Hematopoietic stem cell transplantation: ASBMT/CIBMTR 2010
tandem meeting highlights and discussion
Noelle V. Frey and David L. Porter*
The American Society for Blood and Marrow Transplantation (ASBMT)
and the Center for International Blood and Marrow Transplantation
Research (CIBMTR) held their 12th Annual Tandem Meeting this Febru-
ary in Orlando, Florida. This International Transplant Meeting brought
together a record 2,570 attendees from 45 countries, and included the
state of the art educational and plenary sessions and 478 oral and poster
presentations. Recently, the American Journal of Hematology published a
series of articles reviewing the ‘‘Top 10 clinically oriented abstracts’’ pre-
sented at the 2009 American Society of Hematology meeting . Given
how well this series was received, we believed it would be worthwhile
providing a similar review of relevant abstracts from this year’s BMT
meetings. There has been dramatic progress in this field that we believe
is of great interest and importance to the hematology/oncology commun-
ity. There was an incredible body of work presented and it is misleading
to suggest that there is a ‘‘top 10’’ list. Many more abstracts than can be
presented here are worthy of discussion and recognition and any exclu-
sion of important studies is solely a reflection of space limitation rather
than quality of work. We tried to pick abstracts that were important,
novel, biologically interesting, and that address either changing or con-
troversial areas in the field. All 10 abstracts are published in full in the
February 2010 issue of Biology of Blood and Marrow Transplantation
(volume 16, No. 2) and are identified here by their abstract number.
Frequency of CD41CD25hiFOXP31Regulatory T Cells Has
Diagnostic and Prognostic Value As a Biomarker for Acute
The diagnosis and severity of acute graft versus host disease (GVHD) is
typically based on clinical and laboratory observations that are often subjec-
tive or inconclusive. For instance, a skin rash may be graded as GVHD by one
observer and attributed to an allergic drug reaction by a second observer. Biop-
sies of involved organs may be useful but can be associated with significant
risk and may also return conflicting or inconclusive results. For many years
investigators have attempted to identify biomarkers to predict and diagnose
GVHD [2,3] and ideally herald the onset and severity before clinical symptoms
develop allowing for early intervention and better, more effective, and targeted
immunosuppressive therapies. To date, however there are no validated diag-
nostic or prognostic noninvasive tests for acute GVHD.
Regulatory T cells (Tregs) have been found to be important mediators of
tolerance after experimental hematopoietic SCT, and have been used to pre-
vent and treat GVHD in murine models . While there is great interest in
using Tregs therapeutically in clinical transplantation, just the presence and
number of Tregs could serve as a useful biomarker for GVHD. The study by
Magenau et al. uses flow cytometry to measure CD41/CD25hi/FOXP31
Tregs in 215 patients with (n 5 60) and without (n 5 155) GVHD.
Patients with GVHD (N 5 60) had a Treg frequency that was 40% less
(0.66% ±0.07, P < 0.001) than those without GVHD and Treg frequency
was identified as a significant independent biomarker of GVHD. Further-
more, Treg frequency correlated with the maximum overall grade of GVHD
(r 5 20.33; P < 0.001), suggesting Treg values could predict severity and
potential prognosis of GVHD.
To test this they then divided patients according to the median Treg fre-
quency. Patients with Treg frequency below the median had significantly
higher nonrelapse mortality (largely attributable to GVHD) compared to
patients with Treg frequency above the median 41% vs. 8%, P 5 0.03. This
translated into inferior 2 year survival of 38% versus 63% (P 5 0.03). There
was no difference in relapse mortality according to Treg frequency.
This analysis shows that the frequency of CD41CD25hiFOXP31Tregs at
the onset of GVHD correlates with ultimate severity, nonrelapse mortality,
and overall survival. It will be of interest to determine whether Tregs can pre-
dict the onset of GVHD and whether therapy can be targeted depending on
the frequency of regulatory T cells identified at GVHD onset. This relatively
simple and rapid flow cytometry assay may have important diagnostic and
prognostic value in patients developing clinical findings consistent with graft-
versus-host disease after hematopoietic SCT.
CCR5 Expression on Circulating Blood DC Post Allogeneic
Hematopoietic Cell Transplant is Highly Predictive for the
Development of Clinically Significant Acute Graft versus Host
GVHD affects 20–70% of allogeneic SCT recipients and can result in sig-
nificant transplant-related morbidity and mortality due to tissue injury and
opportunistic infections from intensive and chronic immunosuppressive ther-
apy [5–7]. GVHD is initiated by both host and donor antigen presenting cells
[including dendritic cells (DC)] and mediated by memory and effector T cells
of donor origin. A better understanding of the pathogenesis of GVHD is
needed and could lead to more effective preventative or therapeutic inter-
ventions and better outcomes from SCT.
Sartor and colleagues report results of their investigations into the rela-
tionship between the severity of acute GVHD and the expression of the che-
mokine receptors CCR5 and CCR7 on dendritic cells, which are critical mol-
ecules for mediating DC trafficking into tissues. They evaluated serial periph-
eral blood samples from 32 patients after allogeneic SCT and 11 developed
grade II-IV GVHD. The percentage of DC expressing either CCR5 or CCR7
was calculated and correlated with the development of acute GVHD. CCR7
expression showed no association with GVHD. In contrast, higher CCR5
expression was detected on DC in patients developing grade II-IV GVHD
compared to DC in patients with grade 0-I GVHD (P < 0.0001). All 11
patients with grade II-IV GVHD expressed CCR5 in over 35% of their DCs
while only 2 of 21 patients with grade 0–1 GVHD expressed CCR5 at this
high a percentage. Most importantly, the expression of CCR5 on DC pre-
ceded the development of moderate to severe GVHD by a median of 19
days (range 2–47 days; samples drawn twice weekly).
This is an exciting study which identifies a biologic marker which predicts
for the development of GVHD; if verified, this could result in preventative
modulation of immunosuppressive therapy for certain patients found to be at
higher and lower risk for GVHD. In addition this study highlights a specific
potential target for GVHD intervention (the CCR5 receptor), which has
gained notoriety as the site of entry for HIV into lymphocytes. Other studies
have suggested that CCR5 is important for development of GVHD [8,9]. For
this reason CCR5 antagonists such as maraviroc may be potential media-
tors of GVHD and should be studied in clinical trials.
Common Cold Viruses Early After HSCT Are Associated With
Life Threatening Alloimmune Lung Syndromes (#36)
Alloimmune lung syndromes after allogeneic SCT include Idiopathic Pneu-
monia Syndrome (IPS) and bronchiolitis obliterans (BO), and are major
causes of morbidity and mortality. The incidence appears higher after alloge-
neic stem cell transplant compared to autologous stem cell transplant sug-
gesting pulmonary toxicity is not solely related to high dose conditioning
therapy. Inflammatory cytokines have been implicated in the pathogenesis of
IPS and the risk of BO is higher in patients with chronic GVHD [10,11]
Nevertheless the precise etiology of pulmonary toxicity after transplant is not
C 2010 Wiley-Liss, Inc.
American Journal of Hematology
Early infection with common respiratory viruses (RV) after lung transplant
has been associated with both acute and chronic rejection. To determine if an
infection with RVs was associated with alloimmune lung syndromes after hema-
topoietic SCT, Versluys et al. performed a prospective trial in 110 pediatric
patients receiving a variety of graft sources for both malignant and nonmalig-
nant diseases and conditions with either TBI (33) or chemotherapy based (77)
conditioning regimens. They used quantitative PCR of nasopharyngeal aspi-
rates to monitor for the most common RVs and found that 50% of patients had
evidence of infection at a median of day 116 after transplant (range: 7–100).
The most frequent infection was Rhinovirus (28), followed by Parainfluenzavirus
1–3, Coronavirus, Influenza A virus and Adenovirus. They reported that clinical
symptoms were mild and all patients recovered spontaneously.
During this time, patients were monitored for pulmonary toxicity and 16%
were diagnosed with IPS and 11% ultimately diagnosed with BO. Multivari-
able analysis showed that any RV infection was associated with subsequent
development of an alloimmune lung syndrome (P < 0.0001) independent of
the type of viral infection. Interestingly the development of acute GVHD was
associated with a lower risk of an alloimmune lung syndrome (P 5 0.004),
perhaps related to the protective effects of prolonged immunosuppression.
Most striking was the finding that development of an alloimmune lung syn-
drome was the only predictor for mortality (P 5 0.04). Overall survival was
73% for all patients but 53% for patients who developed pulmonary toxicity.
Although tissue damage, inflammatory cytokines, and an allogeneic ‘‘graft
vs. lung’’ effect have all been implicated in the development of IPS and BO,
the precise etiology of these syndromes is not well-defined. This study impli-
cated common RV as a major risk factor for alloimmune lung syndromes. It
is possible that these infections enhance local inflammation or changes that
make the lung a target for allogeneic recognition. This is supported by the
protective effects of acute graft vs. host disease perhaps related to the pro-
longed use of immunosuppression. This study is important for several rea-
sons. The high incidence of respiratory virus infection (50%) is concerning in
itself and may support the use of reverse isolation precautions so common
in many transplant centers. This study suggests a possible mechanism of
pulmonary toxicity after allogeneic transplant and should lead to further pro-
spective studies for early monitoring, protection, and intervention of patients
undergoing transplant. It would also be of interest to determine if early com-
mon RV infections occur with this frequency and are associated with pulmo-
nary toxicity and adult patients undergoing HSCT.
Prochymal Improves Response Rates in Patients with Steroid-
Refractory Acute Graft Versus Host Disease (SR-GVHD)
Involving the Liver and Gut: Results of a Randomized,
Placebo-Controlled, Multicenter Phase III Trial in GVHD (41)
Treatment options for steroid-refractory GVHD (SR-GVHD) are unsatisfac-
tory and prognosis is poor. The use of conventional intensive therapies to
inhibit T-cells and inflammatory cytokines often result in high response rates
ranging between 30 and 70%, but consistently long-term survival is limited
ranging between 5 and 30% [12,13]. Available therapies are limited both by
lack of response as well as by high mortality from infectious complications
related to intensive immunosuppression. There is immediate need to
develop effective and safe therapies for SR-GVHD.
Martin et al. presented promising results of a phase III study comparing
institutionally selected second line therapy with or without the addition of
Prochymal, a mesenchymal stem cell (MSC) product derived from unrelated
volunteer adult donors.
This was a large study enrolling 244 patients. Most patients have
advanced GVHD; IBMTR severity index grade for Prochymal vs. placebo
treated patients was B in 22 vs. 26%, C in 51 vs. 58%, and D in 27% vs.
16%. The groups were well matched and randomized in a 2: 1 fashion.
Although the intention to treat analysis showed no difference in durable com-
plete response (DCR) rates (35 vs. 30%, P 5 0.3), there was a trend toward
better DCR in the treated population at 40% vs. 28% (P 5 0.08). For the 22
patients with involvement of three organs, the rate of CR/PR at day 28 was
63% for the treatment group compared to 0% for the placebo group (P <
0.05). Importantly there was no significant difference in infections, relapse
(9% vs. 8%) or adverse events.
Various case reports and phase II trials have demonstrated potential effi-
cacy with a good safety profile of MSCs for GVHD. This study can be com-
mended simply for completing a randomized study in a large group of
patients with SR-GVHD. Response rates in the MSC-treated patients were
reasonable, and higher than placebo-treated patients. Nevertheless, despite
including such a large number of patients, many questions remain unan-
swered. Would MSCs be most effective combined with a specific consistent
second-line therapy? Numerous trials of SR-GVHD show high response
rates but ultimately limited survival due to recurrent GVHD, infections, and
even relapse; long-term outcomes beyond day 100 from this trial will be
important to report for the transplant community. Finally, given the sugges-
tion of important activity, further studying the role of MSCs for GVHD ther-
apy earlier in the course of the disease will be important.
Second Solid Cancers After Allogeneic Hematopoietic-Cell
Transplantation Using Busulfan-Cyclophosphamide
The number of patients undergoing autologous and allogeneic SCT has
continued to increase over time. This, in combination with improvements in
short-term treatment-related mortality rates has led to an increased preva-
lence of SCT recipients in the population who have unique long-term health
care needs related to their survivorship. A potentially devastating long-term
complication of SCT is the development of secondary malignancies .
Secondary myelodysplastic syndrome or acute myeloid leukemia usually
occur within the first 7 years after SCT . The risk of developing solid
tumors however continues to increase with time and patients are often no
longer under the care of a transplant physician at the time of increased risk.
Secondary solid tumors predominantly occur in the upper GI tract, oral cav-
ity, brain, soft tissues and skin. A clear dose response has been found with
the use of total body radiation and the incidence of solid tumors after SCT
[16,17]. In addition to increased risk from the direct cytotoxic effects of the
conditioning regimen, chronic inflammation (as in the setting of GVHD),
chronic immunosuppression (with increase risk of viral infection and
decreased tumor surveillance) and increased genetic susceptibility may also
play roles in the pathogenesis of these secondary tumors after allogeneic
The authors in this study report the incidence and risk factors associated
with the development of solid tumors in 4349 pediatric and adult patients
who underwent allogeneic stem cell transplant (SCT) for acute myelogenous
leukemia (AML) in CR1 or chronic myelogenous leukemia (CML) in first
chronic phase. All subjects received chemotherapy only conditioning regi-
mens with busulfan and cyclophosphamide. The median time of follow-up for
survivors was 8.2 years; 47% of patients were alive and evaluable at 5 years
after SCT and 18% were alive and evaluable at 10 years after SCT. Sixty-six
solid cancers were reported; the cumulative incidence of solid tumors at 3, 5
and 10 years after SCT were 0.7, 0.9, and 2.0% for AML patients and 0.5,
1.1, and 3.4% for CML patients. These rates were higher than expected
rates in the general population. Significantly higher rates of solid tumors
were found [reported as observed to expected ratio (O/E)] for cancers of the
lip (O/E 5 25.7), tongue (O/E 5 9.1), mouth (O/E 5 7.2), esophagus (O/E
5 10.3), lung (O/E 5 2.6), soft tissue (O/E 5 7.1) and brain (O/E 5 4.7).
On Cox-regression analysis, risk factors for developing solid tumors included
older age, chronic GVHD and use of peripheral blood (as opposed to bone
marrow) as a stem cell source.
This study supports the fact that SCT recipients are at significant long-
term risk for the development of secondary solid tumors. Further longer
term reports from larger cohorts of SCT recipients are needed to better
define overall risk over time. It is important for patients and their physicians
to be aware of these risks to modify screening and preventative techniques
in this patient population.
Pre-Transplant Consolidation Chemotherapy Does Not
Improve Rates of Relapse Following Reduced Intensity
Conditioning (RIC) Hematopoietic Stem Cell Transplantation
(HCT) for AML in CR1 (#63)
Post remission chemotherapy with cytarabine before myeloablative alloge-
neic SCT has not been shown to affect outcomes for patients with AML
[18,19]. Transplants using a reduced intensity conditioning regimen (RIC-
SCT) are being used more frequently as post remission therapy for AML in
520American Journal of Hematology
an effort to limit transplant related toxicity and broaden potential treatment
options for older and sicker patient populations. The role of pretransplant
consolidative chemotherapy may be different in the RIC-SCT setting than
the myeloablative setting. One could hypothesize that with less intensive
conditioning therapy, additional rounds of cytarabine-based consolidation
chemotherapy before RIC-SCT would result in lower relapse rates by mini-
mizing residual disease. Alternatively, RIC-SCT recipients tend to be older
and sicker than myeloablative SCT recipients and increased rounds of ther-
apy before SCT may contribute to more treatment-related mortality.
In this report, McCormack and colleagues retrospectively reviewed out-
comes of 61 patients at their institution who underwent nonmyeloablative SCT
and evaluated the impact of pretransplant consolidation chemotherapy on out-
come. All patients had AML in CR1 at time of transplant and received either
HLA matched sibling (n 5 18), cord blood (n 5 42) or unrelated (n 5 1) donor
grafts. Of these patients, 26 received pretransplant consolidation (73%
received 1 round; range 1–3) and 35 received none: 58% and 40% in each
group respectively had high-risk cytogenetics. In univariate analysis, exposure
to pre-SCT consolidation therapy had no impact on 2 year OS or relapse rates
and did not increase treatment related mortality rates (See Table I). In multi-
variate analysis (variables tested: comorbidity score, number of induction
cycles to achieve CR, high risk cytogenetics) exposure to consolidation ther-
apy still had no effect on relapse. The only variable significantly associated
with treatment related mortality was comorbidity score.
This study suggests that in the RIC-SCT setting, pre transplant consolida-
tion may not impact outcomes. It also further validates the value of the pre-
transplant comorbidity score on predicting treatment-related mortality. It is
important to point out that the numbers of patients evaluated in this study
are small and composed mostly of cord blood recipients. The study is likely
underpowered to detect a significant difference in outcomes and outcomes
from RIC-SCT cord recipients are likely different from recipients of RIC sib-
ling or unrelated SCTs. Nevertheless, this is an important topic that warrants
further investigation in the cord blood, sibling and unrelated setting using
larger cohorts of patients.
Multi Tumor Antigen Specific Cytotoxic T Lymphocytes for
Therapy of Hematologic Malignancies (#64)
Tumor-specific immunotherapy holds great promise, but in most cases
tumor-specific antigens are not well defined and numerous strategies have
been limited in part by the inability to generate functional tumor-specific T
cells. In some cases this is due to the low frequency of tumor-reactive T
cells. Furthermore, even when they can be isolated they may be anergized,
tolerized, or after allogeneic SCT, they may be senescent and unable to
expand . The most successful use of targeted cellular therapy has been
with the generation of viral-specific T cells to treat viral-associated malignan-
cies such as EBV-associated Hodgkin’s disease or post-transplant lympho-
proliferative disorders .
