Myeloma Bone Disease: A Comprehensive Review

Guizhi Fuling decoction protects against bone destruction via suppressing exosomal ERK1 in multiple myeloma

BACKGROUND

Myeloma-related bone disease (MBD) is a common complication of multiple myeloma (MM) that deteriorates patients' quality of life and affects overall survival. Modulating the interaction between myeloma cells and the bone marrow microenvironment may offer therapeutic potential. While certain natural medicines may regulate bone homeostasis by directly targeting osteoclasts or osteoblasts, few studies have explored the effects of intervening in myeloma cells on osteoclasts, particularly through the role of exosomes.

PURPOSE

To investigate the inhibitory effect of Guizhi Fuling Decoction (GZFL) on bone lesions formation induced by exosomes secreted by myeloma cells and provide evidence to support the clinical application of GZFL in treating MBD.

METHODS

TRAP staining and Von Kossa staining were used to evaluate the inhibition of GZFL on RANKL-induced osteoclastogenesis in vitro. Micro-CT and bone histomorphometric analyses were performed to identify the protective effect of GZFL on bone destruction in vivo. RNA immunoprecipitation (RIP), RNA-seq, and UHPLC-MS/MS were conducted to investigate the MBD targets of GZFL. A clinical trial was carried out to evaluate the efficacy of GZFL capsules in the treatment of MBD.

RESULTS

The main bioactive components of GZFL, paeoniflorin, quercitrin and kaempferol, could target ERK1 and downregulate its expression in MM exosomes. In vitro, GZFL treatment inhibited the promoting effect of MM exosomes on osteoclast (OC) formation, bone resorption, and activated ERK1 expression. In vivo, GZFL prolonged survival rate, inhibited the exacerbation of bone lesions caused by MM exosomes and RANKL-induced ERK1 activation in mice model. Clinical data showed that GZFL capsule combined with bortezomib (Bortezomib) and dexamethasone (PD) significantly reduced the numeric rating scale, as well as the expression levels of ERK and RANKL in bone marrow. ERK1 levels exhibited a positive correlation with both the number of bone lesions and RANKL levels. Higher ERK1 expression indicated a worse prognosis.

CONCLUSION

GZFL inhibited MBD progression by reducing MM-derived exosomal ERK1, thereby suppressing RANKL-induced ERK1 activation and the downstream OC formation. GZFL combined with PD regimen had good clinical efficacy and safety in the treatment of MBD.

The butyrate derived from probiotic Clostridium butyricum exhibits an inhibitory effect on multiple myeloma through cell death induction

Multiple myeloma (MM) is a hematological malignancy characterized by a poor prognosis. While certain probiotics have been shown to produce antitumor molecules that inhibit solid tumor progression, it remains unclear whether probiotic-derived compounds can exert similar effects on hematological tumors, such as MM. In this study, we screened the cell-free culture supernatants (CFCS) of 24 probiotic strains for antitumor effects against multiple myeloma (MM) cells and identified that the CFCS from Clostridium butyricum (C. butyricum) demonstrated the most significant reduction in MM cell viability. Further fractionation of this CFCS through reverse-phase and gel filtration chromatography revealed a high enrichment of butyrate in the antitumor fraction, as confirmed by gas chromatography-mass spectrometry. Butyrate reduced MM cell viability in a concentration-dependent manner. Butyrate was significantly more cytotoxic to RPMI-8226 cells than peripheral blood mononuclear cells (PBMCs) isolated from two non-cancerous individuals. In the xenograft model of RPMI-8226 cells, butyrate showed significant inhibition of tumor formation. Cell cycle analysis showed that butyrate induced G1 phase arrest and increased sub-G1 phase, suggesting DNA fragmentation. Western blot analysis demonstrated that butyrate treatment led to cleaved poly ADP-ribose polymerase (PARP) accumulation. Additionally, flow cytometry showed an increase in annexin V positive MM cells, indicating apoptosis. Butyrate also exhibited synergistic antitumor activity when combined with bortezomib, a proteasome inhibitor. These findings suggest that probiotic-derived molecules, including butyrate, may enhance the therapeutic effect of hematological malignancy, such as MM.

Dynamic monitoring of M-protein quantification by immunotyping using capillary zone electrophoresis during the chemotherapy of patients with multiple myeloma

Dynamic quantification of monoclonal immunoglobulin proteins (M-proteins) by immunotyping using immunosubtraction (ISUB) through capillary zone electrophoresis (CZE) was performed to examine the efficacy of chemotherapy drugs in patients with multiple myeloma (MM). Twenty-one patients with eight different types of M-protein were analyzed, and M-protein quantification during chemotherapy regimens was dynamically monitored. For patients with M-protein identified by CZE, immunotyping by ISUB can accurately determine the percentage of M-protein. In this study, 15 of the 16 included patients with a definite diagnosis of MM were initially treated with bortezomib chemotherapy, and the treatment efficacy differed significantly among individuals. Three patients showed M-protein clearance, with the M-protein decreasing by more than 50% after the first course of treatment. Capillary-based immunotyping accurately determined the percentage of M-proteins. Dynamic monitoring of M-protein through immunotyping using ISUB can objectively and effectively aid in evaluating treatment efficacy. Clinically, chemotherapeutic drugs that reduce M-protein levels by more than 50% after a treatment course should be selected. The early detection of trace changes in M-protein levels is crucial for disease monitoring and medication guidance. Quantification of M-protein should be regularly undertaken in patients with MM.

Low-intensity pulsed ultrasound regulates bone marrow mesenchymal stromal cells differentiation and inhibits bone loss by activating the IL-11-Wnt/β-catenin signaling pathway

BACKGROUND

Osteoporosis (OP) is a common metabolic bone disease. Low-intensity pulsed ultrasound (LIPUS) can effectively promote bone formation and fracture healing. The Wnt/β-catenin signaling pathway is crucial for regulating bone homeostasis and bone diseases, and its downregulation is one of the main mechanisms of osteoporosis pathogenesis. Interleukin-11 (IL-11), which is regulated by mechanical stress, is a key factor in bone remodeling. Here, we investigated the optimal intervention parameters for LIPUS, the relationships among LIPUS, IL-11, and the Wnt/β-catenin signaling pathway, and the effects of LIPUS on bone loss and potential molecular mechanisms in ovariectomized (OVX) mice.

