M ET ABOL I SM CL IN I CA L A N D E XP E RI ME N TAL 80 ( 20 1 8 ) 8 0– 90

Available online at www.sciencedirect.com

Metabolism
www.metabolismjournal.com

Biology and treatment of myeloma related

bone disease

Evangelos Terpos⁎, Dimitrios Christoulas, Maria Gavriatopoulou

Department of Clinical Therapeutics, University of Athens School of Medicine, Alexandra General Hospital, Athens, Greece

A R T I C LE I N FO AB S T R A C T

Article history: Myeloma bone disease (MBD) is the most common complication of multiple myeloma (MM),
Received 20 July 2017 resulting in skeleton-related events (SREs) such as severe bone pain, pathologic fractures,
Accepted 18 November 2017 vertebral collapse, hypercalcemia, and spinal cord compression that cause significant
morbidity and mortality. It is due to an increased activity of osteoclasts coupled to the
Keywords: suppressed bone formation by osteoblasts. Novel molecules and pathways that are
Multiple myeloma implicated in osteoclast activation and osteoblast inhibition have recently been described,
Bone disease including the receptor activator of nuclear factor-kB ligand/osteoprotegerin pathway,
Receptor activator of nuclear factor- activin-A and the wingless-type signaling inhibitors, dickkopf-1 (DKK-1) and sclerostin.
kB ligand (RANKL) These molecules interfere with tumor growth and survival, providing possible targets for the
Wnt pathway development of novel drugs for the management of lytic disease in myeloma but also for the
treatment of MM itself. Currently, bisphosphonates are the mainstay of the treatment of
myeloma bone disease although several novel agents such as denosumab and sotatercept
appear promising. This review focuses on recent advances in MBD pathophysiology and
treatment, in addition to the established therapeutic guidelines.
© 2017 Elsevier Inc. All rights reserved.

1. Introduction
Multiple myeloma (MM) is a relatively common hematological
malignancy characterized by the accumulation of abnormal
plasma cells in the bone marrow, the production of a monoclonal
protein present in the blood or urine, and associated organ
dysfunction presenting with osteolytic bone destruction, hyper-
calcemia, renal failure, anemia, and an increased risk for
infections. Myeloma Bone disease (MBD), in the form of lytic
lesions or osteopenia due to increased osteoclast activity,
accompanied by suppressed osteoblast function is one of the
devastating consequences of myeloma [1]. MM cells inhibit
osteoblast differentiation and stimulate osteoclast function,
resulting in bone resorption and consequent MBD. In turn,
growth factors released by the increased bone resorptive process,
also increase the growth of MM cells, creating a vicious cycle of
tumor expansion and bone destruction. New insights into the
pathophysiology have enhanced our understanding of myeloma
cell growth and bone destruction. The biologic pathway of the
receptor activator of nuclear factor-kappa B (RANK), its ligand
(RANKL), and osteoprotegerin (OPG) which is the decoy receptor
of RANKL is of major importance for the increased osteoclast
activity observed in MM [2]. More recently, activin-A has been
implicated in MM bone disease, through stimulating RANK
expression and inducing osteoclastogenesis [3]. On the other
hand, Wnt signaling pathway inhibitors, such as dickkopf-1
(DKK-1) and sclerostin, are important inhibitors of osteoblast
function [4,5]. These insights will probably lead to better bone-
directed therapies aimed at restoring bone homeostasis by
targeting either osteoclast or osteoblast activity. This review
summarizes the latest available data for the mechanisms of bone
destruction in MM and novel agents targeting MBD. (See Fig. 1.)

⁎ Corresponding author at: Department of Clinical Therapeutics, University of Athens School of Medicine, Alexandra General Hospital, 80 Vas.
Sofias Avenue, 11528 Athens, Greece.
E-mail addresses: eterpos@med.uoa.gr, eterpos@hotmail.com (E. Terpos).

https://doi.org/10.1016/j.metabol.2017.11.012
0026-0495/© 2017 Elsevier Inc. All rights reserved.
 M ET ABOL I SM CL IN I CA L A N D E XP E RI ME N TAL 8 0 ( 20 1 8 ) 8 0– 9 0
Fig. 1 – Schematic overview of myeloma bone disease pathophysiology. Novel therapeutic targets are highlighted.
2. Normal Bone Remodeling
Normal bone consists of a mineralized part and an organic
part, made of collagen and non-collagen proteins. Osteocytes,
osteoclasts, and osteoblasts maintain homeostasis in normal
physiologic states by balancing bone formation and bone
resorption. Osteocytes make up 90% to 95% of all bone cells,
and osteoclasts and osteoblasts make up fewer than 10% [6].