Gerdemann et al. reported on an important technical advance in the
ability to generate tumor-specific T cells. T cells are activated in the pres-
ence of autologous dendritic cells (DCs) transfected with plasmids encod-
ing multiple potential tumor-associated antigens or pulsed with tumor-asso-
ciated antigen peptides. This permits generation of T cells specific for mul-
tiple antigens and multiple epitopes. Antigens and epitopes would not be
restricted to a specific HLA polymorphism as occurs when tumor-specific T
cells are generated against only 1 specific peptide that is expressed in an
HLA-restricted manner. Polyclonal T cell activation occurs by exposure to a
potent cocktail of cytokines developed to promote generation of Th1 cells
(IL12), inhibit expansion of Tregs (IL-6) and provide enhanced survival and
proliferative signals (IL15). To target lymphoma, they combined three
potential lymphoma associated antigens, SSX2, Survivin, and MAGEA4
and generated ‘‘multi-tumor associated antigen cytotoxic T cells’’ (multiTAA
CTL) against all three antigens from six healthy donors. They showed that
these cells had activity against autologous antigen pulsed targets and
whole antigen expressing fibroblasts and were not reactive against control
targets. Similarly to target myeloid leukemia they combined WT1, Prame,
PR3, and Survivin and generated multispecific T cells against all antigens
from two healthy donors.
To date, tumor-specific cellular therapy has been successful primarily
when well-defined viral associated antigens can be defined and targeted.
Multiple potential tumor-associated antigens have been identified but
development of targeted cellular therapy has been limited by inability to
generate sufficient, HLA-restricted T cells, and in the case of patients
who have had prior allogeneic SCT, donor T cell senescence has limited
ability to expand tumor-specific T cells . This technical advance is
important since it permits generation of CTLs against multiple tumor-
associated antigens and therefore may reduce the risk of tumor escape;
it is likely that multiple antigens will need to be targeted for maximal
efficacy. Furthermore, the ability to generate CTLs with multiple specific-
ities markedly increases the efficiency of this approach and eliminates
the need for specific polymorphic HLA-restriction. It will be of interest to
see if activation by this method can reverse functional tolerance or sen-
escence in patients with primary disease or after allogeneic stem cell
Autologous Stem Cell Transplantation (ASCT) for HIV-Related
Lymphomas in the HAART Era: A Meta-Analysis of Response
and Survival Post Transplant (#114)
The prognosis for HIV-infected patients with non-Hodgkin lymphoma
(NHL) has improved dramatically since the consistent use of highly-active
anti-retroviral therapy (HAART) and conventional chemotherapy. Despite ini-
tial reports showing lower responses and higher mortality from combination
chemotherapy in HIV-infected patients, in the modern era HAART-treated
patients with diffuse large B-cell lymphoma treated with CHOP or rituximab-
CHOP have similar outcomes to patients without HIV infection . Never-
theless, many patients relapse and lymphoma remains a significant cause of
death for patients with HIV-related lymphoma. In the past, HIV infection was
felt to be a contraindication to autologous SCT out of concern for excessive
toxicity and poor response rates. Currently, several reports suggest that HIV-
infected patients may tolerate autologous SCT similar to non-HIV-infected
Sunil et al. performed a meta-analysis that ultimately included five studies
and abstracts dealing with autologous SCT for patients with HIV related lym-
phoma. They were 35 patients with Hodgkin lymphoma and 83 with NHL.
Outcomes were as impressive as would be anticipated in a similar non-HIV
infected population. After transplant, 71% of patients (95%CI 60–80)
achieved complete remission (CR) and 2 year overall survival was 71%
(95%CI 61–79). A CR before transplant was highly predictive of a CR after
transplant in 2 year overall survival. Overall this meta-analysis confirms the
TABLE I. Two-Year Outcomes: Univariate Analysis
consolidation n 5 35
consolidation N 5 26P-Value
48% (30–64%, 95% CI)
29% (14–45%, 95% CI)
27% (30–64%, 95% CI)
35% (12–59%, 965% CI)
43% (23–62%, 95% CI)
6% (30–64%, 95% CI)
TABLE II. Response Rates to Mycophenolate Based on MPA Levels
trough weeks 1
and 2 >0.5 mg/mL
trough weeks 1
and 2 <0.5 mg/mL
MPA trough >0.015 mcg/mL
trough weeks 1 and 2
Mean unbound MPA
trough <0.015 mcg/mL
trough weeks 1 and 2
Day 28 CR/PR 21 (65.6%)/5
19/19 (100%)7/13 (54%)
(P 5 0.002
15/15 (100%) 11/17 (65%)
(P 5 0.02)
Notably there was no association between drug measurement and risk of infection by day 90 or overall survival at day 180.
American Journal of Hematology 521
community opinion that autologous SCT for HIV infected patients should not
be contraindicated and is likely to result in comparable outcomes compared
to a non-HIV-infected group of patients.
There are caveats to this report as there are in any meta-analysis. This is
a retrospective analysis combining results of several case series. In addition
there is likely to be significant reporting bias in this field. However the review
of five studies including 111 patients support the conclusion that autologous
transplant should be offered to HIV-infected patients as clinically appropriate
and is not contraindicated. The authors appropriately conclude that prospec-
tive trials are necessary (and these data confirm that they are appropriate)
and the community should anxiously await results from a planned multicen-
ter prospective trial of autologous SCT in HIV-related lymphoma patients in
development by the Blood and Marrow Transplant Clinical Trials Network
The Graft-Versus-Myeloma Effect Using Nonmyeloablative or
Reduced Intensity Allogeneic Hematopoietic Stem Cell
Transplantation (HSCT) (#204)
A graft vs. myeloma (GVM) effect has been suggested in transplant stud-
ies and has been demonstrated as a ‘‘proof of principle’’ concept using DLI
to treat relapsed myeloma . However outcomes after DLI for relapsed
myeloma have been disappointing  calling in to question the potential
efficacy of nonmyeloablative allogeneic stem cell transplantation. Large ser-
ies of allogeneic SCT are not available to guide treatment decisions.
Dr. Ringden for the CIBMTR reported on outcomes for 177 recipients of
matched sibling allogeneic SCT conditioned with a nonmyeloablative or
reduced intensity conditioning (RIC) regimen for myeloma. The median age
of patients was 50 (range 24–69) and 105 patients received a planned tan-
dem autologous transplant followed by allogeneic SCT. With a median fol-
low-up of 55 months (range 3–98) for all patients, and 25 months (range 3–
76) for recipients of tandem autologous/allogeneic SCT, 3 year overall sur-
vival was quite reasonable at 45% (95% CI 33–58) for recipients of a single
allogeneic SCT and 64% (53–75) for recipients of tandem autologous/alloge-
neic SCT. Treatment related mortality (TRM) at 3 years was 27 (17–38)%
and 16 (10–25)% respectively and relapse rates were 48 (36–60)% and 41
(29–54)%. The 3 year progression free survival (PFS) was 25 (15–37)% and
42 (20–43)% demonstrating that long-term control was possible in some
patients. The multivariate analysis showed that chronic GVHD decreased
the probability of relapse (RR 0.43, P 5 0.012), though this effect was lim-
ited to patients without IgG myeloma for reasons that are difficult to explain.
In addition, PFS was better with autologous 1 allogeneic HSCT compared
to allogeneic SCT (RR 3.6, P 5 0.001), suggesting that dose intensive che-
motherapy still has a major role in care of these patients.
This report has many limitations. In particular it is a retrospective study
and it is not known how patients were selected for specific therapies. Some
findings are not easily explained, such as a benefit of chronic GVHD in
terms of relapse noted only in patients without IgG myeloma. Nevertheless,
it is a large study using available registry data demonstrating that at least in
some patients, a GVM effect can be generated and long-term disease con-
trol achieved. Defining the proper patient population, timing of transplant,
and the role for autologous/allogeneic SCT before RIC allogeneic SCT
remain important subjects for future studies that hopefully will someday har-
ness the GVM effect for maximal benefit.
Mycophenolate Pharmacokinetics and Association with
Response to Acute Graft vs. Host Disease (GVHD) Treatment
Mycophenolate mofetil (MMF) is commonly used for GVHD prophylaxis, par-
ticularly in the setting of nonmyeloablative allogeneic SCT. It is also being used
with increasing frequency to treat GVHD and may be more effective in combina-
tion with steroids than other therapies . However, increasing evidence sug-
gests that variable pharmacokinetics may be critical to efficacy of MMF.
As part of a randomized phase II trial from the Bone Marrow Transplant
Clinical Trials Network (BMT-CTN), MMF 1 g twice daily plus corticosteroids
was given as 1 of 4 possible therapies; MMF pharmacokinetics were studied
in the context of acute GVHD response. This cohort included 32 patients and
MMF pharmacokinetic sampling occurred in weeks 1 and 2. Targets for thera-
peutic concentration of the active metabolite mycophenolic acid (MPA) were
set at 0.5 mg/mL or unbound MPA at 0.015 mcg/mL. One of the most signifi-
cant findings was that approximately half of the patients did not achieve these
drug levels, and drug levels had a direct impact on response rates.
The overall response rate of acute GVHD at day 28 and day 56 for all
patients was impressive at 65.6 and 78% respectively as shown below. Single
mycophenolic acid (MPA) pharmacokinetic measurements during weeks 1
and 2 after treatment did not correlate with CR at either day 28 or 56 (P >
0.07). However, as shown in Table II, if the mean of weeks 1 and 2 are taken
together and the MPA trough was above the thresholds noted, more patients
achieved CR 1 PR compared to cases where the MPA trough was low.
There is increasing use of MMF for the prevention and treatment of acute
GVHD. Although direct comparative data is limited, there is an expectation
that this drug has significant activity and a favorable toxicity profile compared
to other immunosuppressive therapies for GVHD. However, the pharmacoki-
netics have not been well defined in this setting. This analysis from Jacob-
son and colleagues for the BMT-CTN is important since it shows that obtain-
ing therapeutic levels is important to optimize response rates for acute
GVHD without resulting in increased risk of infection or limited survival at
least by day 180. This should directly impact how transplant physicians use
MMF. Further pharmacokinetic studies will be needed to define the optimal
dose and schedule, but consideration should be given to either close drug
monitoring and/or altering dosing from 2 to 3 g/day or body weight dosing.
Director, Blood and Marrow Transplantation, Division of Hematology-Oncology,
University of Pennsylvania Medical Center, Philadelphia, Pennsylvania
Grant sponsor: NIH; Grant number: 5K24CA117879-04
*Correspondence to: David L. Porter, Director, Blood and Marrow Transplantation,
Division of Hematology-Oncology, University of Pennsylvania Medical Center, 3400
Civic Center Boulevard, PCAM 2 West Pavilion, Philadelphia, PA 19104
Conflict of interest: Nothing to report.
Published online 27 April 2010 in Wiley InterScience
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Primary pulmonary non-Hodgkin’s lymphoma: A retrospective
analysis of 29 cases in a Chinese population
Jiajia Huang,1,2Tongyu Lin,1,2Zhi-Ming Li,1,2* Ruihua Xu,1,2Huiqiang Huang,1,2and Wenqi Jiang1,2
Primary pulmonary non-Hodgkin’s lymphoma (PPL) is a rare extrano-
dal lymphoid neoplasm. The present knowledge of this entity is vague
and minimal. A total of 29 patients diagnosed with PPL at Sun Yat-Sen
University Cancer Center in China were retrospectively analyzed. Nine-
teen patients had mucosa-associated lymphoid tissue (MALT) lym-
phoma, nine had diffuse large B-cell lymphoma (DLBCL), and one had
plasmacytic lymphoma. Six patients received PET/CT scans before
treatment, and mean maximum standardized uptake values (mSUVs)
were much higher in the DLBCL cases (n 5 3) than in the MALT lym-
phoma cases (n 5 3). The 3-year overall survival (OS) rate was 79.3%.
Cox regression analysis showed that hilar/mediastinal lymphadenop-
athy (LAP) was an independent predictor of survival (P 5 0.029). The
mean survival time (MST) was 75.5 months for patients who underwent
surgery and 65.7 months for those who didn’t (P 5 0.38). The MST was
77.4 months for patients treated with rituximab and 54.1 months for
those not treated with rituximab (P 5 0.101). Clinical characteristics in
our study were partly similar to those previously reported. However,
we found that hilar/mediastinal LAP seemed to be an effective prog-
nostic factor in Chinese PPL patients. The role of surgery and rituxi-
mab in the management of PPL warrants further investigation.
PPL is quite rare and it is defined as clonal lymphoid proliferation involving
the lung parenchyma and/or bronchi but without extrathoracic extension at
the time of diagnosis or within the subsequent 3 months [1,2]. Patients diag-
nosed with PPL may present with hilar or mediastinal LAP, but most of the
tumor burden is in the lung . PPL represents only 0.4% of all lymphomas,
and less than 1% of NHL [2–4]. The treatment for primary pulmonary lym-
phomas (whether surgery, radiotherapy, chemotherapy, or targeted therapy
alone or in combination) has not been clearly established. The role of rituxi-
mab in the treatment of PPL remains controversial .
In this study, we retrospectively reviewed 29 cases of newly diagnosed
PPL in the Sun Yat-Sen University Cancer Center in China from January
2001 to December 2008 to identify prognostic factors of PPL and optimal
treatment for PPL in the rituximab era. The clinical features of all patients
are presented in Table I. Nineteen patients (65.5%) had MALT lymphoma,
nine (31.0%) had DLBCL, and one (3.4%) had plasmacytic lymphoma. In
most of the patients in this series, surgery provided a definite diagnosis,
whereas bronchoscopic biopsy had a low-diagnostic yield. Of the 16 patients
with PPL who underwent bronchoscopic examination, only four had positive
results. Prior to treatment, all 29 patients were evaluated by CT scans, and
six patients underwent integrated18F-FDG-PET/CT scanning. The radiologi-
cal findings for all patients are listed in Table I. Twenty patients (69.0%) had
unilateral lung involvement and nine (31.0%) had hilar/mediastinal LAP. Of
the six patients who underwent integrated18F-FDG-PET/CT scanning, three
had DLBCL and three had MALT lymphoma. The maximal standardized
uptake values (mSUVs) ranged from 2.0 to 7.6 (mean mSUV, 3.9 ± 1.72) in
the three MALT lymphoma cases and from 10.5 to 16.9 (mean mSUV, 13.5
± 2.74) in the three DLBCL cases.
Clinical characteristics of PPL (MALT vs non-MALT) are shown in Table I.
Patients with MALT lymphoma had a higher frequency of elevated LDH level
at diagnosis (15.8% vs 70.0%, P 5 0.011) and B symptoms (21.1% vs
70.0%, P 5 0.017). Moreover, a significant difference in the rate of hilar/
mediastinal LAP was found between the MALT type lymphoma group and
non-MALT lymphoma group (10.5% vs 70.0%, P 5 0.002).
The primary treatment modalities of all patients were: (a) surgery alone (5
cases); (b) chemotherapy alone (6 cases); (c) surgery followed by chemother-
apy (8 cases); (d) chemotherapy followed by radiotherapy (10 cases). A total
of 13 patients received surgery, including two patients by VATS, one by wedge
resection thoracotomy, and 10 by lobectomy. Twenty-four patients treated with
chemotherapy (median: 5 cycles, range: 2–9 cycles). The most frequently
used first-line treatment were CHOP (cyclophosphamide, doxorubicin, vincris-
TABLE I. Baseline Characteristics of 29 Chinese Patients with PPL
(n 5 19)
(n 5 10)Total (%)
History of smoking
PS ? 2
Radiological findings at diagnosis
Ann Arbor Stage
American Journal of Hematology523
tine, and prednisone) or CHOP-like regimens. Thirteen patients received ritux-
imab (median: 5 cycles, range: 2–9 cycles) in combination with chemother-
apy: seven had MALT lymphoma, five had DLBCL, and one had plasmacytic
lymphoma. The overall response rate to initial chemotherapy was 81%,
including complete remission in four cases and partial response in nine cases.
Ten patients underwent radiation. The total dose of radiotherapy ranged from
30 to 46 Gy. Pneumonia related to radiation was observed in one case.
In a median follow-up of 35 months (range: 5–95 months), 6 of 29 patients
(20.7%) died due to disease progression (3 cases), pneumonia related to
bone marrow suppression after chemotherapy (1 case), renal failure (1
case), and unknown causes (1 case). OS at 3 years was 79.3% and MST
was 73.7 months (95% confidence interval, CI 59.4–88.0). MST was shorter
in patients with hilar/mediastinal LAP than in those without hilar/mediastinal
LAP (50.6 months vs 84.2 months, P 5 0.006) (Fig. 1) and in patients with
non-MALT lymphoma than in those with MALT lymphoma (48.8 months vs
83.1 months; P 5 0.009). Univariate analysis identified non-MALT type (P 5
0.009), B symptoms (P 5 0.012), high-LDH level (P 5 0.011), advanced
Ann Arbor Stage (IIIE-IVE) (P 5 0.012), International Prognostic Index
scores (IPI) 5 3–5 (P 5 0.040), and hilar/mediastinal LAP (P 5 0.006) as
indicators of poor prognosis. Multivariate Cox regression analysis identified
only hilar/mediastinal LAP as an independent predictor of OS (RR 5 11.0,
95% CI: 1.29–94.4, P 5 0.029). The MST was 75.5 months for patients who
underwent surgery initially and 65.7 months for those who did not undergo
surgery (P 5 0.38). The MST was 77.4 months for patients treated with rit-
uximab and 54.1 months for those not treated with rituximab (P 5 0.101).
