The use of zoledronic acid in the management of metastatic bone disease and hypercalcaemia

Bisphosphonates and osteonecrosis of the jaws: Clinical and forensic aspects

OBJECTIVE

This manuscript aims to provide a comprehensive review of the current knowledge in the pathophysiology, diagnosis, prevention, and other relevant clinical and forensic aspects of a potentially severe complication known as medication-related osteonecrosis of the jaw (MRONJ) while synthesizing state-of-the-art information on bisphosphonates and introducing a possible differential diagnosis.

DESIGN

An extensive search was conducted in PubMed (U.S. National Library of Medicine) without a time or language constraint, focusing on the epidemiology, pathophysiology, risk factors, site specificity, signs and symptoms, differential diagnosis, prevention, and forensic aspects of MRONJ. All types of original articles, reviews, case reports, short communications, opinion articles, guidelines, and letters to editors were considered to produce a complete review on this subject.

RESULTS

MRONJ prevention relies on a multidisciplinary approach and is critical since truly effective treatments are lacking. This therapeutic challenge is partly due to uncertainty regarding this condition's pathophysiology. Differential diagnosis of osteonecrosis of the jaws associated with krokodil abuse, one of the most dangerous and homemade psychoactive illicit substances, should be considered.

CONCLUSIONS

Further research into the etiology and site specificity of MRONJ is encouraged, aiming to develop novel treatment prospects. Indeed, comprehending this would allow for increased efficacy and therapeutic options while emphasizing the importance of prevention. In addition, we advocate for greater consensus among the various societies regarding MRONJ's treatment and management.

Oestrogen and zoledronic acid driven changes to the bone and immune environments: Potential mechanisms underlying the differential anti-tumour effects of zoledronic acid in pre- and post-menopausal conditions

Late stage breast cancer commonly metastasises to bone and patient survival averages 2-3 years following diagnosis of bone involvement. One of the most successful treatments for bone metastases is the bisphosphonate, zoledronic acid (ZOL). ZOL has been used in the advanced setting for many years where it has been shown to reduce skeletal complications associated with bone metastasis. More recently, several large adjuvant clinical trials have demonstrated that administration of ZOL can prevent recurrence and improve survival when given in early breast cancer. However, these promising effects were only observed in post-menopausal women with confirmed low concentrations of circulating ovarian hormones. In this review we focus on potential interactions between the ovarian hormone, oestrogen, and ZOL to establish credible hypotheses that could explain why anti-tumour effects are specific to post-menopausal women. Specifically, we discuss the molecular and immune cell driven mechanisms by which ZOL and oestrogen affect the tumour microenvironment to inhibit/induce tumour growth and how oestrogen can interact with zoledronic acid to inhibit its anti-tumour actions.

Zoledronic Acid Regulates Autophagy and Induces Apoptosis in Colon Cancer Cell Line CT26

Zoledronic acid (ZOL) is the third generation of bisphosphonates, which can inhibit many tumors growth, especially to inhibit the growth of colon cancer. However, the molecular mechanism is still very mysterious. In this study, we observed that ZOL could regulate CT26 colon cancer cells autophagy, promote CT26 cells apoptosis, and inhibit CT26 cells proliferation. Western blotting analysis showed that proapoptosis protein caspase-3 was basically unchanged, whereas the expression of the activated caspase-3 was significantly increased, after CT26 cells were treated with different doses of zoledronic acid. Western blot also showed that ZOL could significantly affect the expression of p-p53 and autophagy-related proteins beclin-1 and p62. In conclusion, the antitumor effect of ZOL on CT26 colon cancer cells in vitro is achieved by apoptosis induction and autophagy regulation, resulting in inhibition of cell proliferation.

Anti-tumour activity of bisphosphonates in preclinical models of breast cancer

There is increasing evidence of anti-tumour effects of bisphosphonates from pre-clinical studies, supporting a role for these drugs beyond their traditional use in treatment of cancer-induced bone disease. A range of model systems have been used to investigate the effects of different bisphosphonates on tumour growth, both in bone and at peripheral sites. Most of these studies conclude that bisphosphonates cause a reduction in tumour burden, but that early intervention and the use of high and/or repeated dosing is required. Successful eradication of cancer may only be achievable by targeting the tumour cells directly whilst also modifying the tumour microenvironment. In line with this, bisphosphonates are demonstrated to be particularly effective at reducing breast tumour growth when used in combination with agents that directly target cancer cells. Recent studies have shown that the effects of bisphosphonates on breast tumours are not limited to bone, and that prolonged anti-tumour effects may be achieved following their inclusion in combination therapy. This has opened the field to a new strand of bisphosphonate research, focussed on elucidating their effects on cells and components of the local, regional and distal tumour microenvironment. This review highlights the recent developments in relation to proposed anti-tumour effects of bisphosphonates reported from in vitro and in vivo models, and summarises the data from key breast cancer studies. Evidence for effects on different processes and cell types involved in cancer development and progression is discussed, and the main outstanding issues identified.

