fukuoka, Japan
| | - Yoshinao Oda
- Department of Anatomic Pathology, Pathological Sciences, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yasuharu Nakashima
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka City, 812-8582, Japan
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3
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Iqbal M, Khan AS, Khawaja UA, Saleem A. Giant Cell Tumour of the Patella: A Missing Differential Diagnosis in the Young. Cureus 2022; 14:e25151. [PMID: 35746984 PMCID: PMC9206709 DOI: 10.7759/cureus.25151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2022] [Indexed: 11/05/2022] Open
Abstract
Herein, we discuss the case of a 26-year-old male patient with a diagnosis of giant cell tumour (GCT) of the patella which is an exceptionally uncommon condition. The motive of reporting a rare case such as the giant cell tumour of the bone (GCTB) relies on its diagnostic incidence. Since the symptoms of this tumour overlap more common etiologies than GCT, the diagnosis of such a devastating malignant tumour is usually missed and hence delayed, which leads to poor treatment strategies and ultimately an irreversible fatal outcome.
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4
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Yapar A, Atalay İB, Tokgöz MA, Ulucaköy C, Güngör BŞ. Prognostic significance of the preoperative neutrophil-to-lymphocyte ratio patients with giant cell tumor of bone. Afr Health Sci 2021; 21:1250-1258. [PMID: 35222589 PMCID: PMC8843307 DOI: 10.4314/ahs.v21i3.35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective To evaluate the prognostic significance of neutrophil-to-lymphocyte ratio (NLR) in giant cell tumor of bone (GCT). Methods The patients with GCT were identified in the hospital records and pre-treatment complete blood count results were acquired retrospectively. Whether preoperative NLR lymphocyte-to-monocyte ratio (LMR) and platelet-to-lymphocyte ratio (PLR) values had prognostic significance in predicting recurrence was evaluated by Receiver operating curve (ROC) analysis. Furthermore, the prognostic value of NLR was evaluated by Multivariable Cox Regression analysis. Results There were 96 patients with GCT. It was found that only NLR values had prognostic significance for predicting recurrence (AUC:0.647; 95% CI:0.533–0.762; P=0.021). The statistically significant cut-off value of NLR for predicting recurrence was ≥2.25. NLR was ≥2.25 in 51% (n = 49) of patients. Multivariable analysis showed that NLR ≥2.25 (HR=2.9, 95% CI:1.3–6.6; p=0.009) and lung metastasis (HR=7.9, 95% CI:2.2–28.2; p=0.001) were independent factors of recurrence. In patients with lung metastasis and patients with NLR ≥2.25, recurrence was observed in a sooner period (Log rank test; p=0.001; p=0.009, respectively). Conclusion Our findings showed that NLR is a new and promising inflammation-based prognostic factor in GCT patients.
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Affiliation(s)
- Aliekber Yapar
- Department of Orthopaedics and Traumatology, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, Turkey
| | - İsmail Burak Atalay
- Department of Orthopaedics and Traumatology, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, Turkey
| | - Mehmet Ali Tokgöz
- Department of Orthopaedics and Traumatology, Dr. Nafiz Korez Sincan State Hospital, Ankara, Turkey
| | - Coşkun Ulucaköy
- Department of Orthopaedics and Traumatology, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, Turkey
| | - Bedii Şafak Güngör
- Department of Orthopaedics and Traumatology, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, Turkey
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5
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Wang X, Su P, Kang Y, Xu C, Qiu J, Wu J, Sheng P, Huang D, Zhang Z. Combination of Melatonin and Zoledronic Acid Suppressed the Giant Cell Tumor of Bone in vitro and in vivo. Front Cell Dev Biol 2021; 9:690502. [PMID: 34447747 PMCID: PMC8382950 DOI: 10.3389/fcell.2021.690502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 07/20/2021] [Indexed: 11/13/2022] Open
Abstract
Melatonin (Mlt) confers potential antitumor effects in various types of cancer. However, to the best of our knowledge, the role of Mlt in the giant cell tumor of bone (GCTB) remains unknown. Moreover, further research is required to assess whether Mlt can enhance the therapeutic effect of zoledronic acid (Zol), a commonly used anti-GCTB drug. In this research, we investigated the effects of Mlt, Zol, and the combination of these two drugs on GCTB cells’ characteristics, including cell proliferation, apoptosis, osteogenic differentiation, migration, and invasion. The cell counting kit-8 (CCK-8) assay, colony formation assay, terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling assay (TUNEL), alkaline phosphatase (ALP) staining, alizarin red staining (ARS), scratch wound healing assay, and transwell experiment were performed, respectively. Our results showed that Mlt could effectively inhibit the proliferation, migration, and invasion of GCTB cells, as well as promote the apoptosis and osteogenic differentiation of tumor cells. Of note, a stronger antitumor effect was observed when Mlt was combined with Zol treatment. This therapeutic effect might be achieved by inhibiting the activation of both the Hippo and NF-κB pathways. In conclusion, our study suggests that Mlt can be a new treatment for GCTB, which could further enhance the antitumor effect of Zol.
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Affiliation(s)
- Xudong Wang
- Department of Orthopedics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Orthopedics and Traumatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Peiqiang Su
- Department of Orthopedics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Orthopedics and Traumatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yan Kang
- Department of Orthopedics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Orthopedics and Traumatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Caixia Xu
- Research Centre for Translational Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jincheng Qiu
- Department of Orthopedics, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jinna Wu
- Department of Orthopedics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Orthopedics and Traumatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Puyi Sheng
- Department of Orthopedics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Orthopedics and Traumatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Dongsheng Huang
- Department of Orthopedics, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ziji Zhang
- Department of Orthopedics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Orthopedics and Traumatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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War AR, Dang K, Jiang S, Xiao Z, Miao Z, Yang T, Li Y, Qian A. Role of cancer stem cells in the development of giant cell tumor of bone. Cancer Cell Int 2020; 20:135. [PMID: 32351329 PMCID: PMC7183664 DOI: 10.1186/s12935-020-01218-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 04/17/2020] [Indexed: 02/06/2023] Open
Abstract
The primary bone tumor is usually observed in adolescence age group which has been shown to be part of nearly 20% of the sarcomas known today. Giant cell tumor of bone (GCTB) can be benign as well as malignant tumor which exhibits localized dynamism and is usually associated with the end point of a long bone. Giant cell tumor (GCT) involves mononuclear stromal cells which proliferate at a high rate, multinucleated giant cells and stromal cells are equally present in this type of tumor. Cancer stem cells (CSCs) have been confirmed to play a potential role in the development of GCT. Cancer stem cell-based microRNAs have been shown to contribute to a greater extent in giant cell tumor of bone. CSCs and microRNAs present in the tumors specifically are a great concern today which need in-depth knowledge as well as advanced techniques to treat the bone cancer effectively. In this review, we attempted to summarize the role played by cancer stem cells involving certain important molecules/factors such as; Mesenchymal Stem Cells (MSCs), miRNAs and signaling mechanism such as; mTOR/PI3K-AKT, towards the formation of giant cell tumor of bone, in order to get an insight regarding various effective strategies and research advancements to obtain adequate knowledge related to CSCs which may help to focus on highly effective treatment procedures for bone tumors.
