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Purpose: Anthracyclines (including doxorubicin) are still the backbone of commonly used breast cancer chemotherapy regimens. Despite increasing use of doxorubicin and cyclophosphamide (AC) combinations for treating breast cancer, their potential to cause adverse skeletal effects remains unclear. Methods: This study examined the effects of treatments with the AC regimen on bone and bone marrow in adult female rats. Results: AC treatment for four cycles (weekly intravenous injection of 2 mg/kg doxorubicin and 20 mg/kg cyclophosphamide) resulted in a reduced volume of trabecular bone at the metaphysis, which was associated with reduced serum levels of 25-hydroxy vitamin D3 and alkaline phosphatase. Reductions in densities of osteocytes and bone lining cells were also observed. In addition, bone marrow was severely damaged, including a severe reduction in bone marrow cellularity and an increase in marrow adipocyte content. Accompanying these changes, there were increases in mRNA expression of adipogenesis regulatory genes (PPARγ and FABP4) and an inflammatory cytokine (TNFα) in metaphysis bone and bone marrow. Conclusions: This study indicates that AC chemotherapy may induce some bone loss, due to reduced bone formation, and bone marrow damage, due to increased marrow adiposity. Preventive strategies for preserving the bone and bone marrow microenvironment during anthracycline chemotherapy warrant further investigation. Refereed/Peer-reviewed

Intensive use of cancer chemotherapy is increasingly linked with long-term skeletal side effects such as osteopenia, osteoporosis and fractures. However, cellular mechanisms by which chemotherapy affects bone integrity remain unclear. Methotrexate (MTX), used commonly as an anti-metabolite, is known to cause bone defects. To study the pathophysiology of MTX-induced bone loss, we examined effects on bone and marrow fat volume, population size and differentiation potential of bone marrow stromal cells (BMSC) in adult rats following chemotherapy for a short-term (five once-daily doses at 0.75 mg/kg) or a 6-week term (5 doses at 0.65 mg/kg + 9 days rest + 1.3 mg/kg twice weekly for 4 weeks). Histological analyses revealed that both acute and chronic MTX treatments caused a significant decrease in metaphyseal trabecular bone volume and an increase in marrow adipose mass. In the acute model, proliferation of BMSCs significantly decreased on days 3-9, and consistently the stromal progenitor cell population as assessed by CFU-F formation was significantly reduced on day 9. Ex vivo differentiation assays showed that while the osteogenic potential of isolated BMSCs was significantly reduced, their adipogenic capacity was markedly increased on day 9. Consistently, RT-PCR gene expression analyses showed osteogenic transcription factors Runx2 and Osterix (Osx) to be decreased but adipogenic genes PPARγ and FABP4 up-regulated on days 6 and 9 in the stromal population. These findings indicate that MTX chemotherapy reduces the bone marrow stromal progenitor cell population and induces a switch in differentiation potential towards adipogenesis at the expense of osteogenesis, resulting in osteopenia and marrow adiposity. Refereed/Peer-reviewed

Antimetabolite Methotrexate (MTX) is commonly used in childhood oncology. As a dihydrofolate reductase inhibitor it exerts its action through the reduction of cellular folate, thus its intensive use is associated with damage to soft tissues, bone marrow and bone. In the clinic, MTX is administered with folinic acid (FA) supplementation to alleviate some of this soft tissue damage. However, whether and how FA alleviates damage to the bone and bone marrow requires further investigation. As the Wnt/β-catenin signalling pathway is critical for commitment and differentiation of mesenchymal stem cells down the osteogenic or adipogenic lineage, its deregulation has been found associated with increased marrow adiposity following MTX treatment. In order to elucidate whether FA supplementation prevents MTX-induced bone marrow adiposity by regulating Wnt/β-catenin signalling, young rats were given saline or 0.75mg/kg MTX once daily for 5 days, receiving saline or 0.75mg/kg FA 6h after MTX. FA rescue alleviated the MTX-induced bone marrow adiposity, as well as well as inducing up-regulation of Wnt10b mRNA and β-catenin protein expression in the bone. Furthermore, FA blocked up-regulation of the secreted Wnt antagonist sFRP-1 mRNA expression. Moreover, secreted sFRP-1 protein in the bone marrow and its expression by osteoblasts and adipocytes was found increased following MTX treatment. This potentially indicates that sFRP-1 is a major regulator of defective Wnt/β-catenin signalling following MTX treatment. This study provides evidence that folate depletion caused by MTX chemotherapy results in increased bone marrow adiposity, and that FA rescue alleviates these defects by up-regulating Wnt/-catenin signalling in the bone. Refereed/Peer-reviewed

The bone marrow microenvironment is home to haematopoietic and mesenchymal cell populations that regulate bone turnover through complex interactions. The high proliferative capacity of these cell populations makes them susceptible to damage and injury, which alters the steady-state function of the bone marrow environment. Following cancer chemotherapy, irradiation and long-term glucocorticoid use, a fatty marrow cavity is typically observed, whereby reduced bone and increased fat formation of marrow stromal progenitor cells often results in increased marrow fat, reduced bone mass and increased fracture risk. Although the underlying mechanisms remain to be clearly elucidated, recent investigations have suggested a switch in lineage commitment of bone marrow mesenchymal stem cells down the adipogenic lineage at the expense of osteogenic differentiation, following damage caused by treatment regimens. As the Wnt/β-catenin signaling pathway has been recognized as the key mechanism regulating stromal commitment, its involvement in the osteogenic and adipogenic lineage commitment switch under damaging conditions has been of great interest. This chapter will review the effects of chemotherapy treatment regimens on commitment to the adipogenic and osteogenic lineages of bone marrow stromal progenitor cells. It will also summarize the Wnt/β-catenin signaling pathway and its role in stromal cell lineage commitment and recovery after damage, as well as its potential use as a therapeutic target.