Characterization of cancer-induced bone pain: an exploratory study

PURPOSE

Cancer-induced bone pain (CIBP) is the commonest cause of pain in patients with cancer. Its association with increased morbidity combined with limitations of currently available therapies makes it a clinical challenge. Clinical characterization of this complex pain syndrome is essential in underpinning clinical management and informing future research. The aim of this exploratory study was to characterise CIBP using self-rating scales.

PATIENTS AND METHODS

A cross-sectional survey of patients with CIBP was carried out in a regional oncology centre. Patients described their pain over the preceding 24 h using the McGill Pain Questionnaire, Brief Pain Inventory (BPI), and a breakthrough pain questionnaire. Multiple linear regression analyses were conducted.

RESULTS

Fifty-five patients were recruited. Annoying, gnawing, aching, and nagging were the most commonly used words to describe CIBP. From the BPI, median average pain was 4/10 and worst pain was 7/10 on a 0-10 Numerical Rating Scale. The worst pain score correlated more strongly with BPI interference score (p=0.001). Forty-one patients had breakthrough pain. Patients with breakthrough pain had higher total BPI interference scores than those with no breakthrough pain; median (IQR); 35.0 (2.5-44.7) vs. 18.5 (5.5-26.7), p<0.01. Of the patients, 20/41 (48%) had breakthrough pain of rapid onset (less than 5 min) and short duration (less than 15 min).

CONCLUSION

In CIBP, worst pain most accurately reflects the characteristics of pain flares and functional impairment. Breakthrough pain is often unpredictable, sudden onset and short duration. Further characterization studies of CIBP in the broader cancer population are needed.

Intravenous ibandronate rapidly reduces pain, neurochemical indices of central sensitization, tumor burden, and skeletal destruction in a mouse model of bone cancer

Over half of all chronic cancer pain arises from metastases to bone and bone cancer pain is one of the most difficult of all persistent pain states to fully control. Currently, bone pain is treated primarily by opioid-based therapies, which are frequently accompanied by significant unwanted side effects. In an effort to develop nonopioid-based therapies that could rapidly attenuate tumor-induced bone pain, we examined the effect of intravenous administration of the bisphosphonate, ibandronate, in a mouse model of bone cancer pain. Following injection and confinement of green fluorescent protein-transfected murine osteolytic 2472 sarcoma cells into the marrow space of the femur of male C3H/HeJ mice, ibandronate was administered either as a single dose (300 microg/kg), at Day 7 post-tumor injection, when tumor-induced bone destruction and pain were first evident, or in three consecutive doses (100 microg/kg/day) at Days 7, 8, and 9 post-tumor injection. Intravenous ibandronate administered once or in three consecutive doses reduced ongoing and movement-evoked bone cancer pain-related behaviors, neurochemical markers of central sensitization, tumor burden, and tumor-induced bone destruction. These results support limited clinical trials that suggest the potential of ibandronate to rapidly attenuate bone pain and illuminate the mechanisms that may be responsible for limiting pain and disease progression.

The roles of proteolytic enzymes in the development of tumour-induced bone disease in breast and prostate cancer

Tumour-induced bone disease is a common clinical feature of advanced breast and prostate cancer and is associated with considerable morbidity for the affected patients. Our understanding of the molecular mechanisms underlying the development of bone metastases is incomplete, but proteolytic enzymes are implicated in a number of processes involved in both bone metastasis and in normal bone turnover, including matrix degradation, cell migration, angiogenesis, tumour promotion and growth factor activation. Malignant as well as non-malignant cells in the primary and secondary sites express these enzymes, the activity of which may be regulated by soluble factors, cell- or matrix-associated components, as well as a number of cell signalling pathways. A number of secreted and cell surface-associated proteolytic enzymes are implicated in tumour-induced bone disease, including the matrix metalloproteinases, lysosomal cysteine proteinases and plasminogen activators. This review will introduce the role of proteolytic enzymes in normal bone turnover and give an overview of the studies in which their involvement and regulation in the development of bone metastases in breast and prostate cancer has been described. The results from trials involving protease inhibitors in clinical development will also be briefly discussed.

