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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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Varenna M, Zucchi F, Crotti C, Manara M, Caporali R. Decreasing severity of Paget's disease of bone in northern Italy over the last two decades: results of a monocentric study on 391 patients. Osteoporos Int 2021; 32:1795-1801. [PMID: 33616675 DOI: 10.1007/s00198-020-05789-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 12/07/2020] [Indexed: 10/22/2022]
Abstract
UNLABELLED Patients with Paget's disease of bone recruited over the last 20 years by a single centre were evaluated to find possible clinical changes. All markers of severity showed consistent downward trends. A reduced disease incidence could seemingly refer to lower sensitivity of the diagnostic tools owing to lower severity. INTRODUCTION This study aimed to evaluate if the severity of Paget's disease of bone (PDB) is decreasing and whether a milder phenotype can have affected the results of studies on disease prevalence. METHODS From August 2007 to August 2019, 167 patients with PDB were referred to our centre. Demographic and clinical characteristics were collected and compared with those of a sample of 224 patients enrolled in the same setting between January 2000 and July 2007. Multivariate analyses on 391 patients as a whole were performed assuming the year of presentation as explanatory variable. RESULTS Patients of newer sample were diagnosed at a significantly older age (64.0 ± 11.3 vs 61.1 ± 11.6; p = 0.01). By comparing clinical features acknowledged as markers of disease severity, the mean number of involved bones, the proportion of skeletal involvement, and pre-treatment serum alkaline phosphatase (SAP) values all showed significant decreases (p < 0.001) in the more recent sample. Multivariate analyses confirmed these results for the latter two indices. Further markers of disease severity such as the prevalence of monostotic disease and normal SAP at diagnosis showed the same trend. The sensitivity of tools allowing incidental diagnosis in asymptomatic patients showed a reduced sensitivity: -11% for radiological assessments and -33% for SAP. CONCLUSIONS Allowing for referral differences, our study provides information on reduced severity of PDB over the last two decades. A milder phenotype affects the age at onset and impairs the sensitivity of the diagnostic tools contributing to reduce the prevalence of PDB patients incidentally discovered.
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Affiliation(s)
- M Varenna
- Bone Diseases Unit, Department of Rheumatology, Gaetano Pini Institute, Via Pini, 9, 20122, Milan, Italy.
| | - F Zucchi
- Bone Diseases Unit, Department of Rheumatology, Gaetano Pini Institute, Via Pini, 9, 20122, Milan, Italy
| | - C Crotti
- Bone Diseases Unit, Department of Rheumatology, Gaetano Pini Institute, Via Pini, 9, 20122, Milan, Italy
| | - M Manara
- Department of Rheumatology, Gaetano Pini Institute, Milan, Italy
| | - R Caporali
- Department of Rheumatology, Gaetano Pini Institute, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Iannuzzo G, De Filippo G, Merlotti D, Abate V, Buonaiuto A, Evangelista M, Gentile M, Giaquinto A, Picchioni T, Di Minno MND, Strazzullo P, Gennari L, Rendina D. Effects of Bisphosphonate Treatment on Circulating Lipid and Glucose Levels in Patients with Metabolic Bone Disorders. Calcif Tissue Int 2021; 108:757-763. [PMID: 33559705 PMCID: PMC8166716 DOI: 10.1007/s00223-021-00811-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 01/15/2021] [Indexed: 12/11/2022]
Abstract
Bisphosphonates are the first-choice treatment of osteoporosis and Paget's disease of bone. Among the bisphosphonates, the non-amino-bisphosphonates, such as clodronic acid, are intracellular converted into toxic analogues of ATP and induce cellular apoptosis whereas the amino-bisphosphonates, such as zoledronic acid, inhibit the farnesyl-diphosphate-synthase, an enzyme of the mevalonate pathway. This pathway regulates cholesterol and glucose homeostasis and is a target for statins. In this retrospective cohort study, we evaluated the effects of an intravenous infusion of zoledronic acid (5 mg) or clodronic acid (1500 mg) on blood lipid (i.e. total cholesterol, low-density lipoprotein-cholesterol, high-density lipoprotein-cholesterol and triglycerides) and glucose levels in patients with osteoporosis and Paget's disease of bone. All patients were evaluated before, 1 and 6 months after bisphosphonate treatment. Pagetic and osteoporotic patients treated with zoledronic acid showed a significant reduction in glucose and atherogenic lipids during follow-up whereas these phenomena were not observed after clodronic treatment. The effect on circulating lipid levels was similar in naïve and re-treated Pagetic patients. Zoledronic acid treatment was associated with a reduction in blood glucose and atherogenic lipids in patients with metabolic bone disorders. The extent of change was similar to that obtained with the regular assumption of a low-intensity statin. Further studies are warranted to better evaluate the clinical implications of these observations.
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Affiliation(s)
- Gabriella Iannuzzo
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy, 5, Via Pansini, 80131, Naples, Italy
| | - Gianpaolo De Filippo
- Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Robert-Debré, Service d'Endocrinologie et Diabétologie Pédiatrique, Paris, France
| | - Daniela Merlotti
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Veronica Abate
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy, 5, Via Pansini, 80131, Naples, Italy
| | - Alessio Buonaiuto
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy, 5, Via Pansini, 80131, Naples, Italy
| | - Marco Evangelista
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy, 5, Via Pansini, 80131, Naples, Italy
| | - Marco Gentile
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy, 5, Via Pansini, 80131, Naples, Italy
| | - Alfonso Giaquinto
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy, 5, Via Pansini, 80131, Naples, Italy
| | - Tommaso Picchioni
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | | | - Pasquale Strazzullo
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy, 5, Via Pansini, 80131, Naples, Italy
| | - Luigi Gennari
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Domenico Rendina
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy, 5, Via Pansini, 80131, Naples, Italy.
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Ambrosi F, Righi A, Benini S, Magagnoli G, Chiaramonte I, Manfrini M, Gasbarrini A, Frisoni T, Gambarotti M. Giant Cell Tumor of Bone in Patients under 16 Years Old: A Single-Institution Case Series. Cancers (Basel) 2021; 13:cancers13112585. [PMID: 34070432 PMCID: PMC8197501 DOI: 10.3390/cancers13112585] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/17/2021] [Accepted: 05/21/2021] [Indexed: 01/17/2023] Open
Abstract
Simple Summary Giant cell tumor of the bone is a locally aggressive, rarely metastasizing tumor that accounts for about 5% of bone tumors; it generally occurs in patients between 20 and 45 years old. Sporadic cases (less than 140) have been described as occurring in the first two decades of life. A histone 3.3 (H3.3) gene, H3F3A, has been recently identified in as many as 96% of giant cell tumors of bone. These mutations are useful in the differential diagnosis of giant cell tumor of bone with its mimickers. The immunohistochemical expression of H3F3A resulted comparable to molecular analysis as reported in a recent investigation. In the present study, we describe our series of giant cell tumors of bone in pediatric patients <16 years old. Abstract Background: Giant cell tumor of bone is a locally aggressive, rarely metastasizing tumor that accounts for about 5% of bone tumors and generally occurs in patients between 20 and 45 years old. A driver mutation in the histone 3.3 (H3.3) gene H3F3A has been identified in as many as 96% of giant cell tumors of bone. The immunohistochemical expression of H3F3A H3.3 G34 expression was found in 97.8% of cases. In the present study, we describe our series of cases of giant cell tumor of bone in pediatric patients <16 years old. Methods: All cases of giant cell tumor of bone in pediatric patients <16 years old treated in our institute between 1982 and 2018 were reviewed. Immunohistochemistry and/or molecular analysis for H3F3A gene mutations was performed to confirm the diagnosis. A group of aneurysmal bone cysts in patients <16 years old was used as a control group. Results: Fifteen cases were retrieved. A pronounced female predominance (93%) was observed. A pure metaphyseal central location occurs in 2 skeletally immature patients. Conclusions: Giant cell tumor of bone should be distinguished from its mimickers due to differences in prognosis and treatment. Immunohistochemical and molecular detection of H3F3A gene mutation represents a reliable diagnostic tool.
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Affiliation(s)
- Francesca Ambrosi
- Department of Pathology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.A.); (A.R.); (S.B.); (G.M.)
| | - Alberto Righi
- Department of Pathology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.A.); (A.R.); (S.B.); (G.M.)
| | - Stefania Benini
- Department of Pathology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.A.); (A.R.); (S.B.); (G.M.)
| | - Giovanna Magagnoli
- Department of Pathology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.A.); (A.R.); (S.B.); (G.M.)
| | - Ilaria Chiaramonte
- Department of Orthopaedic Oncology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (I.C.); (M.M.); (T.F.)
| | - Marco Manfrini
- Department of Orthopaedic Oncology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (I.C.); (M.M.); (T.F.)
| | - Alessandro Gasbarrini
- Department of Oncologic and Degenerative Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy;
| | - Tommaso Frisoni
- Department of Orthopaedic Oncology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (I.C.); (M.M.); (T.F.)
| | - Marco Gambarotti
- Department of Pathology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.A.); (A.R.); (S.B.); (G.M.)
