The RANKL/RANK/OPG Pathway
Brendan F. Boyce, MD, and Lianping Xing, MD, PhD
Corresponding author
Brendan F. Boyce, MD
Department of Pathology and Laboratory Medicine,
University of Rochester Medical Center, 601 Elmwood Avenue,
Box 626, Rochester, NY 14642, USA.
E-mail: brendan_boyce@urmc.rochester.edu
Current Osteoporosis Reports 2007, 5:98–104
Current Medicine Group LLC ISSN 1544-1873
Copyright © 2007 by Current Medicine Group LLC
Understanding of osteoclast formation and activation
has advanced considerably since the discovery of the
RANKL/RANK/OPG system in the mid 1990s. Osteo-
blasts and stromal stem cells express receptor activator
of NF-LB ligand (RANKL), which binds to its receptor,
RANK, on the surface of osteoclasts and their precur-
sors. This regulates the differentiation of precursors
into multinucleated osteoclasts and osteoclast activa-
tion and survival both normally and in most pathologic
conditions associated with increased bone resorption.
Osteoprotegerin (OPG) is secreted by osteoblasts and
osteogenic stromal stem cells and protects the skeleton
from excessive bone resorption by binding to RANKL
and preventing it from interacting with RANK. The
RANKL/OPG ratio in bone marrow is thus an important
determinant of bone mass in normal and disease states.
RANKL/RANK signaling also regulates lymph node
formation and mammary gland lactational hyperplasia
in mice, and OPG protects large arteries of mice from
medial calcification. This article reviews the roles of the
RANKL/RANK/OPG system in bone and other tissues.
Introduction
Bone has multiple functions in vertebrates, some obvious,
others less clear. These include protection of vital organs
and hematopoietic marrow, rigid support for muscles, and
storage and release of vital ions, especially calcium. Bone
is continuously renewed by means of a process called
bone remodeling, in which packets or trenches of bone are
removed from the surfaces of cancellous and cortical bone
by osteoclasts. There are more than 1 million of these
microscopic remodeling trenches in the adult skeleton at
any time. These trenches are subsequently filled with new
bone laid down by osteoblasts. (Other durable structures,
such as tendons, teeth, and cartilage, are not remodeled.)
The main function of bone remodeling is thought to be
removal of worn out parts of bones that have been dam-
aged through normal wear and tear. Although much is
known about what accelerates this process in pathologic
states, the molecular mechanisms that control its ini-
tiation, progression, and cessation at any given site in the
skeleton in normal individuals remain poorly understood.
All pathologic conditions that affect the skeleton affect
normal bone remodeling, typically because they accelerate
or inhibit bone resorption or formation. These conditions
include postmenopausal osteoporosis, periodontal disease,
metastatic cancers, multiple myeloma, and rheumatoid
arthritis. Patients affected by these disorders have local or
systemic alteration in the levels of hormones or proinflam-
matory cytokines that are known to stimulate or inhibit
bone resorption or formation. In the early 1980s, Rodan
and Martin [1] proposed that osteoblasts and stromal stem
cells regulated osteoclast formation by expressing factors
within the bone marrow in response to agents known to
stimulate bone resorption, such as parathyroid hormone
(PTH). During the past 10 years, studies of bones from
genetically altered mice and from animal models of bone
diseases have proven this hypothesis and consequently
have greatly increased our knowledge of the molecular
mechanisms whereby factors that regulate the formation
and activity of osteoclasts work. In particular, they led to
the identification in the mid-to-late 1990s of a signaling
system involving receptor activator of NF-LB (RANK), its
ligand (RANKL), and osteoprotegerin (OPG). The iden-
tification of this system was a major breakthrough that
clarified the roles of osteoblasts and stromal cells in these
processes. More recently, it has become increasingly clear
that osteoclasts are not simply bone resorptive cells; they
also have important functions in regulating osteoblasts
and immune cells in pathologic states [2].