Osteoclasts are multinucleated cells originating from hemato-
poietic stem cells committed to monocyte–macrophage lineage.
They contain certain proteins, such as tartrate-resistant acid
phosphatase (TRAP), tartrate-resistant trinucleotide phospha-
tase, carbonic anhydrase II, calcitonin receptors, and a few
cathepsins (lysosomal proteases) [7], whose main function is
bone resorption. Osteoblasts are mononuclear cells originating
from mesenchymal stem cells. They contain the enzyme
alkaline phosphatase, which is used as a marker of osteoblastic
activity [8]. Their normal location is near the bone surface where
new bone is laid down and their main function is bone
formation, by collagen synthesis, osteocalcin production, and
mineralization [9]. Osteoblasts that become a part of mineralized
matrix are called osteocytes. Bone remodeling is a continuous
process, consisting of old bone resorption (osteoclastic activity)
and new bone formation (osteoblastic activity). This process is
well balanced in a normal person to keep the bones in healthy
form [10]. Osteocytes serve as the main regulators of bone
homeostasis between osteoclasts and osteoblasts by secreting
several cytokines that regulate the activity of these cells, such as
sclerostin, DKK1, RANKL, and OPG [6].
Osteoclasts are regulating RANK, its ligand RANKL, and
OPG signaling pathway. RANK-RANKL signaling activates
81
downstream signaling pathways required for osteoclast
development, differentiation, and maturation. RANK is a
transmembrane signaling receptor, member of the tumor
necrosis receptor superfamily, which is mainly expressed on
the surface of osteoclast precursors, produced by bone marrow
stromal cells (BMSCs), osteoblasts, and activated T-lymphocytes
[11,12]. Its expression is induced by cytokines that stimulate
bone resorption [13] such as parathyroid hormone (PTH), 1,25-
dihydroxyvitamin D3 and prostaglandins [14,15]. Interestingly,
apoptotic osteocytes express RANKL stimulating osteoclast
differentiation [16] and recruiting them to sites of remodeling.
The important role of RANKL in normal osteoclastogenesis has
been clearly shown in RANKL or RANK gene knockout mice.
These animals lack osteoclasts, and as result develop severe
osteopetrosis [17–19]. OPG is a soluble decoy receptor for RANKL,
member of the tumor necrosis factor receptor superfamily
[20]. It is produced by osteoblasts, as well as BMSCs and blocks
the interactions of RANKL with RANK, thereby limiting
osteoclastogenesis. It is regulated by interleukin 1 beta (IL-1b),
tumor necrosis factor alpha (TNF-a), transforming growth factor
beta (TGF-b), estradiol and 17b-estriol. OPG-deficient mice
develop severe osteopenia and osteoporosis [21–23]. In normal
subjects, the RANKL/OPG ratio is very low. However, an
abnormal RANKL/OPG ratio is found both in benign and
malignant bone diseases [24].
Osteocytes also regulate osteoblasts by secreting
sclerostin and DKK1, which block canonical Wnt signaling
pathway via binding to low-density lipoprotein receptor–
related proteins 5 and 6 (LRP5/LRP6) on the surface of
osteoblasts [6]. Binding of Wnt glycoproteins to the Wnt
receptor and its co-receptors LRP5/LRP6 leads to stabilization
of β-catenin. In turn, β-catenin accumulates in cytoplasm,
82 M ET ABOL I SM CL IN I CA L A N D E XP E RI ME N TAL 80 ( 20 1 8 ) 8 0– 90
translocates into the nucleus and stimulates expression
of osteoblastic target genes [25]. If the Wnt signal is blocked,
β-catenin is phosphorylated and degraded by the proteasome.
There are many ways of Wnt signaling pathway inhibition:
Members of the dickkopf (DKK) family bind to the LRP5/LRP6
component of the Wnt receptor complex, while secreted
frizzled-related proteins (sFRP), such as sFRP-2 and sFRP-3,
bind to Wnt proteins. Sclerostin inhibits the Wnt pathway by
antagonizing Wnt proteins for the binding to LRP-5/6 receptor.
All result in a suppression of Wnt-signaling and a reduced
osteoblast function.
Besides the central role of osteocytes, osteoblasts and
BMSCs also express OPG and RANKL and regulate osteoclast
differentiation. Because OPG is a Wnt canonical signaling target
[26], osteocytes also regulate osteoclast differentiation via
regulation of Wnt signaling pathway activity in osteoblasts.
However, osteoclasts express semaphorin 4D (SEMA4D), which
inhibits osteoblast differentiation [27].
3. Bone Disease in MM
In MM, the osteocyte-osteoclast-osteoblast axis is disrupted,
leading to an uncoupled bone remodeling, in which bone
construction decreases and bone resorption increases [28].