- Correspondence: ; Tel.: +39-05-1636-6652
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Rendina D, De Filippo G, Merlotti D, Di Stefano M, Mingiano C, Giaquinto A, Evangelista M, Bo M, Arpino S, Faraonio R, Strazzullo P, Gennari L. Increased Prevalence of Nephrolithiasis and Hyperoxaluria in Paget Disease of Bone. J Clin Endocrinol Metab 2020; 105:5896000. [PMID: 32827434 DOI: 10.1210/clinem/dgaa576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 08/20/2020] [Indexed: 12/11/2022]
Abstract
CONTEXT Nephrolithiasis (NL) and primary hyperparathyroidism (HPTH) are metabolic complications of Paget disease of bone (PDB), but recent data regarding their prevalence in PDB patients are lacking. OBJECTIVES Study 1: To compare the prevalence of primary HPTH and NL in 708 patients with PDB and in 1803 controls. Study 2: To evaluate the prevalence of NL-metabolic risk factors in 97 patients with PDB and NL, 219 PDB patients without NL, 364 NL patients without PDB, and 219 controls, all of them without HPTH. DESIGN Cross-sectional multicentric study. SETTING Italian referral centers for metabolic bone disorders. PARTICIPANTS Patients with PDB from the Associazione Italiana malati di osteodistrofia di Paget registry. Participants in the Olivetti Heart and the Siena Osteoporosis studies. MAIN OUTCOME MEASURES HPTH; NL; NL-metabolic risk factors. RESULTS Patients with PDB showed higher prevalence of primary HPTH and NL compared with controls (P < 0.01). The NL recurrence occurs more frequently in patients with polyostotic PDB. About one-half of patients with PDB but without NL showed 1 or more NL-related metabolic risk factors. The hyperoxaluria (HyperOx) prevalence was higher in patients with PDB and NL compared with patients with NL but without PDB and in patients with PDB without NL compared with controls (P = 0.01). Patients with PDB and HyperOx showed a longer lapse of time from the last aminobisphosphonate treatment. CONCLUSIONS NL and HPTH are frequent metabolic complication of PDB. The NL occurrence should be evaluated in patients with PDB, particularly in those with polyostotic disease and/or after aminobisphosphonate treatment to apply an adequate prevention strategy.
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Affiliation(s)
- Domenico Rendina
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Gianpaolo De Filippo
- Assistance Publique-Hôpitaux de Paris, Hôpital Robert-Debré, Service d'Endocrinologie et Diabétologie Pédiatrique, Paris, France
| | - Daniela Merlotti
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Marco Di Stefano
- Department of Medical Science, Gerontology and Bone Metabolic Diseases, University of Torino, Torino, Italy
| | - Christian Mingiano
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Alfonso Giaquinto
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Marco Evangelista
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Mario Bo
- Department of Medical Science, Gerontology and Bone Metabolic Diseases, University of Torino, Torino, Italy
| | - Sergio Arpino
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, Naples, Italy
| | - Raffaella Faraonio
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, Naples, Italy
| | - Pasquale Strazzullo
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Luigi Gennari
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
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Rendina D, De Filippo G, Merlotti D, Di Stefano M, Succoio M, Muggianu SM, Bianciardi S, D'Elia L, Coppo E, Faraonio R, Nuti R, Strazzullo P, Gennari L. Vitamin D Status in Paget Disease of Bone and Efficacy-Safety Profile of Cholecalciferol Treatment in Pagetic Patients with Hypovitaminosis D. Calcif Tissue Int 2019; 105:412-422. [PMID: 31236621 DOI: 10.1007/s00223-019-00578-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 06/18/2019] [Indexed: 01/03/2023]
Abstract
Adequate vitamin D status is essential for skeletal health. Paget's disease of bone (PDB) is a common metabolic skeletal disorder, but data regarding the vitamin D status in PDB patients are lacking. We performed a case-control study to estimate vitamin D status in 708 PDB patients and in 1803 healthy controls from Italy and an observational prospective study to evaluate the efficacy-safety profile of oral cholecalciferol treatment [400.000 International Units (UI) of cholecalciferol administered in cycles of 8 weeks until 25OHD levels reaches 70 nmol/L as primary therapy and 50.000 UI of cholecalciferol administered every 2 weeks for 52 weeks for the maintenance therapy] in 82 PDB patients with hypovitaminosis D, i.e., 25OHD < 50 nmol/L. The main outcome measures for the prospective study were 25OHD levels, metabolic risk factors (RF) for nephrolithiasis, bone pain score (BPS), and pain medication score (PMS). Over half of PDB patients had hypovitaminosis D. Among PDB patients treated with cholecalciferol, 76 patients reached 25OHD levels ≥ 70 nmol/L after the first cycle of primary therapy and the remaining six patients after a second cycle. The maintenance therapy guaranteed 25OHD levels ≥ 70 nmol/L during the entire follow-up. The increase in 25OHD levels reduced PTH, BPS, and PMS levels, without changes in RF for nephrolithiasis. We can conclude that (i) hypovitaminosis D is frequent in PDB patients, (ii) cholecalciferol significantly increased 25OHD levels in PDB patients, and (iii) the correction of hypovitaminosis D improves the quality of life of PDB patients without inducing significant changes in RF for nephrolithiasis.
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Affiliation(s)
- Domenico Rendina
- Department of Medicine and Surgery, Federico II University, 5, via Pansini, 80131, Naples, Italy.
| | - Gianpaolo De Filippo
- Service de Médecine des Adolescents, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin Bicêtre, France
| | - Daniela Merlotti
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Marco Di Stefano
- Department of Medical Science, Gerontology and Bone Metabolic Diseases, University of Torino, Turin, Italy
| | - Mariangela Succoio
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, Naples, Italy
| | - Simona Maria Muggianu
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, Naples, Italy
| | - Simone Bianciardi
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Lanfranco D'Elia
- Department of Medicine and Surgery, Federico II University, 5, via Pansini, 80131, Naples, Italy
| | - Eleonora Coppo
- Department of Medical Science, Gerontology and Bone Metabolic Diseases, University of Torino, Turin, Italy
| | - Raffaella Faraonio
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, Naples, Italy
| | - Ranuccio Nuti
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Pasquale Strazzullo
- Department of Medicine and Surgery, Federico II University, 5, via Pansini, 80131, Naples, Italy
| | - Luigi Gennari
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
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9
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Gennari L, Rendina D, Falchetti A, Merlotti D. Paget's Disease of Bone. Calcif Tissue Int 2019; 104:483-500. [PMID: 30671590 DOI: 10.1007/s00223-019-00522-3] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 12/30/2018] [Indexed: 01/04/2023]
Abstract
Paget's disease of bone (PDB) is a chronic and focal bone disorder, characterized by increased osteoclast-mediated bone resorption and a subsequent compensatory increase in bone formation, resulting in a disorganized mosaic of woven and lamellar bone at one or more affected skeletal sites. As a result, bone pain, noticeable deformities, arthritis at adjacent joints, and fractures can occur. In a small proportion of cases neoplastic degeneration in osteosarcoma, or, less frequently, giant cell tumor has been also described at PDB sites. While recent epidemiological evidences clearly indicate a decrease in the prevalence and the severity of PDB, over the past 2 decades there have been consistent advances on the genetic mechanisms of disease. It is now clear that PDB is a genetically heterogeneous disorder, with mutations in at least two different genes (SQSTM1, ZNF687) and more common predisposing variants. As a counterpart to the genetic hypothesis, the focal nature of lesions, the decline in prevalence rates, and the incomplete penetrance of the disease among family members suggest that one or more environmental triggers may play a role in the pathophysiology of PDB. The exact nature of these triggers and how they might interact with the genetic factors are less understood, but recent experimental data from mice models suggest the implication of paramixoviral infections. The clinical management of PDB has also evolved considerably, with the development of potent aminobisphosphonates such as zoledronic acid which, given as a single intravenous infusion, now allows a long-term disease remission in the majority of patients.
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Affiliation(s)
- Luigi Gennari
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy.