METHODS

Bone marrow mesenchymal stromal cells (BMSCs) were subjected to LIPUS intervention for 0, 10, or 20 min to determine the optimal intervention time. The mediating role of IL-11 in LIPUS intervention was explored through IL-11 knockdown and overexpression. Finally, animal experiments were conducted to investigate the in vivo therapeutic effects of LIPUS.

RESULTS

The optimal intervention time for LIPUS was 20 min. LIPUS promoted IL-11 expression and upregulated the Wnt/β-catenin signaling pathway, thereby promoting osteogenic differentiation and inhibiting adipogenic differentiation of BMSCs. IL-11 mediates the regulation of the Wnt/β-catenin signaling pathway by LIPUS. Additionally, LIPUS effectively improved the bone microstructure in ovariectomized mice, inhibited bone loss, promoted IL-11 expression in bone tissue, and activated the Wnt/β-catenin signaling pathway in the femur.

CONCLUSION

Low-intensity pulsed ultrasound can regulate BMSCs differentiation and inhibit bone loss by promoting IL-11 expression and activating the Wnt/β-catenin signaling pathway.

Enhancing prognosis in multiple myeloma bone disease: insights from a retrospective analysis of surgical interventions

Background

Multiple myeloma (MM) is a hematological malignancy characterized by bone marrow infiltration and osteolytic tumor formation. Despite advancements in the treatment of this disease, MM remains incurable and often leads to complications, such as multiple myeloma bone disease (MMBD). Surgical intervention is frequently necessary to manage symptoms associated with bone disease, including pain and fractures.

Methods

A retrospective review was conducted on 135 patients diagnosed with MMBD who had undergone surgery, compared to 190 patients diagnosed with MM who had not undergone surgery and served as controls. Surgical interventions were performed based on typical clinical presentations of myeloma-related bone disease, as indicated by imaging results. Patients who had only undergone percutaneous kyphoplasty or vertebroplasty (PKP/PVP) were excluded from this study.

Results

Among patients who underwent surgery, the spine was the most common site of bone metastasis, accounting for 50% of cases. The number of operations (overall survival [OS], p = 0.82; progression-free survival [PS], p = 0.41) and the order of surgery and chemotherapy treatment (OS, p = 0.85; PS, p = 0.83) did not significantly impact the outcomes. Further, MM patients with surgery exhibited a significant prognostic difference compared to those without surgery (OS, p < 0.0001). The International Staging System (ISS) stage serves as a prognostic factor for MMBD who have undergone surgery, with higher ISS stages indicating worse prognoses.

Conclusions

These results indicate that surgery and chemotherapy together improved patient survival rates compared to chemotherapy alone, thereby facilitating patients' acceptance of systemic chemotherapy. Furthermore, the appropriate timing of surgery contributes to the positive prognoses of patients with MMBD.

New horizons in our understanding of precursor multiple myeloma and early interception

Multiple myeloma is an incurable plasma cell malignancy that evolves over decades through the selection and malignant transformation of monoclonal plasma cells. The evolution from precursor states to symptomatic disease is characterized by an increasing complexity of genomic alterations within the plasma cells and a remodelling of the microenvironment towards an immunosuppressive state. Notably, in patients with advanced disease, similar mechanisms of tumour escape and immune dysfunction mediate resistance to modern T cell-based therapies, such as T cell-engaging bispecific antibodies and chimeric antigen receptor (CAR)-T cells. Thus, an increasing number of clinical trials are assessing the efficiency and safety of these therapies in individuals with newly diagnosed multiple myeloma and high-risk smoldering multiple myeloma. In this Review, we summarize the current knowledge about tumour intrinsic and extrinsic processes underlying progression from precursor states to symptomatic myeloma and discuss the rationale for early interception including the use of T cell-redirecting therapies.

Drug delivery for age-related bone diseases: From therapeutic targets to common and emerging therapeutic strategies

With the accumulation of knowledge on aging, people have gradually realized that among the many factors that cause individual aging, the accumulation of aging cells is an essential cause of organ degeneration and, ultimately, age-related diseases. Most cells present in the bone microenvironment gradually age over time, leading to an imbalance of osteogenesis, osteoclastogenesis, adipogenesis, and chondrogenesis. This imbalance contributes to age-related bone loss and the development of age-related bone diseases, such as osteoporosis. Bone aging can prolong the lifespan and delay the development of age-related diseases. Nanoparticles have controllable and stable physical and chemical properties and can precisely target different tissues and organs. By preparing multiple easily modified and biocompatible nanoparticles as different drug delivery carriers, specifically targeting various diseased tissues for controlled-release and sustained-release administration, the delivery efficiency of drugs can be significantly improved, and the toxicity and side effects of drugs can be substantially reduced, thereby improving the therapeutic effect of age-related bone diseases. In addition, other novel anti-aging strategies (such as stem cell exosomes) also have significant scientific and practical significance in anti-aging research on age-related bone diseases. This article reviews the research progress of various nano-drug-loaded particles and emerging anti-aging methods for treating age-related bone diseases, offering new insights and directions for precise targeted clinical therapies.

Update on kidney injury caused by multiple myeloma

Multiple myeloma (MM) is a form of clonal plasma cell malignancy that associates with clinical manifestations such as anemia, hypercalcemia, bone pain, and renal impairment. Approximately 20-50% of MM patients at initial diagnosis experience renal injury, a vital complication that significantly influences prognosis and quality of life. This review seeks to clarify the multifaceted mechanisms of renal injury in MM, scrutinizing the pathogenic role of monoclonal proteins, the impact of hypercalcemia, and direct renal infiltration by plasma cells. Furthermore, it evaluates current diagnostic approaches, reviews management strategies, and highlights potential avenues for future research. By incorporating the latest scientific evidence and insights, this article aims to provide a comprehensive understanding of MM-associated renal impairment, offering a valuable resource for researchers and clinicians in handling this complex complication.