Regulation of Osteoclast Formation
and Activation
Osteoclasts are multinucleated cells formed by cyto-
plasmic, but not nuclear, fusion of their mononuclear
precursors. In most circumstances, the number of nuclei
correlates positively with the bone-resorbing activity
of osteoclasts. Osteoclasts are in the myeloid lineage of
hematopoietic cells that also gives rise to macrophages.
Expression of c-Fos in osteoclast precursors (OCPs) is
required for this switch to osteoclast differentiation. c-Fos
is one of a number of transcription factors activated in
 The RANKL/RANK/OPG Pathway
response to RANKL; mice deficient in c-Fos form more
macrophages but no osteoclasts. Osteoclasts attach them-
selves firmly to bone surfaces, with extensions of their
cytoplasm tightly sealed to the underlying bone matrix
using specialized, actin-rich podosomes. Within these
sealed zones, the osteoclasts form ruffled membranes,
which resorb bone effectively by increasing the surface
area of the cell membrane, where hydrochloric acid and
cathepsin K, a proteolytic enzyme, are secreted onto the
bone surface [3]. By this mechanism, osteoclasts simulta-
neously dissolve the mineral and degrade the matrix of
bone, at the same time protecting neighboring cells from
harm by the sealing mechanism. RANKL and C-integrin–
mediated signaling from bone matrix activate osteoclasts
[3]. Osteoclasts work in packs within remodeling units
under the control of cells in the osteoblast lineage. These
osteoblast lineage cells express macrophage colony-
stimulating factor (M-CSF), RANKL, and a growing list
of factors that regulate the formation, fusion, activity, and
survival of osteoclasts.
Recent studies have suggested that osteoclasts are
likely to be involved in the recruitment of packs of bone-
forming osteoblasts to refill the trenches formed on bone
surfaces [2]. These studies examined the mechanisms
whereby intermittent PTH treatment exerts its anabolic
effects and showed that RANKL expression is increased
by osteoblasts and stromal cells following PTH injection,
and this increase leads to activation of existing osteoclasts,
which release one or more factors that stimulate new
bone formation. Bisphosphonate antiresorptive treatment
appears to attenuate, rather than enhance, the anabolic
action of PTH, at least in some studies [4,5]. Osteoclasts
also appear to regulate their own formation as well as
immune responses at sites of inflammation in bone. They
also appear to positively and negatively regulate osteoblast
formation and activity, although the precise mechanisms
whereby they do this remain to be determined [6••,7••].
During embryonic development and until growth plate
closure, when endochondral ossification ceases, osteoclasts
remove bone newly formed under growth plates. This medi-
ates formation of the bone marrow cavity and facilitates
normal hematopoiesis, both of which are defective if there
is a failure of osteoclast formation or activity. Such failure
results in osteopetrosis, the most severe forms of which
can be lethal because of attendant immunodeficiency and
increased risk of infection and recurrent fractures. The
development of osteopetrosis and its attendant failure of
tooth eruption in a variety of knockout mice have identi-
fied essential functions of genes in osteoclast biology that
had been largely unanticipated [3].
Understanding of the molecular mechanisms that
regulate osteoclast formation and activation has advanced
rapidly since the discovery of the RANKL/RANK/OPG
signaling system and following the development in the late
1980s of in vitro assays that facilitated harvesting from
bone marrow or spleen cells of large numbers of OCPs,
Boyce and Xing 99
which could then be cultured in the absence of osteoblasts
and stromal stem cells. The strategy for acquiring OCPs
from these sources was developed in the knowledge that
M-CSF expression by osteoblasts and stromal stem cells
was required for progenitor cells to differentiate into
osteoclasts, but that M-CSF on its own was unable to
complete this process. This requirement for M-CSF was
based on the observation that op/op mice, which do not
express functional M-CSF, have osteopetrosis because
they lack osteoclasts. Indeed, since 1981, when Rodan
and Martin [1] proposed their hypothesis that osteoblasts
and stromal stem cells play a central role in regulating
osteoclast formation and bone resorption, many investi-
gators have attempted to identify the osteoclast-activating
factor that completed the differentiation of precursors
exposed to M-CSF.