- Policlinico Santa Maria alle Scotte, Viale Bracci, 53100, Siena, Italy.
| | - Domenico Rendina
- Department of Medicine and Surgery, Federico II University, Naples, Italy
| | - Alberto Falchetti
- Centro Hercolani and Villa Alba (GVM), 40123 Bologna and EndOsMet, Villa Donatello Private Hospital, 50132, Florence, Italy
| | - Daniela Merlotti
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
- Division of Genetics and Cell Biology, San Raffaele Hospital, Milan, Italy
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10
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Gene-environment interactions in Paget's disease of bone. Joint Bone Spine 2018; 86:373-380. [PMID: 30594595 DOI: 10.1016/j.jbspin.2018.12.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 11/28/2018] [Accepted: 12/19/2018] [Indexed: 12/30/2022]
Abstract
OBJECTIVES This study explored the role of outdoor and indoor air pollutants in Paget's disease of bone (PDB). METHODS We performed a survey in 140 French-Canadian patients with PDB, including 39 carriers of p.Pro392Leu mutation (SQSTM1 gene) and 113 healthy not mutated controls. The survey covered outdoor air pollution near the residence and indoor air pollutants by focusing on heating fuels and exposure to tobacco smoke. In a subgroup of patients, urinary concentrations of 17 heavy metals and 11 polycyclic aromatic hydrocarbons were measured by mass spectrometry. In light of what we learned from the survey and urinary assays, we explored the in vitro effects of certain toxics on osteoclasts in PDB. We conducted in vitro monocytes differentiation from peripheral blood of more than 40 participants, whose osteoclasts were treated with or without the toxic. The morphology of osteoclasts, their bone resorption abilities, gene and protein expression levels, and cellular oxidative stress levels were assayed. RESULTS An inhibitory effect of cigarette smoke condensate and heavy metals was observed on morphology and bone resorption activity of patients' osteoclasts. SQSTM1 gene expression was upregulated in osteoclasts from patients with PDB versus healthy controls in presence of cadmium, and SQSTM1 protein expression was upregulated in presence of bismuth and tobacco smoke condensates, in particular in osteoclasts from carriers of the SQSTM1 mutation. Furthermore, high levels of oxidative stress in patients' osteoclasts were observed. CONCLUSIONS Our in vitro experiments suggest an interaction between SQSTM1 gene and exposure to cadmium and tobacco smoke condensates.
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Gennari L, Rendina D, Picchioni T, Bianciardi S, Materozzi M, Nuti R, Merlotti D. Paget’s disease of bone: an update on epidemiology, pathogenesis and pharmacotherapy. Expert Opin Orphan Drugs 2018. [DOI: 10.1080/21678707.2018.1500691] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Luigi Gennari
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Domenico Rendina
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
- Department of Clinical Medicine and Surgery, Federico II University of Naples, Naples, Italy
| | - Tommaso Picchioni
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Simone Bianciardi
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Maria Materozzi
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Ranuccio Nuti
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Daniela Merlotti
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
- Division of Genetics and Cell Biology, San Raffaele Scientific Institute, Milan, Italy
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12
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Environmental factors associated with familial or non-familial forms of Paget's disease of bone. Joint Bone Spine 2017; 84:719-723. [DOI: 10.1016/j.jbspin.2016.11.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 11/23/2016] [Indexed: 11/22/2022]
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13
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Seton M, Hansen M, Solomon DH. The Implications of the Sequestosome 1 Mutation P392L in Patients with Paget's Disease in a United States Cohort. Calcif Tissue Int 2016; 98:489-96. [PMID: 26713335 PMCID: PMC4847721 DOI: 10.1007/s00223-015-0103-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 12/14/2015] [Indexed: 12/29/2022]
Abstract
Paget's disease of bone (PDB) is associated with a germline mutation in Sequestosome1/p62 (SQSTM1) found in ≤16 % of sporadic cases worldwide, and in 19-46 % of those studied with familial PDB. The P392L is the most prevalent mutation identified to date. This mutation by itself does not confer PDB or define the phenotype of PDB in a given person. Environmental determinants remain elusive, although increasing age of the individual, other gene polymorphisms in the context of SQSTM1 mutations, and measles virus have been implicated. Measles exposure has been unexamined in this context. The goal of this study is to compare the background history and phenotype of patients with PDB carrying the SQSTM1 P392L mutation to those patients without. Focusing on age, ancestry, P329L mutation, family history, measles exposure, distribution of PDB, and age of onset, we examined outcomes at 10 years. We postulated that aging may play a role in defining phenotype, and that this may become more visible in a well-characterized cohort. This is an observational study focused on a cohort of patients with PDB drawn from the New England Registry in whom environmental and family history has been catalogued, linked to radiographic data. Of the 217 persons who were enrolled in the Registry, 42 (19 %) responded to a letter inviting them to participate in testing for the presence of the measles antibody, and in genetic testing for the P392L mutation. The mean age of the cohort in 2001 was 70 years (range 55-79); 27 were men (64 %). The measles antibody was found in all cases tested. Nine patients had the P392L mutation (21 %), 2 with familial PDB. In these persons, early diagnosis of disease and spinal stenosis marked the male phenotype only. European ancestry was noted in the minority of those with P392L mutation. Most deaths recorded occurred in the ninth decade of life or later. Spinal stenosis emerges as a prominent phenotype in SQSTM1 P392L-positive men with aging. In these 42 patients with PDB from the New England Registry, most do not carry the SQSTM1 P392L mutation, and many do not have European ancestry. Exposure to measles was confirmed in the majority.
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Affiliation(s)
- Margaret Seton
- Division of Rheumatology, Brigham & Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA.
| | - Marc Hansen
- Center of Molecular Medicine, University of Connecticut Health Center, 263 Farmington Ave, Farmington, CT, 06030, USA
| | - Daniel H Solomon
- Division of Rheumatology, Immunology & Allergy, Brigham & Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
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14
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Divisato G, Formicola D, Esposito T, Merlotti D, Pazzaglia L, Del Fattore A, Siris E, Orcel P, Brown JP, Nuti R, Strazzullo P, Benassi MS, Cancela ML, Michou L, Rendina D, Gennari L, Gianfrancesco F. ZNF687 Mutations in Severe Paget Disease of Bone Associated with Giant Cell Tumor. Am J Hum Genet 2016; 98:275-86. [PMID: 26849110 PMCID: PMC4746367 DOI: 10.1016/j.ajhg.2015.12.016] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 12/17/2015] [Indexed: 01/12/2023] Open
Abstract
Paget disease of bone (PDB) is a skeletal disorder characterized by focal abnormalities of bone remodeling, which result in enlarged and deformed bones in one or more regions of the skeleton. In some cases, the pagetic tissue undergoes neoplastic transformation, resulting in osteosarcoma and, less frequently, in giant cell tumor of bone (GCT). We performed whole-exome sequencing in a large family with 14 PDB-affected members, four of whom developed GCT at multiple pagetic skeletal sites, and we identified the c.2810C>G (p.Pro937Arg) missense mutation in the zinc finger protein 687 gene (ZNF687). The mutation precisely co-segregated with the clinical phenotype in all affected family members. The sequencing of seven unrelated individuals with GCT associated with PDB (GCT/PDB) identified the same mutation in all individuals, unravelling a founder effect. ZNF687 is highly expressed during osteoclastogenesis and osteoblastogenesis and is dramatically upregulated in the tumor tissue of individuals with GCT/PDB. Interestingly, our preliminary findings showed that ZNF687, indicated as a target gene of the NFkB transcription factor by ChIP-seq analysis, is also upregulated in the peripheral blood of PDB-affected individuals with (n = 5) or without (n = 6) mutations in SQSTM1, encouraging additional studies to investigate its potential role as a biomarker of PDB risk.
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Affiliation(s)
- Giuseppina Divisato
- Institute of Genetics and Biophysics "Adriano Buzzati-Traverso," National Research Council of Italy, 80131 Naples, Italy
| | - Daniela Formicola
- Institute of Genetics and Biophysics "Adriano Buzzati-Traverso," National Research Council of Italy, 80131 Naples, Italy
| | - Teresa Esposito
- Institute of Genetics and Biophysics "Adriano Buzzati-Traverso," National Research Council of Italy, 80131 Naples, Italy
| | - Daniela Merlotti
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena 53100, Italy
| | - Laura Pazzaglia
- Laboratory of Experimental Oncology, Rizzoli Orthopaedic Institute, Bologna 40136, Italy
| | - Andrea Del Fattore
- Bambino Gesù Children's Hospital, Regenerative Medicine Unit, Rome 00146, Italy
| | - Ethel Siris
- Department of Medicine, Columbia University Medical Centre, New York, NY 10032, USA
| | - Philippe Orcel
- Pôle Appareil Locomoteur, Service de Rhumatologie B, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris 75010, France
| | - Jacques P Brown
- Division of Rheumatology, Department of Medicine, Université Laval, Québec, QC 42178, Canada
| | - Ranuccio Nuti
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena 53100, Italy
| | - Pasquale Strazzullo
- Department of Medicine and Surgery, Federico II University, Naples 80131, Italy
| | - Maria Serena Benassi
- Laboratory of Experimental Oncology, Rizzoli Orthopaedic Institute, Bologna 40136, Italy
| | - M Leonor Cancela
- Department of Biomedical Sciences and Medicine and Centre of Marine Sciences, University of Algarve, Faro 8005-139, Portugal
| | - Laetitia Michou
- Division of Rheumatology, Department of Medicine, Université Laval, Québec, QC 42178, Canada
| | - Domenico Rendina
- Department of Medicine and Surgery, Federico II University, Naples 80131, Italy
| | - Luigi Gennari
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena 53100, Italy
| | - Fernando Gianfrancesco
- Institute of Genetics and Biophysics "Adriano Buzzati-Traverso," National Research Council of Italy, 80131 Naples, Italy.