PPL is a very rare entity accounting for only 3.6% of all extranodal lym-
phoma cases . The predominant pathologic subtype in our study was
MALT lymphoma, followed by DLBCL, confirming previous data [6,7]. PET/
CT imaging is a highly sensitive and specific tool for detection and localiza-
tion of HL and aggressive NHL, and it also superior to CT in differentiating
immunophenotypes of lymphoma [5,8–10]. PET scans may be able to reli-
ably distinguish between indolent and aggressive subtypes in lymphoma
patients. In our study, the mSUVs were much higher in DLBCL cases than
MALT lymphoma cases. DLBCL in contrast to MALT lymphoma often shows
aggressive growth, which may increase FDG uptake by the lesions. Further
clinical trials are warranted to determine whether the effectiveness of PET/
CT in PPL depends on the histological subtype.
MALT and non-MALT PPLs are reported to differ in clinical behavior and
prognosis [7,11–13]. In this series, hilar/mediastinal LAP, high-LDH eleva-
tion, and B symptoms were more frequent in non-MALT lymphoma. Our
data demonstrated that hilar/mediastinal LAP was the only independent
prognostic factor in PPL in multivariate analysis. Previous studies have pre-
sented little evidence indicating the prognostic significance of hilar/mediasti-
nal LAP in PPL . Previous reports focused mainly on MALT lymphoma
and some studies did not include patients with hilar/mediastinal LAP
[7,14,15]. Until now, no risk factors have been clearly identified in PPL. Our
findings showed that patients with MALT type PPL survived longer than
those with non-MALT PPL, but unlike other authors [11–13,16].
The optimal modality for the management of PPL has not been estab-
lished so far [16–18]. In patients with MALT primary lung non-Hodgkin’s lym-
phomas (NHL), surgical resection is commonly preferred for localized
tumors. A review of 17 primary pulmonary B-cell lymphoma cases by Fadel
and coworkers suggested that surgery was the treatment of choice in local-
ized PPL cases . However, in our study, the difference in survival
between surgically treated and untreated groups did not reach statistical sig-
nificance, similar to some of the previous reports [6,19].
Although the results of rituximab (a chimeric anti-CD20 antibody) plus
chemotherapy for a wide variety of B-cell lymphomas, including DLBCL and
MALT lymphoma, have been encouraging [20,21], the role of rituximab in
PPL treatment is unclear. In this study, we did a preliminary evaluation of
the efficacy of rituximab in the management of primary pulmonary B-cell
lymphoma. Patients treated with rituximab tended to have better outcomes,
but no statistical difference. Most patients in our study were in early stages.
The impact of rituximab could not be demonstrated, possibly because the
results of surgery and conventional chemotherapy for early-stage disease
were excellent. Multicenter clinical trials will be needed to define the best
In conclusion, the clinical characteristics of Chinese patients with PPL in
our study were partly similar to those previously reported. PET/CT scan may
be helpful in differentiating immunophenotypes and clinical behaviors. Fur-
thermore, we found that hilar/mediastinal LAP could identify patients with sig-
nificantly worse outcomes in Chinese PPL patients. The role of surgery and
rituximab in the management of PPL patients warrants further investigation.
Patients and staging.
in the Sun Yat-Sen University Cancer Center in China from January 2001 to
December 2008 were retrospectively analyzed. The study protocol was
approved by the Institutional Review Board of the Sun Yat-Sen University
Cancer Center. All patients consented to have their medical records
reviewed for research purposes. The diagnosis of PPL was based on the fol-
lowing criteria [2,11]: unilateral or bilateral lung involvement of NHL; no his-
tory of lymphoma; no evidence of extrathoracic lymphoma at the time of
diagnosis by clinical staging workup. No extrathoracic lymphoma was detect-
able within 3 months after the initial diagnosis. Cases with hilar/mediastinal
adenopathy or adjacent chest wall invasion were also included in our study,
as described in previous reports [6,11]. All patients were staged according
to the Ann Arbor staging system . IPI scores were also measured .
All hematoxylin and eosin stained and immunohistochemically stained
slides were reviewed, and pathological subtypes were identified according to
the World Health Organization criteria by histopathologists . Antibodies
to the following antigens were used to confirm the diagnosis in suspected
subtypes: leukocyte common antigen, cluster designation (CD)3, CD5,
CD10, CD19, CD20, CD30, CD45, CD79a, Ki-67, Cyclin D1, kappa and
lambda immunoglobulin, and anaplastic lymphoma kinase. For the cases
with inconclusive morphological features and immunophenotypic findings,
molecular genetic analysis was performed to detect rearrangements of
immunoglobulin heavy chain genes and T-cell receptor gamma chain genes.
The data from 29 patients with newly diagnosed PPL
Response criteria and statistical analysis.
assessed according to the International Working Group Recommendations
for Response Criteria for NHL [25,26]. OS was calculated from the date of
diagnosis to the date of death from any cause or to the date of last follow-
up. Clinical characteristics of PPL cases were summarized by means,
medians, and percentages, and were compared using the g2or Fisher’s
exact test. The primary endpoint of our analysis was OS. Survival curves
were analyzed using the Kaplan-Meier method. The prognostic importance
of different variables in OS was estimated by multivariate analysis using the
Cox regression model. A two-tailed P < 0.05 assessed by the log-rank test
was considered statistically significant. Statistical analysis was performed
using SPSS 16.0 for Windows.
Response to treatment was
1State Key Laboratory of Oncology in Southern China, Sun Yat-sen University,
Guangzhou, Guangdong, People’s Republic of China;2Department of Medical
Oncology, Cancer Center, Sun Yat-sen University, Guangzhou, Guangdong,
People’s Republic of China
*Correspondence to: Zhi-Ming Li, State Key Laboratory of Oncology in Southern
China, Department of Medical Oncology, Sun Yat-Sen University Cancer Center,
651 Dong Feng Rd East, Guangzhou 510060, People’s Republic of China
Overall survival of patients with or without hilar/mediastinal lymphaden-
524 American Journal of Hematology
Conflict of interest: Nothing to report.
Published online 24 March 2010 in Wiley InterScience
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Report of the committee on
The assessment of human organic cation transporter 1 (hOCT1)
mRNA expression in patients with chronic myelogenous leukemia
is affected by the proportion of different cells types in the
analyzed cell population
Zdenek Racil,1* Filip Razga,1Lucie Buresova,2Tomas Jurcek,1Dana Dvorakova,1Daniela Zackova,1
Shira Timilsina,3Petr Cetkovsky,4and Jiri Mayer1
The monitoring of hOCT1 mRNA expression in patients with chronic
myelogenous leukemia (CML) was used for predicting the response to
imatinib treatment. However, different cell populations from patients
who received various degrees of pretreatment were used for this anal-
ysis. Therefore, several biases in the results and their interpretation
may arise. We investigated hOCT1 mRNA expression in different cell
populations of peripheral blood (PB) from healthy volunteers and in
imatinib naı ¨ve de novo CML patients by analyzing changes in hOCT1
mRNA expression during the first 6 months of imatinib therapy. The
hOCT1 mRNA expression was significantly higher in PB polymorpho-
nuclears compared to mononuclears. The hOCT1 mRNA expression in
total PB leukocytes is, therefore, preferentially determined by the per-
centage of polymorphonuclears. Expression in each analyzed group of
cells was always significantly lower in imatinib naı ¨ve de novo CML
patients compared to healthy volunteers. This difference disappeared
after the initiation of imatinib therapy, suggesting that CML tumor bur-
den and the degree of pretreatment at the time of monitoring were
both influencing factors.
Imatinib (IMA) uptake is predominantly mediated by human organic cation
transporter 1 (hOCT1) . Decreased expression or function of this protein
can lead to a reduction of the intracellular concentration of IMA and, there-
fore, lead to pharmacokinetic resistance to the drug [1,2]. There are several
data suggesting a correlation between hOCT1 activity/expression and the
therapeutic outcome of CML patients treated with IMA [3–5]. Unfortunately,
this issue has several uncertainties in the literature that may lead to the mis-
interpretation of previously reported data and the interpretation of future
studies. First, hOCT1 activity, which is measured by a functional assay [1,2],
must be clearly differentiated from mRNA expression monitoring [1,3–5].
Second, the cell populations used for analysis vary widely in cell type, espe-
cially in studies that monitor mRNA hOCT1 expression [1,3–5]. Furthermore,
while some studies have monitored a well-defined group of patients with de
novo chronic phase CML , others make analyses on heterogeneous study
populations that contain pretreated patients [4,5].
We investigated differences in hOCT1 mRNA expression in different cell
populations of PB leukocytes (LEU) from healthy volunteers and patients
with de novo CML, a change in hOCT1 mRNA expression during the first 6
months of IMA treatment, and the relationship between hOCT1 mRNA
expression and the percentage of immature myeloid cells as well as BCR/
ABL transcript levels in PB (as indirect markers of disease burden).
The hOCT1 mRNA expression was measured in PB LEU (n 5 66), PB
PMNC (n 5 35), and PB MNC (n 5 33) from 66 healthy volunteers. Figure
1 summarizes these results and clearly shows a wide range of hOCT1
American Journal of Hematology525
mRNA expression in total LEU as well as in PMNC and MNC. The hOCT1
mRNA expression was significantly higher in PMNC compared to MNC.
Therefore, the total LEU hOCT1 mRNA expression was preferentially deter-
mined by the percentage of PMNC in the total LEU.
Analogous measurements were performed in 23 patients with IMA naı ¨ve
de novo CML. Similarly, a large distribution of expression was seen from
individual groups of cells (Fig. 1). Total hOCT1 mRNA expression in PB
LEU was again significantly influenced by the PMNC hOCT1 mRNA expres-
sion and PMNC percentage. The large variability in the percentage of
PMNC from total LEU in patients with IMA naı ¨ve de novo CML (median:
75%; range: 33–93%) is, therefore, an important factor in the marked varia-
bility seen in hOCT1 mRNA expression in total LEU at the time of CML diag-
nosis. In addition, the hOCT1 mRNA expression from each analyzed group
of cells was always significantly lower in IMA naı ¨ve de novo CML patients
compared to healthy volunteers (Fig. 1). This suggested that CML cells have
an additional effect on the observed hOCT1 mRNA expression level.
The hOCT1 mRNA expression was detected in total LEU and in MNC at
monthly intervals from IMA naı ¨ve de novo CML patients from the time of
diagnosis until the 6th month of IMA therapy. The median hOCT1 mRNA
expression level from total LEU was significantly lower in the CML patients
at the time of diagnosis compared to median expression levels in healthy
individuals ( Fig. 1; P < 0.001; nonparametric Mann Whitney test). However,
after 1 month of IMA treatment, the median hOCT1 mRNA expression level
in total LEU significantly increased (P 5 0.031; nonparametric Wilcoxon
test) and reached the expression levels from healthy volunteers. Therefore,
the previously described difference in expression level disappeared during
this observation period (P 5 0.769; nonparametric Mann Whitney test) (Fig.
2A). The same finding of hOCT1 mRNA expression was seen in the MNC
samples from patients under the same criteria (Figs. 1 and 2B).
The lower hOCT1 mRNA expression level in LEU from IMA naı ¨ve de novo
CML patients compared to healthy volunteers as well as its progressive
increase after the start of IMA therapy could be explained by the initial pres-
ence and subsequent gradual disappearance of tumor cells from the meas-
ured cell population. To confirm this hypothesis, we performed an analysis
on the relationship of hOCT1 expression with the percentage of immature
myeloid cells in the LEU samples (as a marker of disease burden) obtained
from IMA naı ¨ve de novo CML patients. In addition, because of the fact that
a majority of patients did not have immature myeloid cells present in PB
LEU samples after the first month of IMA therapy, we analyzed the depend-
ence of LEU hOCT1 mRNA expression on the amount of BCR /ABL tran-
scripts from these samples. We found a statistically significant relationship
between hOCT1 mRNA expression level and the percentage of immature
myeloid cells at the time of diagnosis as well as the BCR/ABL transcript
level at the first month after the start of IMA treatment (Fig. 3A,B).
Very limited data concerning hOCT1 mRNA expression in different cell
populations exist to date [6–8]. Bazeos et al. reported a higher hOCT1
mRNA expression level in PB PMNC compared to MNC from healthy individ-
uals . In this study, we have enhanced these findings and described the
difference in expression level in IMA naı ¨ve de novo CML patients as well.
Our finding of lower hOCT1 mRNA expression in total LEU from IMA naı ¨ve de
novo CML patients that quickly reached the expression levels of healthy volun-
teers is in accordance with observations from Bazeos et al. . However, the
authors from that study assumed that this finding was related to the achievement
of a complete cytogenetic response. According to our findings, the increase in
hOCT1 mRNA expression after the start of IMA treatment was not caused by the
suppression of inhibitory effects of the BCR/ABL oncogene, as suggested by
Bazeos et al., but rather was due to a significant effect of the lower hOCT1
mRNA expression in immature myeloid cells (mostly CML tumor cells), which
rapidly disappeared from the PB within the first month of IMA therapy.
Several studies have monitored hOCT1 mRNA expression in the MNC frac-
tion of the leukocytes [3,9]. However, the MNC is composed of several types of
cells (including immature myeloid precursors, mostly tumor cells in CML
patients). Although not analyzed, because of a low number of available samples
for hOCT mRNA measurement in MNC (required for statistical significance), we
expected that the impact of the cell composition found in total leukocytes on the
hOCT mRNA expression results would be similar when measured in MNC.
Therefore, it is not surprising that Labussiere et al. and White et al. did not dem-
leukocytes (LEU), polymorphonuclear cells (PMNC), and mononuclear cells (MNC)
in healthy volunteers and in imatinib naı ¨ve de novo CML patients.
The hOCT1 mRNA expressions (median, 25–75% quartiles) in total
(month 0) and during the first 6 months of IMA therapy as well as a comparison of hOCT1 expression in analogous cell populations in healthy volunteers.
The hOCT1 mRNA expression level in total leukocytes (A) and mononuclear cells (B) in IMA naı ¨ve de novo CML patients before the start of IMA treatment
526 American Journal of Hematology
onstrate a relationship between hOCT1 expression measured in IMA naı ¨ve de
novo CML patients and the future therapeutic response [3,9]. Although Wang
et al.  was able to show this relationship, only 16 of the 70 CML patients
from this study were not pretreated. Thus, it is unknown whether the high
hOCT1 mRNA expression level seen in Wang et al. could be a real predictor of
therapeutic response in the future, or whether patients with a high hOCT1
mRNA expression level had a differential leukocyte and mononuclear count
(due to pretreatment) that was close to that of healthy individuals and therefore
higher than other patients in the study. In addition, Wang et al. did not clearly
define the cell population in which measurements was carried out, which cre-
ates additional uncertainty in their results. Similarly, Crossman et al. demon-
strated a relationship between of hOCT1 mRNA expression and the achieve-
ment of a complete cytogenetic response . However, all patients in that study
were pretreated and this fact could explain why there was no observed differ-
ence between expression of hOCT1 mRNA in CML patients and healthy
donors. Furthermore, Crossman et al. used bone marrow MNC for monitoring
hOCT1 mRNA expression. The influence from the higher percentage of different
myeloid precursors in these samples, as well as the greater heterogeneity in
hOCT1 mRNA expression, is likely to exceed the influence of the immature cells
in the PB samples that we have described in the present study.
In summary, our study has shown that monitoring hOCT1 mRNA expres-
sion in total PB leukocytes is controversial. However, we have shown that
this level corresponds to the current differential count of leukocytes and the
quantity of tumor cells at the time of testing, rather than being a prognostic
factor that correlates with the future therapeutic response of patients with
CML. Although we did not assess enough patients in this study for unequiv-
ocal evidence, it can be assumed that an analogous situation exists in moni-
toring the hOCT1 mRNA expression level in PB mononuclear cells, as it is
also a mixture of cells (although less heterogeneous than the total leuko-
cytes) with different expression levels of hOCT1 mRNA. Finally, the question
remains of whether or not the dependencies of hOCT1 mRNA expression in
total leukocytes described in this study also apply to functional assays that
analyze the activity of the hOCT1 transporter. It would be of great interest to
perform analogous analyses to those in this study for monitoring the activity
of the hOCT1 transporter. These data would be essential for the evaluation
of all studies that assess the importance of this parameter as a marker of
therapeutic response to IMA in de novo CML patients.
A total volume of 10 mL of PB in ethylenediaminetetraacetic acid was
obtained from 66 healthy volunteers and from a cohort of 23 IMA naı ¨ve de
novo CML patients (month 0 5 M0 samples). CML patients were investi-
gated monthly for a period of 6 months from the start of IMA treatment (M1–
M6 samples). All volunteers and patients signed an informed consent form
and the study was approved by the institutional review board.