Identification of RANKL, RANK, and OPG
Four groups using different approaches discovered the
factors expressed by osteoblasts and stromal stem cells
that regulate osteoclastogenesis. OPG was discovered
unexpectedly by researchers at Amgen in studies designed
to identify tumor necrosis factor receptor (TNFR)–related
molecules that might have therapeutic utility [8]. These
researchers made transgenic mice overexpressing various
TNFR-related cDNAs and found that mice overexpress-
ing one particular cDNA developed marked osteopetrosis
because they had no osteoclasts. They named the protein
encoded by the gene osteoprotegerin (ie, the bone pro-
tector) because it appeared to protect the skeleton from
low bone mass and increased risk of fracture by limit-
ing osteoclastic bone resorption. About the same time,
researchers at the Snow Brand Milk Products Company
in Japan discovered an identical molecule by purifying a
factor from human embryonic fibroblasts that inhibited
osteoclastogenesis [9]. Both groups quickly identified the
ligand of this protein, using it as a probe in expression
cloning experiments. They called it OPG ligand (OPGL)
and osteoclast differentiation factor (ODF), respectively
[10,11]. It turned out to be identical to a member of the
TNF ligand family, which had been identified the year
before as RANKL [12] and TNF-related activation-
induced cytokine (TRANCE) [13]. Soon after OPGL/ODF
was identified as a ligand for OPG, the cellular receptor
was shown to be identical to the already known RANK,
which researchers at Immunex had discovered while they
were sequencing cDNAs from a human bone marrow–
derived myeloid dendritic-cell cDNA library [12]. They
had shown that RANK had partial homology to a portion
of the extracellular domain of human CD40, a member of
the TNFR superfamily. Intriguingly, it also was involved
in the activation of T cells in the immune system. They
isolated RANKL by direct expression screening and,
like Wong et al. [13], found that it increased survival of
RANK-expressing T cells and proliferation of dendritic
100 Epidemiology and Pathophysiology
cell–stimulated naive T cells. The American Society
for Bone and Mineral Research [14] recommended that
RANKL and OPG should be the “official” names for
these proteins. The discoveries that RANKL is involved
in osteoclast and T-cell biology have spawned the now-
growing field of osteoimmunology.
RANKL
RANKL is a type II homotrimeric transmembrane pro-
tein expressed both as a membrane-bound and a secreted
protein, which is derived from the membrane form as a
result of either proteolytic cleavage or alternative splicing
[15,16]. Most of the factors known to stimulate osteoclast
formation and activity stimulate RANKL expression in
osteoblasts and stromal cells. RANKL is highly expressed
in lymph nodes, thymus, and lung and is expressed at
low levels in a variety of other tissues, including spleen
and bone marrow. It is expressed by synovial cells and is
secreted by activated T cells in inflamed joints of patients
with rheumatoid arthritis. These sources of RANKL
appear to be responsible, at least in part, for mediating
the joint destruction in affected patients [17]. However,
T-cell production of RANKL also induces expression of
interferon-C by activated osteoclasts through c-Fos. This
negatively regulates osteoclast formation [18], which can
be further enhanced by T-cell–produced interferon-B,
which degrades TNFR-associated factor 6 (TRAF6), an
essential adapter protein recruited to RANK to mediate
RANK signaling, as discussed later [19]. Because of these
competing effects of RANKL signaling, it is not clear
whether it plays an important role in mediating bone
destruction in inflamed joints [20]. Recently, Zhao et al.
[7••] reported that osteoclasts and osteoblasts directly
affect one another through ephrinB2-EphB4 bidirectional
signaling, in which ephrinB2 ligand reverse signals into
OCPs to suppress osteoclast differentiation by inhibiting
the c-Fos–nuclear factor of activated T cell c (NFATc)1
cascade, whereas EphB4-receptor forward signaling
enhances osteoblast differentiation.