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15
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Griz L, Fontan D, Mesquita P, Lazaretti-Castro M, Borba VZC, Borges JLC, Fontenele T, Maia J, Bandeira F. Diagnosis and management of Paget's disease of bone. ACTA ACUST UNITED AC 2015; 58:587-99. [PMID: 25211441 DOI: 10.1590/0004-2730000002941] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2013] [Accepted: 03/18/2014] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To conduct a literature review on the diagnosis and management of Paget's disease of bone. MATERIALS AND METHODS This scientific statement was generated by a request from the Brazilian Medical Association (AMB) to the Brazilian Society of Endocrinology and Metabolism (SBEM) as part of its Clinical Practice Guidelines program. Articles were identified by searching in PubMed and Cochrane databases as well as abstracts presented at the Endocrine Society, Brazilian Society for Endocrinology Annual Meetings and the American Society for Bone and Mineral Research Annual Meeting during the last 5 years. Grading quality of evidence and strength of recommendation were adapted from the first report of the Oxford Centre for Evidence-based Medicine. All grades of recommendation, including "D", are based on scientific evidence. The differences between A, B, C and D, are due exclusively to the methods employed in generating evidence. CONCLUSION We present a scientific statement on Paget's disease of bone providing the level of evidence and the degree of recommendation regarding causes, clinical presentation as well as surgical and medical treatment.
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Affiliation(s)
- Luiz Griz
- Department of Endocrinology, Diabetes and Bone Diseases, Agamenon Magalhães Hospital, University of Pernambuco, Recife, PE, Brazil
| | - Daniele Fontan
- Department of Endocrinology, Diabetes and Bone Diseases, Agamenon Magalhães Hospital, University of Pernambuco, Recife, PE, Brazil
| | - Patricia Mesquita
- Department of Endocrinology, Diabetes and Bone Diseases, Agamenon Magalhães Hospital, University of Pernambuco, Recife, PE, Brazil
| | - Marise Lazaretti-Castro
- Division of Endocrinology, Department of Medicine, Federal University of Sao Paulo, Sao Paulo, SP, Brazil
| | | | | | - Thyciara Fontenele
- Department of Endocrinology, Diabetes and Bone Diseases, Agamenon Magalhães Hospital, University of Pernambuco, Recife, PE, Brazil
| | - Juliana Maia
- Department of Endocrinology, Diabetes and Bone Diseases, Agamenon Magalhães Hospital, University of Pernambuco, Recife, PE, Brazil
| | - Francisco Bandeira
- Department of Endocrinology, Diabetes and Bone Diseases, Agamenon Magalhães Hospital, University of Pernambuco, Recife, PE, Brazil
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16
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Rendina D, De Filippo G, Ralston SH, Merlotti D, Gianfrancesco F, Esposito T, Muscariello R, Nuti R, Strazzullo P, Gennari L. Clinical characteristics and evolution of giant cell tumor occurring in Paget's disease of bone. J Bone Miner Res 2015; 30:257-63. [PMID: 25196811 DOI: 10.1002/jbmr.2349] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Revised: 08/17/2014] [Accepted: 08/23/2014] [Indexed: 12/29/2022]
Abstract
Patients with Paget's bone disease (PDB) have an increased risk of developing giant cell tumor (GCT). This study was performed to evaluate the clinical characteristics and evolution of GCT complicating PDB and to compare these clinical characteristics to those observed in two large PDB cohorts, the PDB Italian Registry and the United Kingdom's Multi-Centre Randomised Controlled Trial of Symptomatic Versus Intensive Bisphosphonate Therapy for Paget's Disease (PRISM) study. A systematic literature review identified 117 cases of PDB complicated by GCT (PDB-GCT), which involved the skeletal sites affected by PDB (110 patients) or the extraskeletal tissues adjacent to affected bones (7 patients). In contrast to what previously reported for GCT patients without GCT patients (83.2%) were white and one-fourth of them (24.8%) had multifocal GCTs. Compared to PDB patients without GCT, PDB-GCT patients showed a higher male/female ratio (2.1 versus 1.2) and more severe disease (age at PDB onset 52.1 ± 12.1 versus 63.3 ± 10.6 years; number of affected sites 6.1 ± 2.9 versus 2.34 ± 1.6; prevalence of polyostotic PDB 93.3% versus 60.6%). The mortality rate of PDB-GCT patients was higher than those occurring in GCT patients without PDB (about 50% versus 0% to 5% at 5 years) or in PDB patients without GCT (log rank = 29.002). Moreover, up to 98% of PDB-GCT cases had elevated total alkaline phosphatase levels at neoplasm diagnosis, suggestive of active PDB. Importantly, PDB-GCT patients from Southern Italy (45.6% of all GCT patients) showed a higher prevalence of multifocal GCT (51.7%) and of positive familial history for PDB (70.8%) and GCT (65.0%). Finally, indirect evidence suggests a decline in the incidence of GCT in PDB patients. The occurrence of GCT in PDB patients is associated with severe disease and reduced life expectancy of affected patients. The increased prevalence of familial diseases in PDB-GCT patients from Southern Italy suggests a founder effect. The observed changes over time in the incidence of GCT in PDB patients could be related to improved clinical management and/or living conditions of patients.
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Affiliation(s)
- Domenico Rendina
- Department of Medicine and Surgery, Federico II University, Naples, Italy
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17
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Tan A, Ralston SH. Clinical presentation of Paget's disease: evaluation of a contemporary cohort and systematic review. Calcif Tissue Int 2014; 95:385-92. [PMID: 25160936 DOI: 10.1007/s00223-014-9904-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2014] [Accepted: 07/29/2014] [Indexed: 10/24/2022]
Abstract
Paget's disease of bone (PDB) has become less common over recent decades but it is unclear if this has impacted on clinical presentation. Here we evaluated the presenting features of PDB in a contemporary cohort of UK patients and conducted a systematic review of studies in which the presenting features had been reported. The case series comprised 88 patients referred to a specialist clinic between 2005 and 2013. Bone pain was the most common presenting feature occurring in 73.8% of patients. Others included bone deformity (18.1%), deafness (7.9%) and pathological fracture (5.7%). The disease was asymptomatic in 22% of cases. Antiresorptive treatment was given for pain in 34 cases and 61.7% of patients responded. Patients with a shorter disease duration were more likely to respond (p = 0.047). In the systematic review, bone pain was the most common presenting feature (52.2% of cases) followed by deformity (21.5%), deafness (8.9%) and fracture (8.5%). Time trend analysis in subjects of European descent showed that fracture was less common in studies performed during the past 25 years as compared with older studies (5.5 vs. 10.8% p < 0.001) whereas pain was more common (54.3 vs. 48.3%, p = 0.003). While changes in the mode of presentation of PDB have occurred over recent years, many patients present with complications such as fracture and deformity. Further research is required to determine if early detection and therapeutic intervention might be of value in preventing the morbidity associated with this common disease.
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Affiliation(s)
- Adrian Tan
- Rheumatology and Bone Disease Unit, Centre for Genomic and Experimental Medicine, MRC Institute of Genetics and Molecular Medicine, Western General Hospital, University of Edinburgh, Edinburgh, EH4 2XU, UK
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18
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Gennari L, Merlotti D, Rendina D, Gianfrancesco F, Esposito T, Nuti R. Paget’s disease of bone: epidemiology, pathogenesis and pharmacotherapy. Expert Opin Orphan Drugs 2014. [DOI: 10.1517/21678707.2014.904225] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Rea SL, Walsh JP, Layfield R, Ratajczak T, Xu J. New insights into the role of sequestosome 1/p62 mutant proteins in the pathogenesis of Paget's disease of bone. Endocr Rev 2013; 34:501-24. [PMID: 23612225 DOI: 10.1210/er.2012-1034] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Paget's disease of bone (PDB) is characterized by focal areas of aberrant and excessive bone turnover, specifically increased bone resorption and disorganized bone formation. Germline mutations in the sequestosome 1/p62 (SQSTM1/p62) gene are common in PDB patients, with most mutations affecting the ubiquitin-associated domain of the protein. In vitro, osteoclast precursor cells expressing PDB-mutant SQSTM1/p62 protein are associated with increases in nuclear factor κB activation, osteoclast differentiation, and bone resorption. Although the precise mechanisms by which SQSTM1/p62 mutations contribute to disease pathogenesis and progression are not well defined, it is apparent that as well as affecting nuclear factor κB signaling, SQSTM1/p62 is a master regulator of ubiquitinated protein turnover via autophagy and the ubiquitin-proteasome system. Additional roles for SQSTM1/p62 in the oxidative stress-induced Keap1/Nrf2 pathway and in caspase-mediated apoptosis that were recently reported are potentially relevant to the pathogenesis of PDB. Thus, SQSTM1/p62 may serve as a molecular link or switch between autophagy, apoptosis, and cell survival signaling. The purpose of this review is to outline recent advances in understanding of the multiple pathophysiological roles of SQSTM1/p62 protein, with particular emphasis on their relationship to PDB, including challenges associated with translating SQSTM1/p62 research into clinical diagnosis and treatment.