Dysregulation of osteoblasts and osteoclasts serves as the
key process in the pathogenesis of myeloma bone disease.
Increased osteoclasts’ activity in MM patients will promote
bone resorption, while suppression of osteoblasts’ activity
can lead to impaired bone formation, with the consequent
formation of pathognomonic osteolytic lesions. In turn,
growth factors released by the increased bone resorptive
process, also increase the growth of MM cells, creating a
vicious cycle of tumor expansion and bone destruction.
MDB is distinct from other metastatic diseases as there is
no bone formation whereas in cancers like prostate and
breast, the osteoclastic, as well as osteoblastic activity, is
increased [29].
In a prospective, single center study on myeloma patients
using femoral neck dual energy X-ray absorptiometry (DXA)
and lumbar spine quantitative computed tomography (QCT),
66% of patients had osteoporosis defined by either lumbar spine
or femoral neck bone density (T-score <−2.5). The severity
of osteoporosis, as defined by initial BMD T-score values,
significantly impacted on patient survival [30]. In another
population-based retrospective cohort study, 165 patients
with myeloma were followed for 537 person-years. In the year
before diagnosis, 16 times more fractures were observed than
expected, mostly pathologic fractures of the vertebrae and ribs.
Subsequently, there was a 9-fold increase in fracture risk [31].
The clinical and economic impact of the associated bone pain,
pathological fractures requiring surgery and/or radiation to
bone, spinal cord compression and hypercalcaemia can be
devastating [32].
3.1. Pathogenesis of the Increased Osteoclast Activity
in Myeloma
The pathogenesis of bone disease in MM is primarily the result
of generalized osteoclast activation. Bone marrow biopsies
from patients with MM show a correlation among tumor
burden, osteoclast numbers, and resorptive surface [33,34].
Osteoclast activity also reflects disease activity [2,35]. The
adherence of abnormal myeloma cells in the BMSCs, through
the binding of vascular cell adhesion molecule-1 (VCAM-1) on
stromal cells and α4β1 integrin on MM cells, leads to the
upregulation of a broad spectrum of factors which stimulate
osteoclast formation, differentiation and activity, as well as
suppression of negative regulators of osteoclastogenesis. These
cytokines and chemokines include macrophage-colony stimu-
lating factor (M-CSF), interleukin-6 (IL-6), IL-1α, IL-1β, IL-11, C-C
motif ligand 3 (CCL3, also known as macrophage inflammatory
protein 1-alpha, MIP-1-α), tumor necrosis factor-alpha and beta
(TNF-α, -β), parathyroid hormone-related peptide (PTHrP), and
vascular endothelial growth factor (VEGF) [36–38]. However,
over the last years it has been established that the RANKL and
OPG system plays the major role in osteoclastogenesis in MM.
3.1.1. The RANK/RANKL Signaling Pathway
An increase in the RANKL/OPG ratio results in bone loss in
inflammatory diseases, including rheumatoid arthritis and in
several cancers [39–41]. Myeloma cells promote an imbalance in
the RANKL/OPG system in the tumor microenvironment: OPG
expression is decreased, whereas RANKL expression is upregu-
lated in bone marrow biopsies of MM patients [42]. Several
studies show that myeloma cells both induce the RANKL
expression by stromal cells within the bone microenvironment
through direct cell to cell contact [43] and directly express RANKL
[44–46]. On the other hand, myeloma cells decrease the
OPG availability within the bone microenvironment through
reducing OPG secretion by osteoblasts and stromal cells [47].
They also produce syndecan-1 (CD138), a transmembrane proteo-
glycan that binds to the heparin-binding domain of OPG and
mediates its internalization and consecutively lysosomal degra-
dation by myeloma cells [48]. The combination of these effects
results in an increased RANKL/OPG ratio in the bone marrow
microenvironment that favors the formation and activation of
osteoclasts. A positive correlation is seen between the number of
osteolytic lesions and increasing levels of serum RANKL [45].
Among patients with MM, those with lower levels of total
RANKL exhibit a significantly longer progression-free survival
(PFS) compared with other patients [49]. Levels of OPG and
RANKL correlate with poor prognosis and severity of bone
disease [2]. Therefore, the RANKL-OPG axis is an important
target in the development of novel therapeutic strategies for
MM bone disease.
3.1.2. Activin-A
Activin-A is a dimeric multifunctional glycoprotein, member of
the transforming growth factor-β (TGF-β) superfamily. Activin-A
regulates a broad spectrum of biological functions, including
hormonal homeostasis, gonadal function, inflammation, muscle
growth and immunity [50,51]. Osteoblasts produce follistatin (an
activin-A antagonist) and activin-A in a differentiation-
dependent manner, leading to autocrine regulation of extracel-
lular matrix formation and mineralization [52]. Activin-A stimu-
lates osteoclasts and has possibly inhibitory effects on osteoblast
function [53,54]. It is elevated in myeloma patients with advanced
disease and correlates with adverse disease features, including
inferior survival and extensive bone disease [55].
