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Rendina D, Falchetti A, Diacinti D, Bertoldo F, Merlotti D, Giannini S, Cianferotti L, Girasole G, Di Monaco M, Gonnelli S, Malavolta N, Minisola S, Vescini F, Rossini M, Frediani B, Chiodini I, Asciutti F, Gennari L. Diagnosis and treatment of Paget's disease of bone: position paper from the Italian Society of Osteoporosis, Mineral Metabolism and Skeletal Diseases (SIOMMMS). J Endocrinol Invest 2024; 47:1335-1360. [PMID: 38488978 PMCID: PMC11142991 DOI: 10.1007/s40618-024-02318-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 01/18/2024] [Indexed: 03/17/2024]
Abstract
INTRODUCTION Paget's disease of bone is a focal skeletal disorder causing bone deformities and impairing bone quality. Despite the prevalence of asymptomatic cases is increasing, the progression of the disease can lead to invalidating complications that compromise the quality of life. Doubts on clinical and therapeutic management aspects exist, although beneficial effects of antiresorptive drugs, particularly bisphosphonates are known. However, limited information is available from randomized controlled trials on the prevention of disease complications so that somewhat contrasting positions about treatment indications between expert panels from the main scientific societies of metabolic bone diseases exist. This task force, composed by expert representatives appointed by the Italian Society of Osteoporosis, Mineral Metabolism and Skeletal Diseases and members of the Italian Association of Paget's disease of bone, felt the necessity for more specific and up to date indications for an early diagnosis and clinical management. METHODS Through selected key questions, we propose evidence-based recommendations for the diagnosis and treatment of the disease. In the lack of good evidence to support clear recommendations, available information from the literature together with expert opinion of the panel was used to provide suggestions for the clinical practice. RESULTS AND CONCLUSION Description of the evidence quality and support of the strength of the statements was provided on each of the selected key questions. The diagnosis of PDB should be mainly based on symptoms and the typical biochemical and radiological features. While treatment is mandatory to all the symptomatic cases at diagnosis, less evidence is available on treatment indications in asymptomatic as well as in previously treated patients in the presence of biochemical recurrence. However, given the safety and long-term efficacy of potent intravenous bisphosphonates such as zoledronate, a suggestion to treat most if not all cases at the time of diagnosis was released.
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Affiliation(s)
- D Rendina
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", 80138, Naples, Italy
| | - A Falchetti
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20122, Milan, Italy
| | - D Diacinti
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - F Bertoldo
- Emergency Medicine, Department of Medicine, University of Verona, 37129, Verona, Italy
| | - D Merlotti
- Department of Medical Sciences, Azienda Ospedaliera Universitaria Senese, 53100, Siena, Italy
| | - S Giannini
- Clinica Medica 1, Department of Medicine, University of Padova, 35122, Padua, Italy
| | - L Cianferotti
- Bone Metabolic Diseases Unit, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, 50121, Florence, Italy
| | - G Girasole
- Rheumatology Department, La Colletta" Hospital, ASL 3 Genovese, 16011, Arenzano, Italy
| | - M Di Monaco
- Osteoporosis Research Center, Fondazione Opera San Camillo, Presidio Di Torino, 10131, Turin, Italy
| | - S Gonnelli
- Department of Medicine, Surgery and Neurosciences, University of Siena, 53100, Siena, Italy
| | - N Malavolta
- Casa Di Cura Madre Fortunata Toniolo, and Centri Medici Dyadea, 40141, Bologna, Italy
| | - S Minisola
- U.O.C. Medicina Interna A, Malattie Metaboliche Dell'Osso Ambulatorio Osteoporosi E Osteopatie Fragilizzanti, Sapienza University of Rome, 00185, Rome, Italy
| | - F Vescini
- Unit of Endocrinology and Metabolism, University-Hospital S. M. Misericordia, Udine, Italy
| | - M Rossini
- Rheumatology Unit, University of Verona, Policlinico GB Rossi, 37134, Verona, Italy
| | - B Frediani
- Department of Medicine, Surgery and Neurosciences, University of Siena, 53100, Siena, Italy
| | - I Chiodini
- Department of Biotechnology and Translational Medicine, University of Milan, 20122, Milan, Italy
- Ospedale Niguarda Cà Granda, Piazza Ospedale Maggiore 3, 20161, Milan, Italy
| | - F Asciutti
- Associazione Italiana Malati Osteodistrofia Di Paget, Siena, Italy
| | - L Gennari
- Department of Medicine, Surgery and Neurosciences, University of Siena, 53100, Siena, Italy.