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Affiliation(s)
- Abdul Rouf War
- 1Laboratory for Bone Metabolism, Key Laboratory for Space Bioscience and Biotechnology, School of Life Sciences, Northwestern Polytechnical University, Xi'an, 710072 Shaanxi China.,2Research Center for Special Medicine and Health Systems Engineering, School of Life Sciences, Northwestern Polytechnical University, Xi'an, 710072 Shaanxi China.,3NPU-UAB Joint Laboratory for Bone Metabolism, School of Life Sciences, Northwestern Polytechnical University, Xi'an, 710072 Shaanxi China
| | - Kai Dang
- 1Laboratory for Bone Metabolism, Key Laboratory for Space Bioscience and Biotechnology, School of Life Sciences, Northwestern Polytechnical University, Xi'an, 710072 Shaanxi China.,2Research Center for Special Medicine and Health Systems Engineering, School of Life Sciences, Northwestern Polytechnical University, Xi'an, 710072 Shaanxi China.,3NPU-UAB Joint Laboratory for Bone Metabolism, School of Life Sciences, Northwestern Polytechnical University, Xi'an, 710072 Shaanxi China
| | - Shanfen Jiang
- 1Laboratory for Bone Metabolism, Key Laboratory for Space Bioscience and Biotechnology, School of Life Sciences, Northwestern Polytechnical University, Xi'an, 710072 Shaanxi China.,2Research Center for Special Medicine and Health Systems Engineering, School of Life Sciences, Northwestern Polytechnical University, Xi'an, 710072 Shaanxi China.,3NPU-UAB Joint Laboratory for Bone Metabolism, School of Life Sciences, Northwestern Polytechnical University, Xi'an, 710072 Shaanxi China
| | - Zhongwei Xiao
- 4Department of Neurology, Shanghai Pudong Hospital, Fudan University, Shanghai, 201399 People's Republic of China
| | - Zhiping Miao
- 1Laboratory for Bone Metabolism, Key Laboratory for Space Bioscience and Biotechnology, School of Life Sciences, Northwestern Polytechnical University, Xi'an, 710072 Shaanxi China.,2Research Center for Special Medicine and Health Systems Engineering, School of Life Sciences, Northwestern Polytechnical University, Xi'an, 710072 Shaanxi China.,3NPU-UAB Joint Laboratory for Bone Metabolism, School of Life Sciences, Northwestern Polytechnical University, Xi'an, 710072 Shaanxi China
| | - Tuanmin Yang
- 5Honghui Hospital, Xi'an, Jiaotong University College of Medicine, Xi'an, Shaanxi China
| | - Yu Li
- 1Laboratory for Bone Metabolism, Key Laboratory for Space Bioscience and Biotechnology, School of Life Sciences, Northwestern Polytechnical University, Xi'an, 710072 Shaanxi China.,2Research Center for Special Medicine and Health Systems Engineering, School of Life Sciences, Northwestern Polytechnical University, Xi'an, 710072 Shaanxi China.,3NPU-UAB Joint Laboratory for Bone Metabolism, School of Life Sciences, Northwestern Polytechnical University, Xi'an, 710072 Shaanxi China
| | - Airong Qian
- 1Laboratory for Bone Metabolism, Key Laboratory for Space Bioscience and Biotechnology, School of Life Sciences, Northwestern Polytechnical University, Xi'an, 710072 Shaanxi China.,2Research Center for Special Medicine and Health Systems Engineering, School of Life Sciences, Northwestern Polytechnical University, Xi'an, 710072 Shaanxi China.,3NPU-UAB Joint Laboratory for Bone Metabolism, School of Life Sciences, Northwestern Polytechnical University, Xi'an, 710072 Shaanxi China
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Suehara Y, Okubo T, Kurihara T, Hayashi T, Kohsaka S, Kazuno S, Sano K, Hasegawa N, Miura Y, Akaike K, Kim Y, Takamochi K, Takahashi F, Ueno T, Kaneko K, Saito T. Protein Expression Profiles Corresponding to Histological Changes with Denosumab Treatment in Giant Cell Tumors of Bone. Proteomics Clin Appl 2019; 13:e1800147. [DOI: 10.1002/prca.201800147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 06/13/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Yoshiyuki Suehara
- Department of Orthopedic SurgeryJuntendo University School of Medicine 2‐1‐1 Hongo Bunkyo‐ku Tokyo 113‐8421 Japan
| | - Taketo Okubo
- Department of Orthopedic SurgeryJuntendo University School of Medicine 2‐1‐1 Hongo Bunkyo‐ku Tokyo 113‐8421 Japan
| | - Taisei Kurihara
- Department of Orthopedic SurgeryJuntendo University School of Medicine 2‐1‐1 Hongo Bunkyo‐ku Tokyo 113‐8421 Japan
- Department of Human PathologyJuntendo University School of Medicine 2‐1‐1 Hongo Bunkyo‐ku Tokyo 113‐8421 Japan
| | - Takuo Hayashi
- Department of Human PathologyJuntendo University School of Medicine 2‐1‐1 Hongo Bunkyo‐ku Tokyo 113‐8421 Japan
| | - Shinji Kohsaka
- Division of Cellular SignalingNational Cancer Center Research Institute 5‐1‐1 Tsukiji Chuo‐ku Tokyo 104‐0045 Japan
| | - Saiko Kazuno
- Laboratory of Proteomics and Biomolecular ScienceResearch Support CenterJuntendo University Graduate School of Medicine 2‐1‐1 Hongo Bunkyo‐ku Tokyo 113‐8421 Japan
| | - Kei Sano
- Department of Orthopedic SurgeryJuntendo University School of Medicine 2‐1‐1 Hongo Bunkyo‐ku Tokyo 113‐8421 Japan
- Department of Human PathologyJuntendo University School of Medicine 2‐1‐1 Hongo Bunkyo‐ku Tokyo 113‐8421 Japan
| | - Nobuhiko Hasegawa
- Department of Orthopedic SurgeryJuntendo University School of Medicine 2‐1‐1 Hongo Bunkyo‐ku Tokyo 113‐8421 Japan
| | - Yoshiki Miura
- Laboratory of Proteomics and Biomolecular ScienceResearch Support CenterJuntendo University Graduate School of Medicine 2‐1‐1 Hongo Bunkyo‐ku Tokyo 113‐8421 Japan
| | - Keisuke Akaike
- Department of Orthopedic SurgeryJuntendo University School of Medicine 2‐1‐1 Hongo Bunkyo‐ku Tokyo 113‐8421 Japan
| | - Youngji Kim
- Department of Orthopedic SurgeryJuntendo University School of Medicine 2‐1‐1 Hongo Bunkyo‐ku Tokyo 113‐8421 Japan
| | - Kazuya Takamochi
- Department of General Thoracic SurgeryJuntendo University School of Medicine 2‐1‐1 Hongo Bunkyo‐ku Tokyo 113‐8421 Japan
| | - Fumiyuki Takahashi
- Department of Respiratory MedicineJuntendo University School of Medicine 2‐1‐1 Hongo Bunkyo‐ku Tokyo 113‐8421 Japan
| | - Takashi Ueno
- Laboratory of Proteomics and Biomolecular ScienceResearch Support CenterJuntendo University Graduate School of Medicine 2‐1‐1 Hongo Bunkyo‐ku Tokyo 113‐8421 Japan
| | - Kazuo Kaneko
- Department of Orthopedic SurgeryJuntendo University School of Medicine 2‐1‐1 Hongo Bunkyo‐ku Tokyo 113‐8421 Japan
| | - Tsuyoshi Saito
- Department of Human PathologyJuntendo University School of Medicine 2‐1‐1 Hongo Bunkyo‐ku Tokyo 113‐8421 Japan