Pre-Transplant Dual-Energy X-ray Absorptiometry (DXA)-Derived Body Composition Measures as Predictors of Treatment Outcomes and Early Post-Transplant Complications in Patients with Multiple Myeloma (MM) Treated with Autologous Hematopoietic Stem Cell Transplantation (AutoHSCT)

Background/Objectives: Changes in muscle mass and bone density are common in multiple myeloma (MM) patients. Dual-energy X-ray absorptiometry (DXA) offers precise, non-invasive insights into a patient's physical condition before autologous stem cell transplantation (autoHSCT). This study examines how pre-transplant body composition impacts treatment outcomes and early complications in MM patients undergoing autoHSCT. Methods: This study is a single-center, retrospective analysis of patients with MM who were treated with first or second autoHSCT and underwent DXA pre-transplant between 11 August 2019 and 12 June 2024. Results: We conducted a study of pre-transplant body composition in 127 patients with MM. Among them, 108 (85%) qualified for first autoHSCT, while 19 (15%) qualified for a second. The median age of the patients was 64 years (range 50-73). In the Cox proportional hazards regression conducted in the group of women, Total Body %Fat was a statistically significant predictor for progression-free survival (PFS) (HR = 0.07, 95% CI = 0.01,0.6, p = 0.0157). In the Mann-Whitney U test conducted on males, Lean Mass/Height2 and Appen. Lean Height2 were statistically significant predictors of early infections after autoHSCT (Z = 1.98, p = 0.0473 and Z = 2.32, p = 0.0204, respectively). In males, Fat Mass/Height2 was a significant predictor of non-infectious toxicity related to treatment (Z = -1.98, p = 0.0476). Conclusions: In women, higher levels of adipose tissue initially appear to exert a protective effect; however, this benefit diminishes over time, with greater fat mass eventually correlating with an increased risk of disease progression. In men, muscle mass has been identified as a significant predictor of early infection risk post-autoHSCT. Furthermore, our findings indicate that an increased amount of adipose tissue in men is statistically associated with a higher risk of non-infectious treatment-related toxicity. These conclusions highlight the critical need for further investigation into the role of body composition.

Interactions between kisspeptin and bone: Cellular mechanisms, clinical evidence, and future potential

The neuropeptide kisspeptin and its cognate receptor have been extensively studied in reproductive physiology, with diverse and well-established functions, including as an upstream regulator of pubertal onset, reproductive hormone secretion, and sexual behavior. Besides classical reproduction, both kisspeptin and its receptor are extensively expressed in bone-resorbing osteoclasts and bone-forming osteoblasts, which putatively permits direct bone effects. Accordingly, this sets the scene for recent compelling findings derived from in vitro experiments through to in vivo and clinical studies revealing prominent regulatory interactions for kisspeptin signaling in bone metabolism, as well as certain oncological aspects of bone metabolism. Herein, we comprehensively examine the experimental evidence obtained to date supporting the interaction between kisspeptin and bone. A comprehensive understanding of this emerging facet of kisspeptin biology is fundamental to exploiting the future therapeutic potential of kisspeptin-based medicines as a novel strategy for treating bone-related disorders.

Galectin-9 - ligand axis: an emerging therapeutic target for multiple myeloma

Galectin-9 (Gal-9) is a tandem-repeat galectin with diverse roles in immune homeostasis, inflammation, malignancy, and autoimmune diseases. In cancer, Gal-9 displays variable expression patterns across different tumor types. Its interactions with multiple binding partners, both intracellularly and extracellularly, influence key cellular processes, including immune cell modulation and tumor microenvironment dynamics. Notably, Gal-9 binding to cell-specific glycoconjugate ligands has been implicated in both promoting and suppressing tumor progression. Here, we provide insights into Gal-9 and its involvement in immune homeostasis and cancer biology with an emphasis on multiple myeloma (MM) pathophysiology, highlighting its complex and context-dependent dual functions as a pro- and anti-tumorigenic molecule and its potential implications for therapy in MM patients.

LILRB4 on multiple myeloma cells promotes bone lesion by p-SHP2/NF-κB/RELT signal pathway

BACKGROUND

Leukocyte Ig-like receptor B family 4 (LILRB4) as an immune checkpoint on myeloid cells is a potential target for tumor therapy. Extensive osteolytic bone lesion is the most characteristic feature of multiple myeloma. It is unclear whether ectopic LILRB4 on multiple myeloma regulates bone lesion.

METHODS

The conditioned medium (CM) from LILRB4-WT and -KO cells was used to analyze the effects of LILRB4 on osteoclasts and osteoblasts. Xenograft, syngeneic and patient derived xenograft models were constructed, and micro-CT, H&E staining were used to observe the bone lesion. RNA-seq, cytokine array, qPCR, the activity of luciferase, Co-IP and western blotting were used to clarify the mechanism by which LILRB4 mediated bone damage in multiple myeloma.

RESULTS

We comprehensively analyzed the expression of LILRB4 in various tumor tissue arrays, and found that LILRB4 was highly expressed in multiple myeloma samples. The patient's imaging data showed that the higher the expression level of LILRB4, the more serious the bone lesion in patients with multiple myeloma. The conditioned medium from LILRB4-WT not -KO cells could significantly promote the differentiation and maturation of osteoclasts. Xenograft, syngeneic and patient derived xenograft models furtherly confirmed that LILRB4 could mediate bone lesion of multiple myeloma. Next, cytokine array was performed to identify the differentially expressed cytokines, and RELT was identified and regulated by LILRB4. The overexpression or exogenous RELT could regenerate the bone damage in LILRB4-KO cells in vitro and in vivo. The deletion of LILRB4, anti-LILRB4 alone or in combination with bortezomib could significantly delay the progression of bone lesion of multiple myeloma.

CONCLUSIONS

Our findings indicated that LILRB4 promoted the bone lesion by promoting the differentiation and mature of osteoclasts through secreting RELT, and blocking LILRB4 singling pathway could inhibit the bone lesion.

BCMA/CD47-directed universal CAR-T cells exhibit excellent antitumor activity in multiple myeloma

BACKGROUND

BCMA-directed autologous chimeric antigen receptor T (CAR-T) cells have shown excellent clinical efficacy in relapsed or refractory multiple myeloma (RRMM), however, the current preparation process for autologous CAR-T cells is complicated and costly. Moreover, the upregulation of CD47 expression has been observed in multiple myeloma, and anti-CD47 antibodies have shown remarkable results in clinical trials. Therefore, we focus on the development of BCMA/CD47-directed universal CAR-T (UCAR-T) cells to improve these limitations.

METHODS

In this study, we employed phage display technology to screen nanobodies against BCMA and CD47 protein, and determined the characterization of nanobodies. Furthermore, we simultaneously disrupted the endogenous TRAC and B2M genes of T cells using CRISPR/Cas9 system to generate TCR and HLA double knock-out T cells, and developed BCMA/CD47-directed UCAR-T cells and detected the antitumor activity in vitro and in vivo.

