Genomewide Pharmacogenetics of Bisphosphonate-Induced
Osteonecrosis of the Jaw: The Role of RBMS3
PAOLA NICOLETTI,aVASSILIKI M. CARTSOS,dPENELOPE K. PALASKA,dYUFENG SHEN,a,b
ARIS FLORATOS,a,bATHANASIOS I. ZAVRASc,e,f
aCenter for Computational Biology and Bioinformatics,bDepartment of Biomedical Informatics, andcHerbert
Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, New York, USA;
dDepartment of Orthodontics, Tufts School of Dental Medicine, Boston, Massachusetts, USA;eDivision of
Oral Epidemiology & Biostatistics, Columbia College of Dental Medicine, New York, New York, USA;
fDepartment of Epidemiology, Mailman School of Public Health, New York, New York, USA
Key Words. Osteonecrosis • Jaw • Bisphosphonates • Pharmacogenetics • Screening • IGFBP7 • ABCC4 •
RBMS3 • Zoledronic acid • Genetic susceptibility • Genomewide association study • ONJ • GWAS
Disclosures: Paola Nicoletti: None; Vassiliki M. Cartsos: None; Penelope K. Palaska: None; Yufeng Shen: None; Aris Floratos: None;
Athanasios I. Zavras: None.
Section Editors: Eduardo Bruera: None; Russell K. Portenoy: Arsenal Medical Inc., Grupo Ferrer, Xenon (C/A); Ameritox, Archimedes
Pharmaceuticals, Boston Scientific, Covidien Mallinckrodt Inc., Endo Pharmaceuticals, Forest Labs, K-Pax Pharmaceuticals, Meda
Pharmaceuticals, Medtronics, Otsuka Pharma, ProStrakan, Purdue Pharma, Salix, St. Jude Medical (RF).
Reviewer “A”: None.
(C/A) Consulting/advisory relationship; (RF) Research funding; (E) Employment; (H) Honoraria received; (OI) Ownership interests; (IP)
Intellectual property rights/inventor/patent holder; (SAB) Scientific advisory board
After completing this course, the reader will be able to:
1. Explain the association between bisphosphonates and osteonecrosis of the jaw.
2. Describe the role of RBMS3 in the risk of BRONJ development.
This article is available for continuing medical education credit at CME.TheOncologist.com.
Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is
association study to search for genetic variants with a large
effect size that increase the risk for BRONJ.
Methods. We ascertained BRONJ cases according to the
Maxillofacial Surgeons. We genotyped cases and a set of
treatment-matched controls using Illumina Human Omni
Express 12v1 chip (733,202 markers). To maximize the
power of the study, we expanded the initial control set by
publicly available sources. Imputation at the whole-ge-
nome level was performed to increase the number of single
sociation were carried out by logistic regression, adjusting
for population structure. We also examined a list of candi-
date genes comprising genes potentially involved in the
pathogenesis of BRONJ and genes related to drug absorp-
tion, distribution, metabolism, and excretion.
Results. Based on principal component analysis, we
initially analyzed 30 white cases and 17 treatment-toler-
ant controls. We subsequently expanded the control set
to include 60 genetically matched controls per case. As-
sociation testing identified a significant marker in the
RBMS3 gene, rs17024608 (p-value < 7 ? 10?8); individ-
uals positive for the SNP were 5.8? more likely to de-
Correspondence: Athanasios I. Zavras, D.M.D., D.M.Sc., M.S., Columbia University Medical Center, 622 W 168th Street, Suite
PH17W-306R, New York, New York 10032, USA. Telephone: 212-342-0425; Fax: 212-342-8558; e-mail: email@example.com.