The bone marrow microenvironment is home to mesenchymal and haematopoietic stem cells, and the interaction between these cell types and their respective progeny allows the maintenance of a steady-state functioning marrow, bone formation and turnover throughout life. Unfortunately, cancer chemotherapy, which commonly includes the anti-metabolite methotrexate (MTX), is a serious risk factor that disrupts homeostasis of the bone marrow and compromises bone formation, leading to myelosuppression and bone loss. MTX has been shown to cause significant damage to the bone marrow and reduce bone volume in both clinical and animal studies. Although the severity of damage to the bone marrow and the degree of ensuing recovery of marrow cell populations are dependent on the MTX dose and length of treatment, in order to re-establish the depleted marrow cavity, haematopoietic stem cells maintained at endosteal niche sites are induced to enter the cell cycle and differentiate down the appropriate lineage. Associated with damaged bone marrow stromal cells and a differentiation switch to adipogenesis at the expense of osteogenesis, are bone loss, increased marrow fat and fracture risk. This chapter will discuss mechanisms of how MTX chemotherapy causes myelosuppression, bone loss and marrow adiposity as reported in both clinical and animal studies, and will summarise changes in the relationship between cells of the mesenchymal and haematopoietic lineages in relation to MTX-induced damage and recovery of the bone and bone marrow.

Cancer chemotherapy disrupts the bone marrow (BM) microenvironment affecting steady-state proliferation, differentiation and maintenance of haematopoietic (HSC) and stromal stem and progenitor cells; yet the underlying mechanisms and recovery potential of chemotherapy-induced myelosuppression and bone loss remain unclear. While the CXCL12/CXCR4 chemotactic axis has been demonstrated to be critical in maintaining interactions between cells of the two lineages and progenitor cell homing to regions of need upon injury, whether it is involved in chemotherapy-induced BM damage and repair is not clear. Here, a rat model of chemotherapy treatment with the commonly used antimetabolite methotrexate (MTX) (five once-daily injections at 0.75 mg/kg/day) was used to investigate potential roles of CXCL12/CXCR4 axis in damage and recovery of the BM cell pool. Methotrexate treatment reduced marrow cellularity, which was accompanied by altered CXCL12 protein levels (increased in blood plasma but decreased in BM) and reduced CXCR4 mRNA expression in BM HSC cells. Accompanying the lower marrow CXCL12 protein levels (despite its increased mRNA expression in stromal cells) was increased gene and protein levels of metalloproteinase MMP-9 in bone and BM. Furthermore, recombinant MMP-9 was able to degrade CXCL12 in vitro. These findings suggest that MTX chemotherapy transiently alters BM cellularity and composition and that the reduced cellularity may be associated with increased MMP-9 expression and deregulated CXCL12/CXCR4 chemotactic signalling. Refereed/Peer-reviewed

The bone marrow is a complex environment that houses haematopoietic and mesenchymal cell populations and regulates bone turnover throughout life. The high proliferative capacity of these cell populations however, makes them susceptible to damage and injury, altering the steady-state of the bone marrow environment. Following cancer chemotherapy, irradiation and long-term glucocorticoid use, reduced bone and increased fat formation of marrow stromal progenitor cells results in a fatty marrow cavity, reduced bone mass and increased fracture risk. These bone and marrow defects are also observed in age-related complications such as estrogen deficiency and increased oxidative stress. Although the underlying mechanisms are yet to be clarified, recent investigations have suggested a switch in lineage commitment of bone marrow mesenchymal stem cells down the adipogenic lineage at the expense of osteogenic differentiation following such stress or injury. The Wnt/β-catenin signalling pathway is however has been recognized the key mechanism regulating stromal commitment, and its involvement in the osteogenic and adipogenic lineage commitment switch under the damaging conditions has been of great interest. This article reviews the effects of various types of stress or injury on the commitment to the adipogenic and osteogenic lineages of bone marrow stromal progenitor cells, and summarizes the roles of the Wnt/β-catenin and associated signalling pathways in the lineage commitment, switch, and recovery after damage, and as a therapeutic target.

The advancement and intensive use of chemotherapy in treating childhood cancers has led to a growing population of young cancer survivors who face increased bone health risks. However, the underlying mechanisms for chemotherapy-induced skeletal defects remain largely unclear. Methotrexate (MTX), the most commonly used antimetabolite in paediatric cancer treatment, is known to cause bone growth defects in children undergoing chemotherapy. Animal studies not only have confirmed the clinical observations but also have increased our understanding of the mechanisms underlying chemotherapy-induced skeletal damage. These models revealed that high-dose MTX can cause growth plate dysfunction, damage osteoprogenitor cells, suppress bone formation, and increase bone resorption and marrow adipogenesis, resulting in overall bone loss. While recent rat studies have shown that antidote folinic acid can reduce MTX damage in the growth plate and bone, future studies should investigate potential adjuvant treatments to reduce chemotherapy-induced skeletal toxicities. Refereed/Peer-reviewed