RESULTS

We obtained fourteen and one specific nanobodies against BCMA and CD47 protein from the immunized VHH library, respectively. BCMA/CD47-directed UCAR-T cells exhibited superior CAR expression (89.13-98.03%), and effectively killing primary human MM cells and MM cell lines. BCMA/CD47-directed UCAR-T cells demonstrated excellent antitumor activity against MM and prolonged the survival of tumor-engrafted NCG mice in vivo.

CONCLUSIONS

This work demonstrated that BCMA/CD47-directed UCAR-T cells exhibited potent antitumor activity against MM in vitro and in vivo, which provides a potential strategy for the development of a novel "off-the-shelf" cellular immunotherapies for the treatment of multiple myeloma.

Positron Emission Tomography/Computed Tomography Transformation of Oncology: Multiple Myeloma

This article provides a comprehensive review of the role of 2-deoxy-2-[18F]fluoro-d-glucose (18F FDG) positron emission tomography/computed tomography (PET/CT) in multiple myeloma (MM) and related plasma cell disorders. MM is a hematologic malignancy characterized by the neoplastic proliferation of plasma cells. 18F FDG PET/CT integrates metabolic and anatomic information, allowing for accurate localization of metabolically active disease. The article discusses the use of 18F FDG PET/CT in initial diagnosis, staging, prognostication, and assessing treatment response. Additionally, it provides valuable insights into the novel imaging targets including chemokine receptor C-X-C motif 4 and CD38.

Sarcoidosis presenting as multiple osseous lesions

Sarcoidosis is a multisystem inflammatory condition presenting with the formation of noncaseating granulomas. These granulomas can be found in nearly every organ of the body, but in 90% of cases the lungs are involved. Osseous manifestations are seen in only 3% to 13% of cases and are typically seen alongside the more common pulmonary manifestations. These lesions can be misdiagnosed as metastatic cancer so biopsy, along with clinical correlation and exclusion of other diseases, is necessary to make the diagnosis. Most patients with primary osseous sarcoidosis remain asymptomatic but routine monitoring is necessary to identify progression to lesion growth, cardiac manifestations, and respiratory involvement.

Redox signaling and antioxidant defense in osteoclasts

Bone remodeling is essential for the repair and replacement of damaged or aging bones. Continuous remodeling is necessary to prevent the accumulation of bone damage and to maintain bone strength and calcium balance. As bones age, the coupling mechanism between bone formation and absorption becomes dysregulated, and bone loss becomes dominant. Bone development and repair rely on interaction and communication between osteoclasts and surrounding cells. Osteoclasts are specialized cells that are accountable for bone resorption and degradation, and any abnormalities in their activity can result in notable alterations in bone structure and worsen disease symptoms. Recent findings from transgenic mouse models and bone analysis have greatly enhanced our understanding of the origin, differentiation pathway, and activation stages of osteoclasts. In this review, we explore osteoclasts and discuss the cellular and molecular events that drive their generation, focusing on intracellular oxidative and antioxidant signaling. This knowledge can help develop targeted therapies for diseases associated with osteoclast activation.

A case report: Nonsecretory multiple myeloma presenting with bone pain

RATIONALE

Nonsecretory multiple myeloma (NSMM) is a rare subtype of multiple myelom, occurring in 1% to 2% of multiple myelom and characterized by the inability of clonal plasma cells to synthesize or secrete immunoglobulins. We describe a 71-year-old male patient who began with bone pain and was referred to hospital several times, but was not properly diagnosed and effectively treated.

PATIENT CONCERNS

A 71-year-old male patient visited our hematology department, complaining of lumbago for 1 year and back pain for half a year.

DIAGNOSES

Low-dose whole-body bone computed tomography: multiple bone destruction of the sternum, ribs, multiple vertebrae and accessories of the spine, pelvis, bilateral humerus, and proximal femur. Monoclonal plasma cells accounted for 17.5% of nuclear cells in bone marrow puncture smear. Fluorescence in situ hybridization detected amplification of CKS1B (1q21) gene. Immunofixation electrophoresis negative. About 10.72% of monoclonal plasma cells were detected by flow cytometry. Finally, he was diagnosed with NSMM.

INTERVENTIONS

The patients received VCD chemotherapy (bortezomib 1.3 mg/m2, d1, d4, d8, d11; cyclophosphamide 300 mg/m2, d1-2, d8-9; dexamethasone sodium phosphate 20 mg, d1-2, d4-5, d8-9, d11-12, once every 21 days).

OUTCOMES

After 2 cycles of VCD treatment, the symptoms of bone pain were significantly relieved, and the efficacy was evaluated as partial response. Follow-up chemotherapy will continue to be completed on schedule. We will continue to follow up to further evaluate the overall survival and progression-free survival.

LESSONS

This case shows that NSMM is easily missed or misdiagnosed.

Roles of IL-11 in the regulation of bone metabolism

Bone metabolism is the basis for maintaining the normal physiological state of bone, and imbalance of bone metabolism can lead to a series of metabolic bone diseases. As a member of the IL-6 family, IL-11 acts primarily through the classical signaling pathway IL-11/Receptors, IL-11 (IL-11R)/Glycoprotein 130 (gp130). The regulatory role of IL-11 in bone metabolism has been found earlier, but mainly focuses on the effects on osteogenesis and osteoclasis. In recent years, more studies have focused on IL-11's roles and related mechanisms in different bone metabolism activities. IL-11 regulates osteoblasts, osteoclasts, BM stromal cells, adipose tissue-derived mesenchymal stem cells, and chondrocytes. It's involved in bone homeostasis, including osteogenesis, osteolysis, bone marrow (BM) hematopoiesis, BM adipogenesis, and bone metastasis. This review exams IL-11's role in pathology and bone tissue, the cytokines and pathways that regulate IL-11 expression, and the feedback regulations of these pathways.

The effect of immunomodulatory drugs on bone metabolism of patients with multiple myeloma

INTRODUCTION

Immunomodulatory drugs (IMiDs) are widely used in the management of newly diagnosed and relapsed/refractory multiple myeloma patients. These agents show their potential effect on myeloma bone disease (MBD), including inhibition of osteoclasts activity and effects on osteoblasts differentiation. It is unclear whether these effects are direct, which may have an impact on bone formation markers when combined with proteasome inhibitors.

AREAS COVERED

This review summarizes the available evidence on the role of IMiDs in microenvironment regulation and their potential effects on bone metabolism. The literature search methodology consisted of searching PubMed for basic and clinical trials using medical subject terms. Included articles were screened and evaluated by the coauthors of this review.

