Skeletal metabolism is regulated by bone cells and their progenitors (Figure 3). Among the population of bone cells are osteoblasts, osteocytes, osteoclasts, and lining cells (Table 16) (1-3). Monocytes, macrophages, and mast cells may also mediate certain aspects of skeletal metabolism. Marrow cells contribute to the population of bone cells. The osteoblast forms bone. Osteoblasts express receptors to many bone-active agents such as PTH, PTHrP, vitamin D metabolites, gonadal and adrenal steroids, and certain cytokines and growth factors. The major product of osteoblasts is type 1 collagen, which along with other proteins, forms the organic osteoid matrix that is mineralized to hydroxyapatite.

Osteocytes are osteoblasts that become encased in bone during its formation and mineralization and reside in the resulting lacuna (2,3). While their synthetic activity decreases, the cells develop processes that communicate as canaliculi with other osteocytes, osteoblasts, and the vasculature. Osteocytes thus present acres of cellular syncytium that permits translocation of bone mineral during times of metabolic activity and can provide minute-to-minute exchanges of minerals from bone matrix.

Osteocytes are also the likely transducers through their canaliculi of mechanical forces on bone and mediate the complex remodeling response to mechanical stimuli of the skeleton that causes appropriate changes in formation and resorption in response to skeletal loading.

The osteoclast resorbs bone. It is a terminally-differentiated, large, multinucleated giant cell that arises from hematopoietic marrow precursors under the influences of hormones, growth factors, and cytokines (3). The osteoclast resorbs bone by attachment with a ruffled border through adhesion molecules and by secretion of hydrogen and chloride ions that dissolve mineral and lytic proteases, notably lysosomal proteases active at low pH and metalloproteinases and cysteine proteinases that dissolve matrix. In contrast to the receptor-rich osteoblast, the mature osteoclast has few receptors, but it robustly expresses the receptor for CT. After completing its function, the terminally-differentiated osteoclast undergoes apoptosis.

Bone-lining cells are flat, elongated cells that cover inactive bone surfaces. Their function is unknown, but they may be osteoblast precursors or function to clean up resorption and formation debris. Mast cells can be seen at sites of bone resorption and may also participate in this process. Cells of the immune system play a key role in bone metabolism, especially resorption, by their interactions with bone cells that are described later.

Growth, modeling, and remodeling are important processes that allow the skeleton to play its many important roles (1). Bone grows and models under the influence of metabolic, mechanical, and gravitational forces during growth through adolescence, changing its size and shape in the process. Bone growth continues until approximately the third decade. Bone mass continues to increase until the fourth decade (Figure 4).

Bone in adults renews itself by remodeling, a cycle in which old bone is first resorbed and new bone is then formed to replace it (2,3). Both cortical bone and trabecular bone remodel, but the latter is more metabolically active. Bone remodeling can be divided into several stages that include resorption by osteoclasts and formation by osteoblasts. Remodeling serves to repair skeletal microdamage and to improve skeletal strength in response to mechanical forces. Osteoclasts and osteoblasts communicate with each other during remodeling in a process that is referred to as coupling and mediated by local regulatory signals that are discussed subsequently. Coupling assures a balance of bone formation and bone resorption in the adult skeleton. The process of bone formation is thus balanced by the process of bone resorption.

Cortical bone is resorbed by "cutting cones" of osteoclasts that tunnel through it (2). Trabecular bone remodels on its surface. Most remodeling occurs in trabecular bone and on the endosteal surfaces of cortical bone, with little periosteal remodeling. However in diseases like hyperparathyroidism, subperiosteal resorption is activated. With aging, periosteal remodeling and expansion seems to compensate (mechanically) for bone loss at other sites.

Bone resorption is mediated by the osteoclast, a large, multinucleated cell that is molecularly equipped to dissolve both the mineral and organic phases of bone (1,3). The processes of osteoblast-mediated bone formation and osteoclast-mediated bone resorption can be assessed by measurementin urine and blood of bone markers. The markers of bone formation include osteoblast products (e.g., alkaline phosphatase and osteocalcin) and by-products of collagen synthesis and osteoclasts products (e.g. tartrate resistant acid phophatase0 and by-products of collagen break down. Approximately 20% of adult bone surface is undergoing remodeling at any time. The homeostatic end-point of skeletal metabolism is to provide the appropriate amount of ambient calcium for the many biological functions that this ion serves, with the structural integrity of the skeleton taking second place. These metabolic activities of bone cells can release into blood and urine certain bone cells and matrix products that can serve as clinically useful markers of skeletal metabolism (Figure 5).

The recent elucidation of this novel pathway of molecular regulation has provided both a physiologic link among bone cell functions as well as a pathogenetic link among cancer cells, the immune system, and bone cells in the regulation of the osteoclastic bone resorption that is the final cellular mediator of most cases of hypercalcemia (Figure 1) (9,10). The molecular participants in this pathway are the membrane-associated protein named RANKL (receptor activator of nuclear factor kappa B ligand,) a member of the tumor necrosis factor family of cytokines; its cognate receptor, RANK, and OPG (osteoprotegerin), a soluble "decoy" receptor for RANKL.

In the physiology of bone metabolism, RANKL is expressed on the surface of osteoblastic stromal cells (9). By binding to RANK, its receptor, on osteoclast precursors, RANKL enhances their recruitment into the osteoclastogenesis pathway in the physiology of bone metabolism. RANKL also activates mature osteoclasts to resorb bone. RANKL is considered as the long-sought "coupling factor" through which osteoblasts regulate osteoclasts and bone formation is coupled to bone resorption. In the pathophysiology of hypercalcemia, many of the tumor cell types that are associated with cancer-stimulated bone resorption express a soluble form of RANKL, sRANKL. Furthermore, during the inflammation that can be associated with malignancy, activated T-lymphocytes also express increased amounts of RANKL, which can stimulate osteoclasts. The activated lymphocytes also expresses interferon gamma (INF), which opposes the effect of RANKL on osteoclast mediated bone resorption. The osteoclastic effects of RANKL can also be attenuated by its soluble decoy receptor, OPG, also produced by osteoblasts and tumor cells. Hypercalcemia results when these opposing regulatory interactions of RANKL, RANK, OPG, and INF allow osteoclastic activation to predominate (Figure 5). New therapies against the increased bone resorption that characterizes many skeletal diseases target this pathway.

These molecular participants in the interaction between bone cells, tumor cells, and the immune system are also regulated by several hormones, growth factors, and cytokines that mediate increased bone resorption, both physiologic and pathophysiologic. They include PTH, PTHrP, TNF, PGE2, vitamin D metabolites, IL-1, and TGF (10).