TNF also mediates joint destruction in patients with
inflammatory arthritis. Its concentration is increased in the
joints and blood of affected patients [21]. In animal models
of inflammatory arthritis, TNF has been shown to increase
OCP numbers in bone marrow [22•] and to increase the
number of circulating OCPs by promoting their egress from
the bone marrow into the peripheral blood. In inflamed
joints, it promotes fusion of these cells into osteoclasts,
along with RANKL and interleukin-1 [23].
RANKL also stimulates the release of immature osteo-
clast progenitors into the circulation. However, it does
not induce OCP mobilization in protein tyrosine phos-
phatase (PTP)F–knockout mice, which have osteoclasts
with defective bone adhesion and resorption [24••]. Thus,
RANKL-induced osteoclast activation may regulate pro-
genitor recruitment as part of homeostasis and host defense,
linking bone remodeling with regulation of hematopoiesis.
RANKL is also expressed in mammary epithelial cells dur-
ing pregnancy [25••]. Its expression is required in mice for
lactational hyperplasia of mammary epithelial cells and
milk production [26]. It is expressed by some malignant
tumor cells, which also express RANK and thus could have
a role in inducing tumor cell proliferation [25••]. To date,
there are no published reports of spontaneous mutations in
the RANKL gene in humans or animals.
RANK
RANK is a type I homotrimeric transmembrane protein,
which is expressed widely in normal cells [27], in mam-
mary glands [26], and in some cancer cells, including
breast and prostate cancers [25••,28], two tumors with
high potential for bone metastasis. Activating muta-
tions of RANK have been reported in exon 1 of RANK
in humans, resulting in an increase in RANK-mediated
NF-LB signaling and an increase in osteoclast formation
and activity. Such mutations appear to account for the
increased osteolysis seen in some patients with familial
Paget’s disease and have confirmed the importance of
this system in humans [29]. A potential role for RANK
in tumor cell proliferation is being investigated [25••]; if
proven, this could be a future target for antitumor ther-
apy. No humans have yet been identified with inactivating
mutations or deletions of RANK. However, a spontaneous
deletion mutation occurred in a line of transgenic mice,
resulting in all of the features of mice with targeted dele-
tion of RANK and confirming the importance of RANK
for osteoclast formation [30].
Osteoprotegerin
OPG is expressed widely in many tissues besides osteo-
blasts, including spleen, bone marrow, heart, liver, and
kidney [27]. A role for OPG in protection against bone
loss in humans is supported by the report of homozygous
deletions of 100 kb of OPG in two patients with juvenile
Paget’s disease, an autosomal recessive disorder charac-
terized by increased bone remodeling, osteopenia, and
fractures [31]. In another report, an inactivating deletion
in exon 3 of OPG occurred in three siblings with idio-
pathic hyperphosphatasia, a crippling, autosomal recessive
bone disorder characterized by increased bone remodel-
ing associated with kyphosis, deformities of long bones,
and acetabular protrusion in affected children [32]. Most
factors that induce RANKL expression by osteoblasts
also regulate OPG expression, some positively and oth-
ers negatively [27]. In general, upregulation of RANKL
expression by cytokines and growth factors is associated
with relative downregulation of OPG, or at least lower
induction of OPG, so that the ratio of RANKL to OPG
changes in favor of osteoclastogenesis. Although there are
contradictory data, many publications support the asser-
tion that the RANKL/OPG ratio is a major determinant of
bone mass in a variety of clinical settings [33]. Bone mass
is also influenced directly by Wnt/C-catenin signaling in
 The RANKL/RANK/OPG Pathway
osteoblasts. This pathway regulates commitment of mes-
enchymal cells to the osteoblast lineage and the amount of
bone laid down by osteoblasts. A recent unexpected obser-
vation is that Wnt/C-catenin signaling directly regulates
OPG expression by osteoblastic cells [34]. Thus, two major
signaling pathways—OPG/RANKL/RANK in osteo-
clasts and Wnt/C-catenin in osteoblasts—appear to have a
central role in determining bone mass. Both involve osteo-
blasts, the former through indirect mechanisms, whereby
osteoblast expression of both RANKL and OPG influence
bone resorption, and the latter through direct regulation of
Wnt/C-catenin–regulated gene expression in osteoblasts.