EXPERT OPINION

As a therapeutic option, IMiDs directly affect preosteoblast/osteoclast differentiation. The combination of proteasome inhibitors may counteract the short-term up-regulation of osteogenic activity markers, and therefore intravenous zoledronic acid is recommended, however, obtaining a more significant myeloma response will have a long-term positive impact on myeloma bone disease.

Novel_circ_003686 regulates the osteogenic differentiation of MSCs in patients with myeloma bone disease through miR-142-5p/IGF1 axis

Objectives

Circ_003686 is a novel_circRNA with abnormally low expression found in the samples of multiple myeloma bone disease (MBD) patients. The current research intended to investigate the effects of novel_circ_003686 in osteogenesis-induced differentiation of bone marrow mesenchymal stem cells (BMSCs) in MBD.

Methods

BMSCs were extracted from MBD patients and normal participants, the pcDNA3.1 encoding the circ_003686 (ov-circ_003686), miR-142-5p-mimic/inhibitor and siRNA oligonucleotides targeting insulin like growth factor 1 (IGF1, si-IGF1) were applied to intervene circ_003686, miR-142-5p and IGF1 levels, respectively. Results: Results showed that ov-circ_003686 could mediate the osteogenesis-induced differentiation of MBD-BMSC, and luciferase assay and RIP experiments confirmed that circ_003686 could bind to miR-142-5p. MiR-142-5p-inhibitor helped osteogenesis-induced differentiation, while miR-142-5p-mimic inhibited osteogenesis-induced differentiation and reversed the promoting effect of ov-circ_003686, suggesting that circ_003686/miR-142-5p axis participated in osteogenesis-induced differentiation of MBD-BMSC. In addition, miR-142-5p binds to the target gene IGF1 and negatively adjust its expression. Si-IGF1 significantly inhibited the osteogenesis-induced differentiation and reversed the promotion effects of miR-142-5p-inhibitor and ov-circ_003686. Moreover, circ_003686/miR-142-5p/IGF1 axis meaningfully regulates protein expressions in the PI3K/AKT pathway.

Conclusion

In conclusion, this research confirmed that circ_003686 regulated the osteogenesis-induced differentiation of MBD-BMSC by sponging miR-142-5p and mediating IGF1, and the PI3K/AKT pathway may also be involved.

Predictors of health-related quality of life of the patients treated for MM: the first study in the Palestinian healthcare system

Little studies were conducted to assess the health -related quality of life (HR-QoL) of patients with multiple myeloma (MM) in developing and resource-limited countries. This study assessed the HR-QoL of patients with MM who received treatment in the Palestinian healthcare system as an example of healthcare systems in developing and resource-limited countries. Predictors of deteriorated HR-QoL of the affected patients were also identified. In this cross-sectional study, the tool was a questionnaire that collected the demographic and disease variables of the patients. The questionnaire also contained the EORTC QLQ-MY24 items. The questionnaire was piloted to ensure readability, clarity, and comprehensibility. Additionally, the test-retest reliability and internal consistency were also assessed. In this study, 45.5% of patients with MM who were treated in the Palestinian healthcare system returned usable questionnaires. The mean age of the patients was 60.7 ± 7.5 years and the mean time elapsed since diagnosis was 2.6 ± 1.7 years. Of the patients, 54.3%, 47.8%, 46.7%, 66.3%, 46.7%, and 46.7% reported frequent bone pain, pain that increased with activity, back pain, feeling ill, lost hair, and feeling restless or agitated, respectively. Higher disease symptom scores were predicted by low self-rated satisfaction with the ability to do daily life activities and low self-rated satisfaction with overall health. The side effects of treatment scores were predicted by longer time elapsed since diagnosis and low self-rated satisfaction with overall health. Future perspective scores were predicted by low self-rated satisfaction with overall health. On the other hand, social support scores were predicted by having a university education and not receiving radiotherapy. Patients with MM who were treated in the Palestinian healthcare system reported a heavy burden of disease symptoms, treatment adverse effects, and dissatisfaction with the information they received about their disease. The findings reported in this study are informative to hemato-oncologists and other healthcare providers who care for patients with MM in Palestine and other developing and resource-limited countries. Policymakers might use the findings reported in this study to design interventions to improve the HR-QoL of the patients.

Postoperative Outcomes in Total Hip and Total Knee Arthroplasty for Patients Who Have Multiple Myeloma

BACKGROUND

Advancements in oncologic care have increased the longevity of patients who have multiple myeloma, although outcomes beyond the early postoperative period following total hip arthroplasty (THA) and total knee arthroplasty (TKA) remain unknown. This study investigated the influence of preoperative factors on implant survivorship following THA and TKA after a minimum 1-year interval for multiple myeloma patients.

METHODS

Using our institutional database, we identified 104 patients (78 THAs, 26 TKAs) from 2000 to 2021 diagnosed with multiple myeloma before their index arthroplasty by International Classification of Diseases, Ninth and Tenth Revisions (ICD-9 and ICD-10) codes 203.0× and C90.0× and corresponding Current Procedural Terminology (CPT) codes. Demographic data, oncologic treatments, and operative variables were collected. Multivariate logistic regressions assessed variables of interest, and Kaplan-Meier curves were used to estimate implant survival.

RESULTS

There were 9 (11.5%) patients who underwent revision THA after an average time of 1,312 days (range, 14 to 5,763), with infection (33.3%), periprosthetic fracture (22.2%), and instability (22.2%) being the most common indications. Of these patients, 3 (33.3%) underwent multiple revision surgeries. There was 1 (3.8%) patient who underwent revision TKA at 74 days postoperatively for infection. Patients treated with radiotherapy were more likely to require revision THA (odds Rratio (OR): 6.551, 95% confidence interval (CI): 1.148-53.365, P = .045), but no predictors of failure were identified for TKA patients.