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Preoperative Denosumab With Curettage and Cryotherapy in Giant Cell Tumor of Bone: Is There an Increased Risk of Local Recurrence? Clin Orthop Relat Res 2018; 476:1783-1790. [PMID: 30778015 PMCID: PMC6259811 DOI: 10.1007/s11999.0000000000000104] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Denosumab is a monoclonal RANKL antibody, which was originally introduced for the treatment of osteoporosis and bone metastases from solid tumors, but more recently has been used for treatment of giant cell tumor of bone (GCTB). In GCTB, denosumab has been used as a single agent in patients with inoperable tumors; it also has been used before surgery in some patients with the aim to downstage the tumor to facilitate a joint-preserving procedure (curettage) rather than a resection. However, few studies are available evaluating the benefits and risks of denosumab for the latter indication. QUESTIONS/PURPOSES (1) Does preoperative treatment with denosumab reduce the risk of local recurrence in patients treated for GCTB? (2) Are there adverse effects of short-term denosumab use before surgery and, if so, what are they? METHODS All patients with a diagnosis of GCTB surgically treated at our institution from June 2009 to June 2016 with curettage and cryotherapy were retrospectively evaluated to compare patients treated with curettage alone versus patients treated with curettage after preoperative therapy with denosumab. During that period, we treated 97 patients for GCTB; 30 patients were excluded because they received a resection; 34 patients were excluded because they received curettage without cryotherapy. Of the remaining 33 patients, four were excluded because they received denosumab only after surgery, one because she received zoledronic acid, one because she received a curettage after her refusal of a resection that was the advised procedure, two because they were lost to followup early, and four because they were treated for recurrence rather than a new diagnosis of GCTB. The remaining 21 patients were included. Twelve lesions had been treated with surgery after denosumab and nine with surgery alone. During the study period, we preferentially used denosumab for the more aggressive-looking lesions. After curettage, cryotherapy of the residual bone walls was performed with argon cryoprobes to -150° C after pouring gel into the cavity, and we then used cement (17 patients) or morcellized allograft (four patients). Tumors were Campanacci Grade 3 in eight of 12 patients in the denosumab group and in two of nine patients in the surgery-only group (p = 0.08), but the extent of epiphyseal juxtaarticular bone involvement was not different between the groups with the numbers available. Median followup was 39 months (range, 14-55 months) in the denosumab group and 27 months (range, 18-92 months) in the surgery-only group. We used chart review to record the proportion of patients in each treatment group who had a local recurrence and to tally adverse events. RESULTS With the numbers available, there was no difference in the proportion of patients experiencing a recurrence (five of 12 in the denosumab group and one of nine in the surgery-only group; p = 0.18). We found no adverse effects associated with denosumab either during or after treatment; specifically, we found no alterations in electrolyte levels, blood count, or liver and renal function parameters. In this small series, no patient has developed osteonecrosis of the jaw. CONCLUSIONS In this small series, use of denosumab before surgery for GCTB appeared to allow the reforming of a bone peripheral rim around the tumor, perhaps facilitating curettage rather than osteoarticular resection in some patients. However, we did not observe a decrease in the risk of local recurrence with the use of denosumab, suggesting that it may not decrease the aggressiveness of the disease; according to our preliminary results, we cannot exclude that the rate of local recurrence could be even higher after curettage in denosumab-treated patients than in nontreated patients, and until or unless larger studies demonstrate such a reduction, primary intralesional surgery without denosumab seems more prudent when curettage is feasible at presentation. We did not observe any adverse effects with denosumab, but we caution readers that this study was underpowered to detect even relatively common complications and relatively large differences in the risk of local recurrence. Future studies should evaluate denosumab prospectively; given the relative rarity of this tumor, we suspect multicenter studies are needed to achieve this. LEVEL OF EVIDENCE Level III, therapeutic study.
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9
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Mancini I, Righi A, Gambarotti M, Picci P, Dei Tos AP, Billings SD, Simi L, Franchi A. Phenotypic and molecular differences between giant-cell tumour of soft tissue and its bone counterpart. Histopathology 2017; 71:453-460. [DOI: 10.1111/his.13249] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 04/28/2017] [Accepted: 05/02/2017] [Indexed: 01/15/2023]
Affiliation(s)
- Irene Mancini
- Department of Clinical and Experimental Biomedical Sciences; University of Florence; Florence Italy
| | - Alberto Righi
- Department of Pathology; Rizzoli Institute; Bologna Italy
| | | | - Piero Picci
- Department of Pathology; Rizzoli Institute; Bologna Italy
| | - Angelo P Dei Tos
- Department of Medicine; University of Padua School of Medicine; Padua Italy
| | | | - Lisa Simi
- Department of Clinical and Experimental Biomedical Sciences; University of Florence; Florence Italy
| | - Alessandro Franchi
- Section of Anatomical Pathology, Department of Surgery and Translational Medicine; University of Florence; Florence Italy
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10
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Fazioli F, Colella G, Miceli R, Di Salvatore MG, Gallo M, Boccella S, De Chiara A, Ruosi C, de Nigris F. Post-surgery fluids promote transition of cancer stem cell-to-endothelial and AKT/mTOR activity, contributing to relapse of giant cell tumors of bone. Oncotarget 2017; 8:85040-85053. [PMID: 29156702 PMCID: PMC5689592 DOI: 10.18632/oncotarget.18783] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 05/29/2017] [Indexed: 12/21/2022] Open
Abstract
Giant cell tumors of bone (GCTB) are rare sarcomas with a high rate of unpredictable local relapse. Studies suggest that surgical methods affect recurrence, supporting the idea that local disease develops from re-growth of residual cancer cells. To identify early prognostic markers of individual risk of recurrence, we evaluated the effect of post-surgery fluids from a cohort of GCTB patients on growth of primary and established sarcoma cell lines, and mice xenograph. Post-surgery fluids increased cell growth and enhanced expression of CD44++, the principal receptor for the extracellular matrix component hyaluronan and the mesenchymal stem marker CD117+. Cancer cells became highly invasive and tumorigenic, acquiring stemness properties, and activated AKT/mTOR pathway. Prolonged stimulation with post-surgery fluids down-regulated the mesenchymal gene TWIST1 and Vimentin protein, and transdifferentiated cells into tubule-like structures positive to the endothelial markers VE-Cadherin and CD31+. In mice, post-surgery fluids gave rise to larger and more vascularized tumors than control, while in patients AKT/mTOR pathway activation was associated with recurrence by logistic regression (Kaplan-Meier; P<0.001). These findings indicate that post-surgery fluids are an adjuvant in mechanisms of tumor regrowth, increasing stem cell growth and AKT/mTOR activity.
