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Therapeutic approaches to myeloma bone disease: An evolving story
Cancer Treatment Reviews, 6, 38, pages 787 - 797
Bone disease is a major morbidity factor in patients with multiple myeloma and significantly affects their overall survival. A complex interplay between malignant plasma cells and other marrow cells results in the generation of a microenvironment capable of enhancing both tumor growth and bone destruction. Bisphosphonates have consistently reduced the incidence of skeletal-related events in patients with multiple myeloma and other osteotropic tumors as well. However, their use is burdened with side-effects, including the risks of osteonecrosis of the jaw and kidney failure, suggesting that they should be discontinued after prolonged administration. New molecular targets of cell cross-talk in myeloma bone marrow are therefore under intensive investigation and new drugs are being explored in preclinical and clinical studies of myeloma bone disease. Compounds targeting osteoclast activation pathways, such as receptor activator of nuclear factor-κB/receptor activator of nuclear factor-κB ligand/osteoprotegerin, B-cell activating factor, mitogen-activated protein kinase and macrophage inflammatory protein-1α/chemokine receptor for macrophage inflammatory protein-1α axes, or soluble agents that improve osteoblast differentiation by modulating specific inhibitors such as Dickkopf-1 and transforming growth factor-β, as well as novel approaches of cytotherapy represent a new generation of promising drugs for the treatment of myeloma bone disease.
Abbreviations: ActRIIA - activin receptor type IIA, Akt - serine/threonine protein kinase, APRIL - proliferation-inducing ligand, BAFF - B-cell activating factor, BAFF-R - B-cell activating factor-receptor, BCMA - B-cell maturation antigen, BM - bone marrow, BMM - bone marrow microenvironment, BMSCs - bone marrow stromal cells, BPs - bisphosphonates, BSAP - bone specific alkaline phosphatase, CCR1 - chemokine receptor for MIP1α-1, CTX - C-telopeptide, DASH - dipeptidyl peptidase-IV activity and/or structure homologues, DKK-1 - Dickkopf-1, DLX5 - distal-less homeobox 5, DPP - dual dipeptidyl peptidase, ERK - extracellular signal-regulated kinases, FAP - fibroblast activation protein, Hsp90 - heat shock protein 90, IL-1 - interleukin-1, JNK - Jun N-terminal Kinase, LDH - lactate dehydrogenase, MAPK - mitogen-activated protein kinase, MBD - myeloma bone disease, M-CSF - macrophage colony-stimulating factor, MEK - mitogen-activated protein kinase, MIP-1α - macrophage inflammatory protein-1α, MM - multiple myeloma, MMPCs - multiple myeloma plasma cells, MRC - Medical Research Council, MSCs - mesenchymal stem cells, NFAT-1 - nuclear factor of activated T-cells-1, NF-kB - nuclear factor-kappaB, NTX - N-telopeptide, OB - osteoblast, OC - osteoclast, ONJ - osteonecrosis of the jaw, OPG - osteoprotegerin, PAM - pamidronate, PARP - poly ADP ribose polymerase, PCR - polymerase chain reaction, PDACs - placenta-derived adherent cells, PTH - parathyroid hormone, RANK - receptor activator of nuclear factor-κB, RANKL - receptor activator of nuclear factor-κB ligand, RUNX-2 - Runt-related transcription factor, s.c. - subcutaneous, SCID - severe combined immunodeficiency, SFRP - secreted frizzled related protein, siRNA - small-interfering RNA, SLRPs - small leucine-rich proteoglycans, SMAD - small mother against decapentaplegic, SOST - sclerosteosis, Src - sarcoma, SREs - skeletal-related events, STAT3 - signal transducer and activator of transcription 3, CAML - calcium-modulator and cyclophilin ligand, TACI - transmembrane activator and CAML interactor, TGF-β - transforming growth factor-β, TK - tyrosine kinase, TNFR - tumor necrosis factor receptor, TNF-α - tumor necrosis factor-α, TRAcP - tartrate-resistant acid phosphatase, VEGF - vascular endothelial growth factor, Wnt - wingless, ZA - zoledronic acid.
Keywords: Multiple myeloma, Myeloma bone disease, Osteolyses, Osteoblasts, Osteoclasts, Skeletal-related events.
Multiple myeloma (MM) is a plasma cell malignancy that, after prostate and breast cancers, more frequently induces bone involvement. 1 Its clinical progression is characterized by the appearance of multiple osteolytic lesions which, through a rapid loss of bone mass, lead to progressive skeletal devastation, with intractable pain, pathological fractures, hypercalcemia and frequent spinal cord compression, all of which define the myeloma bone disease (MBD). 2 At least 15% of MM patients show a pathological fracture at diagnosis, and 60% of them experience this complication during the course of the disease. Each patient usually develops 3–5 skeletal-related events (SREs) every three years. Moreover, MBD is not only a critical morbidity factor, but also adversely affects overall survival since the mortality is 20% higher in patients with multiple SREs. Therefore, treatments that can remarkably reduce the risk of bone complications in MM are urgently needed.3, 4, and 5
Several studies have demonstrated that bone provides a permissive niche to tumor cell growth and that interactions between multiple myeloma plasma cells (MMPCs) and the bone marrow (BM) contribute to bone destruction by deregulation of both soluble factors release and cell-to-cell cross talk. MBD is a consequence of increased osteoclast (OC) activation in parallel with osteoblast (OB) inhibition, resulting in impaired bone remodelling.6, 7, and 8
Bisphosphonates (BPs) represent the current standard of care in the treatment of MBD. However, complications arising from their use have stimulated schedule optimization studies and the search for alternative strategies, which are currently being evaluated in ongoing pre-clinical and clinical studies. 9
Here, we review new therapeutic approaches to MBD, with a special focus on cross-talking between BM and MMPCs as well as on the molecular mechanisms implicated in OC activation and concurrent OB suppression.
Bisphosphonates in MBD
BPs administration has dramatically improved the quality of life in MM patients, significantly reducing SREs and palliating bone pain, with a consequent reduction in the use of analgesic drugs. Before the “BPs era”, SREs occurred in approximately 75% of MM patients. Starting from 1990 and following the introduction of first-generation BPs, namely Etidronate and Clodronate, SREs dropped to 68% and 36% respectively,10 and 11 and subsequently to 25% with the second-generation BPs which include pamidronate (PAM)and particularly zoledronic acid (ZA)( Fig. 1 ).12 and 13
BPs also exert anti-myeloma activity both by inducing apoptosis in MMPCs and modifying the tumor microenvironment.14, 15, and 16 In agreement with these data, a recent analysis from the MRC Myeloma IX Study, including 1960 patients, showed that ZA, in association with other anti-MM drugs, increases overall survival in newly diagnosed MM patients. 17 Therefore, BPs are currently considered the best available treatment for MBD. However, ZA may also induce, as already mentioned, adverse effects, such as kidney failure and osteonecrosis of the jaw (ONJ). The former is due to several potential mechanisms including the capability of BPs to form insoluble aggregates with metal ions in kidney microvessel and the podocyte mitochondrial injury, as well as the degeneration of tubular cells leading to loss of brush border and derangement of tubular Na+, K+ – ATPase expression.18, 19, 20, 21, and 22 The pathogenesis of the latter, on the contrary, is still uncertain, though it is suspected that ZA is capable of inducing a microenvironment modification that results in inhibition of angiogenesis, necrosis of the jaw and increasing susceptibility to infections in these sites.23 and 24
Although several studies have evaluated the prevalence of ONJ, differences in study design and lack of prolonged follow-up have prevented a reliable evaluation of its occurrence.25, 26, 27, 28, 29, and 30 In a large cohort of 1621 patients 31 treated with intravenous BPs, the rough ONJ incidence rates were 8%, 3% and 5% in patients with MM, breast or prostate cancer, respectively. Migliorati et al. 32 have recently revisited the ONJ prevalence in 22 different studies that revealed an overall recurrence of 6.1%. However, in a parallel study the same group 33 reported a weighed prevalence of 13.3% in selected clinical trials characterized by documented follow-up. The use of dentures, history of dental extraction and protracted administration of BPs have been shown to be associated with increased risk for the development of ONJ. 31 On the other hand, cancer patients, especially those with MM, are constitutively at risk for kidney failure, although its occurrence in relation to ZA combined with conventional chemotherapy is not well defined. The rates of kidney failure associated to long-term treatment with ZA have been described to be as high as 30% in all cancer patients receiving ZA.27, 31, 34, 35, 36, 37, 38, and 39
A number of organization have prepared guidelines, mainly based on good-clinical-practice, for use of BPs in MM. For instance, both the European Myeloma Network and the American Society of Clinical Oncology recommend that BPs should be discontinued in patients who develop ONJ and, independently of this complication, after 2 years in patients without active bone disease, although these drugs can be resumed in case of relapse.40 and 41 The National Comprehensive Cancer Network also defines similar recommendations, though a 2 year continuative period of BPs treatment is not considered a further risk for developing ONJ. 42 Alternative therapeutic approaches are thus needed for patients ineligible to receive BPs in the presence of novel SREs.