CONCLUSION

Orthopaedic surgeons should know that multiple myeloma patients have a relatively high risk of revision, particularly following THA. Accordingly, patients who have risk factors for failure should be identified preoperatively to avoid poor outcomes.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

HOXC Cluster Antisense RNA 3, a Novel Long Non-Coding RNA as an Oncological Biomarker and Therapeutic Target in Human Malignancies

HOXC cluster antisense RNA 3 (HOXC-AS3) is a novel long noncoding RNA (lncRNA) that exhibits aberrant expression patterns in various cancer types. Its expression is closely related to clinicopathological features, demonstrating significant clinical relevance across multiple tumors. And HOXC-AS3 plays multifaceted roles in tumor progression, impacting cell proliferation, apoptosis, migration, invasion, epithelial-mesenchymal transition (EMT), autophagy, senescence, tumor growth, and metastasis. In this review, we summarized and comprehensively analyzed the expression and clinical significance of HOXC-AS3 as a diagnostic and prognostic biomarker for malignancies. Additionally, we presented an in-depth update on HOXC-AS3's functions and regulatory mechanisms in cancer pathogenesis. This narrative review underscores the importance of HOXC-AS3 as a promising lncRNA candidate in cancer research and its potential as a predictive biomarker and therapeutic target in clinical applications.

Bone marrow vasculature advanced in vitro models for cancer and cardiovascular research

Cardiometabolic diseases and cancer are among the most common diseases worldwide and are a serious concern to the healthcare system. These conditions, apparently distant, share common molecular and cellular determinants, that can represent targets for preventive and therapeutic approaches. The bone marrow plays an important role in this context as it is the main source of cells involved in cardiovascular regeneration, and one of the main sites of liquid and solid tumor metastasis, both characterized by the cellular trafficking across the bone marrow vasculature. The bone marrow vasculature has been widely studied in animal models, however, it is clear the need for human-specific in vitro models, that resemble the bone vasculature lined by endothelial cells to study the molecular mechanisms governing cell trafficking. In this review, we summarized the current knowledge on in vitro models of bone marrow vasculature developed for cardiovascular and cancer research.

Multiple Myeloma Rather Than Metastatic Lung Cancer: An Unexpected Cause of Spinal Cord Compression

Spinal cord compression caused by cancer metastasis is a medical emergency that should be managed positively. Both multiple myeloma and lung cancer can lead to metastatic deposits in the spinal column to induce compression of the spinal cord. However, co-occurring multiple myeloma and lung cancer in a single patient causing spinal cord compression are rarely reported in the literature. We describe a case of a 61-year-old female with multiple myeloma and lung cancer whose radiologic characteristics of spinal cord compression mimicked those of metastatic lung cancer. Finally, the diagnosis was multiple myeloma. We showed the systematic imaging manifestations of metastatic multiple myeloma and discussed their therapeutic management.

Recent developments in nanomaterials for upgrading treatment of orthopedics diseases

Nanotechnology has changed science in the last three decades. Recent applications of nanotechnology in the disciplines of medicine and biology have enhanced medical diagnostics, manufacturing, and drug delivery. The latest studies have demonstrated this modern technology's potential for developing novel methods of disease detection and treatment, particularly in orthopedics. According to recent developments in bone tissue engineering, implantable substances, diagnostics and treatment, and surface adhesives, nanomedicine has revolutionized orthopedics. Numerous nanomaterials with distinctive chemical, physical, and biological properties have been engineered to generate innovative medication delivery methods for the local, sustained, and targeted delivery of drugs with enhanced therapeutic efficacy and minimal or no toxicity, indicating a very promising strategy for effectively controlling illnesses. Extensive study has been carried out on the applications of nanotechnology, particularly in orthopedics. Nanotechnology can revolutionize orthopedics cure, diagnosis, and research. Drug delivery precision employing nanotechnology using gold and liposome nanoparticles has shown especially encouraging results. Moreover, the delivery of drugs and biologics for osteosarcoma is actively investigated. Different kind of biosensors and nanoparticles has been used in the diagnosis of bone disorders, for example, renal osteodystrophy, Paget's disease, and osteoporosis. The major hurdles to the commercialization of nanotechnology-based composite are eventually examined, thus helping in eliminating the limits in connection to some pre-existing biomaterials for orthopedics, important variables like implant life, quality, cure cost, and pain and relief from pain. The potential for nanotechnology in orthopedics is tremendous, and most of it looks to remain unexplored, but not without challenges. This review aims to highlight the up tp date developments in nanotechnology for boosting the treatment modalities for orthopedic ailments. Moreover, we also highlighted unmet requirements and present barriers to the practical adoption of biomimetic nanotechnology-based orthopedic treatments.

Dynamics of Bone Disease Biomarkers Dickkopf-1 and Sclerostin in Patients with Multiple Myeloma

Dickkopf-1 (DKK-1) and sclerostin are essential Wnt/β-catenin pathway inhibitors, playing an important role in multiple myeloma bone disease (MBD). We aimed to examine the serum DKK-1 and sclerostin variations in newly diagnosed multiple myeloma (NDMM) patients at diagnosis and in the course of therapy, including autologous stem cell transplantation (ASCT). This study included 41 NDMM-patients and 33 controls. MBD was assessed by whole-body low-dose computed tomography. DKK-1 and sclerostin were assayed by commercial ELISA kits. At diagnosis, NDMM-patients revealed significantly higher DKK-1 and sclerostin values (p < 0.0001), showing dependence on disease stage (lowest in ISS-I and highest in ISS-III: p < 0.0012 and p < 0.025, respectively, for both proteins). Bone lesions revealed significant positive correlation with both DKK-1 (p < 0.05) and sclerostin (p < 0.0001). In the course of therapy, significant reduction, more prominent after ASCT, was observed for both parameters in each treatment point compared to the baseline (p < 0.0001). Markedly lower sclerostin (p < 0.01) and DKK-1 (p < 0.05) values were observed in patients with complete and very good partial response compared to those with partial response, stable, or progressive disease. Sclerostin and DKK-1 in NDMM patients reflect the MBD severity and the effect of therapy. Both proteins could represent a novel tool for better disease monitoring and effectiveness of therapy.

Hypophosphatemia in Patients With Multiple Myeloma

Hypophosphatemia is among the most common electrolyte abnormalities, especially among patients with underlying malignancies, and is frequently associated with adverse prognoses. Phosphorus levels are regulated through a number of mechanisms, including parathyroid hormone (PTH), fibroblast growth factor-23 (FGF-23), vitamin D, and other electrolyte levels themselves. Clinically, the findings are nonspecific, and the diagnosis is frequently delayed. This article is a narrative literature review. The PubMed database was searched for relevant articles pertaining to hypophosphatemia causes and consequences in patients suffering from multiple myeloma. We found a variety of causes of hypophosphatemia in patients with multiple myeloma. Tumor-induced osteopenia, although more common among patients with small squamous cell carcinomas, can occur with multiple myeloma as well. Additionally, both light chains themselves and medications can trigger Fanconi syndrome, which leads to phosphorus wasting by the kidney. Bisphosphonates, in addition to being a possible cause of Fanconi syndrome, lead to a decrease in calcium levels, which then stimulates parathyroid hormone (PTH) release, predisposing the patient to significant hypophosphatemia. Additionally, many of the more modern medications used to manage multiple myeloma have been associated with hypophosphatemia. A better understanding of those mechanisms may give clinicians a clearer idea of which patients may need more frequent screening as well as what the potential triggers in the individual patient may be.