Like RANKL, OPG also appears to have roles outside
of bone. For example, it protects large blood vessels of
normal mice from medial calcification and dissection.
This finding is based on the observation of renal and
aortic calcification and aortic dissection occurring in
OPG -/- mice [35]. Furthermore, when OPG -/- mice were
crossed with apoE -/- mice, OPG -/-/apoE -/- double-knockout
mice had acceleration of the calcific atherosclerosis that
typically develops in apoE -/- mice. Although this observa-
tion suggests that OPG may protect against calcification of
atherosclerosis [36], it remains to be determined whether
OPG or RANKL signaling play important roles in car-
diovascular disease. This is a controversial issue [37]. For
example, there is an association between high OPG serum
levels and cardiovascular disease, diabetes, and chronic
renal failure in humans [37]. However, patients with
renal bone disease typically have increased, rather than
decreased, bone resorption because of secondary hyper-
parathyroidism, and they also have vascular calcification;
OPG does not appear to prevent either of these complica-
tions in this setting. It is possible that OPG in the serum
of patients with chronic renal failure is rendered inactive
by being bound to one or more plasma proteins or by
some other mechanism. Further studies will be required
to determine the significance of these observations, which
question the role of the RANKL/OPG ratio in serum
samples as an indicator of bone mass or bone resorption
in some settings [38].
RANKL/RANK Signaling in Osteoclasts
Following the identification of RANKL and RANK, major
efforts were made to identify signaling pathways that
are activated downstream in osteoclasts and OCPs and
to determine more fully the extent of RANKL’s involve-
ment in osteoclast biology and common bone diseases.
RANK, like other TNFRs, has no intrinsic protein kinase
activity to mediate signaling after RANKL binds to it. A
key preliminary step in TNFR downstream signaling is
the binding of TRAFs to the cytoplasmic domain of the
receptors. TRAFs 2, 5, and 6 all bind to RANK, but of
these only TRAF6 appears to have an essential function in
osteoclasts, because only TRAF6 knockout mice develop
osteopetrosis. Two lines of TRAF6-deficient mice have
Boyce and Xing 101
been produced independently; both have osteopetrosis, but,
surprisingly, one has normal numbers of osteoclasts but the
cells are inactive [39], whereas the other has no osteoclasts
[40]. It is not clear why these two phenotypes are different,
but presumably they represent differences in the strategies
to knock out the gene. To date, six signaling pathways have
been shown to be activated by RANK-mediated protein
kinase signaling. The three that directly mediate osteo-
clastogenesis are inhibitor of NF-LB kinase (IKK)/NF-LB,
c-Jun N-terminal kinase (JNK)/activator protein-1 (AP-1),
and calcineurin/NFATc1. Others mediate osteoclast acti-
vation (Src and MKK6/p38/MITF) and survival (Src and
extracellular signal–regulated kinase [ERK]).
Several adapter molecules bind to RANK along
with TRAFs to mediate signaling. These include Grb-2–
associated binder (Gab) protein 2, which recruits a num-
ber of signaling molecules that contain Src homology-2
domains after it is tyrosine phosphorylated. Gab2-deficient
mice have reduced RANKL/RANK-induced osteoclast
differentiation, decreased bone resorption, and mild
osteopetrosis, indicating that Gab2 plays an important
role in RANKL-induced osteoclast formation. Another
adapter molecule is p62, which binds to TRAF6 to medi-
ate RANKL-induced NF-LB activation in osteoclast
precursors. Mice deficient in p62 have normal osteoclast
formation and bone volumes, but they have an impaired
osteoclastogenic response to PTH-related peptide in vivo,
suggesting that it has an important role in induced osteo-
clastogenesis in pathologic conditions. More importantly,
mutations in p62 have been linked to some forms of Pag-
et’s disease, which is characterized by increased osteoclast
formation and activity [41].