Therapeutic approaches targeting OC pathways
OC hyperactivation is a major pathogenetic mechanism in MBD, as shown by analyses on bone marrow biopsies from MM patients that have clearly shown a close relationship between OC number, bone resorption areas and tumor burden. 43
MMPCs interact with bone marrow microenvironment (BMM) and constitute, together with OBs and stromal cells, a functional neoplastic unit secreting a number of soluble factors, such as OC-activating cytokines( Fig. 2 ).These include receptor activator of nuclear factor-κB ligand (RANKL), which plays a major role in MM osteoclastogenesis; IL-6, a survival factor for MMPCs; tumor necrosis factor-α (TNF-α); IL-1;macrophage inflammatory protein-1α (MIP-1α) and macrophage colony-stimulating factor (M-CSF). 44 At the same time, OC activation promotes MMPCs proliferation and survival by the release of IL-6, creating a vicious circle that progressively leads to the onset of bone lesions. Therefore, these reciprocal interactions represent new promising targets for the treatment of MBD ( Table 1 ).
|Therapeutic agents||Drug denomination||Target||Study phase||References|
|RANKL-neutralizing antibody||Denosumab||OC||Phase III clinical trials (already approved for other malignancies)||53|
|Anti-Baff-neutralizing antibody||LY2127399||OC||Phase I clinical trial in association with bortezomib||59|
|Decoy receptor for BAFF and APRIL||Atacicept||OC||Phase I/II clinical trials||60|
|CCR1 inhibitors||MLN3897||OC||Preclinical studies||66|
|Src/Abl inhibitors||Dasatinib||OC||Phase I/II clinical trials (already approved for other malignancies)||72 and 73|
|MEK inhibitors||AS703026; AZD6244||OC||Phase II clinical trials||84, 85, 86, and 87|
|p38MAPK inhibitors||LY2228820||OC||Phase I clinical trials||89, 90, 91, and 93|
|DASH inhibitors||PT-100||OC||Preclinical studies (Phase II/III for other malignancies)||95|
|Hsp90 inhibitors||SNX-2112||OC||Preclinical studies||96|
|Anti-DKK1||BHQ880||OB||Phase II clinical trials||116 and 117|
|TGF-β inhibitors||SB431542; Ki26894||OB||Preclinical studies||130, 131, and 132|
|Decoy receptor for Activin A||ACE-011; RAP-011||OC and OB||Phase II clinical trials||138|
|Cytotherapy||PDACs||OC and OB||Preclinical studies||155|
RANKL binds its receptor, RANK, an integral membrane protein on the surface of OC precursors, and allows their maturation to OCs.45 and 46 Several studies have demonstrated that MMPCs stimulate RANKL production by bone marrow stromal cells (BMSCs) through a cell-to-cell contact, resulting in increased RANKL circulating levels in patients with MM. 47 In normal conditions, osteoprotegerin (OPG), a soluble decoy receptor of RANKL belonging to the tumor necrosis factor receptor (TNFR) superfamily, modulates its effects and prevents excessive bone resorption. 48 In patients with MM, serum OPG levels are instead greatly decreased because of the neutralizing effect of CD138, that produces an increase of the soluble RANKL/OPG ratio correlated with enhanced OC activation and the extent of MBD. 49 The RANK/RANKL/OPG axis, which plays a crucial role in the regulation of the OC function, is an important target of novel therapeutic strategies aimed at down-regulating hyperactive osteoclastogenesis. 43 Recombinant human OPG-Fc inactivates RANKL, 50 thus interfering with bone resorption in patients with MM, post-menopausal osteoporosis or bone metastases from breast cancer. 51
Another RANKL inhibitor is Denosumab (AMG 162, Amgen Pharmaceutical), a fully human anti-RANKL monoclonal antibody with a half-life longer than OPG-Fc and a remarkable anti-resorptive effect. 52 In a recent double-blind study, subcutaneous (s.c.). Denosumab was evaluated in comparison with intravenous ZA in patients with MM or advanced cancers and bone metastases (excluding breast and prostate). The Denosumab effect was judged non-inferior to ZA in preventing or delaying SREs, whereas in another study a single s.c. administration of Denosumab induced reduction in the level of bone resorption markers persistent up to 80 days, compared with the 30 days of BPs. Although ONJ occurred at similar rates in both groups, Denosumab induced renal failure and acute-phase reactions less frequently. 53 These results indicate that Denosumab is a promising treatment in patients with MBD. Additional trials are in progress to investigate its effectiveness in the treatment of cancer-induced bone disease and in other bone loss disorders. 54
B-cell activating factor (BAFF) of the TNF family and proliferation-inducing ligand (APRIL) promote MMPCs survival and BMSC adhesion.55 and 56 BAFF binds the TNF-related receptors, such as B-cell maturation antigen (BCMA), transmembrane activator and calcium-modulator and cyclophilin ligand (CAML) interactor (TACI), and ultimately its own receptor BAFF-R. APRIL binds TACI, BCMA and heparan sulfate proteoglycans, such as syndecan-1. In MM, BAFF and APRIL are expressed by cells of BMM and particularly by OCs. 57
Neri et al. 58 have demonstrated that BAFF-neutralizing antibodies reduce both tumor burden and OC differentiation in vivo, thus reducing the number of osteolytic lesions. A phase I study combining a BAFF-neutralizing antibody with Bortezomib in twenty patients showed an overall response rate of 55%, including six partial responses, four very good partial responses and one complete response, with a safety profile similar to that of Bortezomib used as a single agent, 59 whereas Atacicept (TACI-Ig), a decoy receptor for BAFF and APRIL, is currently being investigated in a Phase I/II clinical trial in patients with refractory or relapsed MM or progressive Waldenström’s macroglobulinemia. Atacicept appears to be safe and clinically active, in that in a recent phase-1 study carried out on 11 patients with MM who completed initial treatment, 5 patients were progression-free after cycle 1 and 4 patients were progression-free after extended therapy. 60
hMIP-1α/CCR1 pathway in MM
hMIP-1α is a chemokine involved in the interactive loop between OCs and MMPCs. It is secreted by both cell types and interacts with 2 receptors, namely chemokine receptor for MIP-1α (CCR1) and CCR5. hMIP-1α exerts osteoclastogenic activity mostly via CCR1, and stimulates migration, adhesion and survival of MMPCs through interactions with both CCR1 and CCR5.61 and 62 Bone marrow expression and serum levels of MIP-1α have indeed been reported to correlate with bone disease extension.63 and 64 In agreement with these evidences, it has been reported that hMIP-1α targeting by neutralizing antibodies or antisense strategies reduces the tumor burden and inhibits the development of osteolytic lesions in vivo. 65
In parallel with these results, Vallet et al. 66 have shown that MLN3897, a specific CCR1 inhibitor, blocks the differentiation of OC progenitors by down-regulating cell-fusion and c-fos expression. Moreover, MLN3897 abrogates the proliferative advantage of MMPCs mediated by OC and interferes with both the adhesion between OC and MM cells, and the OC cytokine secretion. Future trials targeting the hMIP-1α /CCR1 pathway will assess whether or not these results are susceptible of clinical application.
Considerable interest has recently been focused on the possible role of sarcoma (src) oncogene in the pathogenesis of MBD. This gene is highly expressed by several cell types and codes for a non-receptor tyrosine kinase (TK) which phosphorylates a number of substrates, such as adhesion molecules (vinculin), soluble enzymes (enolase, LDH) and transmembrane TK receptors. 67 Src contributes to the regulation of many cellular events, including not only migration, proliferation and differentiation, but also bone homeostasis. The activation of serine/threonine protein kinase (Akt) by this kinase is essential for RANKL-induced OC differentiation and survival, thus emphasizing its involvement in bone remodeling. This role is also confirmed by the occurrence of the osteopetrosis phenotype in src-deficient mice. 68 Therefore, drugs inhibiting the activity of src tyrosine kinase or its downstream effectors may represent an efficient therapeutic strategy for MBD. 69
Dasatinib (BMS354825), a dual Src/Abl inhibitor, has been shown to suppress the proliferation of human MM cells, increase their apoptosis and reduce their ability to produce vascular endothelial growth factor (VEGF) as well as other angiogenic factors. 70 Moreover, administration of Dasatinib (150 mg/kg/die) delayed both tumor growth and angiogenesis in a murine xenograft model of MM, in which Dasatinib exerted a synergic effect with a number of anti-myeloma agents, such as Melphalan, Prednisone, Bortezomib and Thalidomide. 71
A group of seven patients with relapsed MM received Dasatinib, and serum levels of osteocalcin and bone-specific alkaline phosphatase (BSAP) were serially assessed as markers of bone formation, together with the urinary N-telopeptide (NTX) collagen fragment, that is usually released in OC-mediated bone destruction. Following its administration, the evaluation of these parameters showed a decreased OC function, with no change of OB activity. 72 Clinical trials evaluating the role of Dasatinib in MM are ongoing 73 and its overall safety profile seems manageable. However, myelosuppression is a recurrent adverse event, though reversible after dose reduction or treatment discontinuation, and other side effects including pleural effusion, headache, peripheral edema and gastrointestinal symptoms may also occur. 74
This heterodimeric membrane glycoprotein, which is a member of the cell-surface receptor superfamily that mediates cell-to-cell and cell-to-matrix interactions, is highly expressed by OCs. Through αvβ3, these cells bind a variety of extracellular matrix proteins, including vitronectin, osteopontin and bone sialoprotein. The binding of the β3 subunit to the Arg-Gly-Asp amino acid motif, expressed by matrix sialoproteins, drives OC polarization, leading to a ruffled-border rearrangement that is an important initial step of the bone resorption process. 75 Thus, interaction of αvβ3 with matrix sialoproteins ultimately drives the expression of bone-resorbing effectors such astartrate-resistant acid phosphatase (TRAcP), through the activation of extracellular signal-regulated kinases (ERK) 1/2, c-Fos and nuclear factor of activated T-cells (NFATC1) (cytoplasmic, calcineurin-dependent-1). 76 Furthermore, αvβ3 expression is involved in angiogenesis, invasiveness and metastatization of a number of tumors. In MM, αvβ3 enhances PCs adhesion to the extracellular matrix, promotes their growth by cell-to-cell contact with OC and up-regulates the release of metalloproteinase-2 and -9.77 and 78
A fully humanized monoclonal antibody against αvβ3, namely Abegrin (Etaracizumab), has been studied over the past few years. It has been shown to reduce the proliferation and the metastatic potential of several tumors, such as melanoma, ovarian, prostate and breast cancers and to reduce OC bone erosive activity in these tumors, as well as in other skeletal disorders.77, 79, and 80 Our studies have shown that, under certain conditions, MMPCs may acquire an OC-like phenotype as multinucleated cells expressing TRAcP, and produce erosive pits on experimental bone substrate in relation to the expression of αvβ3.81 and 82 Thus, overexpression of αvβ3 in MMPCs apparently correlates with an increase of their OC-like functional properties. Abegrin could be a useful drug in MBD, not only to decrease the bone resorptive activity by OCs but also to down-regulate the direct bone resorption exerted by OC-like MMPCs. 83
Other OC pathway inhibitors
Inhibition of several signaling pathways can concurrently modulate OC differentiation, MM/BMSC interactions and MM growth. Therefore, inhibition of these pathways may be an efficient approach to treat MBD.
