Bisphosphonates (BPs) are the current standard of care for bone lesions in patients with multiple myeloma (MM) but they are associated with a number of side effects such as osteonecrosis of the jaw. The exact mechanisms of osteonecrosis are not elucidated, and its physiopathology is based on several hypotheses such as a decrease in bone remodeling or an inhibitory effect on angiogenesis. The aim of our study was to investigate the mechanism involved in the pathogenesis of osteonecrosis. We examined the apoptosis of circulating endothelial progenitor cells in MM subjects before and after BP treatment and in osteonecrosis patients using a flow-cytometric analysis. Our data showed an increase in endothelial cell apoptosis in MM patients after BP administration and in osteonecrosis subjects. Our study seems in agreement with the hypothesis that BPs can inhibit angiogenesis interfering with endothelial cell proliferation and survival, leading to loss of blood vessels and avascular necrosis.

Walter C, Al-Nawas B, du Bois A, Buch L, Harter P, Grotz KA: Incidence of bisphosphonate-associated osteonecrosis of the jaws in breast cancer patients. Cancer 2009;115:1631–1637.
Woo SB, Hellstein JW, Kalmar JR: Narrative review: bisphosphonates and osteonecrosis of the jaw. Ann Intern Med 2006;144:753–761.
Nastro E, Musolino C, Allegra A, Oteri G, Cicciù M, Alonci A, Quartarone E, Alati C, De Ponte FS: Bisphosphonate-associated osteonecrosis of the jaw in patients with multiple myeloma and breast cancer. Acta Hematol 2007;117:181–187.
Alonci A, Allegra A, Bellomo G, Quartarone E, Oteri G, Nastro E, Cicciù D, De Ponte FS, Musolino C: Patients with bisphosphonate-associated osteonecrosis of the jaw have unmodified levels of soluble vascular endothelial growth factor receptor 1. Leuk Lymph 2007;48:1852–1854.
Tubiana-Hulin M, Spielmann M, Roux C, Campone M, Zeleck L, Gligorov J, Samson J, Lesclous P, Laredo JD, Namer M: Physiopathology and management of osteonecrosis of the jaws related to bisphosphonate therapy for malignant bone lesions: a French expert panel analysis. Crit Rev Oncol Hematol 2009;71:12–21.
Lehrer S, Montazem A, Romanathan L, Pessin-Minsley M, Pfail J, Stock RG, Kogan R: Bisphosphonate-induced osteonecrosis of the jaws, bone markers, and a hypothesized candidate gene. J Oral Maxillofac Surg 2009;67:159–161.
Allen MR, Burr DB: The pathogenesis of bisphosphonate-related osteonecrosis of the jaw: so many hypotheses, so few data. J Oral Maxillofac Surg 2009;67:61–70.
Assael LA: Oral bisphosphonates as a cause of bisphosphonate-related osteonecrosis of the jaws: clinical findings, assessment of risks, and preventive strategies. J Oral Maxillofac Surg 2009;67:35–43.
Hansen T, Kunkel M, Springer E, Walter C, Weber A, Siegel E, Kirkpatrick CJ: Actinomycosis of the jaw: histopathological study of 45 patients shows significant involvement in bisphosphonate-associated osteonecrosis and infected osteoradionecrosis. Virchows Arch 2007;451:1009–1017.
Aons K, Kuijpers SCC, de Jong E, van Merkesteyn JPR: Treating low- and medium-potency bisphosphonate-related osteonecrosis of the jaws with a protocol for the treatment of chronic suppurative osteomyelitis: report of 7 cases. Oral Surg Oral Med Oral Pathol Radiol Endod 2009;107:1–7.
Fournier P, Boissier S, Filleur S, Guglielmi J, Cabon F, Colombel M, Clézardin P: Bisphosphonates inhibit angiogenesis in vitro and testosterone-stimulated vascular regrowth in the ventral prostate in castrated rats. Cancer Res 2002;62:6538–6544.
Wood J, Bonjean K, Ruetz S, Bellahcène A, Devy L, Foidart JM, Castronovo V, Green JR: Novel antiangiogenic effets of the bisphosphonate compound zoledronic acid. J Pharmacol Exp Ther 2002;302:1055–1061.
Santini D, Vincenzi B, Avvisati G, Dicuonzo G, Battistoni F, Gavasci M, Salerno A, Denaro V, Tonini G: Pamidronate induces modifications of circulating angiogenetic factors in cancer patients. Clin Cancer Res 2002;8:1080–1084.
Allegra A, Oteri G, Nastro E, Alonci A, Bellomo G, Del Fabro V, Quartarone E, Alati C, De Ponte FS, Cicciù D, Musolino C: Patients with bisphosphonates-associated osteonecrosis of the jaw have reduced circulating endothelial cells. Hematol Oncol 2007;25:164–169.
Mariucci S, Rovati B, Chatzileontiadou S, Bencardino K, Manzoni M, Delfanti S, Danova M: A six-colour flow cytometric method for simultaneous detection of cell phenotype and apoptosis of circulating endothelial cells. Scand J Clin Lab Invest 2009;69:433–438.
Hristov M, Weber C: Endothelial progenitor cells: characterization, pathophysiology, and possible clinical relevance. J Cell Mol Med 2004;8:498–508.
Leal EC, Aveleira CA, Castilho AF, Serra AM, Baptista FI, Hosoya KI, Forrester JV, Ambrosio AF: High glucose and oxidative/nitrosative stress conditions induce apoptosis in retinal endothelial cells by a caspase-independent pathway. Exp Eye Res 2009;88:983–991.