Orofacial pain in cancer: part II--clinical perspectives and management

Cancer-associated pain is extremely common and is associated with significant physical and psychological suffering. Unfortunately, pain associated with cancer or its treatment is frequently under-treated, probably due to several factors, including phobia of opioids, under-reporting by patients, and under-diagnosis by healthcare workers. The most common etiology of cancer pain is local tumor invasion (primary or metastatic), involving inflammatory and neuropathic mechanisms; these have been reviewed in Part I. As malignant disease advances, pain usually becomes more frequent and more intense. Additional expressions of orofacial cancer pain include distant tumor effects, involving paraneoplastic mechanisms. Pain secondary to cancer therapy varies with the treatment modalities used: Chemo-radiotherapy protocols are typically associated with painful mucositis and neurotoxicity. Surgical therapies often result in nerve and tissue damage, leading, in the long term, to myofascial and neuropathic pain syndromes. In the present article, we review the clinical presentation of cancer-associated orofacial pain at various stages: initial diagnosis, during therapy (chemo-, radiotherapy, surgery), and in the post-therapy period. As a presenting symptom of orofacial cancer, pain is often of low intensity and diagnostically unreliable. Diagnosis, treatment, and prevention of pain in cancer require knowledge of the presenting characteristics, factors, and mechanisms involved.

Biology of Bone Cancer Pain

Bone cancer pain is a devastating manifestation of metastatic cancer. Unfortunately, current therapies can be ineffective, and when they are effective, the duration of the patient's survival typically exceeds the duration of pain relief. New, mechanistically based therapies are desperately needed. Study of experimental animal models has provided insight into the mechanisms that drive bone cancer pain and provides an opportunity for developing targeted therapies. Mechanisms that drive bone cancer pain include tumor-directed osteoclast-mediated osteolysis, tumor cells themselves, tumor-induced nerve injury, stimulation of transient receptor potential vanilloid type 1 ion channel, endothelin A, and host cell production of nerve growth factor. Current and future therapies include external beam radiation, osteoclast-targeted inhibiting agents, anti-inflammatory drugs, transient receptor potential vanilloid type 1 antagonists, and antibody therapies that target nerve growth factor or tumor angiogenesis. It is likely that a combination of these therapies will be superior to any one therapy alone.

Zoledronic acid (Zometa) enhances the cytotoxic effect of gemcitabine and fluvastatin: in vitro isobologram studies with conventional and nonconventional cytotoxic agents

OBJECTIVES

To identify synergistic combinations of clinically available agents with zoledronic acid which would enhance antitumor activity as measured by median effect isobologram analysis and apoptosis assays in vitro.

METHODS

The interaction of zoledronic acid as a doublet with either carboplatin, cisplatin, 5'DFUR, docetaxel, epirubicin, fluvastatin, gemcitabine, imatinib, paclitaxel, trastuzumab, or vinorelbine was studied in a 72-hour in vitro system using defined human cancer cell lines grown as a monolayer in exponential phase. Drug effect on growth was measured by a standard MTT assay. Median effect isobologram analysis was applied to the results to determine the presence of synergism, additive effects, or antagonism of drug combinations. Synergistic combinations were also assayed by a cytoplasmic histone-associated DNA fragmentation apoptosis assay to verify that the effect was not cytostatic.

RESULTS

Zoledronic acid with gemcitabine demonstrated global cytotoxic synergy across 7 of 8 cell lines. Clinically achievable concentrations of fluvastatin with zoledronic acid also demonstrated synergy in 7 of 8 cell lines. All the breast cancer cell lines were sensitive. Zoledronic acid and epirubicin were antagonistic in all 4 breast cell lines studied.

CONCLUSIONS

Combinations of zoledronic acid with either gemcitabine or fluvastatin may have a therapeutic role in treatment of bone metastasis of selected malignancies.