The mitogen-activated or extracellular signal-regulated protein kinase MEK/ERK signaling pathways mediate MMPC proliferation and hyperactive osteoclastogenesis. MEK inhibition, indeed, not only induces G0–G1 cell cycle arrest and apoptosis via caspase 3 and poly-ADP ribose polymerase (PARP) cleavage in MMPCs, but also interferes with the late phase of OC differentiation through down-regulation of NFATC1 and c-FOS. A clinical trial is ongoing.84, 85, 86, and 87
In addition, activation of p38α mitogen-activated protein kinase (MAPK) may increase BMM production of IL-6, MIP-1α, RANKL and other cytokines implicated in MBD by blocking the degradation of their mRNA. Furthermore, p38α MAPK is directly involved in OC maturation, 88 while its inhibitors have been demonstrated to reduce MM growth as well as to inhibit OC activity.89, 90, and 91 Interestingly, down-regulation of p38α MAPK activity significantly enhances Bortezomib-induced MM cytotoxicity, by inhibiting the phosphorylation of heat shock protein (Hsp)-27. 92 On the other hand, Bortezomib exerts its anti-osteoclastogenic effect in part through the inhibition of p38α MAPK pathway, 145 suggesting that the combination of agents targeting this signaling is an attractive treatment option in MBD. Currently, a phase I study is ongoing. 93
Fibroblast activation protein (FAP) is a member of the serine protease family, known as DASH, which exhibits dual dipeptidyl peptidase (DPP) and collagenase proteolytic activity. Ge et al. 94 have demonstrated that FAP expression is consistently up-regulated in OCs after co-culture with MMPCs and in myelomatous SCID-hu mice. Moreover, inhibition of FAP expression by small-interfering RNA (siRNA) reduced MMPC survival in co-cultures. Recently, the same research group 95 has shown that PT-100, a specific DASH inhibitor, abrogates the capacity of OCs to support the survival of primary MMPCs, may affect the expression of adhesion molecules in OCs co-cultured with MMPCs, and finally inhibits the differentiation of OCs. As a result of these effects, PT100 restrains MM tumor growth, resulting in reduction of MM-induced bone disease.
Hsp90 is a chaperone protein that promotes both the maturation and conformational stabilization of a subset of cellular proteins, involved in proliferation and survival signals. SNX-2112, a selective Hsp90 inhibitor, exerts several anti-MM effects, including the induction of MMPC apoptosis via caspase-3, -8, and -9 activation and PARP cleavage. In addition, SNX-2112 suppresses angiogenesis by abrogation of the eNOS/Akt pathway and prevents OC formation by down-regulating both ERK/c-fos and PU.1. 96
OC-mediated bone matrix degradation is primarily induced by acid secretion via chloride channels and protonic ATP pumps, and through the release of collagenolytic enzymes. 97 Among these, Cathepsin-K, a lysosomial proteinase largely produced by OCs, plays a central role in bone remodelling process since knock-down mice develop an osteopetrosis phenotype. 98
The Cathepsin-K inhibitor Odanacatib is presently being investigated for osteoporosis. 99 In patients with bone metastatic breast cancer it has been shown to induce a reduction of NTX excretion similar to that of BPs. 100 Furthermore, Leung et al. 101 have recently described the activity of Odanacatib on lysosomial vesicular trafficking pathways as having a major inhibiting effect on OCs. The blockade of bone matrix degradation enzymes might be a novel therapeutic option in MBD.
Targeting the link between angiogenesis and osteoclastogenesis
VEGF-dependent angiogenesis is enhanced in MM BMM, in parallel with osteoclastogenesis and tumor progression. OCs secrete proangiogenic factors which cooperate with VEGF from MMPCs and MMSCs to increase angiogenesis. VEGF also improves OC survival, their bone resorption activity and recruitment through the activation of the Akt, ERK and MAPK pathways.102, 103, and 104 Therefore, a close link between MMPCs, OCs and vascular endothelial cells can become established in MBD, with a consequent vicious cycle of myeloma cell growth, angiogenesis and bone destruction. 105 Bevacizumab, an anti-VEGF monoclonal antibody, blocks VEGF binding to its receptor. It has been approved for the treatment of several solid cancers and is currently being studied in hematological malignancies, including MM albeit with no end-point for MBD. 106 However, the evaluation of bio-markers functionally implicated in both angiogenesis and bone disease including MIP-1α, is under investigation in these studies. 107
Blocking negative regulators of OB differentiation
Together with enhanced OC activity, OB function in MM is severely impaired, as revealed by the deficiency of osteocalcin and bone morphogenetic proteins in erosive lesions. Therefore, the formation of the osteolytic lesions is not accompanied by concurrent bone remodeling. 108 MMPCs inhibit the differentiation of OB precursors and promote apoptosis in mature OBs through several factors such as DKK-1, IL-7 and IL-3. 109 Another antagonist of terminal OB maturation is transforming growth factor (TGF)-β, whose inhibition releases stromal cells from their differentiation arrest. Interestingly, although immature mesenchymal stromal cells enable MMPC growth and survival, mature OBs seem to prime their apoptosis and cell-cycle arrest in G1 stage, through small leucine-rich proteoglycans (SLRPs), as decorin and lumican. Moreover, mature OBs produce much less IL-6 than mesenchymal stromal cells.110, 111, and 112 Hence, therapeutic strategies improving OB differentiation can be considered a rational approach to MBD ( Fig. 3 ). In this context, the main agents and their study phase are reported in Table 1 .
Dickkopf-1 (DKK1) is among the factors restraining the differentiation of OBs, a soluble inhibitor of wingless (Wnt) signaling, which is secreted by MM cells, particularly in patients with osteolytic lesions.7 and 8
Extracellular antagonists of the Wnt pathway can be divided into two classes: the first includes molecules such as the DKK family which prevent the binding of Wnt ligands to LRP 5/LRP 6 co-receptors, while the second class includes soluble factors such as secreted frizzled related protein (SFRP) family, WIF-1 and Cerberus, that directly bind Wnt proteins. Factors of both classes variably down-regulate OB differentiation.113 and 114
The effects of an anti-DKK1 monoclonal antibody on bone metabolism and tumor growth have been evaluated in a severe combined immunodeficiency (SCID)-rab system. DKK1-neutralizing antibodies increased the number of osteocalcin-expressing OBs and reduced the number of multinucleated TRAcP-expressing OCs, thus restoring the bone mineral density in treated mice, which also showed a reduction of the tumor size. 115
BHQ880, a human IgG1 anti-DKK1, showed a reduction in the bone devastating effects of MMPCs as well as inhibition of their growth in a murine model of human MM. In addition, BHQ880 reduced IL-6 secretion by bone marrow stromal cells, suggesting that DKK1 promotes MMPC growth and survival by enhancing IL-6 production. 116 A phase I-II clinical trial, on patients with refractory/relapsed MM, is presently evaluating the in vivo effect of BHQ880 in combination with conventional chemotherapy and ZA. 117
Bone anabolic effects of PTH
The parathyroid hormone (PTH) is approved for the treatment of postmenopausal osteoporosis.118, 119, and 120 Although the molecular mechanisms underlying this bone anabolic effect are not fully understood, PTH has been demonstrated to increase the expression of genes encoding several components of both canonical and non-canonical Wnt pathways in OBs, and to down-regulate several Wnt signaling inhibitors, such as DKK1, sclerostin and SFRP-2. 121 Furthermore, treatment with PTH affected the expression of bone remodeling regulatory genes independent of the Wnt pathway.122, 123, and 124 In agreement with these data, Pennisi et al. 125 demonstrated that PTH improves the bone mineral density of MBD in vivo by increasing the number of differentiating OBs. For the potential contribution of PTH in tumor growth, the authors also demonstrated that, while PTH has no stimulatory effects on MMPCs in vitro, it can indirectly restrain tumor progression in vivo by both stimulating osteoblastogenesis and improving the production by OBs of anti-myeloma factors, such as decorin, lumican and CYR61. Interestingly, intermittent PTH administration also counteracts the adverse effects of glucocorticoids on bone health by reducing the susceptibility of OBs and osteocytes to apoptosis. 126 In fact, several studies127, 128, and 129 have shown that teriparatide, a recombinant human parathyroid hormone (1–34), restrains dexamethasone-induced osteoporosis more efficiently than BPs. Taken together, these data support the hypothesis that PTH, in combination with anti-MM drugs, may potentially reduce SREs in MBD.
