Metallic implants and CT artefacts in the CTV area: Where are we in 2020?

Radiation therapy (RT) is one of the main modalities of cancer treatment worldwide with computed tomography (CT), as the most commonly used imaging method for treatment planning system (TPS). Image reconstruction errors may greatly affect all the radiation therapy planning process, such as target delineation, dose calculation and delivery, particularly with particle therapy. Metallic implants, such as hip and spinal implants, and dental filling significantly deteriorate image quality. These hardware structures are often very complex in geometry leading to geometric complex artefacts in the clinical target volume (CTV) area, rendering the delineation of CTV challenging. In our review, we focus on the methods to overcome artefact consequences on CTV delineation: 1- medical approaches anticipating issues associated with imaging artefacts during preoperative multidisciplinary discussions while following standard recommendations; 2- common metal artefact reduction (MAR) methods such as manually override artefact regions, ballistics avoiding beam paths through implanted materials, megavoltage-CT (MVCT); 3- prospects with radiolucent implants, MAR algorithms and various methods of dual energy computed tomography (DECT). Despite substantial and broad evidence for their benefits, there is still no universal solution for cases involving implanted metallic devices. There is still a high need for research efforts to adapt technologies to our issue: "how do I accurately delineate the ideal CTV in a metal artefact area?"

Influence of metal ion solutions on rabbit osteoclast activities in vitro.

The purpose of the present study was to compare the effects of various metal ions (aluminium, chromium, cobalt, gold, iron, strontium, titanium and vanadium) on rabbit osteoclast activities, with respect to their number, size, resorptive capacity and their capacity to release proteinases. Marked heterogeneous osteoclastic behaviour was observed early in culture with metal ions (24 h) in term of resorption parameters. In contrast, protease activities (cysteine-proteinase and metalloproteinase activities) were not modulated in our culture conditions. Aluminium, iron, gold and titanium reduced the number of osteoclasts significantly. Aluminium and gold had no effect on osteoclast-mediated resorption on dentin-slices, although aluminium induced a greater number of very small lacunae. Titanium reduced only the mean surface area per lacunae, cobalt reduced the mean surface area of lacunae and increased their number, and iron reduced both parameters. Strontium had no effect on osteoclast formation and on total dentin slice surface resorbed. However, strontium increased the number of small lacunae formed on dentin-slices by osteoclasts. Chromium had no effect on osteoclast activities. These findings indicate that metal ions induce very early effects on osteoclasts, which can contribute to periprosthetic pathologies via different cellular mechanisms.

Bone remodelling and tumour grade modifications induced by interactions between bone and swarm rat chondrosarcoma.

Chondrosarcoma is currently defined as a malignant cartilage tumour arising de novo or within a pre-existing benign cartilage tumour. Chondrosarcoma can be surgically resected, but all grades have significant rates of local recurrence. The purpose of the present study was to develop an animal intraosseous chondrosarcoma model simulating the progression of human chondrosarcoma and elucidating its behaviour and biology. An intraosseous Swarm rat model was designed to assess interactions between bone and chondrosarcoma. A comparison of tumour grading was carried out according to transplantation site. The effects of chondrosarcoma cells (SRC cells) on the mineralisation capacities of osteoblasts and on osteoclast differentiation were studied in relation to modifications observed in vivo at the cellular level. Transplantation of Swarm rat chondrosarcoma within bone marrow or contiguous to induced periosteal lesions led to extensive bone remodelling with trabecular bone rarefaction and periosteal apposition. Transplantation in close contact to bone but without any periosteal lesion had no effect on bone, suggesting that bone healing factors interact with tumour development. With the intramedullary model, the development of tumours of different grade confirms that bone environment is an important factor in malignancy. A decrease of bone nodule formation was noted after cocultures of SRC cells with rat bone marrow, but there was no modification of osteoclast differentiation after cultures of total rabbit bone cells with SRC cells. These data reveal the importance of interactions between bone environment and tumour in inducing bone remodelling and variations in tumour malignancy.

Osteoclastic acidification pathways during bone resorption.