Pilot studies of the effect of zoledronic acid (Zometa) on tumor-derived cells ex vivo in the ATP-based tumor chemosensitivity assay

There is debate regarding the direct effect of bisphosphonates against visceral metastases from solid tumors, despite their proven efficacy against the skeletal complications of metastasis. The aim of this study was to determine whether zoledronic acid showed direct activity against five ovarian cell lines and tumor-derived cells, and whether addition of zoledronic acid to cytotoxic agents increased their cytotoxicity. In this study we used a standardized ATP-based tumor chemosensitivity assay (ATP-TCA) to measure the activity of alendronate, clodronate and zoledronic acid in five ovarian carcinoma cell lines and human solid tumors (breast, lung, ovarian, unknown primary carcinoma, and cutaneous and uveal melanoma) (n=34). We also tested the combination of zoledronic acid with paclitaxel and cisplatin in tumor-derived cells. All five cell lines exhibited greater sensitivity to bisphosphonates than the tumor-derived cells and in all five the IC50 for zoledronic acid was less than 4 muM. In the tumor-derived cells, zoledronic acid showed concentration-dependent inhibition with a median IC50 for all tumors tested of 17 muM and evidence of apoptosis (caspase activation). Simultaneous addition of zoledronic acid to cisplatin or paclitaxel showed no major increase in cytotoxicity. We conclude that the activity of bisphosphonates was greater in cell lines than in tumor-derived cells. However, the pattern of activity of bisphosphonates was the same in cell lines and tumor derived cells. This study suggests a direct, or possibly an indirect, effect of zoledronic acid and other nitrogen-containing bisphosphonates against neoplastic cells, but simultaneous addition with cisplatin or paclitaxel does not substantially increase the activity of the cytotoxic agent.

Combined effects of zoledronic acid and doxorubicin on breast cancer cell invasion in vitro

The bisphosphonate zoledronic acid and the cytotoxic drug doxorubicin induce synergistic levels of apoptosis in breast cancer cells. As zoledronic acid and doxorubicin have been shown to reduce cell invasion and migration, we have investigated if these drugs also act synergistically on breast cancer invasion in vitro. MCF7 cells were treated with 0.05 microM doxorubicin/4 h followed by 1 or 10 microM zoledronic acid/24 h (or the reverse sequence). To study invasion, MCF7 cells were either grown on Transwell membranes coated with Matrigel or in a 24-well plate. Cells were treated sequentially using the above drug combinations, prior to starting the invasion assays for 48 h. Cell growth and death were also assessed under the same conditions. We found that invasion of MCF7 cells treated with zoledronic acid and doxorubicin was significantly reduced when compared with control, but the effect was dependent on drug sequence. At 1 microM, zoledronic acid significantly reduced invasion only if cells were pre-treated with doxorubicin, but cell growth was unaffected. For 10 microM zoledronic acid, invasion was reduced when administered before or after the doxorubicin, but this dose of zoledronic acid caused a significant reduction in MCF7 growth. Apoptosis was not induced by any of the drug doses and combinations. We conclude that pre-treatment with 0.05 microM doxorubicin followed by 1 microM zoledronic acid reduces invasion when cells were grown on Matrigel. For 10 microM zoledronic acid, pre- or post-doxorubicin also reduces invasion, but for this combination inhibition of cell growth may contribute to the reduction in invasion observed.

Clodronate : a review of its use in the prevention of bone metastases and the management of skeletal complications associated with bone metastases in patients with breast cancer

Clodronate (clodronate disodium, Bonefos) is a non-nitrogen-containing bisphosphonate that inhibits osteoclast activity, and thereby inhibits bone resorption. Clodronate has been extensively used in patients with advanced breast cancer, and is generally well tolerated. In patients with primary breast cancer, clodronate is currently the only bisphosphonate shown to improve survival rates and to reduce the incidence of bone metastases in randomised controlled trials. Further trials in patients with early breast cancer are warranted to confirm results to date and to determine the optimal duration of treatment, as well as the efficacy of the drug compared with other bisphosphonates. In the meantime, clodronate is a well established bisphosphonate which has shown beneficial effects in the prevention of bone metastases and on survival in patients with primary breast cancer.

Synergistic cytotoxic effects of zoledronic acid and radiation in human prostate cancer and myeloma cell lines

PURPOSE

The clinical use of the potent bisphosphonate zoledronic acid has increased recently, especially for the treatment of bone metastases. Synergistic effects with chemotherapeutic agents (e.g., doxorubicin, paclitaxel) have been shown. It is not known whether similar synergistic effects exist with radiation.