Re-expansion of vertebral compression fractures in patients with multiple myeloma with percutaneous vertebroplasty using spinejack implants: a preliminary and retrospective study

Objective

To retrospectively evaluate the feasibility and effectiveness of vertebroplasty using Spinejack implantation for the treatment and stabilization of painful vertebral compression fractures, in patients diagnosed with Multiple Myeloma (MM), to allow both an effective pain reduction and a global structural spine stabilization.

Materials and Methods

From July 2017 and May 2022 thirty-nine patients diagnosed MM, with forty-nine vertebral compression fractures underwent percutaneous Vertebroplasty using Spinejack Implants. We analyzed the feasibility and complications of the procedure, the decrease in pain using visual analogue scale (VAS) and Functional Mobility Scale (FMS).

Results

The technical success rate was 100%. No procedure-related major complications or death occurred. In the 6-month follow-up, the mean VAS score decreased from 5.4 ± 1.0 to 0.2 ± 0.5 with a mean reduction of 96.3%. FMS decreased from 2.3 ± 0.5 vs. 1.2 ± 0.4 with a mean reduction of -47.8%. There were no major complications related to incorrect positioning of the Expandable Titanium SpineJack Implants. In five patients, a cement leak was observed with no associated clinical manifestations. The average length of hospital stay was 6-8 Hours6.6 ± 1.2 h. No new bone fractures or local disease recurrence occurred during a median contrast-enhanced CT follow-up of 6 months.

Conclusions

Our results suggest that vertebroplasty, using Spinejack implantation for the treatment and stabilization of painful vertebral compression fractures, secondary to Multiple Myeloma is a safe and effective procedure with long - term pain relief and restoration of vertebral height.

The molecular mechanism of Gorham syndrome: an update

Gorham syndrome, also known as "vanishing osteopathy" and "invasive hemangiomatosis," is a rare clinical syndrome whose etiology is unknown and can invade the whole-body skeleton. At present, more than 300 cases have been reported at home and abroad, usually manifesting as spontaneous chronic osteolysis with no periosteal reaction at the lysis site and occult onset, often with fractures, scoliosis, chylothorax, etc. When waiting for medical treatment, the condition is serious, and the prognosis is poor. At present, there is no effective treatment. The main pathological manifestations of Gorham syndrome are the non-neoplastic abnormal proliferation of lymphatic vessels or blood vessels and osteolysis caused by osteoclast proliferation or increased activity. At present, there is no unified conclusion regarding Gorham syndrome's pathogenesis. This paper starts with the two most studied osteolysis methods at present, osteoclast osteolysis and osteolysis caused by vascular and lymphatic proliferation and summarizes the corresponding most possible molecular mechanisms in recent years to provide more ideas for Gorham syndrome treatment.

Luteolin inhibits the TGF-β signaling pathway to overcome bortezomib resistance in multiple myeloma

Multiple myeloma (MM) is an incurable condition and the second most common hematological malignancy. Over the past few years, there has been progress in the treatment of MM, but most patients still relapse. Multiple myeloma stem-like cells (MMSCs) are believed to be the main reason for drug resistance and eventual relapse. Currently, there are not enough therapeutic agents that have been identified for eradication of MMSCs, and thus, identification of the same may alleviate the issue of relapse in patients. In the present study, we showed that luteolin (LUT), a natural compound obtained from different plants, such as vegetables, medicinal herbs, and fruits, effectively inhibits the proliferation of MM cells and overcomes bortezomib (BTZ) resistance in them in vitro and in vivo, mainly by decreasing the proportion of ALDH1⁺ cells. Furthermore, RNA sequencing after LUT treatment of MM cell lines and an MM xenograft mouse model revealed that the effects of the compound are mediated through inhibition of transforming growth factor-β signaling. Similarly, we found that LUT also significantly reduced the proportion of ALDH1⁺ cells in primary CD138⁺ plasma cells. In addition, LUT could overcome the BTZ treatment-induced increase in the proportion of ALDH1⁺ cells, and the combination of LUT and BTZ had a synergistic effect against myeloma cells. Collectively, our findings suggested that LUT is a promising agent that manifests MMSCs to overcome BTZ resistance, alone or in combination with BTZ, and thus, is a potential therapeutic drug for the treatment of MM.

Murine models of orthopedic infection featuring Staphylococcus aureus biofilm

Introduction: Osteomyelitis remains a major clinical challenge. Many published rodent fracture infection models are costly compared with murine models for rapid screening and proof-of-concept studies. We aimed to develop a dependable and cost-effective murine bone infection model that mimics bacterial bone infections associated with biofilm and metal implants. Methods: Tibial drilled hole (TDH) and needle insertion surgery (NIS) infection models were compared in C57BL/6 mice (female, N = 150 ). Metal pins were inserted selectively into the medullary canal adjacent to the defect sites on the metaphysis. Free Staphylococcus aureus (ATCC 12600) or biofilm suspension (ATCC 25923) was locally inoculated. Animals were monitored for physiological or radiographic evidence of infection without prophylactic antibiotics for up to 14 d. At the end point, bone swabs, soft-tissue biopsies, and metal pins were taken for cultures. X-ray and micro-CT scans were performed along with histology analysis. Results: TDH and NIS both achieved a 100 % infection rate in tibiae when a metal implant was present with injection of free bacteria. In the absence of an implant, inoculation with a bacterial biofilm still induced a 40 %-50 % infection rate. In contrast, freely suspended bacteria and no implant consistently showed lower or negligible infection rates. Micro-CT analysis confirmed that biofilm infection caused local bone loss even without a metal implant as a nidus. Although a metal surface permissive for biofilm formation is impermeable to create progressive bone infections in animal models, the metal implant can be dismissed if a bacterial biofilm is used. Conclusion: These models have a high potential utility for modeling surgery-related osteomyelitis, with NIS being simpler to perform than TDH.

