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Saito M, Marumo K, Kida Y, Ushiku C, Kato S, Takao-Kawabata R, Kuroda T. Changes in the contents of enzymatic immature, mature, and non-enzymatic senescent cross-links of collagen after once-weekly treatment with human parathyroid hormone (1-34) for 18 months contribute to improvement of bone strength in ovariectomized monkeys. Osteoporos Int 2011; 22:2373-83. [PMID: 20959962 DOI: 10.1007/s00198-010-1454-4] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2010] [Accepted: 09/24/2010] [Indexed: 12/12/2022]
Abstract
UNLABELLED Improvements in total content of enzymatic cross-linking, the ratio of hydroxylysine-derived enzymatic cross-links, and non-enzymatic advanced glycation end product cross-link formation from once-weekly administration of hPTH(1-34) for 18 months in OVX cynomolgus monkeys contributed to the improvement of bone strength. INTRODUCTION Parathyroid hormone (PTH) is used for the treatment of osteoporosis. To elucidate the contribution of material properties to bone strength after once-weekly treatment with hPTH(1-34) in an ovariectomized (OVX) primate model, the content of collagen and enzymatic immature, mature, and non-enzymatic cross-links, collagen maturity, trabecular architecture, and mineralization in vertebrae were simultaneously estimated. METHODS Adult female cynomolgus monkeys were divided into four groups (n = 18-20 each) as follows: SHAM group, OVX group, and OVX monkeys given once-weekly subcutaneous injections of hPTH(1-34) either at 1.2 or 6.0 μg/kg (low- or high-PTH groups) for 18 months. The content of collagen, enzymatic and non-enzymatic cross-linking pentosidine, collagen maturity, trabecular architecture, mineralization, and cancellous bone strength of vertebrae were analyzed. RESULTS Low-PTH and high-hPTH treatments increased the content of enzymatic immature and mature cross-links, bone volume (BV/TV), and trabecular thickness, and decreased pentosidine, compared with the OVX group. Stepwise logistic regression analysis revealed that BV/TV, the content of total enzymatic cross-links, and calcium content independently affected ultimate load (model R (2) = 0.748, p < 0.001) and breaking energy (model R (2) = 0.702, p < 0.001). BV/TV was the most powerful and enzymatic cross-link content was the second powerful determinant of both ultimate load and breaking energy. The most powerful determinant of stiffness was the enzymatic cross-link content (model R (2) = 0.270, p < 0.001). CONCLUSION Once-weekly preventive administration of hPTH(1-34) increased the total contents of immature and mature enzymatic cross-links, which contributed significantly to vertebral cancellous bone strength.
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Affiliation(s)
- M Saito
- Department of Orthopaedic Surgery, Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan.
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Viguet-Carrin S, Garnero P, Delmas PD. The role of collagen in bone strength. Osteoporos Int 2006; 17:319-36. [PMID: 16341622 DOI: 10.1007/s00198-005-2035-9] [Citation(s) in RCA: 599] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2005] [Accepted: 09/15/2005] [Indexed: 01/04/2023]
Abstract
Bone is a complex tissue of which the principal function is to resist mechanical forces and fractures. Bone strength depends not only on the quantity of bone tissue but also on the quality, which is characterized by the geometry and the shape of bones, the microarchitecture of the trabecular bones, the turnover, the mineral, and the collagen. Different determinants of bone quality are interrelated, especially the mineral and collagen, and analysis of their specific roles in bone strength is difficult. This review describes the interactions of type I collagen with the mineral and the contribution of the orientations of the collagen fibers when the bone is submitted to mechanical forces. Different processes of maturation of collagen occur in bone, which can result either from enzymatic or nonenzymatic processes. The enzymatic process involves activation of lysyl oxidase, which leads to the formation of immature and mature crosslinks that stabilize the collagen fibrils. Two type of nonenzymatic process are described in type I collagen: the formation of advanced glycation end products due to the accumulation of reducible sugars in bone tissue, and the process of racemization and isomerization in the telopeptide of the collagen. These modifications of collagen are age-related and may impair the mechanical properties of bone. To illustrate the role of the crosslinking process of collagen in bone strength, clinical disorders associated with bone collagen abnormalities and bone fragility, such as osteogenesis imperfecta and osteoporosis, are described.