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3.2. Osteoblast Function is Also Impaired in MM
In the early phase of MM there is an up-regulation of osteoblast
precursors [28]. The interaction of MM cells with BMSCs initiates
the production of IL-1 and TNFα; in turn, these cytokines recruit
osteoblasts that produce IL-6, a potent myeloma cell growth
factor. Nevertheless, as disease progresses, osteoblast function
and maturation are inhibited, resulting in net osteolysis, as the
reducing bone formation rate fails to counter increased
resorption [56]. In bone biopsies from MM patients,
histomorphometric evaluation of osteoblast activity has
revealed osteoblast inhibition, since no evidence of bone
regeneration was detectable within the skeleton lesions or in
their vicinity [57]. Osteoblast apoptosis is markedly increased
due to high cytokine levels and physical interaction between
osteoblasts and MM cells. In vitro studies revealed that
osteoblast growth and function are inhibited when cocultured
with myeloma cells or in medium conditioned by myeloma
cells, suggesting that this effect is due to soluble osteoblast
inhibiting factors [57]. Once deregulated by these inhibitory
factors, the osteoblast function remains almost permanently
ineffective after conventional chemotherapy even in responding
patients. In recent years, more studies are focusing on the
osteoblast-related inhibitory pathways [58]. Functional exhaus-
tion of osteoblasts has been also postulated by the inverse
relation between biochemical indicators of osteoid production,
namely serum osteocalcin and bone-specific alkaline phospha-
tase, and the presence of osteolytic lesions.
3.2.1. Dickkopf-1 (DKK-1) Protein
DKK-1 is expressed by osteoblasts and BMSCs and it antagonizes
the Wnt pathway resulting in inhibition of osteoblasts matura-
tion and new bone formation. DKK-1 is also secreted by myeloma
cells and has been shown to inhibit differentiation of osteoblast
precursor cells in vitro. In MM patients with lytic lesions,
immunohistochemical analysis of bone marrow biopsies
showed that myeloma cells overexpress DKK-1. In fact, bone
marrow plasma from newly diagnosed MM patients contains
nearly 3 times more DKK-1 protein compared to control subjects
and DKK-1 is increased in the serum of MM patients as well [59].
Furthermore, gene expression levels and serum levels of DKK-1
correlate with the extent of bone disease [60,61]. As a result of
high expression of DKK1, mesenchymal stem cells do not
differentiate to osteoblasts [60]. On the other hand, since Wnt
signaling pathway in osteoblasts increases the expression of OPG
and downregulates the expression of RANKL [62,63], inhibition of
Wnt signaling pathway promotes osteoclastogenesis.
3.2.2. Sclerostin
Patients with active myeloma have elevated circulating
sclerostin, which correlates with advanced disease features
including severe bone disease. MM patients who present with
fractures at diagnosis have very high levels of circulating
sclerostin compared with all others, whereas sclerostin
correlates negatively with bone specific alkaline phosphatase
and positively with C-telopeptide of collagen type-1 (a bone
resorption marker) [64]. The source of sclerostin in MBD
remains to be defined, since very little or no sclerostin or
SOST messenger RNA expression in primary MM cells from
patients or MM cell lines has been detected [65,66].
83
4. Treatment
4.1. Bisphosphonates – The Mainstay of Therapy
Bisphosphonates are the standard of care for MBD.
Bisphosphonates are pyrophosphate analogues that inhibit
farnesyl pyrophosphate synthase [67]. They readily bind the
exposed mineralized bone and are taken up by osteoclast
during bone resorption, inhibiting osteoclast recruitment and
maturation, preventing the development of monocytes into
osteoclasts, inducing osteoclast apoptosis and interrupting
their attachment to the bone [68]. Before the advent of
effective bisphosphonate therapy, bone healing occurred
uncommonly in myeloma and was delayed in treated
patients, despite responses to chemotherapy.
Oral clodronate, intravenous pamidronate, and intrave-
nous zoledronic acid have been licensed for the management
of myeloma bone disease [69–72]. Etidronate and ibandronate
were found to be ineffective in myeloma patients [73,74].
4.1.1. Bisphosphonates Head to Head
A large phase III, randomized, double-blind, study was
performed to compare pamidronate to zoledronic acid [75].