Hotspots and trends in multiple myeloma bone diseases: A bibliometric visualization analysis

Objective: This study aims to explore the research hotspots and trends of multiple myeloma bone disease in the past 20 years by bibliometric visualization analysis.

Methods: With the Web of Science Core Collection database as the data source, the relevant publications of multiple myeloma bone disease from 2002 to 2021 are retrieved. These data are analyzed using software CiteSpace 5.8.R3 and Scimago Graphica 1.0.24, together with the Online Analysis Platform of Literature Metrology.

Results: A total of 6,168 published research papers, including 4668 articles and 1500 review papers, are included in this study. Generally speaking, annual publications and citations are on the rise, especially in recent 2 years. The majority of these papers are published in the United States, with Mayo Clinic being the greatest contributor. The most productive journal and author are Blood and Terpos E, respectively, while the most frequently co-cited reference, author and journal are Rajkumar et al., 2014, Lancet Oncol, Kyle RA and Blood, respectively. The major research subject categories are oncology and hematology. The “disease diagnosis”, “prognosis evaluation”, “pathogenesis”, “imaging technology” and “targeted therapy” are recent research frontiers. The burst keywords “transplantation”, “progression”, “activation”, “lenalidomide”, “flow cytometry”, “drug resistance”, “management” and “mesenchymal stem cell” reflect the latest research hotspots.

Conclusion: This study reveals the research hotspots and trends of multiple myeloma bone disease through bibliometric visualization analysis, and provides a valuable reference for further research.

Recent developments on the application of molecular probes in multiple myeloma: Beyond [18F]FDG

Multiple myeloma (MM) is a neoplastic plasma cell proliferative disorder characterized by various osteolytic bone destruction as a radiological morphological marker. Functional imaging, particularly nuclear medicine imaging, is a promising method to visualize disease processes before the appearance of structural changes by targeting specific biomarkers related to metabolism ability, tumor microenvironment as well as neoplastic receptors. In addition, by targeting particular antigens with therapeutic antibodies, immuno-PET imaging can support the development of personalized theranostics. At present, various imaging agents have been prepared and evaluated in MM at preclinical and clinical levels. A summary overview of molecular functional imaging in MM is provided, and commonly used radiotracers are characterized.

Gain of function of a metalloproteinase associated with multiple myeloma, bicuspid aortic valve, and Von Hippel-Lindau syndrome

A patient diagnosed with multiple myeloma, bicuspid aortic valve, and Von Hippel-Lindau syndrome underwent whole-exome sequencing seeking a unified genetic cause for these three pathologies. The patient possessed a single-point mutation of arginine to cysteine (R24C) in the N-terminal region(pro-domain) of matrix metalloproteinase 9 (MMP-9). The pro-domain interacts with the catalytic site of this enzyme rendering it inactive. MMP-9 has previously been associated with all three pathologies suffered by the patient. We hypothesized that the observed mutation in the pro-domain would influence the activity of this enzyme. We expressed recombinant versions of MMP-9 and an investigation of their biochemical properties revealed that MMP-9 R24C is a constitutively active zymogen. To our knowledge, this is the first example of a mutation that discloses catalytic activity in the pro-form in any of the 24 human MMPs.

Pathogenesis and treatment of multiple myeloma

Multiple myeloma (MM) is the second‐ranking malignancy in hematological tumors. The pathogenesis of MM is complex with high heterogeneity, and the development of the disease is a multistep process. Chromosomal translocations, aneuploidy, genetic mutations, and epigenetic aberrations are essential in disease initiation and progression. The correlation between MM cells and the bone marrow microenvironment is associated with the survival, progression, migration, and drug resistance of MM cells. In recent decades, there has been a significant change in the paradigm for the management of MM. With the development of proteasome inhibitors, immunomodulatory drugs, monoclonal antibodies, chimeric antigen receptor T‐cell therapies, and novel agents, the survival of MM patients has been significantly improved. In addition, nanotechnology acts as both a nanocarrier and a treatment tool for MM. The properties and responsive conditions of nanomedicine can be tailored to reach different goals. Nanomedicine with a precise targeting property has offered great potential for drug delivery and assisted in tumor immunotherapy. In this review, we summarize the pathogenesis and current treatment options of MM, then overview recent advances in nanomedicine‐based systems, aiming to provide more insights into the treatment of MM.

Synthesis and Evaluation of Structurally Diverse C-2-Substituted Thienopyrimidine-Based Inhibitors of the Human Geranylgeranyl Pyrophosphate Synthase

Novel analogues of C-2-substituted thienopyrimidine-based bisphosphonates (C2-ThP-BPs) are described that are potent inhibitors of the human geranylgeranyl pyrophosphate synthase (hGGPPS). Members of this class of compounds induce target-selective apoptosis of multiple myeloma (MM) cells and exhibit antimyeloma activity in vivo. A key structural element of these inhibitors is a linker moiety that connects their (((2-phenylthieno[2,3-d]pyrimidin-4-yl)amino)methylene)bisphosphonic acid core to various side chains. The structural diversity of this linker moiety, as well as the side chains attached to it, was investigated and found to significantly impact the toxicity of these compounds in MM cells. The most potent inhibitor identified was evaluated in mouse and rat for liver toxicity and systemic exposure, respectively, providing further optimism for the potential value of such compounds as human therapeutics.

Anti-Multiple Myeloma Potential of Secondary Metabolites from Hibiscus sabdariffa-Part 2

Multiple Myeloma (MM) is an aggressive tumor causing millions of deaths every year and currently available therapies are often unsuccessful or correlated with severe side effects. In our previous work we demonstrated that the Hibiscus sabdariffa hydroalcoholic extract inhibits the growth of the MM cell line and we isolated two metabolites responsible for the activity: Hib-ester and Hib-carbaldehyde. Herein we report their interaction with proteasome, one of the main targets in the fight against MM. The molecular modelling study outlined a good interaction of both compounds with the target and these results prompted us to investigate their potential to inhibit proteasome. Metabolites were then isolated from the calyces and an extract with a high content of Hib-ester and Hib-carbaldehyde was prepared. An anticancer profile was drawn, evaluating apoptosis, autophagy and proteasome inhibition, with the anticancer properties being mainly attributed to the Hib-ester and Hib-carbaldehyde, while the proteasome inhibition of the extract could also be ascribed to the presence of anthocyanins, a class of secondary metabolites already known for their proteasome inhibitory activity.