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Affiliation(s)
- S Viguet-Carrin
- INSERM Research Unit 403 and Claude Bernard University, Lyon, France
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Takashi M, Tsubaki S, Tsuzuki T, Duarte WR, Yamauchi M, Sato H. Differential gene expression of collagen-binding small leucine-rich proteoglycans and lysyl hydroxylases, during mineralization by MC3T3-E1 cells cultured on titanium implant material. Eur J Oral Sci 2005; 113:225-31. [PMID: 15953247 DOI: 10.1111/j.1600-0722.2005.00208.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Titanium implants create a unique ultrastructure (composed of a collagenous zone with relatively disorganized fibril morphology) at the bone-implant interface. The objective of this study was to investigate the temporal mRNA expression patterns, using real-time polymerase chain reaction, of type I collagen (COLI) and regulators for collagen fibrillogenesis, collagen-binding small leucine-rich proteoglycans (SLRPs) and lysyl hydroxylases (LHs), during mineralization, by MC3T3-E1 cells cultured on titanium (Ti). Lysates of the cultures on Ti and on plastic wells (Pl) for 10-50 d were used for the quantification of calcium and mRNA. Although the onset of calcium accumulation in the cultures on Ti (30-40 d) was slower than that of cultures on Pl (20-30 d), the gene expression patterns during mineralization were similar in cells cultured on either material. COLI and fibromodulin were up-regulated just before the onset of mineralization and then down-regulated. Lumican and LH1 were up-regulated just before the onset of mineralization and then returned to the baseline level. Decorin and LH2 were up-regulated at the late mineralization stage. Biglycan was down-regulated once at the early mineralization stage and then returned to the original level. LH3 was maintained at a steady level throughout. This study suggests actual but distinct roles of SLRPs and LHs in the formation of a unique ultrastructure at the bone-implant interface.
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Affiliation(s)
- Matsuura Takashi
- Department of Oral Rehabilitation, Fukuoka Dental College, Tamura 2-15-1, Sawara-ku, Fukuoka 814-0193, Japan.
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Springer ING, Terheyden H, Geiss S, Härle F, Hedderich J, Açil Y. Particulated bone grafts - effectiveness of bone cell supply. Clin Oral Implants Res 2004; 15:205-12. [PMID: 15008932 DOI: 10.1111/j.1600-0501.2004.00976.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The objective of this study was to measure the amount of viable bone cells present in different types of bone graft. MATERIAL AND METHODS Bone chips were harvested from the trabecular or cortical bone of the mandible or the iliac crest and either milled or not. The average size of unmilled bone particles was 5 x 5 x 5 mm and that of milled was 2 x 2 x 2 mm. Drill sludge was obtained using either a ball reamer, a diamond ball or an implant drill (the latter from mandibular bone and of average dimension 1 x 1 x 1 mm). A measure of 0.5 g of each category was cultured in Dulbecco's modified Eagle's medium with additives for four weeks. Cell counts were performed. An analysis of the osteocalcin synthesis, the alkaline phosphatase (ALP) activity, the collagen types and the concentration of bone-specific collagen cross-links in medium supernatants was performed. RESULTS Cells stained positively for osteocalcin and ALP in all groups. Bone-specific collagen cross-links could be quantified and collagen of types I and V was present with no difference in all groups. Unmilled spongy bone chips revealed greater cell counts than milled (P<0.05). Spongy bone chips revealed greater cell counts than cortical bone chips (P<0.05). Drill sludge obtained by hard alloy ball reamer showed the least amount of viable cells (P<0.05). CONCLUSIONS Bone milling reduces the quantity of osteoblasts. Bone obtained by the ball reamer supplies a smaller number of cells than bone obtained by other methods. Unmilled spongy bone chips appear to offer the greatest amount of viable osteoblasts.
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Affiliation(s)
- Ingo N G Springer
- Department of Oral and Maxillofacial Surgery, University of Kiel, Kiel, Germany.