columbia.eduReceived June 16, 2011; accepted for publication September 21, 2011; first published online in The Oncologist Express
on January 20, 2012. ©AlphaMed Press 1083-7159/2012/$40.00/0 http://dx.doi.org/10.1634/theoncologist.2011-0202
velop BRONJ (odds ratio, 5.8; 95% confidence interval,
3.1–11.1). Candidate gene analysis further identified
SNPs in IGFBP7 and ABCC4 as potentially implicated in
Conclusion. Our findings suggest that genetic suscepti-
bility plays a role in the pathophysiology of BRONJ, with
Bisphosphonates (BPs) are widely prescribed antiosteoclastic
medications. The i.v. administered BPs pamidronate and zole-
dronic acid are used in oncology to control bone metastasis and
hypercalcemia. Oral BPs are used to control or prevent bone loss
currently on oral BPs [1–3]. BPs are synthetic analogs of pyro-
for several years. BPs are especially attracted to, and localize in,
areas of the bone undergoing inflammation or resorption. They
are subsequently phagocytozed and internalized by osteoclasts.
These internalized BPs, in turn, trigger apoptosis (cell death) of
the osteoclasts, thus inhibiting osteoclast-mediated bone resorp-
tion [1, 2]. Osteoclasts seem to be affected both in terms of num-
ber and function. Animal studies have also demonstrated some
of the bone because of reduced vasculature .
BPs, especially zoledronic acid, have been associated with a
American Association of Oral and Maxillofacial Surgeons
(AAOMS), BP-related osteonecrosis of the jaw (BRONJ) is de-
tients under BP treatment and with no prior history of radiation
therapy of the jaws . The nonhealing exposed necrotic lesions
ful, persistent, and resistant to treatment. The incidence of
ing on the type of BP, drug administration route [3, 6], dose and
duration of use, comorbidities, and treated condition [1, 3, 6].
Cancer patients are a group with a higher risk for BRONJ,
whereas, among all BPs on the market, zoledronic acid seems to
be the most frequently implicated drug [1, 2]. BRONJ affects as
oral health have been shown to be predisposing factors for
be involved in BRONJ risk [1, 9, 10]. A genetic test capable of
screening subjects for genetic susceptibility to BRONJ prior to
initiating BP therapy would have great clinical utility, especially
netic genomewide association study to identify highly penetrant
polymorphisms associated with BRONJ across multiple drugs.
We recruited patients who had a definite BRONJ diagnosis. We
looked across the whole genome for susceptibility single nucleo-
tide polymorphisms (SNPs) and copy number variation (CNV)
markers using a dense DNA array with ?733,000 markers. Im-
putation analysis allowed the further expansion of the genome-
wide marker panel to include ?3.5 million SNPs. Candidate
SNPs in the insulin-like growth factor (IGF) gene family (IGF1,
sorption, distribution, metabolism, and excretion of drugs
(ADME genes) were specifically inspected .
This research involved a hospital-based case–control study.
The research protocol was reviewed and approved by the in-
stitutional review boards of the recruiting institutions. All the
enrolled subjects signed a written informed consent form. The
eral Hospital, Brigham & Women’s Hospital, the Harvard
School of Dental Medicine and its affiliated clinics, and Nova
University Dental School in Florida. Initially, we searched
ers. Among the BP users, we identified confirmed BRONJ
cases according to the AAOMS diagnostic criteria and unaf-
fected exposed controls. Cases were considered to have devel-
oped BRONJ if all the following three clinical characteristics
developed ONJ, (b) the exposed, necrotic bone in the maxill-
ofacial region persisted for ?8 weeks, and (c) the patient had
no history of radiation therapy to the jaws. Controls were pa-
tients currently under treatment with a BP who had no signs or
symptoms of BRONJ, verified via clinical examination.
Potential participants were contacted by letter and were in-
vited to participate in the study. Patients (cases) with con-
firmed BRONJ status were offered the alternative to
clinic to be examined to ensure their non-BRONJ status. After
signing the consent form, participants were asked to answer a
questionnaire contained questions on demographic character-
fluence the risk for developing BRONJ.
the Oragene DNA collection kit (DNA Genotek, Kanata, Can-
ada). The saliva kits were mailed in one batch to the subcon-
tracting genotyping facility at SABiosciences (Frederick,
MD). DNA was extracted following the manufacturer’s rec-
ommended protocol. High-throughput genotyping was per-
formed using the Human Omni Express 12v1.0 Beadchip
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