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Gennari L, Rendina D, Merlotti D, Cavati G, Mingiano C, Cosso R, Materozzi M, Pirrotta F, Abate V, Calabrese M, Falchetti A. Update on the pathogenesis and genetics of Paget’s disease of bone. Front Cell Dev Biol 2022; 10:932065. [PMID: 36035996 PMCID: PMC9412102 DOI: 10.3389/fcell.2022.932065] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 07/25/2022] [Indexed: 11/24/2022] Open
Abstract
Studies over the past two decades have led to major advances in the pathogenesis of Paget’s disease of bone (PDB) and particularly on the role of genetic factors. Germline mutations of different genes have been identified, as a possible cause of this disorder, and most of the underlying pathways are implicated in the regulation of osteoclast differentiation and function, whereas other are involved in cell autophagy mechanisms. In particular, about 30 different germline mutations of the Sequestosome 1 gene (SQSTM1) have been described in a significant proportion of familial and sporadic PDB cases. The majority of SQSTM1 mutations affect the ubiquitin-binding domain of the protein and are associated to a more severe clinical expression of the disease. Also, germline mutations in the ZNF687 and PFN1 genes have been associated to severe, early onset, polyostotic PDB with increased susceptibly to neoplastic degeneration, particularly giant cell tumor. Mutations in the VCP (Valosin Containing Protein) gene cause the autosomal dominant syndrome “Inclusion Body Myopathy, PDB, Fronto-temporal Dementia,” characterized by pagetic manifestations, associated with myopathy, amyotrophic lateral sclerosis and fronto-temporal dementia. Moreover, germline mutations in the TNFRSF11A gene, which encodes for RANK, were associated with rare syndromes showing some histopathological, radiological, and clinical overlap with PDB and in two cases of early onset PDB-like disease. Likewise, genome wide association studies performed in unrelated PDB cases identified other potential predisposition genes and/or susceptibility loci. Thus, it is likely that polygenic factors are involved in the PDB pathogenesis in many individuals and that modifying genes may contribute in refining the clinical phenotype. Moreover, the contribution of somatic mutations of SQSTM1 gene and/or epigenetic mechanisms in the pathogenesis of skeletal pagetic abnormalities and eventually neoplastic degeneration, cannot be excluded. Indeed, clinical and experimental observations indicate that genetic susceptibility might not be a sufficient condition for the clinical development of PDB without the concomitant intervention of viral infection, in primis paramixoviruses, and/or other environmental factors (e.g., pesticides, heavy metals or tobacco exposure), at least in a subset of cases. This review summarizes the most important advances that have been made in the field of cellular and molecular biology PDB over the past decades.
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Affiliation(s)
- Luigi Gennari
- Department of Medicine Surgery and Neurosciences, University of Siena Italy, Siena, Italy
- *Correspondence: Luigi Gennari, ; Alberto Falchetti,
| | - Domenico Rendina
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Daniela Merlotti
- Department of Medical Sciences, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Guido Cavati
- Department of Medicine Surgery and Neurosciences, University of Siena Italy, Siena, Italy
| | - Christian Mingiano
- Department of Medicine Surgery and Neurosciences, University of Siena Italy, Siena, Italy
| | - Roberta Cosso
- Unit of Rehabilitation Medicine, San Giuseppe Hospital, Istituto Auxologico Italiano, Piancavallo, Italy
| | - Maria Materozzi
- Department of Medicine Surgery and Neurosciences, University of Siena Italy, Siena, Italy
- Age Related Diseases Unit, Division of Genetics and Cell Biology, San Raffaele Scientific Institute, Milano, Italy
| | - Filippo Pirrotta
- Department of Medicine Surgery and Neurosciences, University of Siena Italy, Siena, Italy
| | - Veronica Abate
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Marco Calabrese
- Department of Medicine Surgery and Neurosciences, University of Siena Italy, Siena, Italy
| | - Alberto Falchetti
- Experimental Research Laboratory on Bone Metabolism, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Istituto Auxologico Italiano, Milano, Italy
- *Correspondence: Luigi Gennari, ; Alberto Falchetti,