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Açil Y, Springer ING, Broek V, Terheyden H, Jepsen S. Effects of bone morphogenetic protein-7 stimulation on osteoblasts cultured on different biomaterials. J Cell Biochem 2002; 86:90-8. [PMID: 12112019 DOI: 10.1002/jcb.10197] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The objective of the present study was to investigate the effects of an in vitro stimulation of human osteoblasts by recombinant human bone morphogenetic protein-7 (rhBMP-7) on the collagen types and the quantity of the collagen cross-links synthesized in a three-dimensional culture on various biomaterials for bone replacement. Trabecular bone chips were harvested from human iliac crests, and cell cultures were established at standard conditions. One hundred and fifty nanograms per milliliter of rhBMP-7 was added. For the second passage a cell scraper was used to bring the cells into suspension, and 100 microl osteoblasts (at a density of 3.3 x 10(5)) were transferred onto nine blocks of either Bio-Oss, Tutoplast, or PepGen p-15. Blocks incubated with cells that were not treated with rhBMP-7 served as controls. Cell colonization of the biomaterials was observed by scanning electron microscopy (SEM) and transmission electron microscopy (TEM) after a period of 2, 4, and 6 weeks. Throughout the experiment medium, supernatants were collected and collagen was characterized by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE). Finally, the collagen cross-link residues hydroxylysylpyridinoline (HP) and lysylpyridinoline (LP) were quantified by HPLC. Within 4 weeks the cells became confluent on all of the studied biomaterials. All samples synthesized bone specific LP and collagen type I. However, in rhBMP-7-stimulated samples, the amount of HP and LP found was increased by 45% compared to non-stimulated samples. Cell proliferation and collagen synthesis was similar on the different biomaterials, but was consistently reduced in specimen not stimulated with rhBMP-7. In vitro stimulation of osteoblasts on Bio-Oss, Tutoplast, or PepGen p-15 with rhBMP-7 and subsequent transplantation of the constructs might lead to an enhanced osseointegration of the biomaterials in vivo.
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Affiliation(s)
- Yahya Açil
- Department for Oral and Maxillofacial Surgery, Christian-Albrechts-University of Kiel, Germany.
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Atti E, Gomez S, Wahl SM, Mendelsohn R, Paschalis E, Boskey AL. Effects of transforming growth factor-beta deficiency on bone development: a Fourier transform-infrared imaging analysis. Bone 2002; 31:675-84. [PMID: 12531561 DOI: 10.1016/s8756-3282(02)00905-5] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Transforming growth factor-beta 1 (TGF-beta1) is a cytokine member of the TGF-beta superfamily involved in the control of proliferation and differentiation of various cell types. TGF-beta1 plays an important role in bone formation and resorption. To determine the effect of TGF-beta1 deficiency on bone mineral and matrix, tibias from mice in which TGF-beta1 expression had been ablated (TGF-beta1 null) were analyzed and compared with background- and age-matched wild-type (WT) control animals by Fourier transform-infrared imaging (FTIRI) and histochemistry. FTIRI allows the characterization of nondemineralized thin tissue sections at the ultrastructural level with a spatial resolution of approximately 7 microm. The spectroscopic parameters calculated were: mineral-to-matrix ratio (previously shown to correspond to ash weight); mineral crystallinity (related to the crystallographically determined crystallite size and perfection in the apatite c-axis direction); and collagen maturity (related to the ratio of pyridinoline:deH-DHLNL collagen cross-links). Several fields were selected to represent different stages of bone development within the same specimen from the secondary ossification center to the distal diaphysis. Anatomically equivalent areas were compared as a function of age and genotype. The spectroscopic results were expressed both as color-coded images and as pixel population distributions for each of the three parameters monitored. Based on comparisons of histochemistry and FTIRI, there were distinctive age and genotype variations. At all ages examined, in the TGF-beta1 null mice growth plates, alkaline phosphatase (ALP) activity and collagen maturity were reduced, but no effect on mineral content or crystallinity was noted. In the TGF-beta1 null mice metaphyses, there was a persistence of trabeculae, but no significant alterations in mineral content or crystallinity. In contrast, mineral content, mineral crystallinity, and collagen maturity were reduced in the secondary ossification center and cortical bone of the TGF-beta1 null mice. These results, consistent with a mechanism of impaired bone maturation in the TGF-beta1 null mice, may be directly related to TGF-beta1 deficiency and indirectly to increased expression of inflammatory cytokines in the TGFbeta1 null mice.