The total volume of PB was used for the leukocyte (LEU) separation and
for fractionation into polymorphonuclear cells (PMNCs) and mononuclear
cells (MNCs) using gradient centrifugation Histopaque11077/1119 (Sigma
Diagnostics, St. Louis, USA). The fractionation was performed according to
the manufacturer’s recommendations. For verification of the composition of
leukocyte fractions obtained by separation, microscopic analysis of individual
cell groups (PMNC and MNC) was performed. Smears were processed
using May-Gru ¨nwald and Giemsa-Romanowski solutions. Interestingly, the
MNC fraction from CML patients whose PB was collected at the time of
diagnosis also contained immature cells (e.g. myelocytes, promyelocytes,
Extraction of total RNA from all selected cell fractions (LEU, PMNC, and
MNC) was performed using the RNeasy Mini Kit (Qiagen, Hilden, Germany)
according to the manufacturer’s manual. A cDNA synthesis was performed
using random hexamers and MuLV reverse transcriptase (Applied Biosys-
tems, Foster City, USA).
To detect the expression level of hOCT1, GUS, BCR/ABL, and ABL
mRNA from selected fractions at different time points of IMA therapy, the
TaqMan based real-time reverse transcription PCR (RQ-RT-PCR) with abso-
lute quantification was carried out on an ABI PRISM 7300 (Applied Biosys-
tems Inc, Foster City, USA). The RQ-RT-PCR using the Absolute Q PCR
Mix (ABgene, Epsom, UK) was performed at 958C for 15 min followed by 50
cycles of denaturation at 958C for 15 s and extension at 608C for 1 min.
For hOCT1 cDNA amplification, a TaqMan Gene Expression Assay (serial
number Hs00427552_m1) (Applied Biosystems Inc, Foster City, USA) was
used according to the manufacturer’s recommendations. The final hOCT1
mRNA expression level was then calculated using the following formula:
hOCT1(absolute copies)/GUS(absolute copies)3 100%. To detect the expression of
the control gene GUS in all selected cell fractions, the primer set and probe
from Beillard et al. were used .
The BCR/ABL quantification was performed in LEU using standard meth-
odologies with the primer set and probe previously published by Gabert
et al. . The final BCR/ABL expression was calculated according to BCR/
ABL(absolute copies)/ABL(absolute copies)3 100%.
The RQ-RT-PCR product obtained from the hOCT1 TaqMan Gene Expres-
sion Assay (Hs00427552_m1; Applied Biosystems Inc, Foster City, USA) was
purified using the QIAquick PCR Purification Kit (Qiagen, Hilden, Germany)
and ligated into pCR 2.1 vector using the TA Cloning Kit (Invitrogen, Carlsbad,
USA). Recombinant plasmids were subsequently used for Escherichia coli
transformation. Plasmid DNA was isolated using the QIAprep Spin Miniprep
Kit (Qiagen, Hilden, Germany) and used as the standard for hOCT1 absolute
copy number quantification in 10-fold dilutions (range 106–101copies). Stand-
ards for GUS, BCR/ABL, and ABL with serial numbers CGRS-03, FGRS-10,
and CGRS-01, respectively (FusionQuant1Standards Kit, Ipsogen, Marseille,
France), were used for the absolute quantification of these particular genes.
level at the 1st month after the start of IMA (M1) (B). In the regression analysis, hOCT1 was transformed by adding one and taking the natural logarithm (log denotes
Linear regression fit of hOCT1 mRNA expression and the percentage of immature myeloid cells at the time of diagnosis (M0) (A) and BCR/ABL transcript
American Journal of Hematology527
To ensure reproducibility, all samples were performed and analyzed in dupli-
cate. To obtain robust results, a cDNA from the KCL-22 cell line (DSMZ,
Braunschweig, Germany), which has low hOCT1 mRNA expression, was
used as an internal control for hOCT1 and GUS assessment. In addition,
cDNA from the K562 cell line (DSMZ, Braunschweig, Germany) was used as
an internal control BCR/ABL quantification.
For all statistical analyses, the software Statistica, version 9.0 (StatSoft,
Tulsa, USA) and R (R Development Core Team, Auckland, New Zealand)
1Department of Internal Medicine Hemato-Oncology, Masaryk University and
University Hospital Brno, Brno, Czech Republic;2Institute of Biostatistics and
Analyses, Masaryk University, Brno, Czech Republic;3School of Medicine,
Masaryk University, Brno, Czech Republic;4Institute of Hematology and Blood
Transfusion, Prague, Czech Republic;
Zdenek Racil and Filip Razga contributed equally to this work.
Contract grant sponsor: CELL – The CzEch Leukemia Study Group for Life
Contract grant number: MSM0021622430.
*Correspondence to: Zdenek Racil, Department of Internal Medicine
Hemato-Oncology, University Hospital Brno, Jihlavska 20, Brno 625 00
Conflict of interest: Nothing to report.
Published online 24 March 2010 in Wiley InterScience
1. Thomas J, Wang L, Clark RE, Pirmohamed M. Active transport of imatinib
into and out of cells: Implications for drug resistance. Blood 2004;104:3739–
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optimal response to imatinib have low OCT-1 activity: Higher doses of imatinib may
overcome the negative impact of low OCT-1 activity. Blood 2007;110:4064–4072.
4. Crossman LC, Druker BJ, Deininger MW, et al. hOCT 1 and resistance to
imatinib. Blood 2005;106:1133–1134.
5. Wang L, Giannoudis A, Lane S, et al. Expression of the uptake drug trans-
porter hOCT1 is an important clinical determinant of the response to imatinib
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Informational needs assessment of non-Hodgkin lymphoma
survivors and their physicians
Daphne R. Friedman,1* April D. Coan,2Sophia K. Smith,3James E. Herndon II,4and Amy P. Abernethy5
Cancer Survivorship Care Plans (SCPs) are a recommended part of
medical care for cancer survivors. We sought to identify the medical
and psychosocial informational needs of non-Hodgkin lymphoma sur-
vivors and their physicians in cancer survivorship care to be included
in SCPs. Questionnaires were mailed to eligible lymphoma survivors
and their physicians, querying their preferences about informational
needs in SCPs. The survivor cohort had a median age at diagnosis of
62, with 57% Female, 87% White, and 76% from North Carolina. The
physician cohort was comprised of oncologists (27%) and nononcolo-
gists (73%), and 86% practiced in North Carolina. Greater than 60% of
both survivors and physicians preferred an oncologist and primary
care provider comanage cancer survivorship care. The most highly
rated informational needs were medical issues, although there were
differences between survivors and physicians for many of the informa-
tional needs queried. There was higher concordance between patient
and physician responses for medical issues (63 to 100%) compared to
psychosocial issues (25 to 63%). Important components of SCPs for
lymphoma survivors and their physicians may go unrecognized. Tailor-
ing SCPs to patient or physician users may better accommodate the
differences in need for particular cancer survivorship care information.
As cancer is becoming more treatable and curable, the numbers of cancer
survivors is increasing . Medical complications, long-term and late effects
of therapy, and psychosocial difficulties are among the issues with which
cancer survivors must live [2–4].
In recognition of this, SCPs were recommended, in the first comprehen-
sive manner, by the Institute of Medicine . Several templates exist (e.g.
American Society of Clinical Oncology , Lance Armstrong Foundation/
OncoLink , and Journey Forward ), but patients criticize these tem-
plates as being too technical, lacking personalization, and being deficient in
resource and wellness guides [2,9]. Barriers to development and implemen-
tation of these care plans include difficulty in identifying evidence-based
components , insufficient reimbursement for record abstraction , lack
of specific medical knowledge by primary care physicians (particularly
regarding hematologic malignancies) , and poor communication between
oncologists and primary care physicians [5,13].
Despite a growing body of literature regarding SCPs, the oncology com-
munity has not fully recognized that cancer survivors, oncologists, and pri-
mary care providers have varying levels of knowledge and different experi-
ences, and thus may have different informational needs regarding cancer
survivorship care . By focusing survivorship care based on prioritized
needs, cancer survivors may be more receptive to receiving continued medi-
cal care in all areas.
To address these issues, we focused on a group of survivors who are
treated in a standardized manner, but who are often left out of the SCP
development discussions, specifically survivors of diffuse large B-cell lym-
phoma, the most common type of non-Hodgkin lymphoma. We aimed to (1)
identify the most important informational needs of survivors and their treat-
ing physicians responsible for cancer survivorship care, (2) define the effect
of demographic factors on informational needs, and (3) assess how closely
the informational needs of individual survivors link to that of their physicians.
A total of 178 surveys were mailed to cancer survivors. Fourteen were
excluded because of death (4) or returned mail (10). Sixty-seven of the 164
potential respondents responded, resulting in an overall response rate of
41%. Seventy-eight surveys were mailed to physicians. Two were excluded
because of returned mail. Twenty-two of the 76 potential participants
responded, resulting in an overall response rate of 29%. Baseline character-
528American Journal of Hematology
istics for survivor and physician cohorts are summarized in Table I. Survivor
responders were older at diagnosis than nonresponders (P 5 0.024); other-
wise responders did not differ significantly from nonresponders with respect
to baseline characteristics. Thirteen survivors (19%) completed the survey
less than 2 years since their diagnosis, 26 (39%) completed the survey 2 to
5 years since their diagnosis, and 28 (42%) completed the survey more than
5 years since their diagnosis.
The majority of survivors (63%) and physicians (64%) preferred an oncol-
ogist and primary care provider to comanage cancer survivorship care.
Among survivors, there was no association between having a primary care
physician and the preference of type of physician(s) to manage cancer survi-
vorship care (P 5 0.143).
The queried components of SCPs and their ratings for survivors and
physicians are presented in Table II. Compared to physicians, survivors
were more interested in having a plan for screening of recurrence (P 5
0.012) and late effects of therapy (P 5 0.018) and a summary of treatments
given (P 5 0.044), whereas physicians thought summaries of the treatment
complications (P 5 0.005) were more essential parts of the SCP than survi-
vors. Additionally, a plan to monitor overall health was a more important com-
ponent of cancer survivorship care for survivors than for physicians (P 5
0.0002). Overall, physicians and survivors rated psychosocial issues as less
important in SCPs than medical issues. However, comparing the responses
obtained from survivors and physicians, survivors identified nutrition and exer-
cise (P 5 0.002), insurance (P < 0.0001), and payment for providing cancer
survivorship care (P 5 0.0006) as more important than physicians did.
There were no differences among the survivor subgroups with regards to
who should provide cancer survivorship care, having a primary care physi-
cian or having an oncologist outside of our tertiary referral hospital. Male
survivors rated sexuality and fertility as more important than women (P 5
0.004); otherwise there were no significant differences based on gender.
Survivors who were younger than 60 years old at time of diagnosis identified
a plan for monitoring overall health problems (P 5 0.03), sexuality and fertil-
ity (P 5 0.007), mental health services (P 5 0.044), and financial issues
(P 5 0.042) as more important than survivors who were older than 60 years
old at diagnosis. There were no differences in responses obtained from sur-
vivors greater than 5 years compared to those less than 5 years from the
time of diagnosis.
Physicians of different specialties were equally likely to prefer both oncolo-
gists and primary care physicians comanage cancer survivorship care. Non-
oncologists thought that having a plan to screen for cancer relapse was
more important than oncologists (P 5 0.004), whereas oncologists were
more likely to find that providing insurance information and help with resolv-
ing financial issues were important components of cancer survivorship care
compared to nononcologists (P 5 0.021 and 0.035, respectively).
There were 24 matched survivor physician survey pairs. One survivor had
two physicians and one physician had three survivors; thus one survivor and
one physician contributed more than once to the analyses. As seen in Fig.
1, there was higher concordance between survivors and their physicians
with regards to medical issues (62.5 to 100%) than for psychosocial issues
(25 to 62.5%).
TABLE I. Baseline Characteristics of Survivor and Physician Cohorts
Survivor cohort 9759 6741
Age at diagnosis (years)
Age at survey completion (years)
Time since diagnosis (years)
Location of residence
In state, local
In state, not local
Not in state
Ann Arbor stage of cancer at diagnosis
Received bone marrow transplant
Location of practice
In state, local
In state, not local
Not in state
NS, not significant; NA, not applicable.
American Journal of Hematology529
TABLE II. Importance of Cancer Survivorship Care Plan Components for Survivor and Physician Responders
P valueNMeanSD RankN Mean SDRank
Components pertaining to medical issues
Q1. Your type of cancer and its stage
(how far advanced it is)
Q2. Specific information about your cancer
that might influence whether your
cancer stays away or returns
668.8 2.38 Q1. The patient’s type of cancer and
its stage (how far advanced it was)
Q2. Specific information about the
patient’s cancer that might influence
whether the cancer relapses (risk factors
or other markers such as tumor grade)
Q3. The particular cancer therapy given
(surgery, chemotherapy, hormone,
and/or radiation therapy)
Q4. Summary of the patient’s treatment
success and/or complications
Q5. The treatment side effects the patient
experienced or still experiences
Q6. The risk of future health problems
that could occur due to the patient’s
Q7. A plan to screen for possible cancer
Q8. A plan to screen for possible future
health problems due to cancer therapy
229.0 1.72 NS
22 8.52.26 NS
Q3. The anti-cancer treatments you had
(surgery, chemotherapy, hormone,
and/or radiation therapy)
Q4. Your treatment success and/or
complications you experienced
649.51.33 228.51.97 0.044
Q5. The treatment side effects you
experienced or still experience
Q6. The risk of future health problems
from your cancer treatment
667.7 2.813228.91.24 0.005
669.01.97 22 9.01.53 NS
Q7. A plan to screen for possible return
of your cancer
Q8. A plan to screen for possible future
health problems due to your
Q9. A plan for monitoring your other medical
problems and your overall health
66 9.71.01 22 8.51.980.012
66 9.51.02 228.61.55 0.018
66 9.2 1.76Q9. A plan for monitoring other medical
problems and overall health (not
otherwise related to the patient’s
cancer or therapy)
Components pertaining to psychosocial issues
Q10. Nutrition and exercise678.81.89Q10. Information about nutrition
Q11. Information about sexuality
Q12. Alternative medicine techniques
(for example: herbs and supplements,
chiropractic massage, acupuncture)
Q13. Mental health services
Q11. Sexuality and fertility66 5.73.517 226.82.4 11NS
Q12. Alternative medicine techniques
(for example: herbs and supplements,
chiropractic, massage, acupuncture)
Q13. Mental health services (for example:
care available for depression or anxiety)
Q14. Insurance (health, life or disability)
666.0 3.616227.2 2.110 NS
678.72.710Q14. Insurance information (health,
life, or disability)
Q15. Resolving financial issues
(employment, disability/SSI, retirement)
Q16. Social support (support groups,
therapy, resources in the community)
Q17. Information for family members
and caregivers about cancer and health
Q18. Legal issues (for example: power of
attorney, advanced directives, living wills)
Q19. Physician reimbursement for providing
cancer survivorship care
22 5.62.6 18
Q15. Resolving financial issues (employment,
Q16. Social Support (support groups, therapy,
resources in the community)
Q17. Information for family members and
caregivers about cancer and your health
Q18. Legal issues (for example: power of
attorney, advanced directives, living wills)
Q19. Physician payment for providing cancer
67 7.03.5 15 226.22.916NS
67 5.53.218 22 6.72.514 NS
678.3 2.51222 7.32.49 NS
67 7.13.3 14
22 6.42.315 NS
678.42.71122 6.02.9 170.0006
cancer survivorship care plans. Dark bars in the bar graph reflect concordances.
Concordance of survivors and their physicians for the nineteen survey questions (in order found in the questionnaire) regarding importance of components of
530 American Journal of Hematology
The number of cancer survivors is increasing, and the burden of their dis-
eases and late or long-term effects of cancer therapy has medical, psycho-
social, and economic effects on the survivors themselves and society at
large [3,4,14]. Providing comprehensive and efficient medical care to this
population would help to address these problems. But, what should consti-
tute this medical care?
Instead of moving directly into implementing a ‘‘one-size-fits-all’’ approach,
we decided to query a defined subgroup of non-Hodgkin lymphoma survi-
vors and their physicians, to identify who should provide cancer survivorship
care and to determine the important components of such care. We chose
this group of cancer survivors and their physicians because they have been
evaluated in a limited fashion [12,15,16], and not as thoroughly as breast cancer,
childhood cancer, or Hodgkin lymphoma survivors. In addition, we wanted to
begin our analyses with a homogeneous group of survivors with regards to cura-
tive intent and treatment regimens. Survivors with incurable malignancies or with
cancers treated with a variety of different chemotherapy regimens or therapeutic
modalities might have varying opinions about cancer survivorship care.
Using our mailed questionnaire, we confirmed prior studies’ findings that
survivors and physicians prefer cancer survivorship care coordinated by
both the oncologist and the primary care physician [3,13,17]. We also found
that medical issues were also highly rated as important components in can-
cer survivorship care for both survivor and physician groups. Psychosocial,
alternative medicine, and fertility issues have been noted to be important to
cancer survivors, particularly breast cancer survivors, and are increasingly
being studied in the lymphoma survivor population [4,18]. However, our
results suggest that survivors of diffuse large B-cell lymphoma believe medi-
cal content is a more important component of SCPs.
We found that survivors thought that a plan to monitor overall health was
a more important part of SCPs than physicians. This might imply that survi-
vors view cancer survivorship care as part of their general health mainte-
nance, whereas physicians compartmentalize survivorship care and non-
cancer related care.
Survivors rated nutrition, exercise, and insurance SCP components higher
than their physicians. Whereas physicians might be more comfortable dis-
cussing a survivor’s general health, they may have less immediate informa-
tion and the resources to address these other issues. Notably, the results
found in this cohort vary from those found in other studies, in which there
was more agreement between physicians and a heterogeneous survivor
cohort in expectations for cancer survivorship care .
