To the Editor Giant cell tumor (GCT) is a locally aggressive, benign bone lesion that shows extensive bone destruction that often leads to pain and pathologic fracture. It usually occurs in the epiphysis and metaphysis of bone near the joint. The destruction of subchondral bone impairs joint function. In rare instances, the tumor can spread to the lungs or can present as multifocal disease. On histologic examination, the tumor shows a mixture of cells consisting of osteoclastlike multinucleated giant cells, mononuclear cells, and stromal cells. This unique composition of different cell types has been the subject of the study of osteoclast biology. The preferred treatment options include surgical treatment such as curettage, in conjunction with chemical or physical adjuvant therapy, or extensive resection followed by major reconstructive surgery. The outcome after surgical resection has been affected negatively by tumor recurrence and additional bone destruction. Many topical adjuvant therapies such as phenol, hydrogen peroxide, or liquid nitrogen have been used in an attempt to decrease local recurrence by inducing physical or chemical damage to the remaining GCT cells after curettage, but a specific adjuvant therapy that directly targets osteoclasts and GCT cells is needed. In GCT, the mesenchymal stromal cells are the neoplastic cells and induce recruitment and formation of osteoclasts. The osteoclastic cells, which cause bony destruction, are thought to be recruited from normal monocytic preosteoclasts by stromal cell expression of the ligand for receptor activator of nuclear factor kappaB (RANKL). RANKL is an osteoclastogenesis factor released by osteoblasts, stromal cells, and activated T cells. RANK is a receptor that is present on the cell membrane of osteoclasts, monocytes, and osteoblasts. Studies have shown the role ofRANKL inGCT as evidenced by the inhibitory effect of osteoprotegerin (a decoy receptor of RANKL) on RANKL-mediated tumoral osteoclastogenesis. Cell adhesion of osteoblasts and osteoclastic precursors of hematopoietic origin is a prerequisite for osteoclast maturation. Several studies have demonstrated that interaction of RANKL on osteoblast and RANK on osteoclast precursor provides an essential signal to osteoclast precursors for their maturation into resorbing cells. b1 integrin/focal adhesion kinase (FAK)-mediated signaling is involved in intercellular adhesion molecule 1 (ICAM-1) and RANKL induction of osteoblasts and affects cellular adhesion between osteoblasts and osteoclast precursors through the ICAM-1 andRANKL/RANKpathways and leads to differentiation of osteoclast progenitors to osteoclasts. Therefore, b1 integrin/FAK-mediated signaling is involved in ICAM-1 and RANKL induction of osteoblasts. Small GTPaseRho signaling is involved in b1 integrin-mediated upregulation of ICAM-1 and receptor activator of nuclear factor kappaB ligand on osteoblasts and osteoclast maturation. Clostridium botulinum, producing two classes of enzymes that have very specific protein targets, the neurotoxin A-G and the ADP-ribosyltransferases C2, C3 bot 1, and C3 bot 2. C2 and C3 bot are part of a larger family of ADP-ribosylating toxins, including diphtheria toxin and cholera toxin, which cleave Published online December 29, 2007. Address correspondence and reprint requests to: Hamid Namazi; E-mail: namazih@sums.ac.ir
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