TGF-β is abundantly sequestered in a latent form in bone matrix and released after bone resorption. As a key molecular player of MM progression, it represents a suitable target for novel therapeutics.130 and 131 In fact, Takeuchi et al. have evaluated two inhibitors of TGF-β type I receptor kinase, SB431542 and Ki26894, and found that blockade of TGF-β activity exerts a favorable effect on stromal cells in their differentiation arrest, and that terminally differentiated OBs improve bone quality and inhibit the tumor burden. Moreover, an anti-TGF-β monoclonal antibody was shown to reduce serum M protein levels and improve the bone mass in a murine model of MM. 132
Inhibition of sclerostin as anabolic therapy in MBD
Sclerostin is a protein expressed by osteocytes that down-regulates bone formation by OBs. In humans, homozygous mutation of the sclerosteosis (SOST) gene, which encodes sclerostin, leads to sclerosteosis, a disease with generalized osteosclerosis and increased intracranial pressure due to the bone overgrowth in the skull, whereas heterozygous carriers of the mutation show a normal phenotype, with dense bones and low risk of fracture. Several studies are in progress to evaluate the possibility that the down-regulation of SOST mimics the heterozygous carrier state, with consequent benefits in osteoporosis and other skeletal disorders characterized by bone loss. 133 Interestingly, a recent study by Terpos et al. 134 has detected higher circulating levels of sclerostin in bone fracture-bearing MM patients than in those with no skeletal complications at diagnosis. Its concentration was inversely correlated with BSAP serum levels and directly related to collagen type-I C-telopeptide (CTX) levels. Taken together, these data support the concept that inhibition of sclerostin might be a potential therapeutic approach to enhance OB function in MM.
Novel agents with both bone anabolic and anti-catabolic activity
Since, as we have already mentioned, MBD is characterized by increased OC activity and marked suppression of OB activity, it seems reasonable to hypothesize that new treatment approaches should target the OB-OC axis by combining bone-anabolic with anti-catabolic agents.
Activin A, a recently identified cytokine belonging to TGF-β family, is essentially secreted by OBs, OCs and BMSCs and seems to act in a synergistic way with RANKL, enabling OC formation. 135 It also inhibits OB differentiation by the down-regulation of distal-less homeobox 5 (DLX5) gene expression, through small mother against decapentaplegic (SMAD)-2 activation. Its contribution to the pathogenesis of MBD is supported by the findings of high levels of this cytokine in the marrow of patients with osteolytic lesions, due to the ability of MMPCs to increase Activin A expression by BMSCs through the Jun N-terminal Kinase (JNK) pathway activation. 136 Thus, it can be considered a potential therapeutic target in bone devastating tumors as well as in other skeletal diseases.
ACE-011, a fully human glycosylated fusion protein acting as a decoy receptor for Activin A, includes the extracellular domain of activin receptor type IIA (Act RIIA) and the Fc portion of IgG1. In a Phase I study, ACE-011 was administered to healthy postmenopausal women, resulting in a sustained, dose-dependent increase of serum levels of bone formation markers, such as BSAP, and a concurrent decrease of bone resorption markers, such as CTX, without serious adverse effects. 137
A murine analog of ACE-011, namely RAP-011, has also been tested on a SCID-hu model of MM, including INA-6 MM cells injected in subcutaneously implanted fetal human bone. In this study, RAP-011 successfully reduced the number of osteolytic lesions and increased bone density, as assessed by quantitative polymerase chain reaction and alkaline phosphatase and osteocalcin RNA expression. 136 The evaluation of ACE-011 efficacy in MM is presently under investigation in a randomized, double-blind, placebo controlled study in patients receiving the MPT (Melphalan, Prednisone, Thalidomide) combination therapy. Preliminary results show that ACE-011 is able to induce a significant increase in bone formation biomarkers and antitumor activity with a concurrent decrease of bone pain, in absence of severe toxicity. ACE-011 also increases hemoglobin levels, thus supporting its potential application for chemotherapy-induced anemia. 138
Anti-MM drugs and their effects on MBD
Beyond their direct and indirect anti-tumor effects,139 and 140immunomodulatory drugs, such as Thalidomide and its derivatives Lenalidomide and Pomalidomide, also restrain MBD progression by acting on tumor microenvironment. Anderson et al. 141 demonstrated that CC-4047, a derivative of Thalidomide, is able to down-regulate the expression of an early transcription factor implicated in marrow monocyte commitment along the OC lineage, namely PU.1, and thus inhibits OC formation, with concomitant accumulation of immature granulocytes. In line with these preliminary observations, Breitkreutz et al. 142 demonstrated a similar down-regulation of PU.1 by Lenalidomide and reported that it also inhibits RANKL secretion by BMSCs and down-regulates Cathepsin-K.
Bortezomib is a boron-containing molecule that specifically inhibits the 26S proteasome, with down-regulation of the NF-kB pathway components, reduction of MM/BMM interplays and angiogenesis process.143 and 144 Bortezomib not only reduces tumor burden, but restrains the progression of MBD by interfering with osteoclastogenesis and promoting the differentiation of mesenchymal stem cells to OBs. Bortezomib is apparently effective in disrupting both early OC differentiation by inhibition of p38 protein kinase pathways and the final stage of OC differentiation by inhibiting NF-kB and AP-1 signaling. 145 Terpos et al. 146 have reported that Bortezomib in monotherapy decreases serum and urinary levels of bone resorption markers, including RANKL in patients with MM. Moreover, inhibition of the ubiquitin–proteasome pathway primes OB differentiation by increasing bone morphogenetic protein 2 level in the BMM, by inhibiting DKK1 expression and by blocking the proteolytic degradation of Runt-related transcription factor (RUNX)-2, a differentiating factor in early OBs. 147 Bortezomib also stabilizes Beta-catenin in osteogenic cells in a Wnt independent manner. 148 These effects have been clinically confirmed by the increase of BSAP and osteocalcin serum levels in MM patients responsive to Bortezomib.149 and 150 In fact, BM samples from responder patients show a higher number of functional OBs over-expressing RUNX2. 151
Cytotherapy in MBD
MSCs have been investigated in the treatment of several bone diseases.152 and 153 In 1999, Horwitz et al. 154 used these cells from BM to treat children with Osteogenesis Imperfecta with encouraging results. In particular, this study demonstrated that cytotherapy increases bone mineral density and reduces the frequency of bone fractures. Because this model of cytotherapy has been successfully utilized in some metabolic and traumatic bone diseases, it has also been proposed for repairing osteogenic failure in MBD. In this context, Li et al. 155 tested the ability of human placenta-derived adherent cells (PDACs) to prevent bone loss in a SCID-rab model and showed that intra-lesional injections of PDACs significantly increased bone mineral density of bone grafts with concomitant reduction of tumor burden. This effect was associated with improvement of osteoblastogenesis and concurrent inhibition of osteoclastogenesis, while tumor suppression was correlated to restoration of OB function. Interestingly, PDACs did not remain detectable in vivo for a long time as the majority of them disappeared 3–5 weeks after injection, thus indicating specific temporal boundaries of this kind of therapeutic strategy. The same Authors155 and 156also compared the in vivo effects of PDACs with those of fetal bone-derived MSCs, and demonstrated that, although both cell types similarly inhibited MM growth, treatment of SCID-rab mice with PDACs was associated to a higher bone mass density. However, further studies are required to improve our understanding of MSCs/tumor interactions. 157
The potential use of natural agents is considered an appealing alternative to chemotherapy in cancer treatment. Resveratrol, a polyphenol (trans-3,4′,5-trihydroxystilbene), abundant in red grapes, berries and peanuts, has been reported to exert an antitumor effect. In MBD, Bhardwaj et al. 158 have found that resveratrol inhibits the proliferation and overcomes the chemoresistence of MM cells by suppressing nuclear factor-kappaB (NF-kB) and signal transducer and activator of transcription 3 (STAT3). Furthermore, it has been shown that resveratrol inhibits, at least partly, OC differentiation by impairing RANKL signaling and concurrently promoting OB differentiation by upregulating the nuclear receptor of 1,25(OH)2D3. 159 Other studies have shown that oral administration of resveratrol to ovariectomized rats increases the bone mass density in a manner similar to the BP alendronate.160 and 161 Taken together, these results indicate that resveratrol might be a potential drug in MBD. However, its safe plasma concentration is apparently lower than that required for antitumor effects in vitro, due to its rapid biotransformation into conjugate forms. Pharmacokinetic studies to evaluate more stable resveratrol derivatives are needed before it can be used in the treatment of MBD.
As already stated at the beginning of this review, MBD is not only an important morbidity factor, but also severely affects overall survival in patients with MM. The introduction of BPs has significantly reduced the incidence of SREs, improving the patients’ quality of life. Although the overall safety profile seems to be manageable, their use is still associated with the potential risk of ONJ and kidney failure, leading to treatment discontinuation. Because new pharmacological alternatives are needed, a better characterization of the pathophysiological mechanisms implicated in MBD is mandatory.
The role of OCs is crucial for bone destruction and several drugs targeting the major OC pathways, such as RANK/RANKL/OPG axis, BAFF, MEK and CCL3/CCR1 axes, have already been tested with encouraging preliminary data from preclinical and clinical studies. However, severe impairment of OB activity and alterations of the bone microenvironment contribute to the development of osteolytic disease of the skeleton. New therapeutic strategies should not only reduce OC activation, but also restore OB function and regulate MMPCs-BMM interactions, with a “targeted” approach. To this aim, novel agents disabling negative regulators of OB differentiation, namely anti-DKK1 monoclonal antibody, PTH and TGF-β inhibitors, as well as agents with dual activity in bone remodelling, such as ACE-011, are currently being studied in MBD.
However, although the molecular pathogenesis of MBD is under intensive investigation and gene expression profiling studies have remarked the genetic heterogeneity of MM cells, its treatment is still empirical. Further studies are needed to identify molecular differences between patients with indolent bone disease and those with extensive skeletal involvement, in order to predict different sensitivity to specific target treatments. Thus, new clinical trials should be aimed at evaluating both efficacy and safety of novel combinatory approaches involving conventional BPs, new OC-inhibitors and OB activators. On the other hand, the approaches of regenerative medicine using MSCs from human placenta have demonstrated the capability of these cells to repair the bone loss in a mouse model of MBD. Translation of this pioneering cytotherapy to human clinical setting may thus represent a fascinating perspective for MBD treatment in future.