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Tao X, Liu L, Yang X, Wei Z, Chen Z, Zhang G, Zhang Z, Yue H. Clinical Characteristics and Pathogenic Gene Identification in Chinese Patients With Paget's Disease of Bone. Front Endocrinol (Lausanne) 2022; 13:850462. [PMID: 35355568 PMCID: PMC8959906 DOI: 10.3389/fendo.2022.850462] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 02/07/2022] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the clinical features of sporadic Paget's disease of bone (PDB) in China and further explore the underlying genetic abnormalities of the disease. METHODS Clinical characteristics, biochemical indices, bone turnover markers and radiographic examinations of the patients were collected. Genomic DNA was extracted from peripheral blood and whole-exome sequencing was carried out to identify the potential pathogenic genes. The pathogenicity of the variants was thereafter investigated by bioinformatics analysis. RESULTS A total of 50 patients (57.20 ± 15.52 years, male/female: 1.63: 1) with PDB were included and the mean onset age was 48.34 years (48.34 ± 17.24 years). 94.0% of the patients exhibited symptomatic patterns described as bone pain (86.0%), elevated skin temperature at the lesion site (26.0%), bone deformity (22.0%) and local swelling (18.0%). The most frequently involved lesion sites were pelvis (52.0%), femur (42.0%), tibia (28.0%), skull (28.0%) and spine (18.0%), respectively. Additionally, 40.0% of them accompanied with osteoarthritis, 14.0% with pathological fractures, and the misdiagnosis rate of PDB was as high as 36.0%. Serum level of alkaline phosphatase was significantly increased, with the mean value of 284.00 U/L (quartiles, 177.00-595.00 U/L). Two heterozygous missense mutations of SQSTM1 gene (c.1211T>C, M404T) and one novel heterozygous missense mutation in HNRNPA2B1 gene (c.989C>T, p. P330L) were identified in our study. Moreover, several potential disease-causing genes were detected and markedly enriched in the pathways of neurodegeneration (including WNT16, RYR3 and RYR1 genes) and amyotrophic lateral sclerosis (ALS, including NUP205, CAPN2, and NUP214 genes). CONCLUSION In contrast to Western patients, Chinese patients have an earlier onset age, more severe symptoms, and lower frequency of SQSTM1 gene mutation (4.0%). Moreover, a novel heterozygous missense mutation in HNRNPA2B1 gene was identified in one male patient with isolated bone phenotype. As for other genetic factors, it was indicated that WNT16, RYR3, RYR1, NUP205, CAPN2 and NUP214 genes may be potential pathogenic genes, pathways of neurodegeneration and ALS may play a vital role in the pathogenesis of PDB.
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Affiliation(s)
- Xiaohui Tao
- Shanghai Clinical Research Center of Bone Disease, Department of Osteoporosis and Bone Diseases, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Li Liu
- Shanghai Clinical Research Center of Bone Disease, Department of Osteoporosis and Bone Diseases, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Xingguang Yang
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Zhe Wei
- Shanghai Clinical Research Center of Bone Disease, Department of Osteoporosis and Bone Diseases, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Zhongzhong Chen
- Department of Urology, Shanghai Children’s Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Ge Zhang
- Law Sau Fai Institute for Advancing Translational Medicine in Bone and Joint Diseases, School of Chinese Medicine, Hong Kong Baptist University, Hong Kong, Hong Kong SAR, China
- *Correspondence: Zhenlin Zhang, ; Ge Zhang, ; Hua Yue,
| | - Zhenlin Zhang
- Shanghai Clinical Research Center of Bone Disease, Department of Osteoporosis and Bone Diseases, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
- *Correspondence: Zhenlin Zhang, ; Ge Zhang, ; Hua Yue,
| | - Hua Yue
- Shanghai Clinical Research Center of Bone Disease, Department of Osteoporosis and Bone Diseases, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
- *Correspondence: Zhenlin Zhang, ; Ge Zhang, ; Hua Yue,
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ROMANO F, DI BENEDETTO E, SCARANO E, RICCIO E, ARIANNA R, COLAO A, DI SOMMA C. Treatment of Paget's disease of the bone: long-term effect of neridronate in a real-life setting. Minerva Endocrinol (Torino) 2022; 46:374-383. [DOI: 10.23736/s2724-6507.20.03320-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Gatti D, Rossini M, Viapiana O, Idolazzi L, Adami S. Clinical development of neridronate: potential for new applications. Ther Clin Risk Manag 2013; 9:139-47. [PMID: 23589692 PMCID: PMC3622395 DOI: 10.2147/tcrm.s35788] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Neridronate is an aminobisphosphonate, licensed in Italy for the treatment of osteogenesis imperfecta (OI) and Paget's disease of bone (PDB). A characteristic property of neridronate is that it can be administered both intravenously and intramuscularly, providing a useful system for administration in homecare. In this review, we discuss the latest clinical results of neridronate administration in OI and PDB, as well as in osteoporosis and other conditions. We will focus in particular on the latest evidence of the effect of neridronate on treatment of complex regional pain syndrome type I.