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Affiliation(s)
- E Atti
- Mineralized Tissues Laboratory, Hospital for Special Surgery, New York, NY 10021, USA
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Mestries P, Alexakis C, Papy-Garcia D, Duchesnay A, Barritault D, Caruelle JP, Kern P. Specific RGTA increases collagen V expression by cultured aortic smooth muscle cells via activation and protection of transforming growth factor-beta1. Matrix Biol 2001; 20:171-81. [PMID: 11420149 DOI: 10.1016/s0945-053x(01)00131-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Regenerating agents (RGTA) are defined as heparan sulfate mimics, which in vivo stimulate tissue repair. RGTA are obtained by controlled grafting of carboxymethyl and sulfate groups on dextran polymers. RGTA are selected in vitro, on their ability to protect heparin binding growth factors such as TGF-beta1 for example, as well as to alter extracellular matrix biosynthesis. We had reported that RGTA were able to modulate smooth muscle cell (SMC) collagen biosynthesis. Here, we demonstrated that a specific RGTA (RG-1503), altered differentially collagen type expression by post-confluent SMC and that this action involves TGF-beta1. RG-1503 decreased, by 50%, collagen I and III biosynthesis and stimulated specifically, by twofold, collagen V biosynthesis. TGF-beta1 stimulated collagen I and V by 1.5- and threefold, respectively. A synergic action for RGTA in association with TGF-beta1 was observed specifically for collagen V expression (eightfold increase). The stimulation of collagen V biosynthesis by RGTA was abolished by TGF-beta1 neutralizing antibodies. These modulations occurred at protein and mRNA levels. RG-1503 did not alter TGF-beta1 mRNA steady state level or total TGF-beta1 protein content (latent+active forms). However, RG-1503 significantly induced an elevated proportion of active TGF-beta1 form, which could result from the selective protection from proteolytic degradation of TGF-beta1 by RG-1503. These data open a rationale for understanding the stimulation of tissue repair induced by RGTA, and also, a new insight for developing drugs adapted to inhibit excess collagen deposition in smooth muscle cells associated vascular disorder, and in fibrotic diseases.
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Affiliation(s)
- P Mestries
- Laboratory CRRET UPRES-A CNRS 7053 Université de Paris 12 Val de Marne, Avenue du Général de Gaulle 94010, Créteil cedex, France
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Açil Y, Terheyden H, Dunsche A, Fleiner B, Jepsen S. Three-dimensional cultivation of human osteoblast-like cells on highly porous natural bone mineral. JOURNAL OF BIOMEDICAL MATERIALS RESEARCH 2000; 51:703-10. [PMID: 10880119 DOI: 10.1002/1097-4636(20000915)51:4<703::aid-jbm19>3.0.co;2-a] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
In this study, we investigated the growth and extracellular matrix synthesis of human osteoblast-like cells on highly porous natural bone mineral. Human bone cells were isolated from trabecular bone during routine iliac crest biopsies. Under conventional culture conditions, trabecular bone cells were able to assume the organization of a three-dimensional structure on a porous natural bone mineral (Bio-Oss(R) Block). Scanning electron microscopy examination after 6 weeks revealed multiple cell layers on the trabecular block. Transmission electron microscopy examination after 6 weeks revealed the accumulation of mature collagen fibrils in the intracellular and extracellular spaces, and showed multilayered, rough endoplasmic reticulum as well as mitochondria-rich cells surrounded by dense extracellular matrix. These morphological observations suggest that the cell layer may resemble the natural three-dimensional structure. Biochemical analysis revealed that the hydroxylysylpyridinoline, lysylpyridinoline, and hydroxyproline content of the cell layer increased in a time-dependent manner, whereas in monolayer culture without natural bone mineral, no measurable amounts of hydroxylysylpyridinoline or lysylpyridinoline, and a barely measurable amount of hydroxyproline, were noted. Mature collagen extracted by ethylenediaminetetraacetic acid-demineralization from the cell layer on natural bone mineral showed an identical electrophoretic pattern to that observed in human bone, as evaluated by sodium dodecyl sulphate-polyacrylamide gel electrophoresis. The present study demonstrated an excellent biocompatibility of the highly porous natural bone mineral in a three-dimensional bone cell culture system, and thus its potential for tissue-engineered growth of human bone.
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Affiliation(s)
- Y Açil
- Department for Oral and Maxillofacial Surgery, Kiel University, Arnold-Heller-Strasse 16, 24105 Kiel, Germany.