Conflict of interests
All authors declare no conflict of interest.
This work was supported by the Italian Association for Cancer Research (AIRC 2011, IG 11647), and by the Italian Ministry of Education, University and Research (MIUR), PRIN 2009 (WZHMWJ). The authors are also grateful to Sabino Ciavarella for helpful contribution.
- 1 R. Siegel, E. Ward, O. Brawley, A. Jemal. Cancer statistics, 2011: the impact of eliminating socioeconomic and racial disparities on premature cancer deaths. CA Cancer J Clin. 2011;61(4):212-236 Crossref.
- 2 M.S. Raab, K. Podar, I. Breitkreutz, P.G. Richardson, K.C. Anderson. Multiple myeloma. Lancet. 2009;374(9686):324-339 Crossref.
- 3 L.J. Melton III, R.A. Kyle, S.J. Achenbach, A.L. Oberg, S.V. Rajkumar. Fracture risk with multiple myeloma: a population-based study. J Bone Miner Res. 2005;20:487-493
- 4 R.E. Coleman. Metastatic bone disease: clinical features, pathophysiology and treatment strategies. Cancer Treat Rev. 2001;27(3):165-176 Crossref.
- 5 K.L. Schulman, J. Kohles. Economic burden of metastatic bone disease in the U.S. Cancer. 2007;109(11):2334-2342 Crossref.
- 6 G.D. Roodman. Pathogenesis of myeloma bone disease. Blood Cells Mol Dis. 2004;32:290-292 Crossref.
- 7 G.D. Roodman. Osteoblast function in myeloma. Bone. 2011;48(1):135-140 Crossref.
- 8 S. Yaccoby. Osteoblastogenesis and tumor growth in myeloma. Leuk Lymphoma. 2010;51:213-220 Crossref.
- 9 J. Levy, G.D. Roodman. The role of bisphosphonates in multiple myeloma. Curr Hematol Malig Rep. 2009;4(2):108-112
- 10 A.R. Belch, D.E. Bergsagel, K. Wilson, et al. Effect of daily etidronate on the osteolysis of multiple myeloma. J Clin Oncol. 1991;9(8):1397-1402
- 11 R. Lahtinen, M. Laakso, I. Palva, P. Virkkunen, I. Elomaa. Randomised, placebo-controlled multicentre trial of clodronate in multiple myeloma. Finnish Leukaemia Group. Lancet. 1992;340(8827):1049-1052 Crossref.
- 12 J.R. Berenson, A. Lichtenstein, L. Porter, et al. Long-term pamidronate treatment of advanced multiple myeloma patients reduces skeletal events. Myeloma Aredia Study Group. J Clin Oncol. 1998;16(2):593-602
- 13 L.S. Rosen, D. Gordon, M. Kaminski, et al. Long-term efficacy and safety of zoledronic acid compared with pamidronate disodium in the treatment of skeletal complications in patients with advanced multiple myeloma or breast carcinoma: a randomized, double-blind, multicenter, comparative trial. Cancer. 2003;98(8):1735-1744 Crossref.
- 14 N.D. Modi, S. Lentzsch. Bisphosphonates as antimyeloma drugs. Leukemia. 2011;:18
- 15 D. Ribatti, N. Maruotti, B. Nico, et al. Clodronate inhibits angiogenesis in vitro and in vivo. Oncol Rep. 2008;19(5):1109-1112
- 16 D. Ribatti, B. Nico, D. Mangieri, et al. Neridronate inhibits angiogenesis in vitro and in vivo. Clin Rheumatol. 2007;26(7):1094-1098 Crossref.
- 17 G.J. Morgan, F.E. Davies, W.M. Gregory, et al. First-line treatment with zoledronic acid as compared with clodronic acid in multiple myeloma (MRC Myeloma IX): a randomised controlled trial. Lancet. 2010;376:1989-1999 Crossref.
- 18 S.M. Arum. New developments surrounding the safety of bisphosphonates. Curr Opin Endocrinol Diabetes Obes. 2008;15:508-513
- 19 G.S. Markowitz, P.L. Fine, J.I. Stack, et al. Toxic acute tubular necrosis following treatment with zoledronate (Zometa). Kidney Int. 2003;64(1):281-289 Crossref.
- 20 G.S. Markowitz, G.B. Appel, P.L. Fine, et al. Collapsing focal segmental glomerulosclerosis following treatment with high-dose pamidronate. J Am Soc Nephrol. 2001;12(6):1164-1172
- 21 Y.M. Barri, N.C. Munshi, S. Sukumalchantra, et al. Podocyte injury associated glomerulopathies induced by pamidronate. Kidney Int. 2004;65(2):634-641 Crossref.
- 22 M. Nagahama, D.A. Sica. Pamidronate-induced kidney injury in a patient with metastatic breast cancer. Am J Med Sci. 2009;338(3):225-228 Crossref.
- 23 A. Badros, D. Weikel, A. Salama, et al. Osteonecrosis of the jaw in multiple myeloma patients: clinical features and risk factors. J Clin Oncol. 2006;24:945-952 Crossref.
- 24 A. Corso, M. Varettoni, P. Zappasodi, et al. A different schedule of zoledronic acid can reduce the risk of the osteonecrosis of the jaw in patient with multiple myeloma. Leukemia. 2007;21(7):1545-1548 Crossref.
- 25 C.A. Migliorati, J.B. Epstein, E. Abt, J.R. Berenson. Osteonecrosis of the jaw and bisphosphonates in cancer: a narrative review. Nat Rev Endocrinol. 2011;7(1):34-42 Crossref.
- 26 A.M. Cafro, L. Barbarano, A.M. Nosari, et al. Osteonecrosis of the jaw in patients with multiple myeloma treated with bisphosphonates: definition and management of the risk related to zoledronic acid. Clin Lymphoma Myeloma. 2008;8(2):111-116 Crossref.
- 27 P. Musto, M.T. Petrucci, S. Bringhen, et al. GIMEMA (Italian Group for Adult Hematologic Diseases)/Multiple Myeloma Working Party and the Italian Myeloma Network. A multicenter, randomized clinical trial comparing zoledronic acid versus observation in patients with asymptomatic myeloma. Cancer. 2008;113(7):1588-1595 Crossref.
- 28 C. Walter, B. Al-Nawas, K.A. Grötz, et al. Prevalence and risk factors of bisphosphonate-associated osteonecrosis of the jaw in prostate cancer patients with advanced disease treated with zoledronate. Eur Urol. 2008;54(5):1066-1072 Abstract, Full-text, PDF, Crossref.
- 29 K. Fizazi, M. Carducci, M. Smith, et al. Denosumab versus zoledronic acid for treatment of bone metastases in men with castration-resistant prostate cancer: a randomised, double-blind study. Lancet. 2011;377(9768):813-822 Crossref.
- 30 M. Gnant, B. Mlineritsch, H. Stoeger, et al. Austrian Breast and Colorectal Cancer Study Group, Vienna, Austria. Adjuvant endocrine therapy plus zoledronic acid in premenopausal women with early-stage breast cancer: 62-month follow-up from the ABCSG-12 randomised trial. Lancet Oncol. 2011;12(7):631-641 Crossref.
- 31 K. Vahtsevanos, A. Kyrgidis, E. Verrou, et al. Longitudinal cohort study of risk factors in cancer patients of bisphosphonate-related osteonecrosis of the jaw. J Clin Oncol. 2009;27(32):5356-5362 Crossref.
- 32 C.A. Migliorati, S.B. Woo, I. Hewson, et al. Bisphosphonate osteonecrosis section, Oral Care Study Group, Multinational Association of Supportive Care in Cancer (MASCC)/International Society of Oral Oncology (ISOO). A systematic review of bisphosphonate osteonecrosis (BON) in cancer. Support Care Cancer. 2010;18(8):1099-1106 Crossref.
- 33 M.T. Brennan, L.S. Elting, F.K. Spijkervet. Systematic reviews of oral complications from cancer therapies, Oral Care Study Group, MASCC/ISOO: methodology and quality of the literature. Support Care Cancer. 2010;18(8):979-984 Crossref.
- 34 R. Weide, H. Koppler, L. Antras, et al. Renal toxicity in patients with multiple myeloma receiving zoledronic acid vs. ibandronate: a retrospective medical records review. J Cancer Res Ther. 2010;6(1):31-35
- 35 W.K. Oh, K. Proctor, M. Nakabayashi, et al. The risk of renal impairment in hormone-refractory prostate cancer patients with bone metastases treated with zoledronic acid. Cancer. 2007 Mar 15;109(6):1090-1096
- 36 R.S. Israeli, S.J. Rosenberg, D.R. Saltzstein, et al. The effect of zoledronic acid on bone mineral density in patients undergoing androgen deprivation therapy. Clin Genitourin Cancer. 2007;5(4):271-277 Crossref.
- 37 S. Houston, R.J. Grieve, T. Hickish, F. Percival, E. Hamilton. Renal function changes and NHS resource use in breast cancer patients with metastatic bone disease treated with IV zoledronic acid or oral ibandronic acid: a four-centre non-interventional study. J Med Econ. 2010;13(1):162-167 Crossref.
-  T. Tanvetyanon, P.J. Stiff. Management of the adverse effects associated with intravenous bisphosphonates. Ann Oncol. 2006;17(6):897-907 Crossref.
