Chemotherapy activates inflammasomes to cause inflammation-associated bone loss

Reviewer #1 (Public Review):

Summary:
Doxorubincin has long been known to cause bone loss by increasing osteoclast and suppressing osteoblast activities. The study by Wang et al. reports a comprehensive investigation into the off-target effects of doxorubicin on bone tissues and potential mechanisms. They used a tumor-free model with wild-type mice and found that even a single dose of doxorubicin has a major influence by increasing leukopenia, DAMPs, and inflammasomes in macrophages and neutrophils, and inflammation-related cell death (pyroptosis and NETosis). The gene knockout study shows that AIM2 and NLRP3 are the major contributors to bone loss. Overall, the study confirmed previous findings regarding the impact of doxorubicin on tissue inflammation and expanded the research further into bone tissue. The presented data are consistent; however, a major question remains regarding whether doxorubicin drives inflammation and its related events. Most in vitro studies showed that the effect of doxorubincin cannot be demonstrated without LPS priming. This observation raises the question of whether doxorubincin itself could activate the inflammasome and the related events. In vivo study, on the other hand, suggested that it doesn't require LPS. The inconsistency here was not explained further. Moreover, a tumor-free mouse model was used for the study; however, immune responses in tumor-bearing models would likely be distinct from tumor-free ones. The justification for using tumor-free models is not well-established.

Strengths:
The paper includes a comprehensive study that shows the effects of doxorubincin on cytokine levels in serum, the release of DAMPs and NETosis, and leukopenia using both in vivo and in vitro models. Bone marrow cells, macrophages, and neutrophils were isolated from the bone marrow, and the levels of cytokines in serum were also determined.

They employed multiple knockout models with a deficiency in Aim 2, Nlirp3, and double deficiencies to dissect the functional involvement of these two inflammasomes.

The experiments in general are well designed. The paper is also logically written, and the figures were clearly labeled.

Weaknesses:
Most of the data presented are correlative, and there is not much effort to dissect the underlying molecular mechanism.

It is not entirely clear why a tumor-free model is chosen to study immune responses, as immune responses can differ significantly with or without tumor-bearing.

Immune responses in isolated macrophages, neutrophils, and bone marrow cells require priming with LPS, while such responses are not observed in vivo. There is no explanation for these differences.

The band intensities on Western blots in Fig. 4 and Fig. 5 are not quantified, and the numbers of repeats are also not provided.

Many abbreviations are used throughout the text, and some of the full names are not provided.

Fig. 5B needs a label on the X axis.

Reviewer #2 (Public Review):

Summary:
Wang and collaborators have evaluated the impact of inflammation on bone loss induced by Doxorubicin, which is commonly used in chemotherapy to treat various cancers. In mice, they show that a single injection of Doxorubicin induces systemic inflammation, leukopenia, and significant bone loss associated with increased bone-resorbing osteoclast numbers. In vitro, the authors show that Doxorubicin activates the AIM2 and NLRP3 inflammasomes in macrophages and neutrophils. Importantly, they show that the full knockouts (germline deletions) of AIM2 (Aim2-/-) and NLRP3 (Nlrp3-/-) and Caspase 1 (Casp1-/-) limit (but do not completely abolish) bone loss induced 4 weeks after a single injection of Doxorubicin in mice. From these results, they conclude that Doxorubicin activates inflammasomes to cause inflammation-associated bone loss.

Strengths:
While numerous studies have reported that Doxorubicin activates the inflammasome in myeloid cells and various other cell types, that Doxorubicin induces systemic inflammation, and that both the systemic inflammation and Doxorubicin treatment leads to bone loss, functional experiments demonstrating that NRLP3 and/or AIM2 loss-of-functions, and thus the systemic impairment of the inflammatory response, may prevent bone-loss induced by Doxorubicin were lacking. The strength of this manuscript is that it provides these missing data.

Weaknesses:
However, one could argue that most of the conclusions drawn from the data presented here have been previously reported and that it was very much expected that reducing systemic inflammation in treated animals (in Aim2-/- and/or Nlrp3-/- mice) would preserve bone homeostasis to some extent, similarly to what has been reported in the context of cardiotoxicity induced by Doxorubicin.

Since the manuscript focuses on therapeutic considerations aiming to preserve bone homeostasis in animals treated with Doxorubicin, additional experiments evaluating and comparing various therapeutic options could improve the impact of the study. Drugs targeting the inflammasomes could be tested in addition to the genetic mouse models. Since increased osteoclast numbers (and likely bone resorption) are associated with Doxorubicin-induced bone loss, antiresorptive drugs such as Bisphosphonates or anti-RANKL antibodies could be tested and compared to anti-inflammatory drugs. Since autophagy and senescence have been shown to contribute to bone loss induced by Doxorubicin, it would be interesting to use the pharmacologic inhibitors (targeting autophagy or senescence) used in these previous studies to evaluate the relative impact of these different cellular mechanisms, on bone loss induced by Doxorubicin.

Moreover, the cellular and molecular mechanisms by which Doxorubicin induces bone loss in vivo could be further evaluated. Doxorubicin has been reported to directly affect bone-making osteoblasts and bone-resorbing osteoclasts. It would be important to determine the relative importance of the activation of the AIM2 and NLRP3 inflammasomes in these cells compared to macrophages and neutrophils. Floxed mouse lines exist for both Aim2 and Nlrp3, as well as relevant cell-specific Cre lines. Thus, cell-specific conditional knockouts could have been used in the current study, instead of using global knockout animals. Genetic tools also exist to induce the specific ablation of macrophages or neutrophils and could be used. Furthermore, it is unclear whether local inflammation is induced in the bone marrow of Doxorubicin-treated mice, and what is the relative impact of local versus systemic inflammation in bone loss in these mice. Markers of the inflammasomes, pyroptosis, and NETosis could be evaluated on bone sections, and on bone and bone marrow samples. The effect of Doxorubicin on osteoblast numbers in vivo and on bone resorption (not just osteoclast numbers) should be evaluated as well. These mechanistic aspects are important and needed to better understand the cytotoxic mechanisms triggered by Doxorubicin, and define the best therapeutic approaches to preserve bone integrity in chemotherapy.

Finally, it would be important to assess the bone mass of Doxorubicin-treated control, Aim2-/-, Nlrp3-/- and Cas1-/- mice at a later time point than 4 weeks post-injection. Nlrp3 knockout has been reported to increase the density of the cortical and trabecular bones. The bone mass of Aim2-/-, Nlrp3-/- and Cas1-/- mice at baseline may be higher than that of control mice, and it may take slightly longer for Doxorubicin to reduce bone mass to the same extent than in controls. It would be also interesting to do similar experiments using animals treated multiple times with Doxorubicin instead of using a single injection, since patients receive their chemotherapy multiple times.