Our findings of differences between physicians and survivors regarding
the relative importance of different cancer survivorship care issues con-
firmed our hypothesis that the different ‘‘target audiences’’ might need differ-
ent SCPs. While providing the maximum available information to everyone
might seem optimal, this approach risks overloading the user and diluting
the impact of the most important content. Developing personalized SCPs
could address these barriers and adjust the type, level, and amount of infor-
mation for the end user’s needs.
Limitations of this study include the small sample size, low response rate,
exclusion of survivors with >1.5 years since last contact, and inclusion of
survivors from a single institution. The questionnaire was not formally tested
in a pilot cohort, and the wording of the questions varied slightly between physi-
cian and survivor questionnaires. Because many of our findings echo results
obtained by other studies performed in other survivor groups, we feel that major
improvements in the response rates would unlikely influence our findings.
In contrast to the currently available templates containing standardized
information by cancer type, our findings indicate that SCPs should be indi-
vidually tailored to reflect the prioritized needs of survivors, primary care
physicians, and oncologists. Our findings should be confirmed and com-
pared to other larger cohorts or cohorts of other cancer subtypes. Compara-
tive effectiveness research is needed to evaluate whether the implementa-
tion of personalized survivorship care plans provide higher levels of survivor
and/or physician satisfaction, knowledge, and quality of life than the use of a
single standardized survivorship care plan.
Cancer Center (DCCC) Tumor Registry. Eligible participants seen at Duke for
treatment or for consultation, were treated with curative intent, and had no
evidence of lymphoma at their last visit at Duke. We further limited our cohort
Survivors were identified through the Duke Comprehensive
to lymphoma patients with a diagnosis of diffuse large B-cell lymphoma as
treatment is more standardized, homogenous, and aggressive than for all sub-
types of lymphoma taken together. To reduce the chance of questionnaires
mailed to survivors who had died, moved, or otherwise lost to follow up, eligi-
ble patients were included in this study only if they had been seen within the
Duke University Medical system within 1.5 years prior to the chart review.
Physicians were identified in two ways. The Duke oncologists’ names
were obtained from the DCCC registry. Local oncologists’ and primary care
physicians’ names were obtained from survivors’ questionnaires responses.
were developed by the investigators. The questionnaires were designed after
reviewing available SCP templates, exploring literature regarding medical
and psychosocial issues relevant to cancer survivors and their physicians,
and querying oncologists and internists. Questionnaires for survivors and
physicians included the same components, but the wording was not identi-
cal. Participants rated the importance of each item in a set of medical and
psychosocial informational needs (listed in Table I) using a numeric scale of
1 to 10 for each question. A letter explaining the study was mailed to each
survivor with the questionnaire. After 6 months, a reminder card was mailed
to nonresponders. Following receipt of identified physicians from survivor
questionnaires, survey packages were mailed to the identified physicians.
Survivor surveys were received between June and December 2008. Physi-
cian surveys were received between November 2008 and January 2009.
Informed consent was inferred by a response, per the Duke University
School of Medicine Institutional Review Board (Duke IRB) mailed question-
naire policy. This study was approved by the Duke IRB.
The mailed questionnaires for survivors and for physicians
DCCC registry and chart review. Specifics regarding stage of disease, thera-
pies received, and treatment outcomes were obtained from chart review.
Demographic information was obtained from the
vivor and physician cohorts were summarized by descriptive statistics.
Within these cohorts, the characteristics of responders and nonresponders
were compared using two-sample t-tests (for continuous variables) and Fish-
er’s exact tests, Chi-square tests, or Cochran-Armitage Trend tests (for cate-
gorical variables) to assess selection bias.
Descriptive statistics (mean and standard deviation) were computed for
survivor and physician ratings of individual informational needs. Two-sample
t-tests and exact chi-square tests were used to assess the relationship
between outcome (e.g., informational needs or type of health care provider)
and survivor/physician subgroups. Gender, age at diagnosis (<60 years,
=60 years), and time since diagnosis (<5 years, =5 years) were used as
survivor subgroups and specialty (oncology, nononcology) was considered
for physicians. Sixty years was chosen as the age cut-off, consistent with
the International Prognostic Index . Likewise, 5 years since diagnosis
was chosen as a cut-off, as the 5-year time horizon from diagnosis often
signifies ‘‘cure’’ from cancer.
Initially the survivor and physician cohort were treated as independent
groups and two-sample t-tests were used to detect differences in mean rat-
ings of each individual item between survivors and physicians. Survey
responses from survivors were also matched with their self-identified primary
care physician and/or oncologist to form survivor physician pairs. A physi-
cian may have cared for more than one survivor and a survivor may have
had more than one physician. Thus, in all paired analyses, a survivor or
physician may have contributed more than once to the analyses. Agreement
in ratings of issues concerning survivorship care was assessed between sur-
vivors and their physicians using concordance. Concordance was defined as
complete agreement in response categories. For this analysis, ratings were
categorized as follows: 1–3 (low importance), 4–6 (moderate importance),
and 7–10 (high importance) .
All statistical analyses were conducted with SAS version 9.2 (SAS Insti-
tute, Cary, NC). A significance level of 0.05 was used for all statistical tests.
P-values are presented for descriptive purposes.
Baseline demographics and characteristics for the sur-
1Department of Medicine, Duke University Medical Center, Durham, NC;
2Cancer Biostatistics, Duke Comprehensive Cancer Center, Durham, NC;3Duke
Comprehensive Cancer Center, Durham, NC, and Gillings School of Global Public
Health, University of North Carolina, Chapel Hill, NC;4Department of Biostatistics
and Bioinformatics, Duke University, and Cancer Biostatistics, Duke
Comprehensive Cancer Center, Durham, NC;5Duke Comprehensive Cancer
Center and Department of Medicine, Duke University Medical Center, Durham, NC
American Journal of Hematology531
*Correspondence to: Dr. Daphne Friedman,
Duke University Medical Center DUMC 3382,
Durham, NC 27705
Received for publication 29 January 2010; Revised 23 March 2010;
Accepted 24 March 2010
Conflict of interest: Nothing to report.
Published online 29 March 2010 in Wiley InterScience
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Pain rate and social circumstances rather than cumulative
organ damage determine the quality of life in adults
with sickle cell disease
Charlotte F.J. van Tuijn,1Eduard J. van Beers,1John-John B. Schnog,2and Bart J. Biemond1*
Due to the significant morbidity associated with sickle cell disease (SCD),
sickle cell patients have a reduced quality of life (QoL). Even though pain
is considered an important determinant of QoL in sickle cell patients, fac-
tors such as organ damage and socioeconomic circumstances may also
be important. Therefore, we determined the contribution of chronic organ
damage and sickle cell–related complications to QoL and also analyzed
the effect of vaso-occlusive crises and socioeconomic circumstances on
QoL. Consecutive adult sickle cell patients were included. QoL was repre-
sented in a physical component scale (PCS) and a mental component
scale (MCS) and assessed with SF-36 forms. Higher pain rates were
related to lower QoL scores. Both occupation and the level of education
were significantly related to PCS while no relation with MCS or pain rate
was found. Thirty-five percent of the patients were unemployed when
compared with 6% of the general population and 16% of immigrants with-
out SCD. Neither genotype nor the presence of chronic organ damage
were significantly related to QoL. In conclusion, a reduced QoL was
mainly determined by pain rate, occupation, and educational level.
Chronic organ damage, although a major factor determining life expect-
ancy in SCD, was not a determinant of QoL.
SCD is a hereditary hemoglobinopathy characterized by recurrent micro-
vascular vaso-occlusion and chronic hemolytic anemia resulting in progres-
sive organ damage and reduced life expectancy [1,2]. Given the chronic
nature of SCD and the severity of its complications, patients are likely to
have a significantly reduced QoL. Intuitively and historically, pain is widely
regarded as the major factor in determining QoL in SCD. However, even
though previous studies have indeed demonstrated a reduced QoL of sickle
cell patients, this was often not or not only attributable to pain . Factors
such as anxiety, depression, and socioeconomic circumstances may also
contribute to the reduced QoL of sickle cell patients [3–5].
Sickle cell patients develop organ damage irrespective of their frequency
of acute painful events, which has been related to significant morbidity and
increased mortality, and it seems likely that SCD-related organ damage neg-
atively impacts QoL of sickle cell patients . However, to our knowledge,
the impact of chronic organ damage on QoL in SCD has not been previously
assessed. Therefore, we prospectively assessed the QoL in a cohort of con-
secutive sickle cell patients in whom chronic organ damage, pain rate, and
the history of sickle cell–related complications in the last 5 years was sys-
tematically analyzed. In addition, the impact of occupation and educational
level on QoL of these patients was studied.
One hundred seventeen adult patients with SCD (HbSS, HbSb0, HbSC,
and HbSb1) were eligible for our study. Twenty-three patients were excluded
from analysis because they were not able to fill in the SF-36 questionnaire
for different reasons (illiterate persons, mental retardation or repeated no
show at their appointments). These excluded patients did not differ from the
study population concerning outcome variables (pain, disease severity, edu-
cation, and occupation). QoL was assessed in 51 patients with HbSS, 5 with
HbSb0, 11 with HbSb1, and 27 patients with HbSC.
The QoL data of our population are presented in Table I. As expected, our
patient group scored lower on QoL compared with the healthy Dutch popula-
tion  (see Supporting Information Table IV). No correlation between the
MCS and PCS was found in the sickle cell population (spearman r 5 0.14;
P > 0.20). When comparing male to female sickle cell patients, the overall
PCS appeared to be significantly higher in males when compared with
females (P 5 0.015). We found no significant difference in the overall MCS
between males and females. Older patients scored lower on the PCS in
comparison to younger patients (P 5 0.002) while no significant differences
in QoL scores between genotypes was found (data not shown).
532American Journal of Hematology
The QoL scores in relation to pain rate are depicted in Table II. With
respect to the MCS, the overall score and all subscales, except for mental
health, were significantly lower in patients with the highest pain rate (P 5
0.021). Although significantly lower scores were found on the role-physical
scale (P 5 0.005) and the general health scale (P 5 0.033) in patients with
the highest pain rate, the overall PCS was not determined by the number of
admissions for painful crises (P 5 0.110). Also, analysis by linear regression
confirmed that pain rate is significantly associated with MCS and is less
likely to influence the PCS (data not shown).
The prevalence of different forms of organ damage in our study population
was: pulmonary hypertension (PHT): 24.5%, renal failure: 3.2%, microalbu-
minuria: 21.3%, retinopathy: 31.2%, iron overload: 9.6%, avascular osteo-
necrosis: 11.7%, leg ulcers: 6.4%, Acute chest syndrome (ACS): 25.5%,
priapism: 8.5%, and stroke: 4.3%. Except from lower QoL scores (for the
PCS) in patients with iron overload (P 5 0.017), no association between any
form of organ damage or sickle cell–related complications and QoL scores
was found (Table III). Moreover, when patients with organ damage and com-
plication were divided according the pathogenesis (hemolysis-related compli-
cation versus vaso-occlusion/ischemia-related complications), no significant
differences in QoL was observed when compared with the patients without
organ damage at all.
With respect to the relation between occupation and educational level and
QoL scores, the PCS was strongly associated with occupation and level of
education (P < 0.001). The overall MCS was not related to occupation or
the level of education (P 5 0.206 and P 5 0.177, respectively) (see Sup-
porting Information Tables V and VI). Occupation and the level of education
were not different between different genotypes and were not related to pain
SCD is heterogeneous in its clinical presentation with patients being con-
tinuously admitted for the management of disease-related complications at
one end of the spectrum and patients rarely requiring medical care at the
other . Irrespective of the frequency of acute clinical complications, most
patients develop accumulating organ damage throughout their lives as a
result of chronic hemolytic anemia and ongoing vaso-occlusion . With
respect to QoL, previous studies have reported that sickle cell patients have
lower QoL scores when compared with race- and age-matched controls,
which were related to pain [8–10]. However, its relation to the presence of
chronic organ damage has not been described before. In the present study,
organ damage appeared not to be related to any of the QoL scores. If
patients were grouped according the pathophysiology of their different forms
of organ damage or a history of sickle cell–related complication as recently
proposed by Kato et al. , also no relation with QoL scores was demon-
strated. Surprisingly, PHT, which has been related to early mortality in SCD,
was not related to QoL in our patients. This might be explained by the fact
that our study population consists of patients with mild PHT (regurgitation jet
flow velocity < 2.9 m/sec), which is generally not related to severe com-
plaints or significantly reduced exercise tolerance.
Factors significantly associated with a reduced QoL were pain rate and
social circumstances defined as educational level and occupation. Interest-
ingly, pain rate was only associated with a reduced MCS, whereas the social
circumstances of the patients were related to the PCS. These data suggest
that frequent painful and unpredictable crises are an important psychological
burden rather than a physical burden to sickle cell patients as has been sug-
gested previously . In contrast, social circumstances as reflected by
occupation and level of education were mainly related to the PCS, suggest-
ing that only patients in good physical performance are able to finish school
and find jobs independently of the frequency of admission for painful crises.
This was further supported by the finding that no correlation between the
MCS and PCS was found in the sickle cell population, which is in contrast to
TABLE I. QoL Scores of Sickle Cell Patients
SCD, N 5 32SCD, N 5 61
*Mann-Whitney U test.
TABLE II. QoL in Relation to Pain Rate
None (n 5 25)
>0 < 1 (n 5 48)
> 5 1 (n 5 21)P*
*Kruskal Wallis test.
TABLE III. QoL in Relation to Organ Damage and Sickle Cell–Related Complications
PresentAbsent Present Absent
Acute chest syndrome
0.701 50.2 (10.3)
*Mann-Whitney U test.
American Journal of Hematology 533
the findings of QoL assessments in healthy individuals . Similar to pre-
vious findings of McClish et al. , we did not find a correlation between
genotype and QoL scores. Also, no difference in QoL scores was observed
between patients on hydroxyurea and those who are not on hydroxyurea.
This might be explained by the fact that in our study population, hydroxyurea
was only prescribed to reduce painful crises and the occurrence of acute
chest syndrome. By reducing these complications in patients with an other-
wise more severe clinical presentation, hydroxyurea may have improved the
QoL. This is in line with a previous prospective study of Ballas et al. 
who demonstrated an improved QoL with the use hydroxyurea.
Certain limitations of our study should be taken into account. First, by defin-
ing pain rate by the amount of clinical admissions, the conclusions of our study
may not be extrapolated for the number of painful crises experienced at home,
which have been reported to occur frequently in sickle cell patients . How-
ever, previous studies have shown that pain (during a painful crises as well as
chronic pain) is related to QoL in sickle cell patients [8,10,13]. Second, most
forms of organ damage and sickle cell–related complications were only present
in a relative small group of patients, which may have underpowered our study
to detect an effect of specific forms of organ damage on QoL. Mild PHT, as
one of the most relevant forms of organ damage that has been associated with
poor prognosis, was present in 24% of all sickle cell patients and was not
related to QoL.
In conclusion, the QoL scores in consecutive sickle cell patients appear to
be determined mainly by pain rate and social circumstances. Despite the
contribution of organ damage such as (mild) PHT on prognosis and life
expectancy, cumulative organ damage does not seem to be an important
determinant of QoL in SCD. In terms of clinical presentation, pain rate is the
most important factor for the QoL of adult sickle cell patients.
Adult sickle cell patients visiting the Department of Hematology of the
Academic Medical Centre in Amsterdam were eligible for our study. Inclu-
sion criteria were: high-performance liquid chromatography (HPLC) con-
firmed diagnosis of homozygous sickle cell anemia (HbSS), sickle-C dis-
ease (HbSC), HbSb1-thalassemia (HbSb1-thal), or HbSb0-thalassemia
(HbSb0-thal), age 18 years or older and capable of filling in a questionnaire
(Dutch or English). All data were collected during a routine outpatient clinic
QoL was assessed by the use of SF-36 forms. The SF-36 is a short-form
health survey that has been proven to be valid and reliable in the black popula-
tion . It has been previously used to determine QoL in adults with SCD .
Briefly, it yields eight different scales (physical functioning, role limitations due to
physical problems, role limitations due to emotional problems, social functioning,
mental health, vitality, bodily pain, and general health perceptions) of functional
health and well-being as well as psychometrically based physical and mental
health summary measures. The SF-36 is a generic measure, which is not age,
disease, or treatment specific. Accordingly, the SF-36 has proven to be useful
in surveys of general and specific populations, comparing the relative burden of
diseases . All patients were asked to complete this questionnaire during a
routine outpatient visit. All scale scores are linearly converted to a 0–100 scale,
with higher scores indicating higher levels of functioning or well-being. We ana-
lyzed the scores of our study population and compared the data with the scores
of the general healthy Dutch population .
Data on social circumstances represented by occupation and level of
education were routinely gathered during the first routine visit for every
patient. With respect to occupation patients were divided into: employed,
unemployed, or student. Education level was divided into: high school
or less, vocational education/community college, and tertiary education/
Pain rate was defined as the number of admissions for treatment of a
vaso-occlusive crisis from January 2002 until January 2007 and was deter-
mined by chart review . Subsequently, three groups were arbitrarily
defined: patients without, patients with <1 admission for painful crises per
year, and patients with 1 or >1 admission for painful crisis per year.