- 39 D. Aguiar Bujanda, U. Bohn Sarmiento, M.A. Cabrera Suárez, J. Aguiar Morales. Assessment of renal toxicity and osteonecrosis of the jaws in patients receiving zoledronic acid for bone metastasis. Ann Oncol. 2007;18(3):556-560
- 40 E. Terpos, O. Sezer, P.I. Croucher, et al. The use of bisphosphonates in multiple myeloma: recommendations of an expert panel on behalf of the European Myeloma Network. Ann Oncol. 2009;20:1303-1317 Crossref.
- 41 R.A. Kyle, G.C. Yee, M.R. Somerfield, et al. American Society of Clinical Oncology 2007 clinical practice guideline update on the role of bisphosphonates in multiple myeloma. J Clin Oncol. 2007;25(17):2464-2472 Crossref.
- 42 National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Multiple Myeloma. vol. 1. 2012. Fort Washington, PA: National Comprehensive Cancer Network Inc., 2011.
- 43 N. Raje, G.D. Roodman. Advances in the biology and treatment of bone disease in multiple myeloma. Clin Cancer Res. 2011;17(6):1278-1286 Crossref.
- 44 K. Podar, D. Chauhan, K.C. Anderson. Bone marrow microenvironment and the identification of new targets for myeloma therapy. Leukemia. 2009;23:10-24 Crossref.
- 45 H. Yasuda, N. Shima, N. Nakagawa, et al. Osteoclast differentiation factor is a ligand for osteoprotegerin/osteoclastogenesis-inhibitory factor and is identical to TRANCE/RANKL. Proc Natl Acad Sci USA. 1998;95:3597-3602 Crossref.
- 46 R.N. Pearse, E.M. Sordillo, S. Yaccoby, et al. Multiple Myeloma disrupts the TRANCE/osteoprotegerin cytokine axis to trigger bone destruction and promote tumor progression. Proc Natl Acad Sci USA. 2001;98:11581-11586 Crossref.
- 47 O. Sezer, U. Heider, I. Zavrski, C.A. Kühne, L.C. Hofbauer. RANK ligand and osteoprotegerin in myeloma bone disease. Blood. 2003;101:2094-2098 Crossref.
- 48 L.C. Hofbauer, A.E. Heufelder. Osteoprotegerin and its cognate ligand: a new paradigm of osteoclastogenesis. Eur J Endocrinol. 1998;139:152-154 Crossref.
- 49 E. Terpos, R. Szydlo, J.F. Apperley, et al. Soluble receptor activator of nuclear factor kappa B ligand-osteoprotegerin ratio predicts survival in multiple myeloma: proposal for a novel prognostic index. Blood. 2003;102:1064-1069 Crossref.
- 50 P.J. Kostenuik, H.Q. Nguyen, J. McCabe, et al. Denosumab, a fully human monoclonal antibody to RANKL, inhibits bone resorption and increases BMD in knock-in mice that express chimeric (murine/human) RANKL. J Bone Miner Res. 2009;24:182-195 Crossref.
- 51 P.J. Kostenuik. Osteoprotegerin and RANKL regulate bone resorption, density, geometry and strength. Curr Opin Pharmacol. 2005;5:618-625 Crossref.
- 52 Y.T. Tai, K.C. Anderson. Antibody-Based Therapies in Multiple Myeloma. Bone Marrow Res Bone Marrow Res. 2011;2011:924058
- 53 D.H. Henry, L. Costa, F. Goldwasser, et al. Randomized, double-blind study of denosumab versus zoledronic acid in the treatment of bone metastases in patients with advanced cancer (excluding breast and prostate cancer) or multiple myeloma. J Clin Oncol. 2011;29(9):1125-1132 Crossref.
- 54 D. Santini, M.E. Fratto, B. Vincenzi, et al. Denosumab: the era of targeted therapies in bone metastatic diseases. Curr Cancer Drug Targets. 2009;9(7):834-842 Crossref.
- 55 A.J. Novak, J.R. Darce, B.K. Arendt, et al. Expression of BCMA, TACI, and BAFF-R in multiple myeloma: a mechanism for growth and survival. Blood. 2004;103(2):689-694 Crossref.
- 56 J. Moreaux, E. Legouffe, E. Jourdan, et al. BAFF and APRIL protect myeloma cells from apoptosis induced by interleukin 6 deprivation and dexamethasone. Blood. 2004;103(8):3148-3157 Crossref.
- 57 Y.T. Tai, X.F. Li, I. Breitkreutz, et al. Role of B-cell-activating factor in adhesion and growth of human multiple myeloma cells in the bone marrow microenvironment. Cancer Res. 2006;66(13):6675-6682 Crossref.
- 58 P. Neri, S. Kumar, M.T. Fulciniti, et al. Neutralizing Bcell-activating factor antibody improves survival and inhibits osteoclastogenesis in a severe combined immunodeficient human multiple myeloma model. Clin Cancer Res. 2007;13(19):5903-5909 Crossref.
- 59 < http://clinicaltrials.gov/ct2/show/study/NCT00689507 >.
- 60 J.F. Rossi. Phase I study of atacicept in relapsed/refractory multiple myeloma (MM) and Waldenström’s macroglobulinemia. Clin Lymphoma Myeloma Leuk. 2011;11(1):136-138 Crossref.
- 61 S. Lentzsch, M. Gries, M. Janz, R. Bargou, B. Dorken, M.Y. Mapara. Macrophage inflammatory protein 1-alpha (MIP-1 alpha) triggers migration and signaling cascades mediating survival and proliferation in multiple myeloma (MM) cells. Blood. 2003;101:3568-3573 Crossref.
- 62 J.H. Han, S.J. Choi, N. Kurihara, M. Koide, Y. Oba, G.D. Roodman. Macrophage inflammatory protein-1alpha is an osteoclastogenic factor in myeloma that is independent of receptor activator of nuclear factor kappaB ligand. Blood. 2001;97:3349-3353 Crossref.
- 63 E. Terpos, M. Politou, R. Szydlo, J.M. Goldman, J.F. Apperley, A. Rahemtulla. Serum levels of macrophage inflammatory protein-1 alpha (MIP-1alpha) correlate with the extent of bone disease and survival in patients with multiple myeloma. Br J Haematol. 2003;123(1):106-109 Crossref.
- 64 M. Roussou, A. Tasidou, M.A. Dimopoulos, et al. Increased expression of macrophage inflammatory protein-1alpha on trephine biopsies correlates with extensive bone disease, increased angiogenesis and advanced stage in newly diagnosed patients with multiple myeloma. Leukemia. 2009;23(11):2177-2181 Crossref.
- 65 B.O. Oyajobi, G. Franchin, P.J. Williams, et al. Dual effects of macrophage inflammatory protein-1alpha on osteolysis and tumor burden in the murine 5TGM1 model of myeloma bone disease. Blood. 2003;102:311-319 Crossref.
- 66 S. Vallet, N. Raje, K. Ishitsuka, et al. MLN3897, a novel CCR1 inhibitor, impairs osteoclastogenesis and inhibits the interaction of multiple myeloma cells and osteoclasts. Blood. 2007;110:3744-3752 Crossref.
- 67 M. Marzia, N.A. Sims, S. Voit, et al. Decreased c-Src expression enhances osteoblast differentiation and bone formation. J Cell Biol. 2000;151(2):311-320 Crossref.
- 68 T. Miyazaki, A. Sanjay, L. Neff, S. Tanaka, W.C. Horne, R. Baron. Src kinase activity is essential for osteoclast function. J Biol Chem. 2004;279:17660-17666 Crossref.
- 69 M.C. Frame. Src in cancer: deregulation and consequences for cell behaviour. Biochim Biophys Acta. 2002;1602(2):114-130 Crossref.
- 70 Y. Dai, S. Chen, R. Shah, et al. Disruption of Src function potentiates Chk1-inhibitor-induced apoptosis in human multiple myeloma cells in vitro and in vivo. Blood. 2011;117(6):1947-1957 Crossref.
- 71 A.M. Coluccia, T. Cirulli, P. Neri, et al. Validation of PDGFR beta and c-Src tyrosine kinases as tumor/vessel targets in patients with multiple myeloma: preclinical efficacy of the novel, orally available inhibitor dasatinib. Blood. 2008;112(4):1346-1356 Crossref.
- 72 T.M. Wildes, E. Procknow, K. Weilbaecher, R. Vij. Effect of dasatinib on bone metabolism in multiple myeloma. J Clin Oncol. 2008;26(Suppl. 20):8568
- 73 < http://clinicaltrials.gov/ct2/show/NCT01116128 >.
- 74 A. Gnoni, I. Marech, N. Silvestris, A. Vacca, V. Lorusso. Dasatinib: an anti-tumour agent via Src inhibition. Curr Drug Targets. 2011;12(4):563-578 Crossref.
- 75 I. Nakamura, T. Duong le, S.B. Rodan, G.A. Rodan. Involvement of avb3 integrins in osteoclast function. J Bone Miner Metab. 2007;25:337-344 Crossref.
- 76 T. Dossa, A. Arabian, J. Windle, et al. Osteoclast-specific Inactivation of the integrin-linked kinase (ILK) inhibits bone resorption. J Cell Biochem. 2010;110(4):960-967 Crossref.
- 77 K. Mulgrew, K. Kinneer, X.T. Yao, et al. Direct Targeting of avb3 integrin on tumor cells. Mol Cancer Ther. 2006;5:3122-3129 Crossref.
- 78 R. Ria, A. Vacca, D. Ribatti, F. Di Raimondo, F. Merchionne, F. Dammacco. A(v)b(3) integrin engagement enhances cell invasiveness in human multiple myeloma. Haematologica. 2002;87:836-845
- 79 S. Roux. New treatment targets in osteoporosis. Joint Bone Spine. 2010;7(3):222-228 Crossref.
- 80 A. Teti, S. Migliaccio, R. Baron. The role of the integrin avb3 in the development of osteolytic bone metastases: a pharmacological target for alternative therapy?. Calcif Tissue Int. 2002;71(4):293-299 Crossref.