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Affiliation(s)
- Flavio Fazioli
- Division of Musculoskeletal Oncology Surgery, National Cancer Institute G. Pascale, Naples, Italy
| | - Gianluca Colella
- Department of Human Health, Federico II University of Naples, Naples, Italy
| | - Roberta Miceli
- S.C. Cellular Biology and Biotherapy, National Cancer Institute G. Pascale, Naples, Italy
| | | | - Michele Gallo
- Division of Musculoskeletal Oncology Surgery, National Cancer Institute G. Pascale, Naples, Italy
| | - Serena Boccella
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples Italy
| | - Annarosaria De Chiara
- Division of Pathology, National Cancer Institute G. Pascale Foundation, Naples, Italy
| | - Carlo Ruosi
- Department of Human Health, Federico II University of Naples, Naples, Italy
| | - Filomena de Nigris
- Department of Biochemistry, Biophysics and General Pathology, University of Campania "Luigi Vanvitelli", Naples Italy
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11
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van der Heijden L, Dijkstra PDS, Blay JY, Gelderblom H. Giant cell tumour of bone in the denosumab era. Eur J Cancer 2017; 77:75-83. [PMID: 28365529 DOI: 10.1016/j.ejca.2017.02.021] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 02/12/2017] [Accepted: 02/20/2017] [Indexed: 11/26/2022]
Abstract
Giant cell tumour of bone (GCTB) is an intermediate locally aggressive primary bone tumour, occurring mostly at the meta-epiphysis of long bones. Overexpression of receptor activator of nuclear factor kappa-B ligand (RANKL) by mononuclear neoplastic stromal cells promotes recruitment of numerous reactive multinucleated osteoclast-like giant cells, causing lacunar bone resorption. Preferential treatment is curettage with local adjuvants such as phenol, alcohol or liquid nitrogen. The remaining cavity may be filled with bone graft or polymethylmethacrylate (PMMA) bone cement; benefits of the latter are a lower risk of recurrence, possibility of direct weight bearing and early radiographic detection of recurrences. Reported recurrence rates are comparable for the different local adjuvants (27-31%). Factors increasing the local recurrence risk include soft tissue extension and anatomically difficult localisations such as the sacrum. When joint salvage is impossible, en-bloc resection and endoprosthetic joint replacement may be performed. Local tumour control on the one hand and maintenance of a functional native joint and quality of life on the other hand are the main pillars of surgical treatment for this disease. Current knowledge and development in the fields of imaging, functional biology and systemic therapy are forcing us into a paradigm shift from a purely surgical approach towards a multidisciplinary approach. Systemic therapy with denosumab (RANKL inhibitor) or zoledronic acid (bisphosphonates) blocks, respectively inhibits, bone resorption by osteoclast-like giant cells. After use of zoledronic acid, stabilisation of local and metastatic disease has been reported, although the level of evidence is low. Denosumab is more extensively studied in two prospective trials, and appears effective for the optimisation of surgical treatment. Denosumab should be considered in the standard multidisciplinary treatment of advanced GCTB (e.g. cortical destruction, soft tissue extension, joint involvement or sacral localisation) to facilitate surgery at a later stage, and thereby aiming at immediate local control. Even though several questions concerning optimal treatment dose, duration and interval and drug safety remain unanswered, denosumab is among the most effective drug therapies in oncology.
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Affiliation(s)
- Lizz van der Heijden
- Department of Orthopedic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - P D Sander Dijkstra
- Department of Orthopedic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Jean-Yves Blay
- Department of Medical Oncology, Centre Leon Berard, Lyon, France
| | - Hans Gelderblom
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands.
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12
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Müller DA, Beltrami G, Scoccianti G, Campanacci DA, Franchi A, Capanna R. Risks and benefits of combining denosumab and surgery in giant cell tumor of bone-a case series. World J Surg Oncol 2016; 14:281. [PMID: 27809843 PMCID: PMC5095954 DOI: 10.1186/s12957-016-1034-y] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 10/25/2016] [Indexed: 01/07/2023] Open
Abstract
Background The RANK ligand inhibitor denosumab is being investigated for treatment of giant cell tumor of bone, but the available data in the literature remains sparse and controversial. This study analyzes the results of combining denosumab with surgical treatment and highlights possible changes for the oncologic surgeon in daily practice. Methods A total of 91 patients were treated surgically for giant cell tumor of bone between 2010 and 2014 in an institution, whereas 25 patients of the total additionally received denosumab and were part of this study. The average age of the patients was 35 years. Eleven patients received denosumab pre- and postoperatively, whereas with 14 patients, the denosumab treatment was applied either before (7 patients) or after (7 patients) the surgery. The average preoperative therapy duration was 3.9 months and the postoperative therapy 6 months by default. Results Sixteen patients presented a large tumor extension necessitating a resection of the involved bone or joint. In 10 of these patients, the indication for a resection procedure was abandoned due to the preoperative denosumab treatment and a curettage was performed. In the remaining six cases, the surgical indication was not changed despite the denosumab treatment, and two of them needed a joint replacement after the tumor resection. Also with patients treated with curettage, denosumab seems to facilitate the procedure as a new peripheral bone rim around the tumor was built, though a histologic analysis reveals viable tumor cells persisting in the denosumab-induced bone formation. After an average follow-up of 23 months, one histologically proven local recurrence occurred, necessitating a second curettage. A second patient showed a lesion in the postoperative imaging highly suspicious for local relapse which remained stable under further denosumab treatment. No adverse effect of the denosumab medication was observed in this study. Conclusions Denosumab can be a help to the oncologic surgeon by reconstituting a peripheral rim and switching the stage from aggressive to active or latent disease. But as tumor cells remain in the new-formed bone, the surgical technique of curettage has to be changed from gentle to more aggressive to avoid higher local recurrence rates.