Organ damage and sickle cell–related complications were assessed by
systematic screening and medical record review and defined as follows:
PHT: tricuspid regurgitation jet flow velocity (TRV) equal to or higher than
2.5 m/sec in rest detected by Doppler echocardiography. PHT was con-
sidered absent with no or only trace TRV . Renal failure: an estimated
creatinine clearance lower than 100 mL/min (Cockcroft and Gault). Micro-
albuminuria: urinary creatinine (mmol/L) to urinary albumin (mg/L) ratio
higher than 3.5 for males and higher than 2.5 for females confirmed with
24 hr urine collection with microalbuminuria higher than 30 mg/24 hr .
Retinopathy: presence of at least mild nonproliferative retinopathy .
Iron overload: plasma ferritin level higher than 1,000 mmol/L (on at least
three occasions during steady state) and a history of more than 20 trans-
fused packed cells . Symptomatic avascular osteonecrosis: local pain
and reduced function with documented osteonecrosis of the femoral or
humeral head (hip or shoulder X-ray) or a history of surgical intervention
for osteonecrosis. Leg ulcers: chronic ulcers of the ankle not otherwise
explained. Acute chest syndrome: defined as described by Stuart
and Setty  occurring between January 2002 and January 2007. Priap-
ism: spontaneous painful erection requiring hospital care. Stroke: history
of stroke confirmed by magnetic resonance imaging or computerized
tomography. We analyzed the relation between organ damage and QoL
both for each form of organ damage or complication separate as well as
for groups. Groups were divided in a group with no organ damage or
sickle cell–related complications, a group with organ damage or compli-
cations due to hemolysis (leg ulcers, PHT, priapism, and stroke), or a
group with organ damage related to vaso-occlusion (ACS, retinopathy,
avasculair osteonecrosis, renal failure, and microalbiminuria) as proposed
Hematological and biochemical laboratory parameters were assessed at
the same visit at which the patient completed the QoL questionnaire. Fetal
hemoglobin percentage (HbF%) was determined by cation-exchange HPLC
and a-thalassemia screening was performed with a multiplex PCR assay
. If not available, we used the results from the latest outpatient visit .
All numbers in the tables are medians with corresponding interquartile
ranges unless stated otherwise. Difference in continuous data between
groups was tested with the Mann-Whitney U test. Difference in categorical
data between groups was tested with the x2test or Kruskal Wallis test. P-
values ? 0.05 were considered statistically significant. Multiple linear regres-
sion analyses were performed to analyze the interaction between the differ-
ent scales of the SF-36 questionnaire and pain rate. All missing data were
considered missing at random. In the case that one or more questions were
not answered in a specific scale of the SF-36 questionnaire, the mean value
of the remaining questions on that specific scale was used for the missing
items. When half or more of the questions were not answered, the results of
the specific scale were discarded. Statistical analysis was performed by
using SPSS 12.0.2 (SPSS, Chicago, IL).
1Department of Hematology, Academic Medical Centre, Amsterdam,
The Netherlands;2Department of Hematology and Medical Oncology,
St. Elisabeth Hospital, Curac ¸ao, Netherlands Antilles
Additional Supporting Information may be found in the online version of this article
*Correspondence to: Bart J. Biemond, Department of Hematology, F4-224,
Academic Medical Centre, PO Box 22660, 1100 DD Amsterdam, The Netherlands
Conflict of interest: Nothing to report.
Published online 13 April 2010 in Wiley InterScience
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A specific linkage between the incidence of TP53 mutations and
type of chromosomal translocations in B-precursor acute
lymphoblastic leukemia cell lines
Takeshi Inukai,1* Xiuru Zhang,2Takeshi Kameyama,2Yukiko Suzuki,2Kazuhito Yoshikawa,2Itaru Kuroda,1
Atsushi Nemoto,1Koshi Akahane,1Hiroki Sato,1Kumiko Goi,1Kazunori Nakamoto,3Jun-ichi Hamada,2
Mitsuhiro Tada,2Tetsuya Moriuchi,2and Kanji Sugita1
Chromosomal translocation plays an essential role in leukemogenesis
of childhood B-precursor acute lymphoblastic leukemia (ALL) in com-
bination with specific gene mutations. Although several reports sug-
gest correlation of TP53 mutation with the type of chromosomal trans-
location in childhood B-precursor ALL, it has not been directly con-
firmed in a single cohort study due to the limited incidence of TP53
mutation in primary samples at diagnosis. Leukemia cell lines gener-
ally show higher incidence of gene mutations compared with primary
samples. Thus, to clarify possible differences in cooperation of the
p53 pathway for leukemogenesis with the type of chromosomal trans-
location, TP53 gene mutation was analyzed in 32 B-precursor ALL cell
lines. TP53 mutation was observed in 40.6% (13 cell lines), and mis-
sense mutation of R248Q was the most commonly observed (5 cell
lines). Of note, TP53 mutation was frequently observed among MLL-
rearranged and t(1;19)-positive ALL cell lines, but was very rare among
Philadelphia chromosome-positive and t(17;19)-positive ALL cell lines.
Although the number of samples analyzed is limited, this is the first
direct observation of the correlation between the incidence of TP53
mutation and types of translocation in B-precursor ALLs, suggesting
a functionally different fusion gene product in the p53 pathway for
Chromosomal translocation is one of the most important events in leuke-
mogenesis of childhood B-precursor acute lymphoblast leukemia (ALL), and
its significance in disease prognosis has been well documented. p53 is crit-
ical regulator of cell death, cell cycle progression, and DNA repair, and,
recently, its critical involvement in the efficiency of induced pluripotent stem
cell generation was documented . Of note, TP53 mutation is widely
observed in various tumors including leukemia. An early retrospective study
of exons 5–8 of the TP53 gene in 50 B-precursor ALL cases demonstrated
that only one case (2%) had mutation , and a large retrospective study of
264 childhood B-precursor ALL cases at diagnosis demonstrated that only
five cases (1.9%) had TP53 mutation in exons 5–8, which encode highly
conserved regions during evolution . The incidence of TP53 mutation in
exons 4–9 among poor-outcome childhood ALL cases at diagnosis was 30%
(3/10 cases) . Later studies reported that TP53 mutation might be rela-
tively frequent among ALL with MLL-rearrangement and t(1;19): the inci-
dence of TP53 mutation in exons 5–9 in MLL-rearranged ALL at diagnosis
was 23% (3/13 cases) , and that in exons 2–11 in t(1;19)-ALL at diagno-
sis was 10% (2/20 cases) . In contrast, TP53 mutation was rare in Phila-
delphia chromosome (Ph1)-positive ALL: none of 15 Ph1-positive ALL cases
at diagnosis had TP53 mutation in exons 2–11 . Although these reports
suggest correlation of TP53 mutation with the type of chromosomal translo-
cation in childhood B-precursor ALL, it has not been directly confirmed in a
single cohort study due to the limited incidence of TP53 mutation in primary
samples at diagnosis. Leukemia cell lines are usually established from leu-
kemia in progressed disease status, and, thus, generally show higher inci-
dence of gene mutations compared with primary samples . In fact, Kawa-
mura et al.  reported that the incidence of TP53 mutation was increased
to 80% (4/5 cell lines) among t(1;19)-ALL cell lines, suggesting that the inci-
dence of TP53 mutation might be augmented in cell lines. Accordingly, ALL
cell lines would be useful tools to confirm the correlation of TP53 mutation
with chromosomal translocations.
To clarify the TP53 gene status in B-precursor ALL cell lines with repre-
sentative chromosomal translocations, we analyzed 32 B-precursor ALL cell
lines including 10 MLL-rearranged ALL , 6 t(1;19)-ALL, 7 Ph1-positive
ALL , and 4 t(17;19)-ALL cell lines  using the yeast functional assay
, which is sensitive for detecting TP53 mutation. TP53 mutation was
detected in 13 cell lines (40.6%) (Table I). The incidence of TP53 mutation
in the present study is higher than that in previous reports that used primary
ALL samples at diagnosis, in which TP53 mutation was identified in ? 2% of
the cases [2,3], suggesting that acquisition of TP53 mutation might provide
advantages for disease progression and/or sustained proliferation in vitro.
Among 13 cell lines with TP53 mutation, three cell lines had two types of
mutations simultaneously; one cell line (KOPN36) had double mutation on
the same allele, while two cell lines (KOPB26 and KOPN63) had two muta-
tions on different alleles (Table I). The distribution of the 16 mutations identi-
fied in 13 cell lines is shown in Fig. 1A and compared with that in previous
reports on B-precursor ALL samples [2–7] and T-ALL samples [18,19]. Five
(38.5%) of the 13 cell lines with TP53 mutation had missense mutation of
c.743 G>A resulting in p.R248Q, and 2 cell lines (15.4%) had missense
mutation of c.817C>T resulting in p.R273C; both are well known as hot-
spots. Among the 16 mutations, 11 mutations were located in highly con-
American Journal of Hematology535
served regions. This pattern of distribution was similar to that in B-precursor
ALL samples previously reported, in which 5 (18.5%) of the 27 samples with
TP53 mutation had R248Q. In contrast, R248Q mutation was reported in
only one of 22 samples of T-cell ALL with TP53 mutation.
The incidence of TP53 mutation among MLL-rearranged ALL cell lines
and t(1;19)-ALL cell lines was 60% (6/10) and 66.7% (4/6), respectively,
while that among Ph1-positive ALL cell lines and t(17;19)-ALL cell lines was
14.3% (1/7) and 0% (0/4), respectively (Fig. 1B). Of note, consistent with
the series of clinical samples in previous reports [5–7], the incidence of
TP53 mutation among MLL-rearranged and t(1;19)-positive ALL cell lines
was significantly higher than that among the other ALL cell lines including
Ph1 and t(17;19)-positive ALL cell lines (P < 0.05, chi-squared test).
Although the number of cell lines analyzed is limited, this is the first direct
observation in a single analysis of the correlation between the incidence of
TP53 mutation and types of translocation in B-precursor ALLs. The inci-
dence of TP53 mutation among MLL-rearranged and t(1;19)-positive ALL
cell lines observed in this study was higher than that in previous reports
using clinical samples, suggesting that TP53 mutation plays a role in dis-
ease progression and/or the in vitro proliferative activity of MLL-rearranged
and t(1;19)-positive ALL but not necessarily Ph1 and t(17;19)-positive ALL.
It should be noted that E2A-HLF chimera derived from t(17;19) has the
potential to protect cells from apoptosis induced by activation of the p53
pathway , suggesting that E2A-HLF might overcome at least the pro-
apoptotic activity of p53. Similarly, it was reported that BCR-ABL blocks
apoptotic cell death induced by DNA damage without altering p53-depend-
ent G1 arrest . Thus, E2A-HLF and BCR-ABL may have the potential to
overcome the pro-apoptotic activity of p53 and, thus, TP53 mutation is not
necessary for disease progression. In other words, regardless of the TP53
gene status, Ph1-positive ALL and t(17;19)-ALL could be relatively resistant
to therapeutic modalities that activate the p53 pathway such as irradiation.
In contrast, without TP53 mutation, MLL-rearranged ALL and t(1;19)-ALL
might be relatively sensitive to therapeutic modalities that activate the p53
pathway, and, thus, TP53 mutation could be one of the prognostic factors for
therapeutic outcome in these leukemias.
In conclusion, TP53 mutation was observed in as high as 40% of B-pre-
cursor ALL cell lines, but was significantly less frequent among Ph1 and
t(17;19)-positive ALL cell lines. TP53 mutation might be associated with the
functional significance of the fusion gene product derived from translocation
in the p53 pathway.
32 cell lines established from childhood B-precursor ALL were used: 10
MLL-rearranged ALL cell lines  (KOPN-1, KOPB-26, KOCL-33, 244, 245,
250, 251, 258, 269, and YAMCL-95), 6 t(1;19)-ALL cell lines (697, KOPN-
34, 236 , 263 , YAMN-90, and 292), 7 Ph1-positive ALL cell lines
 (KOPN-30bi, 257bi, 266bi, 272bi, YAMN-73, 283bi, and 291), 4
t(17;19)-ALL cell lines  (UOC-B1, HAL01 , YCUB-2 , Endo-kun),
and 5 other ALL cell lines including 1 with t(12;21) (Reh)  and 4 with
others (Nalm6, KOPN-32 , 235 , and 261 ). Total RNA was
extracted using the Trizol reagent (Invitrogen, Carlsbad, CA), reverse tran-
scription was performed using random hexamer (Amersham Bioscience,
Buckinghamshire, United Kingdom) by Superscript II reverse transcriptase
(Invitrogen), and then incubated with RNase (Invitrogen). The state of the
TP53 gene was tested by the yeast functional assay  as described previ-
ously [22,23]. In brief, RT-PCR amplified TP53 cDNAs were cotransfected
with a linealized gap vector carrying the 50and 30ends of the gene into the
yIG397 strain containing an integrated plasmid with the ADE2 open reading
frame under the control of TP53-responsive promoter. Yeast containing the
mutant TP53 cDNA fails to transcribe ADE mRNA and formed red colonies,
whereas yeast expressing the wild-type TP53 forms white colonies. Thus,
the status of the TP53 gene is quantitatively analyzed by the color of colo-
nies. When functional assay demonstrated the TP53 mutation, sequences of
TABLE I. TP53 Gene Status in B-Precursor ALL Cell Lines
Cell line TranslocationReferences Red colony (%)Mutation Types of mutation
ac.849_861 del CACAGAGGAAGAG.
bc.879_880 insCC, c881A.C c,884A>G c.886_887insA.
536American Journal of Hematology
TP53 gene was analyzed. In brief, yeasts were digested with Zymolyase
(Seikagaku-Kogyo, Tokyo, Japan), and TP53 expression plasmids were
extracted by QIApreo (QIAGEN, Hilden, Germany) and transfected into XL-1
blue E. coli by electroporation. The extracted plasmids were processed for
sequencing with a DyeDeoxy Terminator Kit (Perkin-Elmer, Urayasu, Japan).
1Department of Pediatrics, School of Medicine, University of Yamanashi
Yamanashi, Japan;2Division of Cancer-Related Genes,
Institute for Genetic Medicine, Hokkaido University, Sapporo, Hokkaido, Japan;
3Bioinformatics Support Section, Center for Life Science Research,
University of Yamanashi, Yamanashi, Japan
*Correspondence to: Takeshi Inukai, Department of Pediatrics, School of Medicine,
University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi 409-3898, Japan
Conflict of interest: Nothing to report.
Published online 19 April 2010 in Wiley InterScience
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4. Marks DI, Kurz BW, Link MP, et al. High incidence of potential p53 inactiva-
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5. Lanza C, Gaidano G, Cimino G, et al. Distribution of TP53 mutations among
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6. Kawamura M, Kikuchi A, Kobayashi S, et al. Mutations of the p53 and ras
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7. Nakai H, Misawa S, Tanaka S, et al. p53 Gene mutations and loss of a chro-
mosome 17p in Philadelphia chromosome (Ph1)-positive acute leukemia. Leu-
8. Drexler HG, Fombonne S, Matsuo Y, et al. p53 Alterations in human leuke-
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9. Inukai T, Zhang X, Goto M, et al.Resistance of infant leukemia with MLL
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10. Uno K, Inukai T, Kayagaki N, et al.
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Analysis of p53 mutations in a
TNF-related apoptosis-inducing ligand
A simple p53 functional assay for
Occurrence of TEL-AML1
Distinct prognostic values of p53
cell lines with representative chromosomal translocations. A: Codon distribution of
16 TP53 mutations identified in the 13 B-precursor ALL cell lines in the present
study is indicated at the bottom and compared with that in B-precursor ALL sam-
ples reported in the six previous studies (middle) and in T-ALL samples reported in
the two previous studies (top). The number of codons in which mutation was iden-
tified in multiple samples is indicated. In the previously reported samples, open
and closed symbols indicate samples at diagnosis and samples at relapse, respec-
tively, and triangles indicate cell lines. The location of highly conserved regions
(domains II, III, IV, and V) in the TP53 gene is indicated at the bottom. B: Inci-
dence of TP53 mutation among B-precursor ALL cell lines with various chromoso-
mal translocations is indicated. Closed and open columns demonstrate the number
of cell lines with and without TP53 mutation, respectively. The P-value upon chi-
square test between the incidence of TP53 mutation among MLL-rearranged and
t(1;19)-positive ALL cell lines and that among the other cell lines including Ph1
and t(17;19)-positive ALL cell lines is indicated.
Codon distribution and incidence of TP53 mutation in B-precursor ALL
American Journal of Hematology 537
Clinical manifestations of combined factor V and VIII deficiency:
A series of 37 cases from a single center in India
Auro Viswabandya,1* Shoma Baidya,2Sukesh C. Nair,2Kavitha M. Lakshmi,1Vikram Mathews,1
Biju George,1Mammen Chandy1and Alok Srivastava1
We describe here the clinical manifestations of 37 patients with com-
bined coagulation factor (F) V and FVIII deficiency, which is the com-
monest multiple coagulation factor deficiency state. Only a few cases
are reported in the literature from India. Prolonged bleed post injury/
surgery (62%) is the commonest manifestation in our series, and epis-
taxis (19%) is rare in our patients in comparison to other series
described in the literature. Although the frequency of bleeding mani-
festations differs among various reports, there is no evidence for
increased bleeding manifestation due to combined deficiency of two
coagulation factors as against a single coagulation factor. To the best
of our knowledge, this is the largest series of this disorder described
Combined Factor (F) V and VIII is the commonest combined hereditary
coagulation factor deficiency with a prevalence of 1:1,000,000 . It is an
autosomal recessive disorder of blood coagulation  and the frequency of
such autosomal recessive disorders increases 8–10-folds in populations
where consanguinity is common. It is caused by a defect in lectin mannose
binding protein 1 (LMAN 1) gene or in multiple coagulation factor deficiency
(MCFD) gene 2 [3–5]. It was initially described by Oeri et al.  in 1954 and
so far about 150 patients have been described from around the world [7–
11]. The largest of these studies so far, describe the clinical manifestations
of this disorder in 27 patients of Iranian origin . Patients who are homozy-
gous for this combined factor deficiency state maintain a factor level
between 4% and 30% [12,13]. We present herewith the clinical and pheno-
typic data of combined FV and FVIII deficiency in a large series of 37
patients of Indian origin seen at our center.