There was no difference in time to the first skeletal related
event (SRE) between treatment groups, but the skeletal
morbidity rate was slightly higher in patients treated with
pamidronate. However, use of radiation to bone was signifi-
cantly higher in patients treated with pamidronate compared
with zoledronic acid (p = 0.018). A long-term extension phase
of this study confirmed the equivocal findings that zoledronic
acid and pamidronate had similar efficacy in reducing the risk
of skeletal-related events in MM patients [76]. In the Myeloma
IX trial (conducted by the Medical Research Council [MRC] of
the United Kingdom), zoledronic acid (4 mg IV every 3 to
4 weeks, dose adjusted based on creatinine clearance rates)
significantly reduced the proportion of patients with on-study
SREs compared with clodronate (1600 mg orally daily) in
patients with newly diagnosed, symptomatic MM [77]. After
a median follow-up of 3.7 years, 35% of patients receiving
clodronate had experienced SREs versus 27% of patients
receiving zoledronic acid (p = 0.004). Zoledronic acid also
reduced mortality by 16% (95% CI 4–26) versus clodronate
(hazard ratio [HR] 0.84, 95% CI 0.74–0.96; p = 0.0118), extended
median overall survival by 5.5 months (50 months, vs.
44.5 months, p = 0.04) and increased median progression-
free survival by 2 months (19.5 months, vs. 17.5 months; p =
0.07). These results confirm preclinical studies suggesting
direct anti-myeloma effect of zoledronic acid [78]. Possible
mechanisms include the expansion of gamma/delta T-cells
with possible anti-MM activity and the reduction of IL-6
secretion by bone marrow stromal cells.
4.1.2. Bisphosphonates Adverse-Events
Intravenous bisphosphonates have the potential to cause
acute or chronic renal dysfunction: approximately 12% of
patients with MM, breast cancer, or other solid tumors
evidenced renal deterioration (changes in serum creatinine)
at 24 months of treatment, although in the MRC Myeloma IX
trial [77] there was no difference regarding renal impairment
84 M ET ABOL I SM CL IN I CA L A N D E XP E RI ME N TAL 80 ( 20 1 8 ) 8 0– 90
between intravenous zoledronic acid and oral clodronate arms.
Kidneys, being responsible for 40% of bisphosphonates' excre-
tion via glomerular filtration and active tubular excretion, are
particularly sensitive to bisphosphonates. The nephrotoxicity is
related to the dose, infusion time, and maximum plasma
concentration that affect the intracellular bisphosphonate
concentration. Zoledronic acid dosages should be reduced in
patients who have preexisting renal impairment (creatinine
clearance of 30–60 mL/min). Zoledronic acid has not been
studied in patients with severe renal impairment; and it is not
recommended in this setting. Pamidronate 90 mg infused over
4–6 h is recommended for patients with extensive bone disease
and existing severe renal impairment [79]. After withholding
zoledronic acid or pamidronate in patients who develop renal
deterioration during therapy, bisphosphonate therapy can be
resumed, at previous dosage, when serum creatinine returns to
within 10% of baseline.
Osteonecrosis of the jaw (ONJ) is a rather uncommon (varying
from 2 to 10%), but potentially serious complication of
intravenous bisphosphonates, characterized by the presence
of exposed bone in the mouth [80,81]. Cumulative incidence of
ONJ increases with longer exposure. Invasive dental procedures
are a major risk factor for the development of ONJ [80]. Other
risk factors include poor oral hygiene, age, and duration of
myeloma. Zoledronic acid was associated with a higher
incidence of ONJ in retrospective evaluations [82]. This was
confirmed in the MRC Myeloma IX trial [77] in which zoledronic
acid was associated with higher rates of confirmed ONJ
(4%) than was clodronate (less than 1%; p < 0.0001). In
approximately one half of patients, ONJ lesions will heal [83],
but approximately one half of patients who restart bisphos-
phonate therapy after having stopped it will develop recurrence
of ONJ. Before initiation of bisphosphonates and during
treatment, dental status should be monitored and good
oral hygiene maintained. Dental conditions should be treated
before starting bisphosphonate therapy. Unnecessary invasive
dental procedures should be avoided. Where dental procedures
are required, patients should be treated conservatively,
minimizing invasive procedures. Temporary suspension of
bisphosphonates treatment should be considered if invasive
dental procedures are necessary. Preventive measures during
bisphosphonate treatment have the potential to reduce the
incidence of ONJ about 75% [84]. Antibiotic prophylaxis may
prevent ONJ occurrence after dental procedures [85]. Management
of patients depends on ONJ stage, ranging from oral antimicrobial
rinses to culture-directed long-term antimicrobial therapy and
surgical debridement/resection to reduce the volume of necrotic
bone [86]. Initial therapy of ONJ should include discontinuation
of bisphosphonates until healing occurs [87].