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Affiliation(s)
- Daniel A Müller
- Department of Orthopedic Surgery, University Hospital Balgrist, Forchstrasse 340, 8008, Zürich, Switzerland.
| | - Giovanni Beltrami
- Department of Orthopedic Oncology, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134, Firenze, Italy
| | - Guido Scoccianti
- Department of Orthopedic Oncology, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134, Firenze, Italy
| | - Domenico A Campanacci
- Department of Traumatology and Orthopedic Surgery, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134, Firenze, Italy
| | - Alessandro Franchi
- Division of Anatomic Pathology, Department of Surgery and Translational Medicine, University of Florence, Largo Brambilla 3, 50134, Firenze, Italy
| | - Rodolfo Capanna
- Department of Orthopedic Oncology, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134, Firenze, Italy
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13
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Borkowska A, Goryń T, Pieńkowski A, Wągrodzki M, Jagiełło-Wieczorek E, Rogala P, Szacht M, Rutkowski P. Denosumab treatment of inoperable or locally advanced giant cell tumor of bone. Oncol Lett 2016; 12:4312-4318. [PMID: 28101196 PMCID: PMC5228072 DOI: 10.3892/ol.2016.5246] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Accepted: 07/12/2016] [Indexed: 12/22/2022] Open
Abstract
Giant cell tumor of bone (GCTB) is an osteolytic, locally aggressive tumor that rarely metastasizes and typically occurs in the bones. At present, the primary treatment for GCTB is curettage with local adjuvants. Giant cells express receptor activator of nuclear factor-κB ligand (RANKL). Denosumab, a RANKL inhibitor appears to present an effective therapeutic option in advanced cases of GCTB. The aim of the present study was to confirm the efficacy of denosumab in large group of patients with locally advanced GCTB. A total of 35 patients with histologically confirmed GCTB that were treated with denosumab with no participation in clinical trials between May 2013 and September 2015 were included in the present study. Denosumab treatment was administered until complete tumor resection was feasible or tumor progression or unacceptable toxicity had occurred. The mean denosumab treatment duration was 7.4 months. A total of 17 patients received surgery following denosumab treatment: 11 patients underwent wide en bloc resection with prosthesis implantation in 10 cases and 6 patients were treated with intralesional curettage. Tumor progression was observed in 2 patients that underwent intralesional curettage without prosthesis implantation. In addition, tumor progression was observed during denosumab treatment in 2 patients that had previously undergone radiotherapy. The overall 1-year progression-free survival rate was 92.8%. Thus, for patients with advanced, unresectable, progressive or symptomatic pretreated GCTB, denosumab provides a therapeutic option not previously available, which has become the standard therapy in multidisciplinary management of GCTB.
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Affiliation(s)
- Aneta Borkowska
- Department of Radiation Oncology, Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, 02-781 Warsaw, Poland
| | - Tomasz Goryń
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, 02-781 Warsaw, Poland
| | - Andrzej Pieńkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, 02-781 Warsaw, Poland
| | - Michał Wągrodzki
- Department of Pathology, Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, 02-781 Warsaw, Poland
| | - Ewelina Jagiełło-Wieczorek
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, 02-781 Warsaw, Poland
| | - Paweł Rogala
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, 02-781 Warsaw, Poland
| | - Milena Szacht
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, 02-781 Warsaw, Poland
| | - Piotr Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, 02-781 Warsaw, Poland
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14
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Zhang Y, Ilaslan H, Krishnaney AA, Bauer TW. Morphological Transformation of Giant-Cell Tumor of Bone After Treatment with Denosumab: A Case Report. JBJS Case Connect 2016; 6:e74. [PMID: 29252651 DOI: 10.2106/jbjs.cc.16.00015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
CASE Denosumab, an inhibitor of RANKL (receptor activator of nuclear factor κ-B ligand), was recently introduced for the treatment of giant-cell tumor of bone (GCTB). We describe the clinical, radiographic, and histological features of a GCTB of the spine in a 24-year-old woman that progressed after neoadjuvant treatment with denosumab. Disappearance of the multinuclear osteoclastic giant cells was accompanied by newly formed woven bone, which was deposited in interconnected strands with a prominent fibrovascular stroma that was histologically and radiographically similar to that of an osteoblastoma. CONCLUSION Pathologists, radiologists, and surgeons should be aware of this post-treatment transformation to avoid misdiagnosis.
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Affiliation(s)
- Yaxia Zhang
- Department of Pathology, Robert J. Tomsich Pathology & Laboratory Medicine Institute (Y.Z. and T.W.B.), Department of Diagnostic Radiology (H.I.), Department of Neurosurgery and Center for Spine Health (A.A.K. and T.W.B.), and Department of Orthopaedic Surgery (T.W.B.), Cleveland Clinic, Cleveland, Ohio
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Hakan Ilaslan
- Department of Pathology, Robert J. Tomsich Pathology & Laboratory Medicine Institute (Y.Z. and T.W.B.), Department of Diagnostic Radiology (H.I.), Department of Neurosurgery and Center for Spine Health (A.A.K. and T.W.B.), and Department of Orthopaedic Surgery (T.W.B.), Cleveland Clinic, Cleveland, Ohio
| | - Ajit A Krishnaney
- Department of Pathology, Robert J. Tomsich Pathology & Laboratory Medicine Institute (Y.Z. and T.W.B.), Department of Diagnostic Radiology (H.I.), Department of Neurosurgery and Center for Spine Health (A.A.K. and T.W.B.), and Department of Orthopaedic Surgery (T.W.B.), Cleveland Clinic, Cleveland, Ohio
| | - Thomas W Bauer
- Department of Pathology, Robert J. Tomsich Pathology & Laboratory Medicine Institute (Y.Z. and T.W.B.), Department of Diagnostic Radiology (H.I.), Department of Neurosurgery and Center for Spine Health (A.A.K. and T.W.B.), and Department of Orthopaedic Surgery (T.W.B.), Cleveland Clinic, Cleveland, Ohio
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15
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Song M, Dai W, Sun R, Liang H, Liu B, Wu Y, Ma K, Lu M. Giant cell tumor of the patella with a secondary aneurysmal bone cyst: A case report. Oncol Lett 2016; 11:4045-4048. [PMID: 27313738 DOI: 10.3892/ol.2016.4540] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 03/22/2016] [Indexed: 11/06/2022] Open
Abstract
The substance of the patella is an uncommon location for tumor occurrence and development. The present study reports a case of giant cell tumor (GCT) of the patella, combined with an aneurysmal bone cyst (ABC). To the best of our knowledge, this is the second report of GCT with ABC published in English. GCT is the most common type of benign tumor. Secondary ABC is frequently associated with GCT, but this symbiotic tumor rarely occurs in the patella. A 27-year-old male patient was examined at the outpatient clinic, and clinicopathological characteristics of the tumor were observed. X-ray and computed tomography (CT) scans revealed a lytic lesion located in the center of the right patella. Curettage, followed by autogenic and allograft bone grafting, was performed. Histopathologically, the lesion was diagnosed as a GCT with secondary ABC. No recurrence or metastasis was identified during the 1-year follow-up period. The present study reports a case of GCT with secondary ABC, and discusses the rare location and histopathological type of this tumor, in order to improve diagnosis and treatment of patellar tumors in general.