- 81 N. Calvani, P. Cafforio, F. Silvestris, F. Dammacco. Functional osteoclast-like transformation of cultured human myeloma cell lines. Br J Haematol. 2005;130(6):926-938 Crossref.
- 82 F. Silvestris, P. Cafforio, M. De Matteo, C. Quatraro, F. Dammacco. Expression and function of the calcitonin receptor by myeloma cells in their osteoclast-like activity in vitro. Leuk Res. 2008;32(4):611-623 Crossref.
- 83 M. Tucci, R. De Palma, L. Lombardi, et al. Beta3 subunit integrin mediates the bone-resorbing function exerted by cultured myeloma plasma cells. Cancer Res. 2009;69(16):6738-6746 Crossref.
- 84 K. Kim, S.Y. Kong, M. Fulciniti, et al. Blockade of the MEK/ERKsignalling cascade by AS703026, a novel selective MEK 1/2 inhibitor, induces pleiotropic anti-myeloma activity in vitro and in vivo. Br J Haematol. 2010;149(4):537-549 Crossref.
- 85 Y.T. Tai, M. Fulciniti, T. Hideshima, et al. Targeting MEK induces myeloma-cell cytotoxicity and inhibits osteoclastogenesis. Blood. 2007;110(5):1656-1663 Crossref.
- 86 C.M. Annunziata, L. Hernandez, R.E. Davis, et al. A mechanistic rationale for MEK inhibitor therapy in myeloma based on blockade of MAF oncogene expression. Blood. 2011;117(8):2396-2404 Crossref.
- 87 < http://clinicaltrials.gov/ct2/show/NCT01085214 >.
- 88 M. Matsumoto, T. Sudo, T. Saito, H. Osada, M. Tsujimoto. Involvement of p38 mitogen-activated protein kinase signaling pathway in osteoclastogenesis mediated by receptor activator of NF-kappa B ligand (RANKL). J Biol Chem. 2000;275(40):55-61
- 89 S. Medicherla, M. Reddy, J. Ying, et al. P38alpha-selective MAP kinase inhibitor reduces tumor growth in mouse xenograft models of multiple myeloma. Anticancer Res. 2008;28(6A):3827-3833
- 90 K. Vanderkerken, S. Medicherla, L. Coulton, et al. Inhibition of p38alpha mitogen-activated protein kinase prevents the development of osteolytic bone disease, reduces tumor burden, and increases survival in murine models of multiple myeloma. Cancer Res. 2007;67(10):4572-4577 Crossref.
- 91 K. Ishitsuka, T. Hideshima, P. Neri, et al. P38 mitogen-activated protein kinase inhibitor LY2228820 enhances bortezomib-induced cytotoxicity and inhibits osteoclastogenesis in multiple myeloma; therapeutic implications. Br J Haematol. 2008;141(5):598-606 Crossref.
- 92 T.A. Navas, A.N. Nguyen, T. Hideshima, et al. Inhibition of p38alpha MAPK enhances proteasome inhibitor-induced apoptosis of myeloma cells by modulating Hsp27, Bcl-X(L), Mcl-1 and p53 levels in vitro and inhibits tumor growth in vivo. Leukemia. 2006;20(6):1017-1027 Crossref.
- 93 < http://clinicaltrials.gov/ct2/show/NCT01393990 >.
- 94 Y. Ge, F. Zhan, B. Barlogie, J. Epstein, J. Shaughnessy Jr, S. Yaccoby. Fibroblast activation protein (FAP) is upregulated in myelomatous bone and supports myeloma cell survival. Br J Haematol. 2006;133(1):83-92 Crossref.
- 95 A. Pennisi, X. Li, W. Ling, et al. Inhibitor of DASH proteases affects expression of adhesion molecules in osteoclasts and reduces myeloma growth and bone disease. Br J Haematol. 2009;145(6):775-787 Crossref.
- 96 Y. Okawa, T. Hideshima, P. Steed, et al. SNX-2112, a selective Hsp90 inhibitor, potently inhibits tumor cell growth, angiogenesis, and osteoclastogenesis in multiple myeloma and other hematologic tumors by abrogating signaling via Akt and ERK. Blood. 2009;113(4):846-855 Crossref.
- 97 S.L. Teitelbaum, F.P. Ross. Genetic regulation of osteoclast development and function. Nat Rev Genet. 2003;4(8):638-649 Crossref.
- 98 P. Saftig, E. Hunziker, O. Wehmeyer, et al. Impaired osteoclastic bone resorption leads to osteopetrosis in cathepsin-K-deficient mice. Proc Natl Acad Sci USA. 1998;95(23):13453-13458 Crossref.
- 99 A.G. Costa, N.E. Cusano, B.C. Silva, S. Cremers, J.P. Bilezikian. Cathepsin K: its skeletal actions and role as a therapeutic target in osteoporosis. Nat Rev Rheumatol. 2011;7(8):447-456 Crossref.
- 100 A.B. Jensen, C. Wynne, G. Ramirez, et al. Effect of cathepsin k inhibition on suppression of bone resorption in women with breast cancer and established bone metastases in a 4-week, double-blind, randomized controlled trial. J Clin Oncol. 2008;26(Suppl. 1):1023
- 101 P. Leung, M. Pickarski, Y. Zhuo, P.J. Masarachia, L.T. Duong. The effects of the cathepsin K inhibitor odanacatib on osteoclastic bone resorption and vesicular trafficking. Bone. 2011;49(4):623-635 Crossref.
- 102 Q. Yang, K.P. McHugh, S. Patntirapong, X. Gu, L. Wunderlich, P.V. Hauschka. VEGF enhancement of osteoclast survival and bone resorption involves VEGF receptor-2 signaling and beta3-integrin. Matrix Biol. 2008;27(7):589-599 Crossref.
- 103 K. Henriksen, M. Karsdal, J.M. Delaisse, M.T. Engsig. RANKL and vascular endothelial growth factor (VEGF) induce osteoclast chemotaxis through an ERK1/2-dependent mechanism. J Biol Chem. 2003;278(49):48745-48753 Crossref.
- 104 Y. Tanaka, M. Abe, M. Hiasa, et al. Myeloma cell-osteoclast interaction enhances angiogenesis together with bone resorption: a role for vascular endothelial cell growth factor and osteopontin. Clin Cancer Res. 2007;13(3):816-823 Crossref.
- 105 M. Abe. Link between osteoclastogenesis, angiogenesis and myeloma expansion. Clin Calcium. 2008;18(4):473-479
- 106 < http://clinicaltrials.gov/ct2/show/NCT00428545 >.
- 107 < http://clinicaltrials.gov/ct2/show/NCT00410605 >.
- 108 F. Silvestris, L. Lombardi, M. De Matteo, A. Bruno, F. Dammacco. Myeloma bone disease: pathogenetic mechanisms and clinical assessment. Leuk Res. 2007;31(2):129-138 Crossref.
- 109 E. Terpos, M.A. Dimopoulos, O. Sezer. The effect of novel anti-myeloma agents on bone metabolism of patients with multiple myeloma. Leukemia. 2007;21:1875-1884
- 110 K. Takeuchi, M. Abe, et al. Tgf-Beta inhibition restores terminal osteoblast differentiation to suppress myeloma growth. Plos one. 2010;5(3):e9870 Crossref.
- 111 S. Yaccoby. Osteoblastogenesis and tumor growth in myeloma. Leuk Lymphoma. 2010;51(2):213-220 Crossref.
- 112 X. Li, A. Pennisi, S. Yaccoby. Role of decorin in the antimyeloma effects of osteoblasts. Blood. 2008;112(1):159-168 Crossref.
- 113 H. Hu, M.J. Hilton, X. Tu, K. Yu, D.M. Ornitz, F. Long. Sequential roles of Hedgehog and Wnt signaling in osteoblast development. Development. 2005;132(1):49-60
- 114 Y. Kawano, R. Kypta. Secreted antagonists of the Wnt signalling pathway. J Cell Sci. 2003;116(Pt 13):2627-2634 Crossref.
- 115 S. Yaccoby, W. Ling, F. Zhan, R. Walker, B. Barlogie, J.D. Shaughnessy Jr. Antibody based inhibition of DKK1 suppresses tumor-induced bone resorption and multiple myeloma growth in vivo. Blood. 2007;109(5):2106-2111 Crossref.
- 116 M. Fulciniti, P. Tassone, T. Hideshima, et al. Anti DKK1 mAb (BHQ880) as a potential therapeutic agent for multiple myeloma. Blood. 2009;114(2):371-379 Crossref.
- 117 < http://clinicaltrials.gov/ct2/show/NCT00741377 >.
-  R.M. Neer, C.D. Arnaud, J.R. Zanchetta, et al. Effect of parathyroid hormone (1-34) on fractures and bone mineral density in postmenopausal women with osteoporosis. N Engl J Med. 2001;344(19):1434-1441 Crossref.
- 119 M.E. Kraenzlin, C. Meier. Parathyroid hormone analogues in the treatment of osteoporosis. Nat Rev Endocrinol. 2011 Jul 12;7(11):647-656 Crossref.
- 120 L. Shen, X. Xie, Y. Su, C. Luo, C. Zhang, B. Zeng. Parathyroid hormone versus bisphosphonate treatment on bone mineral density in osteoporosis therapy: a meta-analysis of randomized controlled trials. PLoS One. 2011;6(10):e26267 Crossref.
- 121 T. Bellido, A.A. Ali, I. Gubrij, et al. Chronic elevation of parathyroid hormone in mice reduces expression of sclerostin by osteocytes: a novel mechanism for hormonal control of osteoblastogenesis. Endocrinology. 2005;146(11):4577-4583 Crossref.