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Affiliation(s)
- Davide Gatti
- Rheumatology Unit, Department of Medicine, University of Verona, Verona, Italy
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Brunetti G, Marzano F, Colucci S, Ventura A, Cavallo L, Grano M, Faienza MF. Genotype-phenotype correlation in juvenile Paget disease: role of molecular alterations of the TNFRSF11B gene. Endocrine 2012; 42:266-71. [PMID: 22638612 DOI: 10.1007/s12020-012-9705-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Accepted: 05/11/2012] [Indexed: 12/23/2022]
Abstract
Juvenile Paget disease (JPD) {MIM 239000} is a rare inherited bone disease that affects children. The patients affected with JPD present an altered bone turnover, therefore, show a phenotype characterized by progressive bone deformities, fractures, and short stature. Deletions or missense mutations of the TNFRSN11B gene are common in these children. This gene encodes a soluble protein, the osteoprotegerin, which leads to uncontrolled osteoclastogenesis when mutated. JPD is characterized by a strong genotype-phenotype correlation, so depending on the alteration of the TNFRSN11B gene, the phenotype is variable. This review describes the different clinical features which are characteristic of JPD and the correspondence with the different molecular alterations of the TNFRSN11B gene.
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Affiliation(s)
- Giacomina Brunetti
- Department of Basic Medical Sciences, Section of Human Anatomy and Histology, University of Bari, Bari, Italy
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Neve A, Corrado A, Cantatore FP. Osteocytes: central conductors of bone biology in normal and pathological conditions. Acta Physiol (Oxf) 2012; 204:317-30. [PMID: 22099166 DOI: 10.1111/j.1748-1716.2011.02385.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Osteocytes are the most abundant and longest-living cells in the adult skeleton. For a long time, osteocytes were considered static and inactive cells, but in recent years, it has been suggested that they represent the key responder to various stimuli that regulate bone formation and remodelling as well as one of the key endocrine regulators of bone metabolism. Osteocytes respond to mechanical stimuli by producing and secreting several signalling molecules, such as nitric oxide and prostaglandin E(2) , that initiate local bone remodelling. Moreover, they can control bone formation by modulating the WNT signalling pathway, an essential regulator of cell fate and commitment, as they represent the main source of sclerostin, a negative regulator of bone formation. Osteocytes can also act as an endocrine organ by releasing fibroblast growth factor 23 and several other proteins (DMP-1, MEPE, PHEX) that regulate phosphate metabolism. It has been demonstrated that various bone diseases are associated with osteocyte abnormalities, although it is not clear if these changes are the direct cause of the pathology or if they are secondary to the pathological changes in the bone microenvironment. Thus, a better understanding of these cells could offer exciting opportunities for new advances in the prevention and management of different bone diseases.
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Affiliation(s)
- A Neve
- Rheumatology Clinic, Department of Medical and Occupational Sciences, University of Foggia, Italy
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Abstract
PURPOSE OF REVIEW The review summarizes the recent findings relevant to the clinical management, genetic predisposition, and molecular mechanisms implicated in Paget's disease of bone (PDB). RECENT FINDINGS PDB is characterized by focal regions of increased bone remodeling and abnormal bone architecture. PDB is treated effectively with amino-bisphosphonates, which can produce very prolonged disease remission. The disease has a strong genetic component and a large number of studies focus on the cellular mechanisms affected by mutations in the SQSTM1 (sequestosome 1) gene which are associated with PDB. Identifying other genes associated with PDB is an additional active research focus. SUMMARY In recent years, there has been a great progress in the understanding of the epidemiology, genetics and molecular biology of PDB. However, an integrative view of the disease cause is still missing and is likely to be attained only with further discoveries of genetic factors, environmental factors, and the interactions between them. Investigations of the cellular mechanisms that are disrupted in PDB contribute greatly to the understanding of normal bone remodeling.
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Affiliation(s)
- Dorit Naot
- Department of Medicine, University of Auckland, Auckland, New Zealand.
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