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Affiliation(s)
- Sarah L Rea
- Department of Endocrinology and Diabetes, Level 1, C Block, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Western Australia 6009, Australia.
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Corral-Gudino L, Borao-Cengotita-Bengoa M, Del Pino-Montes J, Ralston S. Epidemiology of Paget's disease of bone: a systematic review and meta-analysis of secular changes. Bone 2013; 55:347-52. [PMID: 23643679 DOI: 10.1016/j.bone.2013.04.024] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2013] [Revised: 04/24/2013] [Accepted: 04/25/2013] [Indexed: 01/23/2023]
Abstract
CONTEXT Several studies have suggested that the prevalence and severity of PDB have fallen in recent years. The magnitude of this trend and its globalization have not been well established. OBJECTIVE The objective of this study is to estimate the pooled magnitude of the changes in the prevalence of PDB and as a secondary objective, to make up a world atlas of PDB prevalence. METHODS A systematic review of English and non-English articles using MEDLINE (1946 to 2013) and EMBASE (1980 to 2013) was the method used. Search terms included epidemiology, incidence, prevalence, cohort studies, osteitis deformans or Paget's disease of bone. Studies with incidence and/or prevalence rate for PDB were included. Two authors independently extracted the data using predefined data fields and quality assessment. A pooled analysis based on random-effects models was carried out for secular trends. RESULTS Twenty-eight articles documented the prevalence of PDB; four articles the incidence and two articles the rate of new referrals. The prevalence of PDB varied greatly between the different countries, from 0.00028% in Japan to 5.4% in the UK. There were available data on changes in prevalence from two different surveys over two different time frames in Europe and New Zealand. In all but one city (Turin), a drop in the prevalence of PDB was recorded (pooled OR 0.64; 95% CI 0.45-0.91). CONCLUSION The incidence and prevalence rates of PDB vary widely between populations but both have decreased in most regions over recent years. The changes are heterogeneous however and within countries, the largest changes have been in areas that previously had a high prevalence. The reasons for these changes remain unclear at present but are likely to be due to an interaction between genetic factors and environmental triggers which may differ in different regions.
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Affiliation(s)
- Luis Corral-Gudino
- Servicio de Medicina Interna, Hospital El Bierzo, Ponferrada, Leon, Spain.
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Corral-Gudino L, García-Aparicio J, Sánchez-González MD, Mirón-Canelo JA, Blanco JF, Ralston SH, del Pino-Montes J. Secular changes in Paget's disease: contrasting changes in the number of new referrals and in disease severity in two neighboring regions of Spain. Osteoporos Int 2013; 24:443-50. [PMID: 22395312 DOI: 10.1007/s00198-012-1954-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Accepted: 02/10/2012] [Indexed: 11/28/2022]
Abstract
SUMMARY We studied the changes in the number of new referrals with Paget's disease of bone (PDB) and severity of PDB in a high prevalence focus and its neighboring region. Referral of patients changed only in the high prevalence focus. The severity of PDB decreased in both regions. These results could suggest the effects of an environmental influence on disease activity. INTRODUCTION The prevalence and severity of PDB have decreased in several countries over recent years. We previously reported a high radiological prevalence of PDB in Vitigudino. Here we sought to determine if secular changes in the number of new referrals and severity of PDB had occurred over recent years. METHODS We studied 280 patients with clinically diagnosed PDB who were evaluated at a regional referral center for metabolic bone disease between 1986 and 2009. Changes in the number of new referrals were calculated by relating these data to the number of subjects at risk as determined by population registers. Trends in disease severity were analyzed with alkaline phosphatase (ALP) activity and disease extent on scan. RESULTS Referrals from the Vitigudino region increased substantially between 1986 and 2003 but fell markedly between 2004 and 2009, although by this time there had been depopulation of the region due to emigration. No significant changes in the rates of referral occurred in the remainder of Salamanca. ALP activity and disease extent decreased in Salamanca, but only ALP activity decreased in Vitigudino. Referrals rate and severity of PDB in Vitigudino were greater than in the remainder of Salamanca. CONCLUSIONS Referral of patients with clinically diagnosed PDB has remained stable for most of Salamanca during the past 24 years, but substantial changes have been observed in Vitigudino. In agreement with other reports, the severity of PDB has decreased in both regions consistent with the effects of an environmental influence on disease activity.
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Affiliation(s)
- L Corral-Gudino
- Department of Internal Medicine, RETICEF, Hospital el Bierzo, Medicos sin Fronteras 7. Ponferrada, 24411, Leon, Spain.
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Gianfrancesco F, Rendina D, Merlotti D, Esposito T, Amyere M, Formicola D, Muscariello R, De Filippo G, Strazzullo P, Nuti R, Vikkula M, Gennari L. Giant cell tumor occurring in familial Paget's disease of bone: report of clinical characteristics and linkage analysis of a large pedigree. J Bone Miner Res 2013; 28:341-50. [PMID: 22936311 DOI: 10.1002/jbmr.1750] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Revised: 08/13/2012] [Accepted: 08/24/2012] [Indexed: 11/10/2022]
Abstract
Neoplastic degeneration represents a rare but serious complication of Paget's disease of bone (PDB). Although osteosarcomas have been described in up to 1% of PDB cases, giant cell tumors are less frequent and mainly occur in patients with polyostotic disease. We recently characterized a large pedigree with 14 affected members of whom four developed giant cell tumors at pagetic sites. The high number of affected subjects across multiple generations allowed us to better characterize the clinical phenotype and look for possible susceptibility loci. Of interest, all the affected members had polyostotic PDB, but subjects developing giant cell tumors showed an increased disease severity with a reduced clinical response to bisphosphonate treatment and an increased prevalence of bone pain, deformities, and fractures. Together with an increased occurrence of common pagetic complications, affected patients of this pedigree also evidenced a fivefold higher prevalence of coronary artery disease with respect to either the unaffected family members or a comparative cohort of 150 unrelated PDB cases from the same geographical area. This association was further enhanced in the four cases with PDB and giant cell tumors, all of them developing coronary artery disease before 60 years of age. Despite the early onset and the severe phenotype, PDB patients from this pedigree were negative for the presence of SQSTM1 or TNFRSF11A mutations, previously associated with enhanced disease severity. Genome-wide linkage analysis identified six possible candidate regions on chromosomes 1, 5, 6, 8, 10, and 20. Because the chromosome 8 and 10 loci were next to the TNFRSF11B and OPTN genes, we extended the genetic screening to these two genes, but we failed to identify any causative mutation at both the genomic and transcription level, suggesting that a different genetic defect is associated with PDB and potentially giant cell tumor of bone in this pedigree.
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Gu JM, Zhang ZL, Zhang H, Hu WW, Wang C, Yue H, Ke YH, He JW, Hu YQ, Li M, Liu YJ, Fu WZ. Thirteen Chinese patients with sporadic Paget's disease of bone: clinical features, SQSTM1 mutation identification, and functional analysis. J Bone Miner Metab 2012; 30:525-33. [PMID: 22491873 DOI: 10.1007/s00774-012-0352-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Accepted: 02/23/2012] [Indexed: 12/18/2022]
Abstract
To increase awareness of the rarity of Paget's disease of bone (PDB) in the Chinese population, we characterized the clinical manifestations and features of 13 Chinese sporadic PDB patients. The clinical features of our Chinese PDB patients show similarities with cases reported in Western countries. The most common lesion sites were the pelvis, femur, and tibia; the next most common lesion sites were the spine and skull. Most patients had a higher serum alkaline phosphatase (ALP) level. Treatment with bisphosphonates was effective. In addition, we screened for PDB-causing mutations and performed a functional analysis in an attempt to elucidate the molecular pathogenesis of PDB. A total of 216 persons, including 13 sporadic PDB patients, three unaffected relatives of 1 patient, and 200 healthy donors, were recruited. All eight exons and exon-intron boundaries of the SQSTM1 gene were amplified by polymerase chain reaction (PCR) and directly sequenced. We identified a 53-year-old man who harbored a heterozygous T-to-C transversion at position 1250 in exon 8 (1250T > C), which resulted in a methionine-to-threonine (ATG > ACG) substitution at codon 404 (M404T). The M404T mutant SQSTM1 protein exhibited increased NF-κB activation and drove a significantly increased number of osteoclast-like cells (OLCs) that formed in response to RANKL and an increased number of OLC nuclei. This is the first report of an SQSTM1 genetic mutation that contributes to the pathogenesis of PDB in Chinese patients. These results may partially explain the mechanism by which this SQSTM1 mutation contributes to the pathogenesis of sporadic PDB in Chinese patients.