- 122 R. Serra, A. Karaplis, P. Sohn. Parathyroid hormone-related peptide (PTHrP)-dependent and -independent effects of transforming growth factor beta (TGF-beta) on endochondral bone formation. J Cell Biol. 1999;145(4):783-794 Crossref.
- 123 E.H. Allan, K.D. Häusler, T. Wei, et al. EphrinB2 regulation by PTH and PTHrP revealed by molecular profiling in differentiating osteoblasts. TJ J Bone Miner Res. 2008;23(8):1170-1181 Crossref.
- 124 M.G. Sabbieti, D. Agas, L. Xiao, et al. Endogenous FGF-2 is critically important in PTH anabolic effects on bone. J Cell Physiol. 2009;219(1):143-151 Crossref.
- 125 A. Pennisi, W. Ling, X. Li, et al. Consequences of daily administered parathyroid hormone on myeloma growth, bone disease, and molecular profiling of whole myelomatous bone. PLoS One. 2010;5(12):e15233 Crossref.
- 126 R.S. Weinstein, R.L. Jilka, M. Almeida, P.K. Roberson, S.C. Manolagas. Intermittent parathyroid hormone administration counteracts the adverse effects of glucocorticoids on osteoblast and osteocyte viability, bone formation, and strength in mice. Endocrinology. 2010;151(6):2641-2649 Crossref.
- 127 K.G. Saag, E. Shane, S. Boonen, et al. Teriparatide or alendronate in glucocorticoid-induced osteoporosis. N Engl J Med. 2007;357(20):2028-2039 Crossref.
- 128 K.G. Saag, J.R. Zanchetta, J.P. Devogelaer, et al. Effects of teriparatide versus alendronate for treating glucocorticoid-induced osteoporosis: thirty-six-month results of a randomized, double-blind, controlled trial. Arthritis Rheum. 2009;60(11):3346-3355 Crossref.
- 129 J.P. Devogelaer, R.A. Adler, C. Recknor, et al. Baseline glucocorticoid dose and bone mineral density response with teriparatide or alendronate therapy in patients with glucocorticoid-induced osteoporosis. J Rheumatol. 2010;37(1):141-148 Crossref.
- 130 K.S. Mohammad, C.G. Chen, G. Balooch, et al. Pharmacologic inhibition of the TGF-beta type I receptor kinase has anabolic and anti-catabolic effects on bone. PLoS One. 2009;4(4):e5275 Crossref.
- 131 T. Matsumoto, M. Abe. TGF-β-related mechanisms of bone destruction in multiple myeloma. Bone. 2011;48(1):129-134 Crossref.
- 132 K. Takeuchi, M. Abe, M. Hiasa, et al. Tgf-beta inhibition restores terminal osteoblast differentiation to suppress myeloma growth. PLoS One. 2010;5(3):e9870 Crossref.
- 133 E.M. Lewiecki. Sclerostin: a novel target for intervention in the treatment of osteoporosis. Discov Med. 2011;12(65):263-273
- 134 E. Terpos, D. Christoulas, E. Katodritou, et al. Elevated circulating sclerostin correlates with advanced disease features and abnormal bone remodeling in symptomatic myeloma; reduction post-bortezomib monotherapy. Int J Cancer. 2011 Nov 2;10.1002/ijc.27342
- 135 K. Fuller, K.E. Bayley, T.J. Chambers. Activin A is an essential cofactor for osteoclast induction. Biochem Biophys Res Commun. 2000;268(1):2-7 Crossref.
- 136 S. Vallet, S. Mukherjee, N. Vaghela, et al. Activin A promotes multiple myeloma-induced osteolysis and is a promising target for myeloma bone disease. Proc Nat Acad Sci USA. 2010;107(11):5124-5129 Crossref.
- 137 J. Ruckle, M. Jacobs, W. Kramer, et al. Single-dose, randomized, double-blind, placebo-controlled study of ACE-011 (ActRIIA-IgGl) in postmenopausal women. J Bone Miner Res. 2009;24(4):744-752 Crossref.
- 138 K.M. Abdulkadyrov, G.N. Salogub, N.K. Khuazheva, et al. ACE-011, a soluble activin receptor type Iia IgG-Fc fusion protein, increases hemoglobin (Hb) and improves bone lesions in multiple myeloma patients receiving myelosuppressive chemotherapy: preliminary analysis. Blood. 2009;114:749
- 139 N. Mitsiades, C.S. Mitsiades, V. Poulaki, et al. Apoptotic signaling induced by immunomodulatory thalidomide analogs in human multiple myeloma cells: therapeutic implications. Blood. 2002;99:4525-4530 Crossref.
- 140 S. Lentzsch, R. LeBlanc, K. Podar, et al. Immunomodulatory analogs of thalidomide inhibit growth of Hs Sultan cells and angiogenesis in vivo. Leukemia. 2003;17(1):41-44 Crossref.
- 141 G. Anderson, M. Gries, N. Kurihara, et al. Thalidomide derivative CC-4047 inhibits osteoclast formation by down-regulation of PU.1. Blood. 2006;107(8):3098-3105 Crossref.
- 142 I. Breitkreutz, M.S. Raab, S. Vallet, et al. Lenalidomide inhibits osteoclastogenesis, survival factors and bone-remodeling markers in multiple myeloma. Leukemia. 2008;22(10):1925-1932 Crossref.
- 143 J. Adams. The proteasome: a suitable antineoplastic target. Nat Rev Cancer. 2004;4(5):349-360 Crossref.
- 144 M. Karin, A. Lin. NF-kappaB at the crossroads of life and death. Nat Immunol. 2002;3(3):221-227 Crossref.
- 145 I. von Metzler, H. Krebbel, M. Hecht, et al. Bortezomib inhibits human osteoclastogenesis. Leukemia. 2007;21(9):2025-2034
- 146 E. Terpos, O. Sezer, P. Croucher, M.A. Dimopoulos. Myeloma bone disease and proteasome inhibition therapies. Blood. 2007;110(4):1098-1104 Crossref.
- 147 N. Giuliani, V. Rizzoli, G.D. Roodman. Multiple myeloma bone disease: pathophysiology of osteoblast inhibition. Blood. 2006;108(13):3992-3996 Crossref.
- 148 Y.W. Qiang, B. Hu, Y. Chen, et al. Bortezomib induces osteoblast differentiation via Wnt-independent activation of beta-catenin/TCF signaling. Blood. 2009;113(18):4319-4330 Crossref.
- 149 C. Shimazaki, R. Uchida, S. Nakano, et al. High serum bone-specific alkaline phosphatase level after bortezomib-combined therapy in refractory multiple myeloma: possible role of bortezomib on osteoblast differentiation. Leukemia. 2005;19(6):1102-1103 Crossref.
- 150 M. Zangari, S. Yaccoby, L. Pappas, et al. A prospective evaluation of the biochemical, metabolic, hormonal and structural bone changes associated with bortezomib response in multiple myeloma patients. Haematologica. 2011;96(2):333-336 Crossref.
- 151 N. Giuliani, F. Morandi, S. Tagliaferri, et al. The proteasome inhibitor bortezomib affects osteoblast differentiation in vitro and in vivo in multiple myeloma patients. Blood. 2007;110(1):334-338 Crossref.
- 152 H. Anita, Jennifer J. Westendorf, Michael J. Yaszemski, Sundeep Khosla. Mesenchymal stem cells for bone repair and metabolic bone diseases. Mayo Clin Proc. 2009;84(10):893-902
- 153 B.L. Yen, H.I. Huang, C.C. Chien Jr. Isolation of multipotent cells from human term placenta. Stem Cells. 2005;23(1):3-9 Crossref.
- 154 E.M. Horwitz, D.J. Prockop, L.A. Fitzpatrick, et al. Transplantability and therapeutic effects of bone marrow-derived mesenchymal cells in children with osteogenesis imperfecta. Nat Med. 1999;5(3):309-313 Crossref.
- 155 X. Li, W. Ling, A. Pennisi, et al. Human placenta-derived adherent cells prevent bone loss, stimulate bone formation, and suppress growth of multiple myeloma in bone. Stem Cells. 2011;29(2):263-273
- 156 S. Barlow, G. Brooke, K. Chatterjee, et al. Comparison of human placenta-and bone marrow-derived multipotent mesenchymal stem cells. Stem Cells Dev. 2008;17(6):1095-1107
- 157 Klopp AH, Gupta A, Spaeth E, Andreeff M, Marini F 3rd. Dissecting a Discrepancy in the Literature: Do Mesenchymal Stem Cells Support or Suppress Tumor Growth? Stem Cells. 2010.
- 158 A. Bhardwaj, G. Sethi, S. Vadhan-Raj, et al. Resveratrol inhibits proliferation, induces apoptosis, and overcomes chemoresistance through down-regulation of STAT3 and nuclear factor-kappaB-regulated antiapoptotic and cell survival gene products in human multiple myeloma cells. Blood. 2007;109(6):2293-2302 Crossref.
- 159 P. Boissy, T.L. Andersen, B.M. Abdallah, M. Kassem, T. Plesner, J.M. Delaissé. Resveratrol inhibits myeloma cell growth, prevents osteoclast formation, and promotes osteoblast differentiation. Cancer Res. 2005;65(21):9943-9952 Crossref.
- 160 K. Mizutani, K. Ikeda, Y. Kawai, Y. Yamori. Resveratrol attenuates ovariectomy-induced hypertension and bone loss in stroke-prone spontaneously hypertensive rats. J Nutr Sci Vitaminol (Tokyo). 2000;46(2):78-83 Crossref.
- 161 Z.P. Liu, Wx. Li, B. Yu. Effects of trans-resveratrol from Polygonum cuspidatum on bone loss using the ovariectomized rat model. J Med Food. 2005;8(1):14-19 Crossref.
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