METHODS AND MATERIALS

IM-9 myeloma cells and C4-2 prostate cancer cells were treated with up to 200 microM concentrations of zoledronic acid, irradiated with single doses of up to 1,000 cGy, or exposed to combinations of both treatments. Cell viability was then determined via yellow dye 3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyl-tetrazolium bromide assay and the affected fractions analyzed using the median effect principal, a method developed and validated by Chou and Talalay.

RESULTS

A statistically significant synergistic cytotoxic effect of the combination of zoledronic acid and radiation was documented. The extent of the effect was cell type-dependent, with the C4-2 cells showing a greater synergistic effect than the IM-9 cells.

CONCLUSIONS

The combined use of zoledronic acid and radiotherapy shows enhanced in vitro cytotoxicity for two human prostate and myeloma cancer cell lines over that expected for a simple additive effect from each treatment alone. A clinical trial is under way to test this combination therapy.

Bone cancer pain: the effects of the bisphosphonate alendronate on pain, skeletal remodeling, tumor growth and tumor necrosis

Patients with metastatic breast, lung or prostate cancer frequently have significant bone cancer pain. In the present report we address, in a single in vivo mouse model, the effects the bisphosphonate alendronate has on bone cancer pain, bone remodeling and tumor growth and necrosis. Following injection and confinement of green fluorescent protein-transfected murine osteolytic tumor cells into the marrow space of the femur of male C3H/HeJ mice, alendronate was administered chronically from the time the tumor was established until the bone cancer pain became severe. Alendronate therapy reduced ongoing and movement-evoked bone cancer pain, bone destruction and the destruction of sensory nerve fibers that innervate the bone. Whereas, alendronate treatment did not change viable tumor burden, both tumor growth and tumor necrosis increased. These data emphasize that it is essential to utilize a model where pain, skeletal remodeling and tumor growth can be simultaneously assessed, as each of these can significantly impact patient quality of life and survival.

The pathophysiology of cancer-induced bone pain: current understanding

Cancer-induced bone pain (CIBP) is a common clinical problem. Although treatment has been revolutionised in the past 10 years with the introduction of bisphosphonates, pain arising spontaneously or from movement, remains a leading cause of unresolved pain in many patients. Until recently little was understood about the peripheral and central mechanisms of bone pain. Insight into the mechanisms of osteoblast and osteoclast activation, via receptor activator for nuclear factor KB (RANK) dependent and independent mechanisms and a re-evaluation of primary afferent terminals within bone have led to a suggestion that CIBP may be a mixture of inflammatory and neuropathic stimuli. The recently published animal model of localised but progressive bone destruction has allowed greater insight into the peripheral and dorsal horn pathophysiology, which hitherto was precluded. Immunocytochemical markers of neurotransmitters and receptors indicate that CIBP has unique characteristics, unlike neuropathy or inflammation. Evidence for an increased excitability within the dorsal horn, and especially Lamina I, and possible mechanisms underlying this unique pain state will be discussed.

Sequence- and schedule-dependent enhancement of zoledronic acid induced apoptosis by doxorubicin in breast and prostate cancer cells

We investigated whether the combination of zoledronic acid and doxorubicin induced apoptosis of breast and prostate cancer cell lines, and if synergistic interaction was present. We investigated whether the levels of cell death altered depending on the sequence in which the drugs were administered and the possible mechanism of action responsible for the increased cell death following combined treatments. Breast and prostate cancer cells were treated with zoledronic acid alone, doxorubicin alone, or drugs in sequence (doxorubicin before, after, or with zoledronic acid), and the levels of apoptotic death were determined by evaluation of nuclear morphology. We found that clinically relevant concentrations of doxorubicin and zoledronic acid induced sequence- and schedule-dependent apoptosis of breast and prostate cancer cells. For maximal apoptosis, cells had to be pretreated for 24 hr with doxorubicin before immediate treatment with zoledronic acid for 1 hr. This observation is a characteristic feature of cell cycle phase-specific synergistic effect. Replacing zoledronic acid with the nonnitrogen-containing bisphosphonate clodronate did not induce increased apoptosis. Induction of apoptosis was mainly via inhibition of the mevalonate (MVA) pathway, as addition of the MVA pathway intermediary geranylgeraniol inhibited the induction of apoptosis by doxorubicin followed by zoledronic acid. In conclusion, combined treatment of breast and prostate cancer cell lines with clinically relevant doses of doxorubicin and zoledronic acid induces apoptosis in a synergistic fashion. These findings may have relevance for the clinical setting, particularly breast cancer patients receiving these drugs in the adjuvant setting.