There is evidence that patients with osteoporosis using
nitrogen-containing bisphosphonates (pamidronate and zoledro-
nic acid) therapy have an increased risk of congestive heart failure
and atrial fibrillation. This potential risk should be weighed
against the reduction in the risk of osteoporotic fractures [88,89].
Bisphosphonates have been associated with atypical femoral
fractures (AFFs), rare fractures with a transverse, brittle mor-
phology [90]. The underlying cause of AFFs and their causal
relationship to bisphosphonates is unknown and prospective
studies investigating fracture pattern, microscopic bone pathol-
ogy and pharmacologic exposures should be conducted. A
recent study suggests that decreasing bone turnover through
long-term antiresorptive treatment not only changes bone’s
nanoscale material properties but also affects toughness on the
length scale of hundreds of micrometers through reductions in
extrinsic and intrinsic toughening mechanisms [91].
4.1.3. Optimal use of Bisphosphonates
Numerous guidelines have been published by different associa-
tions and study groups for the optimal use of bisphosphonates in
MM patients. The common resultant of all these, with little
variation, is that bisphosphonates should be administered
monthly over a 2-year period in patients with lytic bone disease
on plain radiographs and patients with osteopenia or osteopo-
rosis. The International Myeloma Working Group (IMWG)
recommends that bisphosphonates should be given until disease
progression in patients without a complete response or very
good partial response [87] based on the MRC Myeloma IX trial
findings of improvements in overall survival and reductions in
SREs in patients who received bisphosphonate treatment for
more than 2 years [92]. However, for patients with a complete
response or a very good partial response, the optimal duration of
bisphosphonates is an active area of investigation, given that
prolonged exposure to bisphosphonates may increase the risk
for side effects. Currently, the IMWG panel recommends 12 to
24 months of treatment (timed from the start of treatment) and
then continuation at the discretion of the provider. For those
patients who discontinue bisphosphonate use after 2 years, the
drug should be re-administered if relapse occurs.
Data from retrospective studies suggest that a reduced
schedule (monthly administration of zoledronic acid during the
first year and then every 3 months) may be safer than the
standard monthly schedule, while maintaining antiresorptive
efficacy [93]. Similar studies focusing in lowering bisphosphonate
dose have promising results: 30 mg of pamidronate vs. 90 mg did
not show any difference in skeletal related events between the
two doses tested [94]. Measurement of serum C-telopeptide
pyridinoline crosslinks of type I collagen (ICTP), serum carboxy-
terminal cross-linking telopeptide of type I collagen (CTX) and
urinary NTX (all markers of bone resorption) is recommended in
monitoring bone turnover during anti-myeloma therapies [95]
to establish their efficacy in bone disease. In this context, the
Z-MARK study evaluated efficacy and safety of less-frequent
zoledronic acid dosing based on bone turnover markers in
patients with 1 to 2 years of prior bisphosphonate therapy [96].
Patients received zoledronic acid (4 mg) every 4 or 12 weeks
based on urinary N-telopeptide of type 1 collagen (uNTX) levels
(every 4 weeks if uNTX ≥50 nmol/mmol creatinine, every
12 weeks if uNTX <50). Patients in whom an SRE or disease
progression developed were treated on the every-4-weeks
schedule thereafter. SRE occurred in only 5.8% of patients in
year 1 and 4.9% of patients in year 2, suggesting that less
frequent dosing of zoledronic acid beyond 1 to 2 years
maintains a low SRE rate and can be safely administered.
4.2. RANKL/RANK Pathway Regulators – Targeting
the Osteoclast
4.2.1. RANKL Inhibitors
Preclinical models of MM demonstrated that RANKL inhibition
can prevent bone destruction caused by myeloma cells. RANKL
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inhibition with recombinant RANK-Fc protein not only reduced
MM-induced osteolysis, but also caused a marked decline in
tumor burden [44,97]. Similar results were obtained using
recombinant OPG for the treatment of MM-bearing animals
[98]. These data gave the rationale for using RANKL inhibition in
the clinical setting.
Denosumab is a fully human monoclonal antibody that binds
RANKL with high affinity and specificity and inhibits RANKL-
RANK interaction, mimicking the endogenous effects of OPG. It is
highly specific because it binds only to RANKL and not to other
members of the TNF family, including TNF-α, TNF-β, TNF-related
apoptosis-inducing ligand, and CD40 ligand [99]. Denosumab
inhibits bone resorption, increases cortical and cancellous bone
mass, and improves trabecular microarchitecture in knock-in
mice that express chimeric (murine/human) RANKL [100].
Denosumab has been approved for increasing bone density in
patients with osteoporosis and for preventing SREs in patients
with metastatic bone disease [101].
In a phase I trial, 25 patients with MM with radiologically
confirmed bone lesions, received a single dose of either
denosumab or pamidronate. Denosumab decreased bone
resorption within 24 h of administration, as reflected by levels
of urinary and serum NTX. That was similar in magnitude but
more sustained than with intravenous pamidronate [102].