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Affiliation(s)
- Mingzhi Song
- Department of Orthopedics, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116011, P.R. China; Department of Orthopedics, The Third Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116200, P.R. China
| | - Wei Dai
- Department of Nursing, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116011, P.R. China; Department of Operation Room, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116011, P.R. China
| | - Ran Sun
- Department of Nursing, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116011, P.R. China; Department of Operation Room, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116011, P.R. China
| | - Hongfeng Liang
- Department of Nursing, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116011, P.R. China; Department of Operation Room, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116011, P.R. China
| | - Bingwu Liu
- Department of Radiology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116011, P.R. China
| | - Yuxuan Wu
- Department of Orthopedics, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116011, P.R. China; Department of Orthopedics, The Third Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116200, P.R. China
| | - Kai Ma
- Department of Orthopedics, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116011, P.R. China
| | - Ming Lu
- Department of Orthopedics, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116011, P.R. China
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16
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Mukaihara K, Suehara Y, Kohsaka S, Akaike K, Tanabe Y, Kubota D, Ishii M, Fujimura T, Kazuno S, Okubo T, Takagi T, Yao T, Kaneko K, Saito T. Protein Expression Profiling of Giant Cell Tumors of Bone Treated with Denosumab. PLoS One 2016; 11:e0148401. [PMID: 26863138 PMCID: PMC4749282 DOI: 10.1371/journal.pone.0148401] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 01/18/2016] [Indexed: 11/30/2022] Open
Abstract
Giant cell tumors of bone (GCTB) are locally aggressive osteolytic bone tumors. Recently, some clinical trials have shown that denosumab is a novel and effective therapeutic option for aggressive and recurrent GCTB. This study was performed to investigate the molecular mechanism underlying the therapeutic effect of denosumab. Comparative proteomic analyses were performed using GCTB samples which were taken before and after denosumab treatment. Each expression profile was analyzed using the software program to further understand the affected biological network. One of identified proteins was further evaluated by gelatin zymography and an immunohistochemical analysis. We identified 13 consistently upregulated proteins and 19 consistently downregulated proteins in the pre- and post-denosumab samples. Using these profiles, the software program identified molecular interactions between the differentially expressed proteins that were indirectly involved in the RANK/RANKL pathway and in several non-canonical subpathways including the Matrix metalloproteinase pathway. The data analysis also suggested that the identified proteins play a critical functional role in the osteolytic process of GCTB. Among the most downregulated proteins, the activity of MMP-9 was significantly decreased in the denosumab-treated samples, although the residual stromal cells were found to express MMP-9 by an immunohistochemical analysis. The expression level of MMP-9 in the primary GCTB samples was not correlated with any clinicopathological factors, including patient outcomes. Although the replacement of tumors by fibro-osseous tissue or the diminishment of osteoclast-like giant cells have been shown as therapeutic effects of denosumab, the residual tumor after denosumab treatment, which is composed of only stromal cells, might be capable of causing bone destruction; thus the therapeutic application of denosumab would be still necessary for these lesions. We believe that the protein expression patterns and the results of the network analysis will provide a better understanding of the effects of denosumab administration in patients with GCTB.
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Affiliation(s)
- Kenta Mukaihara
- Department of Orthopedic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Yoshiyuki Suehara
- Department of Orthopedic Surgery, Juntendo University School of Medicine, Tokyo, Japan
- * E-mail:
| | - Shinji Kohsaka
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York, United States of America
| | - Keisuke Akaike
- Department of Orthopedic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Yu Tanabe
- Department of Orthopedic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Daisuke Kubota
- Department of Orthopedic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Midori Ishii
- Department of Orthopedic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Tsutomu Fujimura
- Laboratory of Biochemical Analysis, Central Laboratory of Medical Sciences, Juntendo University School of Medicine, Tokyo, Japan
| | - Saiko Kazuno
- Laboratory of Biochemical Analysis, Central Laboratory of Medical Sciences, Juntendo University School of Medicine, Tokyo, Japan
| | - Taketo Okubo
- Department of Orthopedic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Tatsuya Takagi
- Department of Orthopedic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Takashi Yao
- Department of Human Pathology, Juntendo University School of Medicine, Tokyo, Japan
| | - Kazuo Kaneko
- Department of Orthopedic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Tsuyoshi Saito
- Department of Human Pathology, Juntendo University School of Medicine, Tokyo, Japan
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17
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Lau CPY, Wong KC, Huang L, Li G, Tsui SKW, Kumta SM. A mouse model of luciferase-transfected stromal cells of giant cell tumor of bone. Connect Tissue Res 2015; 56:493-503. [PMID: 26327464 DOI: 10.3109/03008207.2015.1075519] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
A major barrier towards the study of the effects of drugs on Giant Cell Tumor of Bone (GCT) has been the lack of an animal model. In this study, we created an animal model in which GCT stromal cells survived and functioned as proliferating neoplastic cells. A proliferative cell line of GCT stromal cells was used to create a stable and luciferase-transduced cell line, Luc-G33. The cell line was characterized and was found that there were no significant differences on cell proliferation rate and recruitment of monocytes when compared with the wild type GCT stromal cells. We delivered the Luc-G33 cells either subcutaneously on the back or to the tibiae of the nude mice. The presence of viable Luc-G33 cells was assessed using real-time live imaging by the IVIS 200 bioluminescent imaging (BLI) system. The tumor cells initially propagated and remained viable on site for 7 weeks in the subcutaneous tumor model. We also tested in vivo antitumor effects of Zoledronate (ZOL) and Geranylgeranyl transferase-I inhibitor (GGTI-298) alone or their combinations in Luc-G33-transplanted nude mice. ZOL alone at 400 µg/kg and the co-treatment of ZOL at 400 µg/kg and GGTI-298 at 1.16 mg/kg reduced tumor cell viability in the model. Furthermore, the anti-tumor effects by ZOL, GGTI-298 and the co-treatment in subcutaneous tumor model were also confirmed by immunohistochemical (IHC) staining. In conclusion, we established a nude mice model of GCT stromal cells which allows non-invasive, real-time assessments of tumor development and testing the in vivo effects of different adjuvants for treating GCT.
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Affiliation(s)
- Carol P Y Lau
- a Department of Orthopaedics and Traumatology , The Chinese University of Hong Kong , Shatin , NT , Hong Kong
| | - Kwok Chuen Wong
- a Department of Orthopaedics and Traumatology , The Chinese University of Hong Kong , Shatin , NT , Hong Kong
| | - Lin Huang
- b Department of Surgery , Prince of Wales Hospital , Shatin , NT , Hong Kong , and
| | - Gang Li
- a Department of Orthopaedics and Traumatology , The Chinese University of Hong Kong , Shatin , NT , Hong Kong
| | - Stephen K W Tsui
- c School of Biomedical Sciences, The Chinese University of Hong Kong , Shatin , NT , Hong Kong
| | - Shekhar Madhukar Kumta
- a Department of Orthopaedics and Traumatology , The Chinese University of Hong Kong , Shatin , NT , Hong Kong
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18
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Girolami I, Mancini I, Simoni A, Baldi GG, Simi L, Campanacci D, Beltrami G, Scoccianti G, D'Arienzo A, Capanna R, Franchi A. Denosumab treated giant cell tumour of bone: a morphological, immunohistochemical and molecular analysis of a series. J Clin Pathol 2015; 69:240-7. [PMID: 26338802 DOI: 10.1136/jclinpath-2015-203248] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 08/16/2015] [Indexed: 11/03/2022]
Abstract
AIMS Denosumab, a fully human monoclonal antibody directed against RANKL, has recently been introduced in the treatment strategy of giant cell tumour of bone (GCTB). Aim of this study was to investigate the phenotypical modifications induced by denosumab treatment in a series of 15 GCTB. METHODS The tumours were characterised for histone 3.3 mutations, and studied immunohistochemically for the modifications of RANKL, RANK, SATB2 and RUNX2 expression, as well as of tumour proliferative activity and angiogenesis. RESULTS Nine of 11 tumours investigated presented a histone 3.3 mutation in H3F3A, and 2 of these for which the analysis was carried out in pretreatment and post-treatment specimens showed the same mutation in both. Denosumab induced the disappearance of osteoclast-like giant cells, leaving residual spindle neoplastic cells arranged in a storiform pattern, with deposition of trabecular collagen matrix and osteoid, which tended to maturation in the peripheral portions of the lesion. RANK and RANKL expression was variable, with no significant variation after treatment. Moreover, we did not observe any significant modification of the expression of the osteoblastic markers SATB2 and RUNX2. Denosumab treatment determined a significant reduction of the proliferative index and of tumour angiogenesis (p=0.001, Wilcoxon rank-sum test). CONCLUSIONS These results indicate that denosumab induces a partial maturation towards the osteoblastic phenotype of the neoplastic cells of GCTB, with production of fibrous and osteoid matrix, but with minor immunophenotypical changes. Finally, we first report an antiangiogenic activity of denosumab in GCTB, possibly mediated by a RANKL-dependent pathway.