All patients with combined FV and FVIII deficiency seen at our center over
a period of 20 years, between 1988 and 2008 were included in this analysis.
History of bleeding was considered significant if
i. After dental extraction bleeding persisted for more than 48 hr or
required repeat surgical intervention.
ii. Menstrual period lasted 6 days or more with history of clots and
required hormonal therapy for control.
iii. Epistaxis was spontaneous and persisted even after local measures
iv. Gastrointestinal bleed, presented as hematemesis or malaena.
v. Post-traumatic bleed if the bleeding was significant with minor trauma.
vi. Any other history of bleeding that required blood product support.
For hematoma, the nature of the injury and for hemarthrosis, the radiologi-
cal changes in the joint were documented.
FVIII coagulant (FVIII: C) activity was measured on citrated plasma sam-
ples from these patients by one-stage APTT method while FV coagulant
activity was measured by a PT based method. From 1998 till 2001, the fac-
tor assay was done by Coag-a-mate; RA4 (Organon Teknika), from 2001 till
2006 by CA-1500 Sysmex coagulometer (Sysmex, Hyogo, Japan) and from
2006 onwards by ACL Advance (Beckman Coulter). For the diagnosis of
combined FV and VIII deficiency, the cut-off values for FV (<40%) and FVIII:
C (<45%) was considered as previously described .
There were a total of 37 cases of combined FV and FVIII deficiency diag-
nosed during this time. There were 21 (57%) female and 16 (43%) male
patients, with a mean age of 17 years (range: 1–49). Twenty-eight (76%)
out of 37 cases were born of consanguineous marriages. A family history
of bleeding was present in 14 (38%) cases. Nineteen patients (51%) were
symptomatic prior to 5 years of age. The mean level of FV was 12.5%
(range: 5–31), and the mean level of FVIII was 8.8% (range: 1227). In 11
out of 37 (30%) patients both FV and FVIII levels were 10% or lower.
Seven out of 37 (19%) patients had both factor levels more than 10%.
Nineteen patients (51%) had one factor level above and the other below
the 10% limit (five patients had FV level less than 10% and fourteen
patients had FVIII level less than 10%). Median levels of FV and FVIII
around 10% was typical of the homozygous state for the combined defi-
ciency of FV and FVIII [11–13].
Prolonged bleeding post injury/surgery was the commonest bleeding man-
ifestation seen in 23 (62%) cases. The other significant symptoms were
bleeding from tooth socket in 21 (57%) cases, gum bleed in 18 (49%), easy
bruisability in 11 (30%), epistaxis in seven (19%), hemarthrosis in five
(13%), gastrointestinal bleed in one (3%) case. No patient had presented
with intracranial bleed. Menorrhagia was seen in 6/9 (66%) females who had
Our data shows that there are differences in the clinical manifestations of
patients in India compared to those described in the only other large series
reported so far in the literature from Iran. The clinical manifestations in our
patients have been compared with that of other large series in Table I. Epis-
taxis (77% and 48%) was the most common symptom among patients from
Iran [7,9]. However, this occurred much less frequently (epistaxis, 19%) in
our patients. Epistaxis was also significantly less in our patients when com-
pared to that from Israel ; (57% vs. 19%). Hemarthrosis was observed in
13% of our patients though this has not been reported from the other small
series reported from India . Though hemarthrosis has been reported
from the series published from Iran [7,9], it has not been reported from that
reported from Israel . Bleeding following circumcision was a major fea-
ture in patient from Iran [7,9]. But since this is not a common practice in this
part of the world, only one of our patients had presented with this symptom.
Gum bleeding, which occurred in almost half of our patients was not docu-
mented in the Iranian series but was shown to be present in a smaller group
of patients from India  and from Israel . Prolonged bleeding post
trauma/surgical procedure was the most frequent (62%) symptom in our
patients. Our data shows that the pattern of bleeding among patients
with combined FV and FVIII deficiency in India is different from that
reported from Iran and Israel, even though the mean factor levels are
similar. At present, we are not able to explain the difference in clinical
behavior in our patients but the change in the life style may be a factor
because similar observation has also been documented from other small
series India .
When we compared between three groups of patients (1st group: both FV
and FVIII <10%; 2nd group: both FV and FVIII levels >10%; 3rd group:
either FV or FVIII <10%) there was no difference between different bleeding
symptoms. The same has also been reported from both the series from Iran
[7,9]. When we compared between two groups of patients (1st group: both
FV and FVIII <5%; 2nd group: both FV and FVIII >5%), there were no dif-
ferences in the bleeding symptoms observed. This shows that presence of
two defects do not make the severity of bleeding greater than that expected
in patients with single coagulation defects of similar degrees.
We have reported here the clinical manifestations in 37 patients with com-
bined FV and FVIII deficiency from India. This is the largest series in the
world describing the clinical manifestations of patients with combined factor
V and VIII deficiency reported so far. It is evident from this as well as pre-
vious studies [7,9–11] that the bleeding symptoms in combined FV and FVIII
deficiency is almost similar to the deficiency of single coagulation factor.
There is no clear evidence to support increased bleeding manifestations due
to the combined deficiency of two coagulation factors.
In combined FV and FVIII deficiency, our knowledge about the clinical
manifestation so far is based on just one or two large series published in
the literature. There is a need for careful documentation of clinical data
from different population to see what the profile is for large number of
patients and whether there are any ethnic differences. Further molecular
538 American Journal of Hematology
studies to identify the causative mutations in patients with this disease
will shed light on the basis for the clinical diversity seen among the
1Department of Hematology, Christian Medical College, Vellore, Tamil Nadu, India;
2Department of Clinical Pathology, Christian Medical College
Vellore, Tamil Nadu, India
*Correspondence to: Auro Viswabandya, Department of Hematology
Christian Medical College, Vellore, Tamil Nadu 632 004, India
Conflict of interest: Nothing to report.
Received for publication 25 February 2010; Revised 25 March 2010;
Accepted 15 April 2010
Published online 21 April 2010 in Wiley InterScience
1. Peyvandi F, Duga S, Akhavan S, Mannucci PM. Rare coagulation deficien-
cies. Haemophilia 2002;8:308–321.
2. Nichols WC, Seligsohn U, Zivelin A, et al. Mutations in the ER-Golgi inter-
mediate compartment protein ERGIC- 53 cause combined deficiency of coag-
ulation factors V and VIII. Cell 1998;93:61–62.
3. Nichols WC, Seligsohn U, Zivelin A, et al. Linkage of combined factors V and
VIII deficiency to chromosome 18q by homozygosity mapping. J Clin Invest
4. Girolami A, Gastaldi G, Patrssi G, et al. Combined congenital deficiency
of factor V and factor VIII. Report of a further case with some considera-
tions on the hereditary transmission of this disorder. Acta Haematol 1976;
5. Zhang B, Cunningham MA, Nichols WC, et al. Bleeding due to disruption
of a cargo-specific ER-to-golgi transport complex. Nat Genet 2003;34:220–
6. Oeri J, Matter M, Isensrhmid H. Angeborener mangel an faktor V(parahaemo-
philie) verbunden mit echter haemophilie A bein zwei burden. Med Probl Pae-
7. Peyvandi F, Tuddenham EGD, Akhtari AM, et al. Bleeding symptoms in 27
Iranian patients with the combined deficiency of factor V and factor VIII. Br J
8. Mannucci P, Duga S, Peyvandi F. Recessively inherited coagulation disorders.
9. Mansouritorgabeh H, Rezaieyazdi Z, Pourfathollah A, et al.
symptoms in-patients with combined factors V and VIII deficiency in north-
eastern Iran. Haemophilia 2004;10:271–275.
10. Shetty S, Madkaikar M, Nair S, et al. Combined factor V and VIII deficiency
in Indian population. Haemophilia 2000;6:504–507.
11. Seligsohn U, Zivelin A, Zwand E. Combined factor Vand factor VIII deficiency in
among non-Ashkenazi Jews. N Engl J Med 1981;307:1191–1195.
12. Soff GA, Levin J. Familial multiple coagulation factor deficiencies. Semin
Thromb Haemost 1981;7:112–148.
13. Giddings JC, Sugrue A, Bloom AL. Quantitation of coagulant antigens
and inhibition of activated protein C in combined factor V/VIII deficiency. Br J
TABLE I. Comparison of Clinical Manifestations Between Our Patients and Other Large Series from Literature
(n 5 37)
Peyvandi et al. 
(n 5 27)
Shetty et al. 
(n 5 9)
Seligsohn et al. 
(n 5 14)
et al.  (n 5 19)
Prolonged bleed post injury/
FV: C (%) (mean and range)
FVIII: C (%) (mean and range)
Expression of CD1d and presence of invariant NKT cells in
classical Hodgkin lymphoma
Chuanhui Xu,1Riemer de Vries,1Lydia Visser,1Arjan Diepstra,1Stephan D. Gadola,2
Sibrand Poppema,1and Anke van den Berg1*
We studied CD1d-restricted invariant natural killer T (iNKT) cells in
classical Hodgkin lymphoma (cHL). Tumor cells stained positive for
CD1d in 21/44 cHL cases, whereas in non-Hodgkin lymphoma (NHL),
only 9/31 stained positive. In contrast, CD1c expression was more
common in NHL. The percentage of iNKT cells in cHL cell suspensions
was similar to the percentage in reactive lymph nodes and was not
related to the CD1d expression status of the tumor cells. In conclu-
sion, we found expression of CD1d in HRS cells in half of the cHL
cases, and also observed a substantial population of iNKT cells in cHL
Classical Hodgkin lymphoma (cHL) is a B-cell neoplasm characterized by
a minority of neoplastic cells, the Hodgkin and Reed-Sternberg (HRS) cells,
which are located within an extensive infiltrate of reactive cells, such as T
cells, B cells, plasma cells, stromal cells, eosinophils, and macrophages.
The HRS cells shape their microenvironment by attracting specific favorable
T cell subsets, like regulatory T (Treg) and T helper 2 (TH-2) cells and pro-
ducing factors such as CC-chemokine ligand 17 (CCL17 or TARC), trans-
forming growth factor (TGF)-b and interleukin (IL)-10 . Additionally, HLA
class I is downregulated in HRS cells in 65% of the cHL cases and HLA
class II in 40%, possibly as a strategy to escape from an effective immune
surveillance . All together, these factors may suppress the development of
an effective antitumor response and provide a microenvironment that is
favorable for the HRS cells.
Recent studies have suggested that T cells restricted to nonclassical
MHC class I-like CD1 molecules may be involved in immune surveillance of
hematological malignancies [3–6]. CD1 molecules are nonclassical MHC
class I-like molecules that present lipid antigens to T cells, triggering a spe-
cific immune response. Of the five CD1 isoforms (CD1a, CD1b, CD1c,
CD1d, and CD1e) expressed in human tissue, only CD1c and CD1d are
expressed in B cells . The T cell receptors (TCRs) of T cells that recog-
nize CD1c are indistinguishable from those that recognize MHC class I or II
complexes. Most CD1c-restricted T cells appear to be TH-1-like cells that
provide adaptive immunity to microbial-lipid antigens . In contrast, CD1d
presents lipid antigens to natural killer T (NKT) cells. The best characterized
CD1d-restricted NKT cells in humans are the invariant NKT (iNKT) cells,
also known as type I NKT cells. These cells are characterized by the
expression of an invariant Va24Ja18 chain paired to a semi-invariant Vb11
chain . Two distinct functional subsets of human iNKT cells are recog-
nized in terms of cytokines production and cytotoxic activation. CD42 iNKT
cells are more likely to be cytotoxic and produce TH-1 type cytokines,
whereas CD41 iNKT cells are more likely to produce both TH-1 and TH-2
type cytokines after stimulation . Several studies have shown the impor-
American Journal of Hematology539
tance of iNKT cells in B cell malignancies [4–6]. In chronic lymphocytic leu-
kemia (CLL), CD1d1 tumor cells loaded with aGalCer can activate iNKT
cells and in turn induce cell death of tumor cells . Malignant multiple mye-
loma is characterized by a reversible functional defect in iNKT cells in com-
parison with nonprogressive myeloma and premalignant myeloma . Fur-
thermore, iNKT cells were shown to induce effective antilymphoma
responses and were essential for the survival of mice in murine lymphoma
models . The role of iNKT cells in the immune surveillance in cHL is
unknown. Here, we examined the expression of CD1c and CD1d in HRS
cells and tumor infiltrating cells in 44 cHL cases, as well as in four cHL cell
lines. Furthermore, we studied the presence of iNKT cells in cell suspen-
sions of 10 cHL cases.
CD1c was undetectable in cHL cell lines L428, KMH2, L1236, and U-HO1
(data not shown). In tonsil tissue, CD1c stained positive in the mantle zone
(MZ) and predominantly negative in the germinal centers (GC) of secondary
lymphoid follicles (Fig. 1A) consistent with the previously reported expres-
sion pattern . HRS cells in cHL were consistently CD1c negative in all
cases (Fig. 1B), whereas 14 out of 39 non-Hodgkin lymphomas (NHL) were
positive (Table I). The absence of CD1c expression in both GC B cells and
HRS cells is consistent with the current assumption that HRS cells are
derived from GC B cells . CD1c expression has been reported in some
other B-cell NHL subtypes, including GC B cell derived follicular lymphoma
. In B-cell NHL, an inverse correlation was noticed between CD1c and
the proliferative activity assessed by expression of Ki-67 . This is in line
with the lack of CD1c staining in GC B cells that show a high proliferation
index and high CD1c expression in the MZ B cells that are in a resting state.
Ki-67 was shown to be highly expressed in HRS cells  correlating with
the lack of CD1c expression. CD1c expression was found in reactive cells in
all cases with a percentage varying from a few to the vast majority, similar to
the CD1c expression pattern observed in interfollicular regions of tonsil tissue.
In contrast, CD1d was detected in all four cHL cell lines, varying from
weakly positive in U-HO1 to strongly positive in the other three cHL cell lines
(Fig. 1C–F). By flowcytometry, we validated that CD1d was present on the
membrane in cHL cell lines (data not shown). In normal tonsil tissue, CD1d
staining was observed mainly in the MZ and showed no positive staining in
the GC (Fig. 1G) consistent with the reported results . CD1d was
detected in HRS cells in 21 out of 44 cHL cases (48%) (Fig. 1H, Table I,
Supporting Information Table I), showing both cytoplasmic and membranous
staining. No correlation was found with EBV status and CD1d expression
(Table I). CD1d was also positive in the reactive background, usually in
more than half of the reactive cells. Nine of the 39 NHL cases were positive
for CD1d (23%, Table I), i.e., in three out of 19 GC B cell derived NHL and
in six out of 20 non-GC B cell NHL (Table I, Supporting Information Table I).
The CD1d expression in HL is remarkable since GC B cells and the majority
of the GC B cell derived NHL are negative. Positivity of HRS cells indicates
that these cells might have acquired CD1d expression during malignant
transformation. CD1d expression has been detected in some B cell malig-
nancies, such as CLL  and multiple myeloma . In these B cell malig-
nancies, iNKT cells activated by a-GalCer loaded CD1d1 tumor cells
resulted in the induction of apoptosis of the tumor cells in vitro [4,5].
Since half of the cHL cases were positive for CD1d in HRS cells, we fur-
ther investigated the iNKT cell population in cell suspensions of cHL and
reactive lymph node (RLN). The mean percentage of iNKT cells was 4%
(range 0.8–8%) in cHL and 4% (range 0.4–7%) in RLN (Table II). iNKT cells
were present at similar percentage in either CD1d positive or CD1d negative
in the mantle zone area and predominantly negative in the germinal center area in
tonsil (A and G). Original image magnification: 3200. CD1c is negative in HRS
cells (arrows), but positive in reactive cells (B). CD1d is positive both in HRS cells
(arrows) and reactive cells (H). Original magnification 3400. CD1d is weakly posi-
tive in U-HO1, and strongly positive in the other three cHL cell lines (C–F). Origi-
nal image magnification: 3400. [Color figure can be viewed in the online issue,
which is available at www.interscience.wiley.com.]
CD1c and CD1d expression in cHL. Both CD1c and CD1d are positive
TABLE I. Comparison of Expression of CD1c and CD1d in cHL and NHL
Lymphoma CD1c positive (%)CD1d positive (%)
cHL (n 5 44)0 48
NHL (n 5 39) 36
CLL (n 5 13)
MCL (n 5 7)
FL (n 5 9)
DLBCL (n 5 10)
cHL, classical Hodgkin lymphoma; NHL, non-Hodgkin lymphoma; CLL, chronic
lymphocytic leukemia; MCL, mantle cell lymphoma; FL, follicular lymphoma;
DLBCL, diffuse large B cell lymphoma.