Dimmeler S, Hermann C, Zeiher AM: Apoptosis of endothelial cells: contribution to the pathophysiology of atherosclerosis? Eur Cytokine Network 1998;9:687–689.
Vermes I, Haanen C, Steffens-Naken H, Reutelingsperger G: A novel assay for apoptosis: flow cytometric detection of phosphatidylserine expression on early apoptotic cells using fluorescein labeled annexin V. J Immunol Methods 1995;184:39–51.
Fadok VA, Bratton DL, Henson PM: Phagocyte receptors for apoptotic cells: recognition, uptake and consequences. J Clin Invest 2001;108:957–962.
Barnett D, Janossy G, Lubenko A, Matutes A, Newland A, Reilly JT: Guidelines for the flow cytometric enumeration of CD34+ haematopoietic stem cells. Clin Lab Haematol 1999;21:301–308.
Markovic O, Marisavijevic D, Cemerikic V, Vidović A, Perunicić M, Todorović M, Elezović I, Colović M: Expression of VEGF and microvessel density in patients with multiple myeloma: clinical and prognostic significance. Med Oncol 2008;25:451–457.
Negaard HF, Iversen N, Bowitz-Lothe IM, Sandset PM, Steinsvik B, Ostenstad B, Iversen PO: Increased bone marrow microvascular density in haematological malignancies is associated with differential regulation of angiogenic factors. Leukemia 2009;23:162–169.
Ria R, Todoerti K, Berardi S, Coluccia AM, De Luisi A, Mattioli M, Ronchetti D, Morabito F, Guarini A, Petrucci MT, Dammacco F, Ribatti D, Neri A, Vacca A: Gene expression profiling of bone marrow endothelial cells in patients with multiple myeloma. Clin Cancer Res 2009;15:5369–5378.
Kim WU, Kang SS, Yoo SA, Hong KH, Bae DG, Lee MS: Interaction of vascular endothelial growth factor 165 with neuropilin- 1 protects rheumatoid sinoviocytes from apoptotic death by regulating BCL-2 expression and Bax translocation. J Immunol 2006;177:5727–5735.
Ruixing Y, Dezhai Y, Hai W, Kai H, Xianghong W, Yuming C: Intramyocardial injection of vascular endothelial cell growth factor gene improves cardiac performance and inhibits cardiomyocyte apoptosis. Eur J Heart Fail 2007;9:343–351.
Carneiro A, Falcao M, Pirraco A Milheiro-Oliveira P, Falcao-Reis, Soares R: Comparative effects of bevacizumab, ranibizumab and pegaptanib at intravitreal dose range on endothelial cells. Exp Eye Res 2009;88:522–527.
Ge YL, Zhang X, Zhang JY, Hou L, Tian RH: The mechanism on apoptosis by inhibiting VEGF expression in human breast cancer cells. Int Immunopharmacol 2009;9:389–395.
Reszka AA, Halasy-Nagy J, Rodan GA: Nitrogen-bisphosphonates block retino blastoma phosphorylation and cell growth by inhibiting the cholesterol biosynthetic pathway in a keratinocyte model for esophageal irritation. Mol Pharmacol 2001;59:193–202.
Reid IR, Bolland MJ, Grey AB: Is bisphosphonate-associated osteonecrosis of the jaw caused by soft tissue toxicity? Bone 2007;41:318–320.
Walter C, Klein MO, Pabst A, Al-Nawas B, Duschner H, Ziebart T: Influence of bisphosphonates on endothelial cells, fibroblast, and osteogenic cells. Clin Oral Invest 2010;14:35–41.
Landesberg R, Cozin M, Cremers S: Inhibition of oral mucosal cell wound healing by bisphosphonates. J Oral Maxillofacial Surg 2008;66:839–847.
Folkman J: Angiogenesis and apoptosis. Semin Cancer Biol 2003;13:159–167.
Winn RK, Harlan JM: The role of endothelial cell apoptosis in inflammatory and immune diseases. J Thromb Haemost 2005;3:1815–1824.
Bombeli T, Karsan A, Tait JF, Harlan JM: Apoptotic vascular endothelial cells become procoagulant. Blood 1997;89:2429–2442.
Beaudry P, Force J, Naumov GN, Wang A, Baker CH, Ryan A, Soker S, Johnson BE, Folkman J, Heymach JV: Differential effects of vascular endothelial growth factor receptor-2 inhibitor ZD6474 on circulating endothelial progenitors and mature circulating endothelial cells: implications for use as a surrogate marker of antiangiogenic activity. Clin Cancer Res 2005;11:3514–3522.
Ferretti G, Fabi A, Carlini P: Zoledronic-acid-induced circulating level modifications of angiogenic factors, metallo-proteinases and proinflammatory cytokines in metastatic breast cancer patients. Oncology 2005;69:35–43.
Cetinkaya BO, Keles GC, Ayas B, Gurgor P: Effects of risedronate on alveolar bone loss and angiogenesis, a stereologic study in rats. J Periodontol 2008;79:1950–1961.
Dimmeler S, Haendeler J, Galle J, Zeiher AM: Oxidized low density lipoprotein induces apoptosis of human endothelial cells by activation of CPP32-like proteases: a mechanistic clue to the response to injury hypothesis. Circulation 1997;95:1760–1763.
Terpos E, Sezer O, Croucher PI, García-Sanz R, Boccadoro M, San Miguel J, Ashcroft J, Bladé J, Cavo M, Delforge M, Dimopoulos MA, Facon T, Macro M, Waage A, Sonneveld P, European Myeloma Network: The use of bisphosphonate in multiple myeloma: recommendations of an expert panel on behalf of the European Myeloma Network. Ann Oncol 2009;20:1303–1317.
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