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Affiliation(s)
- Ilaria Girolami
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Irene Mancini
- Department of Clinical and Experimental Biomedical Sciences, University of Florence, Florence, Italy
| | - Antonella Simoni
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | | | - Lisa Simi
- Department of Clinical and Experimental Biomedical Sciences, University of Florence, Florence, Italy
| | - Domenico Campanacci
- Department of Orthopaedic Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Giovanni Beltrami
- Department of Orthopaedic Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Guido Scoccianti
- Department of Orthopaedic Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Antonio D'Arienzo
- Department of Orthopaedic Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Rodolfo Capanna
- Department of Orthopaedic Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Alessandro Franchi
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
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19
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Martins AFL, Souza POC, Rege ICC, Morais MO, Mendonça EF. Glucocorticoids, calcitonin, and osteocalcin cannot differentiate between aggressive and nonaggressive central giant cell lesions of the jaws. Oral Surg Oral Med Oral Pathol Oral Radiol 2015; 120:386-95. [DOI: 10.1016/j.oooo.2015.05.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 05/15/2015] [Accepted: 05/21/2015] [Indexed: 10/23/2022]
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Rutkowski P, Ferrari S, Grimer RJ, Stalley PD, Dijkstra SPD, Pienkowski A, Vaz G, Wunder JS, Seeger LL, Feng A, Roberts ZJ, Bach BA. Surgical downstaging in an open-label phase II trial of denosumab in patients with giant cell tumor of bone. Ann Surg Oncol 2015; 22:2860-8. [PMID: 26033180 PMCID: PMC4531146 DOI: 10.1245/s10434-015-4634-9] [Citation(s) in RCA: 119] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2015] [Indexed: 11/25/2022]
Abstract
Background Surgical resection with curative intent for giant cell tumor of bone (GCTB) may be associated with severe morbidity. This interim analysis evaluated reduction in surgical invasiveness after denosumab treatment in patients with resectable GCTB. Methods Patients with primary or recurrent GCTB, for whom the initially planned surgery was associated with functional compromise or morbidity, received denosumab 120 mg subcutaneously every 4 weeks (additional doses on days 8 and 15 of the first cycle). Planned and actual GCTB-related surgical procedures before and after denosumab treatment were reported. Patients were followed for surgical outcome, adverse events, and recurrence following resection. Results Overall, 222 patients were evaluable for surgical downstaging (54 % were women; median age 34 years). Lesions (67 % primary and 33 % recurrent) were located in the axial (15 %) and appendicular skeleton (85 %). At the data cutoff date, most patients had not yet undergone surgery (n = 106; 48 %) or had a less morbid procedure (n = 84; 38 %) than originally planned. Median (interquartile range) time on denosumab was 19.5 (12.4–28.6) months for the 106 patients who had not undergone surgery and were continuing on monthly denosumab. Native joint preservation was 96 % (n = 24/25) for patients with planned joint/prosthesis replacement and 86 % (n = 30/35) for patients with planned joint resection/fusion. Of the 116 patients who had surgery (median postsurgical follow-up 13.0 [8.5–17.9] months), local recurrence occurred in 17 (15 %) patients. Conclusion For patients with resectable GCTB, neoadjuvant denosumab therapy resulted in beneficial surgical downstaging, including either no surgery or a less morbid surgical procedure. Electronic supplementary material The online version of this article (doi:10.1245/s10434-015-4634-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Piotr Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Memorial Center and Institute of Oncology, Roentgen Str 5, 02-781, Warsaw, Poland,
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Balla P, Maros ME, Barna G, Antal I, Papp G, Sapi Z, Athanasou NA, Benassi MS, Picci P, Krenacs T. Prognostic impact of reduced connexin43 expression and gap junction coupling of neoplastic stromal cells in giant cell tumor of bone. PLoS One 2015; 10:e0125316. [PMID: 25933380 PMCID: PMC4416750 DOI: 10.1371/journal.pone.0125316] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 03/12/2015] [Indexed: 12/05/2022] Open
Abstract
Missense mutations of the GJA1 gene encoding the gap junction channel protein connexin43 (Cx43) cause bone malformations resulting in oculodentodigital dysplasia (ODDD), while GJA1 null and ODDD mutant mice develop osteopenia. In this study we investigated Cx43 expression and channel functions in giant cell tumor of bone (GCTB), a locally aggressive osteolytic lesion with uncertain progression. Cx43 protein levels assessed by immunohistochemistry were correlated with GCTB cell types, clinico-radiological stages and progression free survival in tissue microarrays of 89 primary and 34 recurrent GCTB cases. Cx43 expression, phosphorylation, subcellular distribution and gap junction coupling was also investigated and compared between cultured neoplastic GCTB stromal cells and bone marow stromal cells or HDFa fibroblasts as a control. In GCTB tissues, most Cx43 was produced by CD163 negative neoplastic stromal cells and less by CD163 positive reactive monocytes/macrophages or by giant cells. Significantly less Cx43 was detected in α-smooth muscle actin positive than α-smooth muscle actin negative stromal cells and in osteoclast-rich tumor nests than in the adjacent reactive stroma. Progressively reduced Cx43 production in GCTB was significantly linked to advanced clinico-radiological stages and worse progression free survival. In neoplastic GCTB stromal cell cultures most Cx43 protein was localized in the paranuclear-Golgi region, while it was concentrated in the cell membranes both in bone marrow stromal cells and HDFa fibroblasts. In Western blots, alkaline phosphatase sensitive bands, linked to serine residues (Ser369, Ser372 or Ser373) detected in control cells, were missing in GCTB stromal cells. Defective cell membrane localization of Cx43 channels was in line with the significantly reduced transfer of the 622 Da fluorescing calcein dye between GCTB stromal cells. Our results show that significant downregulation of Cx43 expression and gap junction coupling in neoplastic stromal cells are associated with the clinical progression and worse prognosis in GCTB.