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Affiliation(s)
- Jie-Mei Gu
- Metabolic Bone Disease and Genetic Research Unit, Department of Osteoporosis and Bone Diseases, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, 200233, China
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Shaker JL. Paget's Disease of Bone: A Review of Epidemiology, Pathophysiology and Management. Ther Adv Musculoskelet Dis 2012; 1:107-25. [PMID: 22870432 DOI: 10.1177/1759720x09351779] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Paget's disease of bone is a common disorder which may affect one or many bones. Although many patients are asymptomatic, a variety of symptoms and complications may occur. Fortunately, effective pharmacologic therapy, primarily with potent bisphosphonates, is now available to treat patients with complications or symptoms. This review of Paget's disease of bone will include epidemiology and pathophysiology, complications and clinical findings, indications for treatment, and the drugs currently available to treat this condition.
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Michou L, Collet C, Morissette J, Audran M, Thomas T, Gagnon E, Launay JM, Laplanche JL, Brown JP, Orcel P. Epidemiogenetic study of French families with Paget's disease of bone. Joint Bone Spine 2012; 79:393-8. [DOI: 10.1016/j.jbspin.2011.07.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Accepted: 07/18/2011] [Indexed: 10/17/2022]
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Gianfrancesco F, Rendina D, Di Stefano M, Mingione A, Esposito T, Merlotti D, Gallone S, Magliocca S, Goode A, Formicola D, Morello G, Layfield R, Frattini A, De Filippo G, Nuti R, Searle M, Strazzullo P, Isaia G, Mossetti G, Gennari L. A nonsynonymous TNFRSF11A variation increases NFκB activity and the severity of Paget's disease. J Bone Miner Res 2012; 27:443-52. [PMID: 21987421 DOI: 10.1002/jbmr.542] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Mutations in the SQSTM1 gene were identified as a common cause of Paget's disease of bone (PDB) but experimental evidence demonstrated that SQSTM1 mutation is not sufficient to induce PDB in vivo. Here, we identified two nonsynonymous single nucleotide polymorphisms (SNPs) (C421T, H141Y and T575C, V192A) in the TNFRSF11A gene, associated with PDB and with the severity of phenotype in a large population of 654 unrelated patients that were previously screened for SQSTM1 gene mutations. The largest effect was found for the T575C variant, yielding an odds ratio of 1.29 (p = 0.003), with the C allele as the risk allele. Moreover, an even more significant p-value (p = 0.0002) was observed in the subgroup of patients with SQSTM1 mutation, with an odds ratio of 1.71. Interestingly, patients with the C allele also showed an increased prevalence of polyostotic disease (68%, 53%, and 51% in patients with CC, CT, and TT genotypes, respectively; p = 0.01), as well as an increased number of affected skeletal sites (2.9, 2.5, and 2.0 in patients with CC, CT, and TT genotypes, respectively, p = 0.008). These differences increased when analyses were restricted to cases with SQSTM1 mutation. In human cell lines, cotrasfection with mutated SQSTM1 and TNFRSF11A(A192) produced a level of activation of NFκB signaling greater than cotrasfection with wild-type SQSTM1 and TNFRSF11A(V192), confirming genetics and clinical evidences. These results provide the first evidence that genetic variation within the OPG/RANK/RANKL system influences the severity of PBD in synergistic action with SQSTM1 gene mutations.
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Affiliation(s)
- Fernando Gianfrancesco
- Institute of Genetics and Biophysics Adriano Buzzati-Traverso, National Research Council of Italy, Naples, Italy.
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Garfinkle J, Melançon D, Cortes M, Tampieri D. Imaging pattern of calvarial lesions in adults. Skeletal Radiol 2011; 40:1261-73. [PMID: 20526773 DOI: 10.1007/s00256-010-0971-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2010] [Revised: 05/05/2010] [Accepted: 05/11/2010] [Indexed: 02/02/2023]
Abstract
Calvarial lesions often present themselves as clinically silent findings on skull radiographs or as palpable masses that may cause localized pain or soreness. This review aims to explore the radiographic, computed tomography (CT), and magnetic resonance imaging (MRI) characteristics of calvarial neoplastic, inflammatory, and congenital lesions that are common in adults in order to facilitate a structured approach to their diagnosis and limit the differential diagnosis. In addition to reviewing the literature, we reviewed the records of 141 patients of the Montreal Neurological Institute and Hospital with radiologically documented calvarial lesions between 2001 and June 2009. CT is ideal for detecting bony lesions and is helpful in precisely localizing a lesion pre-surgically. MRI is best at identifying intradiploic lesions before they affect the cortical tables and is able to establish extraosseous involvement, especially when paramagnetic contrast is employed.
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Affiliation(s)
- Jarred Garfinkle
- Department of Diagnostic and Interventional Neuroradiology, Montreal Neurological Institute and Hospital-McGill University Health Center, 3801 Rue University, Montreal, Quebec, Canada.
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Michou L, Brown JP. Emerging strategies and therapies for treatment of Paget's disease of bone. Drug Des Devel Ther 2011; 5:225-39. [PMID: 21607019 PMCID: PMC3096538 DOI: 10.2147/dddt.s11306] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2011] [Indexed: 01/16/2023] Open
Abstract
Paget's disease of bone (PDB) is a progressive monostotic or polyostotic metabolic bone disease characterized by focal abnormal bone remodeling, with increased bone resorption and excessive, disorganized, new bone formation. PDB rarely occurs before middle age, and it is the second most frequent metabolic bone disorder after osteoporosis, affecting up to 3% of adults over 55 years of age. One of the most striking and intriguing clinical features is the focal nature of the disorder, in that once the disease is established within a bone, there is only local spread within that bone and no systemic dissemination. Despite many years of intense research, the etiology of PDB has still to be conclusively determined. Based on a detailed review of genetic and viral factors incriminated in PDB, we propose a unifying hypothesis from which we can suggest emerging strategies and therapies. PDB results in weakened bone strength and abnormal bone architecture, leading to pain, deformity or, depending on the bone involved, fracture in the affected bone. The diagnostic assessment includes serum total alkaline phosphatase, total body bone scintigraphy, skull and enlarged view pelvis x-rays, and if needed, additional x-rays. The ideal therapeutic option would eliminate bone pain, normalize serum total alkaline phosphatase with prolonged remission, heal radiographic osteolytic lesions, restore normal lamellar bone, and prevent recurrence and complications. With the development of increasingly potent bisphosphonates, culminating in the introduction of a single intravenous infusion of zoledronic acid 5 mg, these goals of treatment are close to being achieved, together with long-term remission in almost all patients. Based on the recent pathophysiological findings, emerging strategies and therapies are reviewed: ie, pulse treatment with zoledronic acid; denosumab, a fully human monoclonal antibody directed against RANK ligand; tocilizumab, an interleukin-6 receptor inhibitor; odanacatib, a cathepsin K inhibitor; and proteasome and Dickkopf-1 inhibitors.
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Affiliation(s)
- Laëtitia Michou
- Department of Medicine, CHUQ (CHUL), Research Centre and Division of Rheumatology, Laval University, Quebec City, QC, Canada.