Several transcription factors have essential functions
in osteoclast formation. All were discovered unexpect-
edly after the generation of mice with targeted deletion
of the genes encoding them developed osteopetrosis.
These include NF-LB p50 and p52, c-Fos, and NFATc1
[42]. NF-LB p50/p52 -/- mice live until 4 to 6 weeks of age
with severe osteopetrosis and no osteoclast formation.
Nfatc1-/- mice die early during embryonic development
from severe cardiac anomalies before the skeleton is
formed [43]. Like NF-LB, NFATc1 also has important
roles in immune cell function, and its role as the master
gene regulating osteoclastogenesis was identified in molec-
ular rescue experiments. Retroviral expression of NFATc1
induces osteoclast formation from M-CSF–treated NF-LB
p50/p52 -/- or c-Fos -/- osteoclast precursors in the absence
of RANKL [44], suggesting that NFATc1 is downstream
from NF-LB and c-Fos in RANKL-induced osteoclast
differentiation (Fig. 1). However, the precise relationship
among NF-LB, AP-1, and NFAT family members remains
to be determined. We have demonstrated that overexpres-
sion of c-Fos in NF-LB p50/p52 -/- cells induces osteoclast
formation, but overexpression of NF-LB p50 and p52 in
c-Fos -/- cells has no effect, which puts c-Fos downstream
of NF-LB (Fig. 1). Further study is needed to determine
102 Epidemiology and Pathophysiology

by cyclosporine A, a calcineurin inhibitor, was associated

with bone loss in vivo, rather than with inhibition of resorp-
Accessory cells
tion and preservation of bone mass, presumably because its
Activated T cells role in osteoblasts is dominant over that in osteoclasts [48].
Synovial cells Osteoblasts Thus, this transcription factor has multiple complex func-
Endothelial cells
tions in both osteoclasts and osteoblasts.

Osteoimmunology, Immunoreceptors,
Unknown and RANKL
RANKL ligands
It has long been recognized that proinflammatory cyto-
OSCAR
kines, which mediate immune responses, can also affect
TREM-2
osteoclasts and osteoblasts, either positively or negatively.
RANK FcRG More recent studies have determined that some of the

TR AF6 ITAM ITAM

DAP12
PLCG
IKKs
Calcium
NF-KB
Calcineurin
c-Fos
NFATc1
Osteoclast
precursor
Osteoclast
differentiation
Figure 1. Signaling pathways essential for osteoclastogenesis in
pathologic bone disorders. DAP12—DNAX-activating protein 12;
FcRH—Fc receptor common H subunit; IKKs—inhibitors of NF-LB
kinase; ITAM—immunoreceptor tyrosine-based activation motif;
NFATc1—nuclear factor of activated T cell c1; OSCAR—osteoclast-
associated receptor; PLCH—phospholipase CH; RANK—receptor
activator of NF-LB; RANKL—receptor activator of NF-LB ligand;
TRAF6—tumor necrosis factor receptor–associated factor 6;
TREM— triggering receptor expressed in myeloid cells.
whether NF-LB directly regulates c-Fos gene expression
[44]. A recent study demonstrated that NF-LB p65 binds
transiently to the NFATc1 promoter within 1 hour of treat-
ment with RANKL, but NF-LB p52 does not, and p50
binding appears to be much less than that of p65. This is
associated with recruitment of preexisting NFATc2 to the
NFATc1 promoter and leads later to recruitment of c-Fos
and an autoamplification of NFATc1 expression [45••].
NFATc1 also positively regulates expression of osterix,
a transcription factor essential for osteoblast function [46].