These results were confirmed in another phase I trial, in
which denosumab was given at multiple doses [103].
In a phase II trial, the ability of denosumab to affect bone
resorption markers or to reduce serum M-protein levels in
relapsed or plateau-phase myeloma subjects was evaluated. All
subjects received denosumab monthly (120 mg given as a
subcutaneous injection), with loading doses on days 8 and 15
of the first month, until disease progression or subject discon-
tinuation. Results of this study demonstrated that no subjects in
either cohort met the protocol-defined objective response
criteria of complete response (CR) or partial response (PR), but
denosumab effectively inhibited the RANKL pathway regardless
of previous exposure to bisphosphonates, as evidenced by
suppressed levels of the bone turnover marker, serum CTX, by
more than 50% [104]. In another phase II trial Fizazi et al
evaluated the effect of denosumab in patients with bone
metastases and elevated urinary NTX levels despite ongoing
intravenous bisphosphonate therapy. Patients were stratified by
tumor type (total 111 patients; 9 patients with MM, 50 patients
with prostate cancer, 46 patients with breast cancer and 6
patients with other solid tumor) and screening NTX levels and
randomly assigned to continue intravenous bisphosphonates
every 4 weeks or receive subcutaneous denosumab 180 mg
every 4 weeks or every 12 weeks. Denosumab normalized
urinary NTX levels more frequently than the continuation of
intravenous bisphosphonate (64% vs. 37% respectively; p = 0.01),
while fewer patients receiving denosumab experienced on-
study SREs than those receiving intravenous bisphosphonate
(8% vs. 17% respectively) [105]. This study showed that
denosumab inhibits bone resorption and prevents SREs even in
patients who are refractory to bisphosphonate therapy.
In a phase 3 trial of denosumab vs zoledronic acid in
patients (n = 1776) with bone metastases and solid tumors or
MM, denosumab was superior to zoledronic acid for the
primary end point of prevention of skeletal-related events.
There was no difference in overall survival between the two
85
groups; however, an ad hoc overall survival analysis in the
MM subset of patients (n = 180) favored zoledronic acid
(hazard ratio (HR) 2.26; 95% confidence interval (CI) 1.13-4.50;
p = 0.014) [106]. Nevertheless, for MM, imbalances in baseline
disease characteristics, stem cell transplant, and withdrawals
(due to consent withdrawal or loss to follow-up) favored
zoledronic acid. These baseline and on-study imbalances may
partially account for the difference observed between treat-
ment groups [107]. To address the discrepancies definitively, a
randomized, double-blind, multicenter phase 3 study is
currently comparing denosumab with zoledronic acid in the
treatment of bone disease in patients with newly diagnosed
MM. A total of 1718 pts were randomized, 859 to each arm. The
study was presented only as abstracts to-date. Denosumab
demonstrated non-inferiority to zoledronic acid in delaying
time to first on-study SRE in myeloma patients. A landmark
analysis at 15 months suggested a significant benefit for
denosumab with respect to time to first SRE. The rates of renal
adverse events were significantly lower in denosumab patients
[108,109]. A phase II study of denosumab in MM patients with
renal insufficiency is ongoing (NCT02833610).
Denosumab appears to have little toxicity, mainly asthenia,
and multiple phase III trials of denosumab in patients with solid
tumors and bone metastasis are ongoing. However it is crucial
to mention that RANKL is involved in dendritic cell survival
[110] and that the anti-RANKL strategy may have an effect on
the immune system and a possible increase in infection rate,
especially in cancer patients who have already had severe
immunodeficiency.
4.2.2. Activin Inhibitors
Activin is an osteoclast agonist that is involved in osteoclast
development and differentiation through stimulation of RANK
expression, as well as an osteoblast antagonist [3]. It is secreted
by BMSCs and osteoclasts in MBD. In the preclinical setting,
RAP-011, a fusion protein of the extracellular domain of the
high-affinity activin receptor IIA (ActRIIA) and human immu-
noglobulin G (IgG) Fc domain with potent inhibitory effect on
activin, prevented the formation of osteolytic lesions in a
murine MM model by stimulating bone formation through
osteoblasts, while having no effect on osteoclast activity [111].
In ovariectomized mice with prior bone loss, RAP-011 increased
bone formation, mass and strength [112].
Sotatercept (ACE-011) is the humanized counterpart of
RAP-011. In non-human primates sotatercept has been shown
to increase bone mass and enhance bone strength [113,114].