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Rendina D, Gianfrancesco F, De Filippo G, Merlotti D, Esposito T, Aloia A, Benvenuto D, Vivona CL, Annunziata G, Nuti R, Strazzullo P, Mossetti G, Gennari L. Epidemiological, clinical, and genetic characteristics of Paget's disease of bone in a rural area of Calabria, Southern Italy. J Endocrinol Invest 2010; 33:519-25. [PMID: 20061786 DOI: 10.1007/bf03346640] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND The prevalence of Paget's disease of bone (PDB) is unknown in peninsular Southern Italy, although an elevated clinical severity of the disease was reported in patients from Campania. AIM This study was performed to evaluate the epidemiological and genetic characteristics of PDB in a rural area of Calabria, the southernmost region in the Italian peninsula. SUBJECTS AND METHODS We examined 1068 consecutive pelvic radiographs of patients older than 40 yr referred for any reason to the "Spinelli" Hospital, Belvedere Marittimo, from January 1st 2004 to December 31st 2006. In subjects with radiological findings of pelvic PDB, a 99m Technetium methylene diphosphonate bone scan and the sequence analysis of the sequestosome 1 (SQSTM1) gene were subsequently performed. RESULTS In the examined geographic area, the crude radiographic prevalence of pelvic PDB was 0.74% (8/1068; male:female 5:3, mean age 71.6 ± 13.1 yr) whereas the estimated overall prevalence of PDB between 0.82% and 1.21%. PDB patients from Calabria showed clinical characteristics similar to those reported in patients from Campania. The disease was also frequently complicated by osteoarthritis and the right side of the body was more affected than the left. The SQSTM1 gene analysis revealed the presence of a novel missense mutation (M401V) in exon 8 in one subject with a familial and aggressive form of PDB. CONCLUSION The study results confirmed that patients with PDB from rural districts of Southern Italy show an earlier onset and an increased clinical severity of the disease that appears mostly independent from the presence of germinal SQSTM1 mutations.
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Affiliation(s)
- D Rendina
- Department of Clinical and Experimental Medicine, Federico II University Medical School, via S. Pansini, 5 - 80131 Naples, Italy
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Falchetti A, Marini F, Masi L, Amedei A, Brandi ML. Genetic aspects of the Paget's disease of bone: concerns on the introduction of DNA-based tests in the clinical practice. Advantages and disadvantages of its application. Eur J Clin Invest 2010; 40:655-67. [PMID: 20658751 DOI: 10.1111/j.1365-2362.2010.02312.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND A large amount of genetic studies have clearly demonstrated the existence of a genetic susceptibility to Paget's disease of bone (PDB). Although the disease is genetically heterogeneous, the SQSTM1/p62 gene, encoding a protein with a pathophysiological role in both osteoclast differentiation and activity, has been found worldwide to harbour germline mutations in most of the PDB patients from geographically distant populations originating from different areas of Europe, both in sporadic and familial cases. MATERIALS AND METHODS Thus, SQSTM1/p62 gene mutations may confer an increased lifetime risk of developing PDB. RESULTS Several different genotype-phenotype analyses have shown a high penetrance for such mutations. These results suggest the opportunity to perform genetic testing in affected individuals and then, after the identification of a SQSTM1/p62 gene germline mutation, in their relatives as a real and concrete strategy to increase the diagnostic sensitivity in most of the asymptomatic mutant carriers. However, it is of note to underlie that an incomplete penetrance for SQSTM1/p62 gene mutations has also been reported. CONCLUSIONS In light of all these contradictory evidences, a review on whether, when and why apply the DNA test to those subjects, its interpretation and clinical application is necessary. In fact, a growing number of preventive care options are now available to affected patients and families and the process of systematically assessing risk is becoming increasingly important for both patients and physicians.
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Affiliation(s)
- Alberto Falchetti
- Regional Center for Hereditary Endocrine Tumors, Unit of Metabolic Bone Diseases, AOUC, Department of Internal Medicine, University of Florence, Florence, Italy
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Pagetʼs disease of bone: thereʼs more than the affected skeletal – a clinical review and suggestions for the clinical practice. Curr Opin Rheumatol 2010; 22:410-23. [DOI: 10.1097/bor.0b013e32833af61e] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Gennari L, Gianfrancesco F, Di Stefano M, Rendina D, Merlotti D, Esposito T, Gallone S, Fusco P, Rainero I, Fenoglio P, Mancini M, Martini G, Bergui S, De Filippo G, Isaia G, Strazzullo P, Nuti R, Mossetti G. SQSTM1 gene analysis and gene-environment interaction in Paget's disease of bone. J Bone Miner Res 2010; 25:1375-84. [PMID: 20200946 DOI: 10.1002/jbmr.31] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Even though SQSTM1 gene mutations have been identified in a consistent number of patients, the etiology of Paget's disease of bone (PDB) remains in part unknown. In this study we analyzed SQSTM1 mutations in 533 of 608 consecutive PDB patients from several regions, including the high-prevalence area of Campania (also characterized by increased severity of PDB, higher number of familial cases, and peculiar phenotypic characteristics as giant cell tumor). Eleven different mutations (Y383X, P387L, P392L, E396X, M401V, M404V, G411S, D423X, G425E, G425R, and A427D) were observed in 34 of 92 (37%) and 43 of 441 (10%) of familial and sporadic PDB patients, respectively. All five patients with giant cell tumor complicating familial PDB were negative for SQSTM1 mutations. An increased heterogeneity and a different distribution of mutations were observed in southern Italy (showing 9 of the 11 mutations) than in central and northern Italy. Genotype-phenotype analysis showed only a modest reduction in age at diagnosis in patients with truncating versus missense mutations, whereas the number of affected skeletal sites did not differ significantly. Patients from Campania had the highest prevalence of animal contacts (i.e., working or living on a farm or pet ownership) without any difference between patients with or without mutation. However, when familial cases from Campania were considered, animal contacts were observed in 90% of families without mutations. Interestingly, a progressive age-related decrease in the prevalence of animal contacts, as well as a parallel increase in the prevalence of SQSTM1 mutations, was observed in most regions except in the subgroup of patients from Campania. Moreover, patients reporting animal contacts showed an increased number of affected sites (2.54 +/- 2.0 versus 2.19 +/- 1.9, p < .05) over patients without animal contacts. This difference also was evidenced in the subgroup of patients with SQSTM1 mutations (3.84 +/- 2.5 versus 2.76 +/- 2.2, p < .05). Overall, these data suggest that animal-related factors may be important in the etiology of PDB and may interact with SQSTM1 mutations in influencing disease severity.
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Affiliation(s)
- Luigi Gennari
- Department of Internal Medicine, Endocrine-Metabolic Sciences and Biochemistry, University of Siena, Siena, Italy.
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Osteogenic sarcoma in a child with familial expansile osteolysis syndrome: an accidental association? J Pediatr Hematol Oncol 2010; 32:e50-3. [PMID: 20168251 DOI: 10.1097/mph.0b013e3181c5ab68] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We present the first reported case of a child with familial expansile osteolysis syndrome (FEO) who developed osteogenic sarcoma (OS) of the iliac bone. A 17-year-old adolescent presented with pain and a mass on the left pelvis. He was from a family with several members who had been diagnosed with FEO, from which he also suffered. The median life expectancy of affected members of the family was reported as 25 to 30 years, with death ensuing as a result of various respiratory and cardiac complications of severe skeletal deformations, characteristic of increased bone turnover as seen in FEO. Biopsy of the patient's mass revealed chondroblastic OS. He was treated according to the P9754 protocol for patients with newly diagnosed nonmetastatic OS. Chemotherapy consisted of HD-MTX, ifosfomide, doxorubicin, and cisplatin. Complete resection of the tumor was carried out, but the patient subsequently developed metastatic disease and died (histologic response to neoadjuvant chemotherapy-85%). The patient's alkaline phosphatase level that was highly elevated before the start of chemotherapy, dropped significantly during treatment, with repeated elevation soon after definitive surgery, while he was recuperating and not on treatment. We speculate that chemotherapy affected not only the malignant cells of OS but normal osteoblasts as well, with a decreasing level of alkaline phosphatase even in the absence of any clinical and radiographic signs of OS. We also think that increased bone turnover, characteristic of a condition such as FEO, may facilitate de novo development of OS.
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VARENNA MASSIMO, ZUCCHI FRANCESCA, GALLI LAURA, MANARA MARIA, DE MARCO GABRIELE, SINIGAGLIA LUIGI. Demographic and Clinical Features Related to a Symptomatic Onset of Paget’s Disease of Bone. J Rheumatol 2009; 37:155-60. [DOI: 10.3899/jrheum.090674] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective.Paget’s disease of bone (PDB) is a focal disorder of skeletal remodeling that can lead to bone pain, deformity, and fractures, but it can often be asymptomatic for a long time. This study investigated which factors may distinguish patients with clinical manifestations from asymptomatic patients.Methods.The study group consisted of 224 patients with PDB referred to our Bone Disease Unit. For all patients, data were collected about clinical and demographic variables and diagnostic procedures. Logistic regression analyses were used to assess the role of recorded variables on the odds of being diagnosed clinically rather than by chance.Results.Among the 124 patients with clinical manifestations leading to the diagnosis (55.4%), 36 subjects complained of bone pain, 32 articular pain, 42 back pain, 2 headache; 9 had fractures in Paget bone, and 3 had bone deformity. In 100 patients (44.6%) PDB was diagnosed by chance. At the multivariate analysis, only the number of bones involved (OR for 1 site increment = 1.18, 95% CI: 1.007–1.402; p = 0.04) acted as an independent predictor for a clinical diagnosis. Some skeletal localizations were associated with a clinical diagnosis: the involvement of lumbar spine (OR = 2.085, 95% CI: 1.024–4.224; p = 0.043) was more likely in symptomatic patients; pelvis and tibia showed a borderline statistical significance. The skull was predictive for asymptomatic PDB.Conclusion.A systematic laboratory screening including serum alkaline phosphatase of an older subject complaining of bone pain, articular pain, or back pain is the sole strategy to improve the diagnostic sensitivity for PDB.