TABLE II. iNKT Cells in cHL and RLN
Cases SubtypeCD1d in HRS% iNKT % CD41 iNKT
540American Journal of Hematology
cHL cases. Two distinct iNKT subsets have been distinguished as Th1 type
(CD42iNKT) and Th2 type (CD41iNKT) in terms of cytokine production
and cytotoxic activation . We observed a similar percentage of CD41
iNKT cells, i.e., around 50%, in cHL and RLN (Table II). Given the high
expression of CCL17 in HRS cells of cHL  and the high expression of
the CCL17 receptor, CCR4, on CD41 iNKT cells , it might be speculated
that especially the CD41 iNKT cells are present in the close vicinity of HRS
cells and might favor the survival and growth of HRS cells. Since it is known
that the rosetting CD41CD262 T cells in HL have several features of
anergy , the CD1d-restricted iNKT cells might also be dysfunctional or
anergic favoring HRS cells survival by escaping from an effective immuno-
surveillance in cHL.
Taken together, we showed expression of CD1d in HRS cells of cHL cell
lines and a significant proportion of cHL cases as well as the presence of a
marked population of iNKT cells in the reactive background of cHL. The CD1d-
iNKT cell axis might play a role in the disturbed immunoregulation in cHL.
Patient samples and cell lines.
of nodular sclerosis (NS), four cases of mixed cellularity (MC), and one case
of not otherwise specified cHL (NOS). Frozen samples of 39 NHL cases
were used and consisted of 13 chronic lymphocytic leukemia, seven mantle
cell lymphoma, nine follicular lymphoma, and 10 diffuse large B cell lym-
phoma cases. Cell suspensions were available of eight NS and two MC cHL
cases. The cHL cell lines L428, KMH2, L1236, and U-HO1  were cul-
tured in RPMI-1640 medium (Lonza Walkersville, Walkersville, MD) supple-
mented with ultraglutamine-1, 100 U/ml penicillin/streptomycin, 10% fetal
calf serum (5% for L428) (Lonza Walkersville).
Frozen cHL samples consisted of 39 cases
clonal antibodies against CD1c (L161, Abd Serotec, Oxford, UK) and CD1d
(NOR3.2, Abcam, Cambridge, UK) (both 1:100) on frozen cHL tissue sec-
tions and cytospins using standard laboratory protocols and appropriate pos-
itive and negative controls. Cases were defined positive when more than
50% of tumor cells showed a clear staining.
Immunohistochemistry was performed with mono-
labeled Mouse Anti-Human iNKT Cell (clone 6B11, BD Bioscience, San
Jose, CA), FITC labeled anti-TCR Vb11 (clone C21, Beckman Coulter, Full-
erton, CA) and CyQ labeled anti-CD4 (clone Edu-2, IQ Products, Groningen,
Netherlands). A total of 100,000 lymphocytes were collected. The percent-
age of iNKT cells was determined by positive staining for both 6B11 and
Vb11, and the percentage of CD41 iNKT cells was determined by the per-
centage of CD41 cells among the gated iNKT cells by flowcytometer (Cal-
ibur, Becton Dickinson, San Jose, CA). We used an iNKT cell clone as a
positive control, and samples without primary antibody were included as a
negative control. cHL cell lines were stained with PE labeled CD1d (clone
51.1, eBioscience, Hatfield, UK), and a IgG2b isotype control antibody, to
show the presence of membrane CD1d.
Cells (1 3 106) were stained simultaneously with PE
1Department of Pathology and Medical Biology, University Medical Center
Groningen, University of Groningen, Groningen, The Netherlands;
Infection, Inflammation and Repair, University of Southampton, Southampton
General Hospital, Southampton, United Kingdom
Additional Supporting Information may be found in the online version of this article.
*Correspondence to: A. van den Berg, Department of Pathology and Medical
Biology, University Medical Center Groningen, University of Groningen, PO Box
30.001, Hanzeplein 1, Groningen, 9700 RB, The Netherlands
Conflict of interest: Nothing to report.
Published online 21 April 2010 in Wiley InterScience
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Analysis of the REL, BCL11A, and MYCN proto-oncogenes
belonging to the 2p amplicon in chronic lymphocytic leukemia
Clara Deambrogi,1Lorenzo De Paoli,1Marco Fangazio,1Stefania Cresta,1Silvia Rasi,1Valeria Spina,1
Valter Gattei,2Gianluca Gaidano,1and Davide Rossi1*
The genetic profile of chronic lymphocytic leukemia (CLL) is character-
ized by a pool of recurrent lesions, including trisomy 12, deletions of
13q14, 11q22-q23, 17p13, and 6q21, and t(14)(q32) translocations .
The aforementioned lesions can be detected by FISH and may harbor
prognostic information . Array-based comparative genomic hybrid-
ization (aCGH) has identified gain of multiple regions on the short arm
of chromosome 2 as a recurrent CLL lesion, that contain the REL,
BCL11A, and MYCN proto-oncogenes that are involved in hematologic
malignancies [2–5]. The exact prevalence of REL, BCL11A, and MYCN
gains at the time of CLL diagnosis is currently unknown in consecu-
tive series of the disease. Moreover, some studies indicate that 2p
gains as a whole may herald progressive and/or poor risk disease, yet
the prognostic contribution of the individual genes included in the
amplicon, i.e., REL, BCL11A, and MYCN, remains undefined [4–6]. The
American Journal of Hematology541
aim of this study was twofold: (i) characterize the prevalence of REL,
BCL11A, and MYCN gains in a consecutive CLL series at the time of
diagnosis; (ii) define the prognostic relevance of REL, BCL11A, and
MYCN gains in CLL.
The study is based on a consecutive series of 176 newly diagnosed and
phenotypically typical CLL (median Matutes score: 5; range 4–5) [7,8], rep-
resentative of all disease stages. The biological and clinical characteristics
of the CLL series are reported in Table I. By FISH, gain of REL was
observed in 6/176 (3.4%) cases, gain of BCL11A in 5/176 (2.8%), and gain
of MYCN in 4/176 (2.3%). The median percentage of nuclei harboring gains
was 46.8% (range: 18.0–85.0%) for REL, 66% (range: 14.0–77.4%) for
BCL11A, and 78.2% (range: 45.0–90.0%) for MYCN. The number of addi-
tional copies was 1 for REL, 1 for BCL11A, and 1 for MYCN. REL, BCL11A,
and MYCN were concomitantly gained in the same clone in 4/176 (2.3%)
cases. REL and BCL11A, but not MYCN, were concomitantly gained in the
same clone in 1/176 (0.5%) cases. In 1/176 (0.5%) cases, the sole REL
gene was gained.
Analysis of survival in patients with 2p gains revealed that all but one
patient with 2p gains including MYCN have died for CLL progression or
transformation to Richter syndrome (Table II). In contrast, the two patients
harboring 2p gains not including MYCN were alive and treatment free after
a follow-up of 88 and 105 months, respectively (Table II).
On the basis of these observations, we analyzed the impact of MYCN
gain on CLL presentation and outcome. By comparing biological and clinical
features at diagnosis, no differences were observed between CLL with gain
of MYCN compared with those devoid of such genetic lesion, with the possi-
ble exception of a higher absolute lymphocyte count in cases carrying
MYCN gain (P 5 0.029; Table I).
The impact of MYCN gain on CLL prognosis was estimated by utilizing
OS as a clinical endpoint. In the whole CLL cohort, after a median follow-up
of 72.1 months for alive patients, 39/176 patients had died, accounting for a
5-years OS of 84.1%. By univariate analysis, CLL harboring MYCN gain at
diagnosis were at increased risk of death (Events/N: 3/4; HR: 5.35; 95% CI
1.62–17.68; P 5 0.006; 6-years OS: 25.0%; 95% CI 0–67.5%) compared
with CLL without MYCN gain (Events/N: 36/172; 6-year OS: 80.8%; 95% CI
74.0–87.6%) (Table III and Fig. 1). Other features at diagnosis associated
with CLL survival by univariate analysis were those expected in a consecu-
tive CLL series and included IGHV homology ?98% (P 5 0.005), 112 (P 5
0.049), 11q22-q23 deletion (P 5 0.014), 17p13 deletion (P < 0.001), TP53
mutations (P 5 0.048), CD38 expression (P 5 0.006), age >70 years (P <
0.001), Binet stage B-C (P < 0.001), and beta-2-microglobulin > 2.5 mg/l (P
5 0.001) (Table III).
By multivariate analysis, gain of MYCN was selected as an independent
predictor of OS in this CLL cohort (HR: 4.79; 95% CI 1.31–17.39; P 5
0.017), along with 17p13 deletion (HR: 2.28; 95% CI 1.01–5.15; P 5 0.045),
age > 70 years (HR 3.89; 95% CI: 1.88–8.05; P < 0.001), and Binet stage
B-C (HR: 3.31; 95% CI 1.55–7.06; P 5 0.002) (Table III).
This study suggests that: (i) gains of REL, BCL11A, and MYCN occur at
low frequency at CLL diagnosis; and (ii) 2p gains including MYCN might
have potential prognostic relevance in CLL.
Gains of REL, BCL11A, or MYCN have been reported by Chapiro et al.  to
occur in 10% CLL, a prevalence that is higher than the 2–3% prevalence
observed in our cohort. The discrepancy between our study and the study by
Chapiro et al.  may be explained by the differences that distinguish the two CLL
cohorts. Indeed, Chapiro et al.  analyzed REL, BCL11A, or MYCN in 86 CLL,
all Binet stage B-C, at the time of treatment requirement. On the contrary, our
study was based on a consecutive series of 176 CLL, that included all Binet
stages and that in all cases have been analyzed at the time of diagnosis.
Some studies suggest that, in CLL, 2p gains as a whole may associate
with poor risk features, such as advanced stage, unmutated IGHV genes,
and 17p13 deletion [4–6]. Our results are consistent with these observations
and suggest that, among individual proto-oncogenes included in the 2p
amplicon, poor prognosis may be heralded by gain of MYCN. The relevance
of MYCN gain in determining CLL prognosis is also suggested by the obser-
vation that, in our cohort, the negative prognostic impact associated with
gain of MYCN appears to be independent of stage at presentation, IGHV
mutation status, or presence of 17p13 deletion. Future studies are required
to validate these results in larger patient populations.
TABLE I. Biological and Clinical Characteristics and Cause of Death of the CLL Series According to MYCN Statusa
IGHV homology ? 98%
CD38 ? 30%
ZAP70 ? 20%
CD49d ? 30%
Binet stage B-C
Lymph node size ? 3 cm
PB lymphocytes (3109/l)
BM lymphocytes (%)b
Diffuse BM pattern
Beta-2-microglobulin > 2.5 mg/l
LDH > ULN
Cause of death
0/4 46/172 (26.7%)
1/3 (33.3%)18/36 (50.0%)
a25th–75th percentiles are reported in parentheses for continuous variables.
bPercentage of BM lymphocytes was determined on BM biopsies.IGHV, immunoglobulin heavy chain variable gene; HCDR3, immunoglobulin heavy chain complementar-
ity determining region 3; PB, peripheral blood; BM, bone marrow.
542American Journal of Hematology
Patients. The study was based on a consecutive series of 176 previously
untreated CLL who presented for initial evaluation at the Division of Hema-
tology of the Amedeo Avogadro University of Eastern Piedmont from June
1996 through June 2008. Patients provided informed consent in accordance
with local IRB requirements and Declaration of Helsinki. CLL diagnosis was
based on NCI criteria and confirmed by a flow cytometry score >3 [7,8].
The following biological variables were analyzed on peripheral blood mono-
nuclear cells (PBMNC) collected at diagnosis: (i) IGHV gene homology to
germline; (ii) FISH karyotype; (iii) TP53 mutations; (iv) CD38, ZAP70, and
CD49d expression. Patients were managed according to NCI guidelines .
Interphase FISH. Probes used for FISH analysis were as follows: (i)
LSI13 and LSID13S319 for detection of 13q14 deletion; CEP12 for detec-
tion of aneuploidy of chromosome 12; LSIp53 for detection of 17p13 dele-
TABLE II. Biological and Clinical Characteristics at Diagnosis of the CLL Patient with MYCN gain
Patient with MYCN gain
Patient 1Patient 2Patient 3 Patient 4
IGHV homology ? 98%
CD38 ? 30%
ZAP70 ? 20%
CD49d ? 30%
ECOG performance status
PB lymphocytes count (3109/l)
BM lymphocytes infiltration percentage (%)
Diffuse BM pattern
LDH > ULN
Treatment free survival (months)
Lines of therapies
Alkylator agents refractoriness
Richter’s syndrome transformation
Overall survival (months)
PB, peripheral blood; BM, bone marrow; NA, not applicable.
TABLE III. Biological and Clinical Characteristics of the CLL Series Predicting OS by Univariate and Multivariate Cox Analysis
HR95% LCI 95% UCIP HR95% LCI 95% UCIP
IGHV homology ? 98%
CD38 ? 30%
CD49d ? 30%
Age > 70 years
Binet stage B-C
Lymph node size ? 3 cm
PB lymphocytes > 20 3 109/l
BM lymphocytes > 50%
Diffuse BM pattern
Beta-2-microglobulin > 2.5 mg/l
LDH > ULN
2.289 1.017 5.1510.045
aEvents/patients 5 39/173. HR, hazard ratio; LCI, lower confidence interval; UCI, upper confidence interval; IGHV, immunoglobulin heavy chain variable gene; PB, periph-
eral blood; BM, bone marrow.
American Journal of Hematology543
tion; LSIATM for detection of 11q22-q23 deletion; LSI N-MYC for detection Download full-text
of MYCN gain; LSI IGH dual color break-apart for detection of t(14)(q32)
translocation (Abbott, Rome, Italy); (ii) 6q21/alpha-satellite for detection of
6q21 deletion (Kreatech Biotechnology, Amsterdam, The Netherlands); (iii)
BAC clones 373L24-rel for detection of REL gain and 440P05-BCL11A for
detection of BCL11A gain. Nuclei were counterstained with 40,60-diamidino-
2-phenylindole (DAPI) and antifade, and signals were visualized using an
Olympus BX51 microscope (Olympus Italia, Milan, Italy). For each probe,
at least 500 interphase cells with well-delineated fluorescent spots were
Analysis of IGHV rearrangements. IGHV rearrangements were amplified
from genomic DNA and directly sequenced . Sequences were aligned to
ImMunoGeneTics (IMGT) directories, and considered mutated if homology
to the corresponding germline gene was <98%.
Analysis of TP53 mutations. Mutation analysis of TP53 exons 2 through
10 was performed by DNA direct sequencing on an ABI Prism 3100 auto-
mated DNA sequence analyzer (Applied Biosystems, Foster City, CA) .
Flow cytometry. A FACScalibur flow cytometer (Becton-Dickinson, San
Jose, CA) was utilized for flow cytometric analysis. Expression of CD38,
ZAP70, and CD49d was analyzed as reported . Cut-off points of 30%,
20%, and 30% were utilized to define positivity for CD38, ZAP70, and
Statistical analysis. Overall survival (OS) was measured from CLL diagno-
sis to last follow-up (censoring) or death. Categorical variables were com-
pared by chi-square test or exact tests when appropriate. Continuous varia-
bles were compared by Mann-Whitney test. Survival analysis was performed
by Kaplan-Meier method using log-rank statistics to test for significant associ-
ations. Multivariate analysis was performed by Cox proportional hazard
regression. All statistical tests were two-sided. Statistical significance was
defined as P-value < 0.05. The analysis was performed with SPSS software
v.17.0 (Chicago, IL).
D.R. and C.D. designed the study, interpreted data, performed statistical
analysis, and drafted the manuscript; G.G. contributed to study design, data
interpretation, and drafting the manuscript; L.D.P. and M.F. collected biologi-
cal and clinical data; S.C. performed FISH analysis; S.R. and V.S. performed
IGHV gene and TP53 mutation analysis; and V.G. contributed to data analy-
sis and interpretation.
1Division of Hematology, Department of Clinical and Experimental Medicine and
BRMA, Amedeo Avogadro University of Eastern Piedmont and Azienda
Ospedaliero-Universitaria Maggiore della Carita `, Novara, Italy;
2Clinical and Experimental Onco-Hematology Unit, Centro di Riferimento
Oncologico, I.R.C.C.S., Aviano, Italy
Contract grant sponsors: Progetto Giovani Ricercatori 2008, Ministero della Salute,
Rome, Italy; Progetto FIRB-Programma Futuro in Ricerca 2008, Miur Rome, Italy;
Ricerca Sanitaria Finalizzata, Regione Piemonte, Torino, Italy; Progetto Integrato
Oncologia, Ministero della Salute, Rome, Italy; Fondazione CRT, Torino, Italy;
Novara-AIL Onlus, Novara, Italy; Ministero della Salute (Ricerca Finalizzata
I.R.C.C.S. and Alleanza Contro il Cancro), Rome, Italy; AIL Venezia, Pramaggiore,
Italy; Ricerca Scientifica Applicata, Regione Friuli Venezia Giulia, Trieste, Italy;
Associazione Franca Capurro per Novara Onlus
*Correspondence to: D. Rossi, Division of Hematology, Department of Clinical and
Experimental Medicine and BRMA, Amedeo Avogadro University of Eastern
Piedmont, Via Solaroli 17, 28100 Novara, Italy
Received for publication 8 March 2010; Accepted 16 April 2010
Conflict of interest: Nothing to report.
Published online 21 April 2010 in Wiley InterScience
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544American Journal of Hematology