Overexpression of a constitutively active NFATc1 in osteo-
blasts in transgenic mice leads to osteosclerosis associated
with increased osteoblastic bone formation and increased
osteoclast activity; the net effect is reduced bone formation
and osteoporosis [47]. NFATc1 is activated by calcium/
calcineurin signaling. Surprisingly, inhibition of its activity
transcription factors, which regulate immune responses,
also regulate osteoclast formation and osteoblast func-
tion. Furthermore, osteoblasts play essential roles in
regulating hematopoietic stem cell niches from which
immune cells are derived. Finally, it is becoming increas-
ingly clear that osteoclasts regulate osteoblast formation
and functions. Recognition of the complex interactions
among these various cell types has spawned the formal
identification of the osteoimmune system and the growth
of osteoimmunology as a new field of research. Recent
studies have helped to clarify the mechanisms whereby
immune responses modulate and increase osteoclast for-
mation through calcium signaling, as well as some of the
molecules involved. Apparently involved are osteoclast-
associated receptor (OSCAR) and triggering receptor
expressed in myeloid cells (TREM)-2, both of which are
immunoglobulin-like receptors expressed by OCPs, and
the adapter proteins, Fc receptor common H subunit
(FcRH) and DNAX-activating protein 12 (DAP12). These
adapter proteins have immunoreceptor tyrosine-based
activation motifs (ITAMs), which activate calcium signal-
ing and NFATc1 [49,50] (Fig. 1). OSCAR and TREM-2
interact with unidentified ligands on osteoblasts, and
NFATc1 regulates OSCAR expression. DAP12/FcRH
double-knockout mice are severely osteopetrotic because
they have impaired RANKL-induced NFATc1 activation
and osteoclast formation [50]. Interestingly, this receptor-
mediated signaling pathway is necessary but not suffi-
cient for osteoclastogenesis because it cannot induce
osteoclast formation on its own. It is thought that sig-
naling through these receptors and RANKL/RANK in
inflammatory disorders provides an NFATc1-mediated
amplifying mechanism to increase osteoclast formation
beyond that of RANKL alone (Fig. 1). Pro-inflammatory
cytokines such as TNF also can augment this mechanism
for enhanced osteoclast formation in inflammatory bone
disease to mediate joint destruction. For example, TNF
induces c-fms expression by OCPs [22•], increasing pro-
liferation and survival of these cells and enhancing their
departure from the bone marrow into the bloodstream,
from which they can accumulate increased numbers at
sites of inflammation.
 The RANKL/RANK/OPG Pathway
Conclusions
Discovery of the RANKL/RANK/OPG system repre-
sents the most important advance in osteoclast biology
in the past decade. This system helps maintain skeletal
homeostasis and is disrupted in most diseases that affect
the skeleton by altered levels of RANKL, OPG, or both,
which are expressed by osteoblasts and stromal cells or
other cells. Osteoclasts not only respond to signals from
osteoblasts and other cell types involved in immune
responses, but they also regulate osteoblast functions.
In addition, RANKL/RANK signaling and OPG play
important roles in the development of other tissues (at
least in mice) and appear to be involved in the growth of
some malignant tumors.
Despite recent advances, many important questions
remain. For example, what switches this system on and
off during normal bone remodeling? At what stage in their
differentiation do cells in the osteoblast lineage regulate
normal and pathologic bone remodeling? Where do they
reside in bone marrow? Do they interact with other cells,
such as lymphocytes, that produce RANKL in pathologic
conditions? How exactly do immune cells influence the
function of osteoclasts, osteoblasts, and stromal stem cells
in normal and disease states? Stromal cells circulate in the
blood like OCPs. Do they have important roles directing
RANKL/RANK-mediated normal and pathologic bone
remodeling? Will measuring serum levels of RANKL
or OPG be helpful in the management of patients with
bone and joint diseases? How does RANKL/RANK sig-
naling regulate cancer cell growth or metastasis to bone
and interactions between cancer cells and other cells in
bone? The osteoclast secretes and responds to cytokines
in immune responses. How important are osteoclasts and
their precursors in amplifying their own formation and
immune reactions? Elucidation of the roles of RANKL/
RANK and OPG in these various types of cells and in
normal and disease states is likely to lead to the develop-
ment of new drugs designed to specifically influence the
production of these cytokines or responses to them.
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