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9
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Uzawa K, Grzesik WJ, Nishiura T, Kuznetsov SA, Robey PG, Brenner DA, Yamauchi M. Differential expression of human lysyl hydroxylase genes, lysine hydroxylation, and cross-linking of type I collagen during osteoblastic differentiation in vitro. J Bone Miner Res 1999; 14:1272-80. [PMID: 10457259 DOI: 10.1359/jbmr.1999.14.8.1272] [Citation(s) in RCA: 123] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The pattern of lysyl hydroxylation in the nontriple helical domains of collagen is critical in determining the cross-linking pathways that are tissue specific. We hypothesized that the tissue specificity of type I collagen cross-linking is, in part, due to the differential expression of lysyl hydroxylase genes (Procollagen-lysine,2-oxyglutarate,5-dioxygenase 1, 2, and 3 [PLOD1, PLOD2, and PLOD3]). In this study, we have examined the expression patterns of these three genes during the course of in vitro differentiation of human osteoprogenitor cells (bone marrow stromal cells [BMSCs]) and normal skin fibroblasts (NSFs). In addition, using the medium and cell layer/matrix fractions in these cultures, lysine hydroxylation of type I collagen alpha chains and collagen cross-linking chemistries have been characterized. High levels of PLOD1 and PLOD3 genes were expressed in both BMSCs and NSFs, and the expression levels did not change in the course of differentiation. In contrast to the PLOD1 and PLOD3 genes, both cell types showed low PLOD2 gene expression in undifferentiated and early differentiated conditions. However, fully differentiated BMSCs, but not NSFs, exhibited a significantly elevated level (6-fold increase) of PLOD2 mRNA. This increase coincided with the onset of matrix mineralization and with the increase in lysyl hydroxylation in the nontriple helical domains of alpha chains of type I collagen molecule. Furthermore, the collagen cross-links that are derived from the nontriple helical hydroxylysine-aldehyde were found only in fully differentiated BMSC cultures. The data suggests that PLOD2 expression is associated with lysine hydroxylation in the nontriple helical domains of collagen and, thus, could be partially responsible for the tissue-specific collagen cross-linking pattern.
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Affiliation(s)
- K Uzawa
- Dental Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599-7455, USA
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Bailey AJ, Knott L. Molecular changes in bone collagen in osteoporosis and osteoarthritis in the elderly. Exp Gerontol 1999; 34:337-51. [PMID: 10433388 DOI: 10.1016/s0531-5565(99)00016-9] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- A J Bailey
- Collagen Research Group, Division of Molecular and Cellular Biology, University of Bristol, Langford, UK.
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Laitinen M, Halttunen T, Jortikka L, Teronen O, Sorsa T, Lindholm TS. The role of transforming growth factor-beta on retarded osteoblastic differentiation in vitro. Life Sci 1999; 64:847-58. [PMID: 10096435 DOI: 10.1016/s0024-3205(99)00006-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Various matrix growth factors play important roles in the development and growth of cartilage and bone. Among them transforming growth factor-beta superfamily and especially bone morphogenetic proteins are known to be important factors, since they induce bone and cartilage formation in ectopic sites in vivo. We have previously shown that the human osteosarcoma cell line Saos-2 expresses molecules that in vivo induce new bone formation with asymmetric bone maturation. In this study we examined the role of Saos-2-conditioned medium in prolonged cultures of mesenchymal C3H/10T1/2 cells. The C3H/10T1/2 cells were cultured with Saos-2-conditioned medium for 28 days. We show that Saos-2-treated C3H/10T1/2 cells performed retarded osteoblastic differentiation when compared to recombinant BMP-2 and -4 induced differentiation. We further show that this retardation is due to excessive amounts of transforming growth factor-beta in Saos-2-conditioned medium. Our results also suggest that this model can well be used to study additional cofactors involved in retarded osteogenesis.
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Affiliation(s)
- M Laitinen
- Institute of Medical Technology, University of Tampere and University Central Hospital of Tampere, Finland.
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Abstract
AbstractUnderstanding how the regulation of growth factor pathways alters during prostate cancer (PC) progression may enable researchers to develop targeted therapeutic strategies for advanced disease. PC progression involves the shifting of cells from androgen-dependent growth to an androgen-independent state, sometimes with the loss or mutation of the androgen receptors in PC cells. Both autocrine and paracrine pathways are up-regulated in androgen-independent tumors and may replace androgens as primary growth stimulatory factors in cancer progression. Our discussion focuses on growth factor families that maintain homeostasis between epithelial and stromal cells in the normal prostate and that undergo changes as PC progresses, often making stromal cells redundant. These growth factors include fibroblast growth factor, insulin-like growth factors, epidermal growth factor, transforming growth factor α, retinoic acid, vitamin D3, and the transforming growth factor β families. We review their role in normal prostate development and in cancer progression, using evidence from clinical specimens and models of PC cell growth.
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Affiliation(s)
- Pamela J Russell
- Oncology Research Centre, Prince of Wales Hospital, High Street, Randwick, New South Wales, Australia, 2031 and Division of Medicine, University of New South Wales, Kensington, New South Wales 2052, Australia
| | - Suzanne Bennett
- Oncology Research Centre, Prince of Wales Hospital, High Street, Randwick, New South Wales, Australia, 2031 and Division of Medicine, University of New South Wales, Kensington, New South Wales 2052, Australia
| | - Phillip Stricker
- Department of Urology, St. Vincent’s Hospital, 438 Victoria St., Darlinghurst, New South Wales 2010, Australia
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