Osteoclasts resorb bone by attaching to the surface and then secreting protons into an extracellular compartment formed between osteoclast and bone surface. This secretion is necessary for bone mineral solubilization and the digestion of organic bone matrix by acid proteases. This study summarizes the characterization and role of each type of ion transport and defines the main biochemical mechanisms involved in the dissolution of bone mineral during bone resorption. The primary mechanism responsible for acidification of the osteoclast-bone interface is vacuolar H+-adenosine triphosphatase (ATPase) coupled with Cl- conductance localized to the ruffled membrane. Carbonic anhydrase II (CAII) provides the proton source for extracellular acidification by H+-ATPase and the HCO3- source for the HCO3-/Cl- exchanger. Whereas some transporters are responsible for the bone resorption process, others are essential for pH regulation in the osteoclast. The HCO3-/Cl- exchanger, in association with CAII, is the major transporter for maintenance of normal intracellular pH. An Na+/H+ antiporter may also contribute to the recovery of intracellular pH during early osteoclast activation. Once this mechanism has been rendered inoperative, another conductive pathway translocates the protons and modulates cytoplasmic pH. Inward-rectifying K+ channels may also be involved by compensating for the external acidification due to H+ transport. These different effects of transport processes, either on bone resorption or pH homeostasis, increase the number of possible sites for pharmacological intervention in the treatment of metabolic bone diseases.

Potential synergies between matrix proteins and soluble factors on resorption and proteinase activities of rabbit bone cells.

Human growth hormone (GH) has recently been found to stimulate osteoclastic resorption, cysteine-proteinase and metalloproteinase activities (MMP-2 and MMP-9) in vitro via insulin-like growth factor-I (IGF-I) produced by stromal cells. The present study investigated the effects of two extracellular matrix components (vitronectin and type-I collagen) on hGH- and hIGF-1-stimulated osteoclastic resorption and proteinase activities in a rabbit bone cell model. After 4 days of rabbit bone cell culture on dentin slices with vitronectin coating, hGH and hIGF-1 stimulated bone resorption and hIGF-1 upmodulated cysteine-proteinase activities. MMP-2 expression (but not resorption, cathepsin or MMP-9 activities) was upmodulated by hGH and hIGF-1 on dentin slices coated with type I collagen as compared to those without coating. Then, vitronectin was synergistic with hIGF-1 in the regulation of cysteine-proteinase production whereas collagen showed synergy with hGH and hIGF-1 in the regulation of MMP-2 production. Anti-alphavbeta3 totally abolished the effects of hGH and hIGF-1 on metalloproteinase release, but had no influence on cathepsin release. The results suggest that cysteine-proteinase modulation is not mediated by alphavbeta3 integrin (strongly expressed on osteoclastic surface) whereas the resorption process and metalloproteinase modulation are clearly mediated by this integrin. Our finding about the collagen coating also suggests that hGH- and hIGF-1-stimulated MMP-2 activity are mediated, along with alphavbeta3 integrin, by another adhesion molecule.

Ultrastructural evidence in vitro of osteoclast-induced degradation of calcium phosphate ceramic by simultaneous resorption and phagocytosis mechanisms.

Osteoclasts are physiological polykaryons specialized in the resorption of calcified tissue. In the context of the clinical use of calcium-phosphate (CaP) ceramics as bone substitutes, this study used transmission electron microscopy to investigate the in vitro mechanisms of CaP ceramic degradation by osteoclastic cell types. Osteoclasts cultured on CaP ceramic developed typical ultrastructural features of bone osteoclasts, such as a polarized dome shape, a clear zone and a ruffled border. Modification of the shape and density of CaP crystals under the ruffled border indicated an acidic microenvironment. Moreover, osteoclasts were able to degrade ceramic by simultaneous resorption and phagocytosis mechanisms. Phagocytosis did not alter the ability of osteoclasts to resorb CaP ceramic. The phagocytosis mechanism consisted of three steps: crystal phagocytosis, disappearance of the endophagosome envelope membrane and fragmentation of phagocytosed crystals within the cytoplasm. The common mechanism of phagocytosis described here is similar to that observed with the monocyte/macrophage lineage, confirming that osteoclasts are part of the mononuclear phagocyte system. Osteoclasts are thus clearly involved in CaP degradation by means of resorption and phagocytosis.

gp130 Cytokine family and bone cells.

Bone tissue is continually being remodelled according to physiological circumstances. Two main cell populations (osteoblasts and osteoclasts) are involved in this process, and cellular activities (including cell differentiation) are modulated by hormones, cytokines and growth factors. Within the last 20 years, many factors involved in bone tissue metabolism have been found to be closely related to the inflammatory process. More recently, a cytokine family sharing a common signal transducer (gp130) had been identified, which appears to be a key factor in bone remodelling. This family includes interleukin 6, interleukin 11, oncostatin M, leukaemia inhibitory factor, ciliary neurotrophic factor and cardiotrophin-1. This paper provides an exhaustive review of recent knowledge on the involvement of gp130 cytokine family in bone cell (osteoblast, osteoclast, etc.) differentiation/activation and in osteoarticular pathologies.