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MESH Headings
- Actins/genetics
- Actins/metabolism
- Adolescent
- Adult
- Aged
- Alkaline Phosphatase/deficiency
- Alkaline Phosphatase/genetics
- Antigens, CD/genetics
- Antigens, CD/metabolism
- Antigens, Differentiation, Myelomonocytic/genetics
- Antigens, Differentiation, Myelomonocytic/metabolism
- Bone Marrow Cells/metabolism
- Bone Marrow Cells/pathology
- Bone Neoplasms/diagnosis
- Bone Neoplasms/genetics
- Bone Neoplasms/metabolism
- Bone Neoplasms/pathology
- Bone and Bones/metabolism
- Bone and Bones/pathology
- Child
- Child, Preschool
- Connexin 43/genetics
- Connexin 43/metabolism
- Gap Junctions/metabolism
- Gap Junctions/pathology
- Gene Expression Regulation, Neoplastic
- Giant Cell Tumor of Bone/diagnosis
- Giant Cell Tumor of Bone/genetics
- Giant Cell Tumor of Bone/metabolism
- Giant Cell Tumor of Bone/pathology
- Giant Cells/metabolism
- Giant Cells/pathology
- Hematopoietic Stem Cells/metabolism
- Hematopoietic Stem Cells/pathology
- Humans
- Macrophages/metabolism
- Macrophages/pathology
- Middle Aged
- Monocytes/metabolism
- Monocytes/pathology
- Neoplastic Stem Cells/metabolism
- Neoplastic Stem Cells/pathology
- Primary Cell Culture
- Receptors, Cell Surface/genetics
- Receptors, Cell Surface/metabolism
- Signal Transduction
- Survival Analysis
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Affiliation(s)
- Peter Balla
- 1st Department of Pathology & Experimental Cancer Research, Semmelweis University Budapest, Hungary
| | - Mate Elod Maros
- 1st Department of Pathology & Experimental Cancer Research, Semmelweis University Budapest, Hungary
- Department of Neuroradiology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Gabor Barna
- 1st Department of Pathology & Experimental Cancer Research, Semmelweis University Budapest, Hungary
| | - Imre Antal
- Department of Orthopaedics, Semmelweis University, Budapest, Hungary
| | - Gergo Papp
- 1st Department of Pathology & Experimental Cancer Research, Semmelweis University Budapest, Hungary
| | - Zoltan Sapi
- 1st Department of Pathology & Experimental Cancer Research, Semmelweis University Budapest, Hungary
| | | | - Maria Serena Benassi
- Laboratory of Experimental Oncology, Institute of Orthopaedics Rizzoli, Bologna, Italy
| | - Pierro Picci
- Laboratory of Experimental Oncology, Institute of Orthopaedics Rizzoli, Bologna, Italy
| | - Tibor Krenacs
- 1st Department of Pathology & Experimental Cancer Research, Semmelweis University Budapest, Hungary
- Hunragian Academy of Sciences-Semmelweis University (MTA-SE) Tumor Progression Research Group, Budapest, Hungary
- * E-mail:
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Developmental pathways hijacked by osteosarcoma. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2014; 804:93-118. [PMID: 24924170 DOI: 10.1007/978-3-319-04843-7_5] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Cancer of any type often can be described by an arrest, alteration or disruption in the normal development of a tissue or organ, and understanding of the normal counterpart's development can aid in understanding the malignant state. This is certainly true for osteosarcoma and the normal developmental pathways that guide osteoblast development that are changed in the genesis of osteogenic sarcoma. A carefully regulated crescendo-decrescendo expression of RUNX2 accompanies the transition from mesenchymal stem cell to immature osteoblast to mature osteoblast. This pivotal role is controlled by several pathways, including bone morphogenic protein (BMP), Wnt/β-catenin, fibroblast growth factor (FGF), and protein kinase C (PKC). The HIPPO pathway and its downstream target YAP help to regulate proliferation of immature osteoblasts and their maturation into non-proliferating mature osteoblasts. This pathway also helps regulate expression of the mature osteoblast protein osteocalcin. YAP also regulates expression of MT1-MMP, a membrane-bound matrix metalloprotease responsible for remodeling the extracellular matrix surrounding the osteoblasts. YAP, in turn, can be regulated by the ERBB family protein Her-4. Osteosarcoma may be thought of as a cell held at the immature osteoblast stage, retaining some of the characteristics of that developmental stage. Disruptions of several of these pathways have been described in osteosarcoma, including BMP, Wnt/b-catenin, RUNX2, HIPPO/YAP, and Her-4. Further, PKC can be activated by several receptor tyrosine kinases implicated in osteosarcoma, including the ERBB family (EGFR, Her-2 and Her-4 in osteosarcoma), IGF1R, FGF, and others. Understanding these functions may aid in the understanding the mechanisms underpinning clinical observations in osteosarcoma, including both the lytic and blastic phenotypes of tumors, the invasiveness of the disease, and the tendency for treated tumors to ossify rather than shrink. Through a better understanding of the relationship between normal osteoblast development and osteosarcoma, we may gain insights into novel therapeutic avenues and improved outcomes.
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Lau CPY, Huang L, Wong KC, Kumta SM. Comparison of the anti-tumor effects of denosumab and zoledronic acid on the neoplastic stromal cells of giant cell tumor of bone. Connect Tissue Res 2013; 54:439-49. [PMID: 24060052 DOI: 10.3109/03008207.2013.848202] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Denosumab and Zoledronic acid (ZOL) are two antiresorptive drugs currently in use for treating osteoporosis. They have different mechanisms of action but both have been shown to delay the onset of skeletal-related events in patients with giant cell tumor of bone (GCT). However, the anti-tumor mechanisms of denosumab on the neoplastic GCT stromal cells remain unknown. In this study, we focused on the direct effects of denosumab on the neoplastic GCT stromal cells and compared with ZOL. The microscopic view demonstrated a reduced cell growth in ZOL-treated but not in denosumab-treated GCT stromal cells. ZOL was found to exhibit a dose-dependent inhibition in cell growth in all GCT stromal cell lines tested and cause apoptosis in two out of three cell lines. In contrast, denosumab only exerted a minimal inhibitory effect in one cell line and did not induce any apoptosis. ZOL significantly inhibited the mRNA expression of receptor activator of nuclear factor kappa-B ligand (RANKL) and osteoprotegerin (OPG) in two GCT stromal cell lines whereas their protein levels remained unchanged. On the contrary, denosumab did not regulate RANKL and OPG expression at both mRNA and protein levels. Moreover, the protein expression of Macrophage Colony-Stimulating Factor (M-CSF), Alkaline Phosphatase (ALP), and Collagen α1 Type I were not regulated by denosumab and ZOL either. Our findings provide new insights in the anti-tumor effect of denosumab on GCT stromal cells and raise a concern that tumor recurrence may occur after the withdrawal of the drug.
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Affiliation(s)
- Carol P Y Lau
- Department of Orthopedics and Traumatology, The Chinese University of Hong Kong , Hong Kong, SAR , P. R. China and
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