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Abstract
Paget's disease of bone is a focal bone disorder that is common among older people of Western European descent. It is an unusual disorder, for although we now have safe and highly effective treatment, there are many aspects of its pathogenesis and natural history that we do not yet understand. Recent years have seen significant advances in the understanding of its epidemiology, genetics and molecular biology, but an integrated view that incorporates all these aspects remains elusive. In this review we examine some of the outstanding problems, the solutions to which seem likely to change our understanding of bone cell biology.
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Affiliation(s)
- Brya Matthews
- a Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, New Zealand.
| | - Tim Cundy
- b Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, New Zealand.
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Abstract
Giant cell tumor (GCT) of the bone, also called osteoclastoma, is a rare complication of Paget's bone disease. We report a patient from Southern Italy who developed a GCT infiltrating the neighboring tissues. The natural history and the therapeutic outcomes of this unique complication of Paget's bone disease are presented.
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Abstract
Paget's disease of bone is a focal disorder of aging bone. The classic late-onset Paget's disease is often caused by a P392L mutation in the gene SQSTM1, which disturbs signaling pathways in osteoclasts on cell activation. This prevalent mutation is neither necessary nor sufficient to cause Paget's disease. Its identification, along with the elucidation of other mutations underlying early-onset Paget's and Paget's disease seen in association with inclusion body myopathy and frontotemporal dementia, have redefined our understanding of genetic disorders of bone remodeling by emphasizing the importance of environmental determinants in their pathophysiology.
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Affiliation(s)
- Margaret Seton
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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38
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Mossetti G, Gennari L, Rendina D, De Filippo G, Merlotti D, De Paola V, Fusco P, Esposito T, Gianfrancesco F, Martini G, Nuti R, Strazzullo P. Vitamin D receptor gene polymorphisms predict acquired resistance to clodronate treatment in patients with Paget's disease of bone. Calcif Tissue Int 2008; 83:414-24. [PMID: 19020788 DOI: 10.1007/s00223-008-9193-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2008] [Accepted: 10/29/2008] [Indexed: 01/14/2023]
Abstract
Bisphosphonates are first-choice drugs for treatment of Paget's disease of bone (PDB); nevertheless, acquired resistance to bisphosphonate therapy has been described in PDB patients. The 1,25(OH)(2)D(3)/vitamin D receptor (VDR) system influences the effectiveness of antiresorptive treatments in metabolic bone disorders. This study evaluated the relationship between acquired resistance to clodronate treatment and BsmI, TaqI, and FokI VDR polymorphisms in Caucasian patients with polyostotic PDB (n = 84). We also evaluated the influence of mutations in exons 7 and 8 of the sequestosome 1 (SQSTM1) gene on the occurrence of this phenomenon. All patients were treated from diagnosis for several cycles with intravenous clodronate infusion (1500 mg/cycle). Acquired resistance to clodronate treatment was defined as the failure of total alkaline phosphatase serum levels to be suppressed to at least 50% of the patient's previous highest levels during a subsequent treatment course with the same compound, which produced a >50% response after the first exposure. During an observation period of 10.6 +/- 2.7 years, 31 PDB patients (36.9%) showed acquired resistance to clodronate. It was observed that the bb and TT VDR genotypes as well as a lower persistence of the biochemical response to the first treatment course were significantly and independently associated with the risk of developing resistance to clodronate treatment. SQSTM1 gene mutations, considered altogether, did not influence the occurrence of this phenomenon. Our results indicate that 3'VDR allelic variants and duration of biochemical response to the first treatment course are independent predictors of acquired resistance to clodronate treatment in patients with polyostotic PDB.
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Affiliation(s)
- Giuseppe Mossetti
- Department of Clinical and Experimental Medicine, Federico II University Medical School, Via S. Pansini 5, Naples, 80131, Italy.
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39
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Abstract
Paget's disease of bone is a common condition characterised by increased and disorganised bone turnover which can affect one or several bones throughout the skeleton. These abnormalities disrupt normal bone architecture and lead to various complications such as bone pain osteoarthritis, pathological fracture, bone deformity, deafness, and nerve compression syndromes. Genetic factors play an important role in PDB and mutations or polymorphisms have been identified in four genes that cause classical Paget's disease and related syndromes. These include TNFRSF11A, which encodes RANK, TNFRSF11B which encodes osteoprotegerin, VCP which encodes p97, and SQSTM1 which encodes p62. All of these genes play a role in the RANK-NFkappaB signalling pathway and it is likely that the mutations predispose to PDB by disrupting normal signalling, leading to osteoclast activation. Although Paget's has traditionally be considered a disease of the osteoclast there is evidence that stromal cell function and osteoblast function are also abnormal, which might account for the fact that the disease is associated with increased bone formation as well as resorption. Environmental factors also contribute to Paget's disease. Most research has focused on paramyxovirus infection as a possible environmental trigger but evidence in favour of the involvement of viruses in the disease remains conflicting. Other factors which have been implicated as possible disease triggers include mechanical loading, dietary calcium and environmental toxins. Further work will be required to identify additional genetic variants that predispose to Paget's disease and to determine how the causal mutations and predisposing polymorphisms interact with environmental factors to influence bone cell function and cause the focal bone lesions that are characteristic of the disease.
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Affiliation(s)
- Stuart H Ralston
- Rheumatic Diseases Unit, Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh EH4 2XU, UK.
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40
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Abstract
Paget's disease of bone is a common disease characterised by focal areas of increased bone turnover, affecting one or several bones throughout the skeleton. Paget's disease is often asymptomatic but can be associated with bone pain and other complications such as osteoarthritis, pathological fracture, bone deformity, deafness, and nerve compression syndromes. Genetic factors have an important role in this disease, and mutations have been identified in four genes that cause Paget's disease and related syndromes. The most important of these is Sequestosome 1 (SQSTM1), which is a scaffold protein in the nuclear factor kappaB (NFkappaB) signalling pathway. Patients with SQSTM1 mutations have severe Paget's disease of bone and a high degree of penetrance with increasing age. Environmental factors also contribute. Most research has focused on paramyxovirus infection as a possible trigger, but evidence for this notion is conflicting. Other potential triggers include deficiency of dietary calcium and repetitive mechanical loading of the skeleton. Medical management of Paget's disease of bone is based on giving inhibitors of osteoclastic bone resorption, and bisphosphonates are the treatment of first choice. Bisphosphonate therapy is primarily indicated for patients who have bone pain arising from increased metabolic activity in affected bones. Bisphosphonate therapy is highly effective at reducing bone turnover, and it has been shown to heal radiological lesions and restore normal histology; however, the long-term effects of bisphosphonates on disease progression have not been adequately studied. No firm evidence as yet exists to show that bisphosphonates can prevent the development of complications of Paget's disease of bone, and further work is needed to address the effects of treatment on long-term clinical outcome.
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Affiliation(s)
- Stuart H Ralston
- Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK.
| | - Anne L Langston
- Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - Ian R Reid
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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41
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Bibliography. Current world literature. Parathyroids, bone and mineral metabolism. Curr Opin Endocrinol Diabetes Obes 2007; 14:494-501. [PMID: 17982358 DOI: 10.1097/med.0b013e3282f315ef] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hoch B, Hermann G, Klein MJ, Abdelwahab IF, Springfield D. Giant cell tumor complicating Paget disease of long bone. Skeletal Radiol 2007; 36:973-8. [PMID: 17437100 DOI: 10.1007/s00256-007-0310-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2006] [Revised: 02/08/2007] [Accepted: 03/08/2007] [Indexed: 02/02/2023]
Abstract
Giant cell tumor (GCT) is a rare complication of Paget disease of bone. It usually occurs in the skull or pelvic bones of patients with long-standing polyostotic disease. This report describes a 62-year-old patient who presented with monostotic Paget disease of the distal femur complicated by GCT. He had a 2-year history of discomfort and pain in his left knee. Conventional plain films and MRI demonstrated the characteristic bone changes of Paget disease and an associated lytic lesion involving the epiphyseal and metaphyseal regions of the distal femur. A diagnostic curettage showed the characteristic histopathologic features of Paget disease and GCT. There was no evidence of malignancy. The clinicopathologic features of this rare lesion are described and correlated with a review of the literature.
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Affiliation(s)
- Benjamin Hoch
- Department of Pathology, Mount Sinai Medical Center, One Gustave L. Levy Place, Box 1194, New York, NY 07422, USA.
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