Cysteine protease production by human osteosarcoma cells (MG63, SAOS2) and its modulation by soluble factors.

The production of cysteine protease by two human osteosarcoma cell lines (MG-63 and SaOS2) was analyzed, as well as their modulation by interleukin 1beta (hIL-1 beta), interleukin 6 (hIL-6), insulin growth factor-1 (hIGF-1), oncostatin M (hOSM), leukemia inhibitory factor (hLIF) and growth hormone (hGH). Cysteine protease activities were detected using a synthetic substrate. The protease activities (especially cathepsin L activity) of both cell lines were increased significantly in the presence of hIL-1 beta, hIL-6 and hOSM. In contrast, hIGF-1 and hGH decreased these activities, and no effect was detectable in the presence of hLIF. The addition of antibodies against the gp-130 chain of the hIL-6 and hOSM receptors totally inhibited the stimulating effect of these two cytokines on cysteine protease activities. In increasing collagen type I degradation, hIL-1beta, hIL-6 and hOSM could be involved in bone resorption, whereas the inhibitory action of hIGF-1 and hGH on collagen type I degradation suggest that this factor could play a role in bone formation.

[In vitro effects of growth hormone on osteoclastic activity: clinical applications]. / Effets in vitro de l'hormone de croissance sur l'activité des ostéoclastes : intérêt clinique.

PURPOSE OF THE STUDY: This study was designed to investigate the in vitro effects of human growth hormone (hGH) on osteoclastic resorption in a nonfractionated rabbit bone cell model. MATERIAL AND METHODS: Rabbit bone cells were cultured on dentine slices in the presence of parathyroid hormone and vitamin D3. The percentage of dentine slice surface resorbed, number of lacunae per surface unit and mean area of lacunae were compared between cell cultures grown in the presence of graded concentrations of hGH and human insulin-like growth factor-1 (hIGF-1) and controls. RESULTS: After 4 days of culture, rabbit bone cells cultured on dentine slices in the presence of hGH and hIGF-1 showed significantly stimulated osteoclastic resorption activity. When neutralizing anti-hIGF-1 anti-serum (4 microg/l) was added to the starting culture, the stimulatory effects of hIGF-1 and hGH on osteoclastic resorption activity were totally abolished. DISCUSSION: These findings indicate that the effects of hGH stimulation on osteoclastic resorption in vitro are mediated via local hIGF-1 secretion by stromal cells such as osteoblasts. Proteases appear to play a role in the degradation of the organic matrix. Our experiments show that hIGF-1 and hGH stimulate the production of matrix metalloproteinases MMP-9 and MMP-2. Similar to the resorption activity, hGH stimulates protease activity via stromal cell production of hIGF-1. CONCLUSION: This study suggests that natural or synthetic MMP inhibitor modulation of protease activity could reduce the degradation of the organic matrix and then prevent, for example, inflammatory reactions subsequent to prosthetic loosening.

Growth hormone stimulatory effects on osteoclastic resorption are partly mediated by insulin-like growth factor I: an in vitro study.

This study investigated the possible role in vitro of insulin-like growth factor I (IGF-I) as a mediator of the effects of growth hormone (GH) on osteoclastic resorption in an unfractioned rabbit bone cell model. After 4 days of rabbit bone cell culture, human GH (hGH) (50 ng/mL) and human IGF-I (hIGF-I) (50 ng/mL) significantly increased the formation of osteoclast-like cells with a lower level than parathyroid hormone (50 ng/mL) or VD3 (10(-8) mol/L). As well as parathyroid hormone and 1-alpha,25-dihydroxyvitamin D3, addition of hGH (1, 10, and 50 ng/mL) and hIGF-I (1, 10, and 50 ng/mL) stimulated the resorption activity of osteoclasts in terms of the percentage of dentin slice surface resorbed, number of lacunae per surface unit, and mean area of lacunae as compared to the control. When neutralizing antiserum against hIGF-I (4 micrograms/mL) was added at the start of culture, the stimulatory effects of hIGF-I and hGH on osteoclastic resorption activity were totally abolished. These results indicate that the effects of GH stimulation on osteoclastic resorption in vitro are mediated via local IGF-I secretion by stromal cells such as osteoblasts. As IGF-I receptors have recently been reported on rabbit osteoclasts, a direct action of IGF-I on mature osteoclasts could be envisaged. Further experiments will be required to determine the real level of IGF-I implicated in the stimulation of bone osteoclastic resorption.