In a phase 1 study in healthy postmenopausal volunteers,
single-dose sotatercept was associated with increased serum
levels of the bone formation marker bone-specific alkaline
phosphatase (bALP) and decreased bone resorption markers
CTX and TRACP-5b, reflecting an increase in bone formation
and a decrease in bone resorption respectively [115]. No safety
concerns were noted in this study.
In a multicenter phase 2 trial, patients with osteolytic bone
lesions due to MM were randomized to receive either four 28-day
cycles of sotatercept or placebo as subcutaneous injection with
concomitant anticancer therapy consisting of oral melphalan,
prednisolone and thalidomide (MPT). Sotatercept treatment
demonstrated clinically significant increases in biomarkers of
bone formation, decreases in bone pain, and anti-tumor activity,
86 M ET ABOL I SM CL IN I CA L A N D E XP E RI ME N TAL 80 ( 20 1 8 ) 8 0– 90
as well as increase in haemoglobin levels [116], but further
research is needed to support these findings.
It has been shown in vitro that lenalidomide stimulates
secretion on BMSCs via an AKT-mediated increase in JNK signaling
[117]. A clinical trial with sotatercept in combination with
lenalidomide/dexamethasone or pomalidomide/dexamethasone
is ongoing in MM (NCT01562405).
4.3. Wnt Pathway Regulators – Helping the Osteoblast
4.3.1. DKK-1 Antagonists
DKK-1 plays an important role in the dysfunction of osteoblasts
observed in MM. The effect of anti-DKK1 therapy on tumor
growth and bone metabolism has been tested in mice.
Antibodies neutralizing DKK-1 restored the bone mineral
density of the implanted myelomatous bone in mice, reduced
number of multinucleated TRAP-expressing osteoclasts and
increased the numbers of osteocalcin-expressing osteoblasts.
Furthermore, the anti-DKK1–treated mice showed reduced
tumor burden [118]. In addition, inhibition of DKK1 reduced
tumor growth, as an indirect effect via modification of the
tumor microenvironment [119].
BHQ880, an IgG antibody, the first-in-class, fully human
anti-DKK-1 neutralizing antibody seems to promote bone
formation and thus it inhibits tumor-induced osteolytic disease
in preclinical studies [119]. Inhibiting DKK-1 with BHQ880 in the
5T2MM murine model of myeloma reduced the development of
osteolytic bone lesions and in vivo growth of MM cells [120]. A
phase I/II study of BHQ880 in combination with zoledronic acid
in relapsed or refractory myeloma patients has demonstrated
increases in bone strength at the spine and hip [121].
4.3.2. Sclerostin Antagonists
Inhibition of sclerostin could be an important strategy in the
treatment of bone diseases with a high catabolic rate. Several
studies have already demonstrated the importance of sclerostin
in osteoporosis [122,123]. Clinical trials with the experimental
sclerostin-neutralizing antibody romosozumab for the treat-
ment of postmenopausal osteoporosis are ongoing. Preliminary
results have shown an increase in bone mineral density [124].
5. Conclusion
Osteolytic bone disease is a central feature of MM and is caused
by factors produced by tumor cells that stimulate osteoclasts to
resorb bone and inhibit osteoblast activity. The resulting
osteolytic lesions and/or osteoporosis and their clinical conse-
quences, including fracture and severe pain, diminish both
survival and quality of life, with major economic impact.
Bisphosphonates remain the cornerstone of therapeutic
management of myeloma bone disease, offering considerable
benefit in preventing or delaying skeletal-related events and
relieving pain. Pamidronate and zoledronic acid seem to be
equally potent in treating bone disease manifestations, but the
latest MRC-IX data supporting survival benefit for patients
treated with zoledronic acid versus clodronate have revealed
zoledronic acid as the preferred bisphosphonate in myeloma
patients. However preventative steps should be taken to avoid
renal impairment and osteonecrosis of the jaw while dosing of
bisphosphonates should follow approved indications, with
adjustments if necessary.
Over the last few years, study of normal bone metabolism
and mechanisms of myeloma bone disease, has identified
several factors, which provide novel targets for treating patients
with MM bone disease. The identification of the role of RANKL/
OPG pathway in MM has led to the development of the RANKL
inhibitor denosumab which may be incorporated as therapy
for bone disease in the near future, after its first approval
for osteoporosis patients. Sotatercept, an activin inhibitor,
enhances the deposition of new bone tissue and prevents bone
loss in addition to antitumor activity. Antibodies to DKK-1 and
sclerostin are currently under investigation in clinical trials in
patients with MM and the first results are highly anticipated.
Advances in the treatment of MBD will translate into a better
quality of life for patients.
Conflicts of Interest Statement
ET discloses research support from Amgen and Janssen;
honoraria from Amgen, Janssen, Celgene and Novartis.
DC and MG have nothing to disclose.
No grants are related to this paper.
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