From www.bloodjournal.org by guest on June 18, 2017. For personal use only.
1424
CORRESPONDENCE
3. Frecha C, Costa C, Nègre D, et al. Stable transduction of quiescent T cells without
induction of cycle progression by a novel lentiviral vector pseudotyped with measles
virus glycoproteins. Blood. 2008;112(13):4843-4852.
4. Frecha C, Costa C, Lévy C, et al. Efficient and stable transduction of resting
B lymphocytes and primary chronic lymphocyte leukemia cells using measles
virus gp displaying lentiviral vectors. Blood. 2009;114(15):3173-3180.
5. Frecha C, Lévy C, Costa C, et al. Measles virus glycoprotein-pseudotyped lentiviral
vector-mediated gene transfer into quiescent lymphocytes requires binding to both
SLAM and CD46 entry receptors. J Virol. 2011;85(12):5975-5985.
6. Finkelshtein D, Werman A, Novick D, Barak S, Rubinstein M. LDL receptor and
its family members serve as the cellular receptors for vesicular stomatitis virus.
Proc Natl Acad Sci U S A. 2013;110(18):7306-7311.
BLOOD, 27 FEBRUARY 2014 x VOLUME 123, NUMBER 9
7. Mangeot PE, Dollet S, Girard M, et al. Protein transfer into human cells by
VSV-G-induced nanovesicles. Mol Ther. 2011;19(9):1656-1666.
8. Verhoeyen E, Dardalhon V, Ducrey-Rundquist O, Trono D, Taylor N,
Cosset FL. IL-7 surface-engineered lentiviral vectors promote survival and
efficient gene transfer in resting primary T lymphocytes. Blood. 2003;101(6):
2167-2174.
9. Frecha C, Lévy C, Cosset FL, Verhoeyen E. Advances in the field of lentivectorbased transduction of T and B lymphocytes for gene therapy. Mol Ther. 2010;
18(10):1748-1757.
© 2014 by The American Society of Hematology
To the editor:
Statin and aspirin use is associated with improved outcome of FCR therapy in
relapsed/refractory chronic lymphocytic leukemia
Statins and aspirin are widely prescribed medications that have long
been associated with improved survival outcome in patients with
various types of cancers.1,2 Both statins and aspirin were found to
induce apoptosis of chronic lymphocytic leukemia (CLL) cells.3,4
The intake of statins and aspirin was associated with reduced incidence of CLL.5,6 However, statin intake did not affect treatment-free
survival in patients with early CLL.7,8 Whether statin or aspirin use
will benefit patients with advanced CLL is unknown.
Therefore, we retrospectively investigated the clinical outcome of
patients with relapsed/refractory CLL treated with salvage fludarabine, cyclophosphamide, and rituximab (FCR)9 with or without
concomitant statins, aspirin, or both. We analyzed 280 patients who
received salvage FCR between 1999 and 2012. The patients’ median
age was 59 years (range: 31-84). The median progression-free
survival (PFS) of all patients was 1.7 years, and the median overall
survival (OS) was 4.0 years. Of the 280 patients, 58 patients received
statins, aspirin, or both; 21 (8%) were taking aspirin only; 17 (6%)
statins only; and 20 (7%) used both for at least 1 month prior to,
during, and 1 month after salvage therapy. Among statin users, 15
patients (41%) were using atorvastatin, 12 patients (32%) were using
simvastatin, 7 patients (19%) were using pravastatin, 2 patients (5%)
were using rosuvastatin, and 1 patient (3%) was using lovastatin.
Clinical characteristics of statin and/or aspirin users were similar to
those of nonusers except for age. Patients on both statin and aspirin
were 6 years older than nonusers (P , .01).
The overall response rate of patients receiving statins and aspirin
concomitantly was superior (100%; 40% complete response, 60%
partial response) to that of other patients (81% for aspirin-only users,
82% for statin-only users, and 72% for those who took neither drug;
P , .01). Early death (during chemotherapy and up to 6 weeks
afterward) was not observed in patients receiving aspirin, statins, or
both but occurred in 6% of nonusers. Patients receiving both statins
and aspirin had median PFS and OS of 6.1 and 9.2 years, respectively,
compared with 1.6 years and 3.7 years in nonusers (PFS P 5 .003; OS
P 5 .05; Figure 1). Compared with nonusers, patients who took both
statins and aspirin had a 66% reduced risk of disease progression and
a 60% reduced risk of death (PFS hazard ratio [HR] 5 0.34, 95%
confidence interval [CI] 5 0.18-0.65, P , .001; OS HR 5 0.40, 95%
CI 5 0.21-0.79, P 5 .008).
In a fitted multivariate model controlling for clinicopathological characteristics found to be statistically significant from univariate analyses including Rai stage, cytogenetic abnormalities, the
number of previous treatments, refractoriness to fludarabine, IgVH
mutation status, b2-microglobulin, hemoglobin, platelet, lactate
dehydrogenase, and creatinine level, use of both medications was
also associated with a much more favorable outcome (PFS adjusted HR 5 0.27, 95% CI 5 0.14-0.53, P # .001; OS adjusted
HR 5 0.29, 95% CI 5 0.15-0.58, P , .001), whereas single-agent
use of aspirin or statins did not affect PFS or OS.
Our findings demonstrate for the first time that concurrent
administration of statins and aspirin to CLL patients with relapsed/
refractory disease receiving salvage FCR significantly improve both
response rate and survival. This is consistent with previous preclinical studies suggesting the possible synergistic effect between
statins and chemotherapy.10 Therefore, a prospective study aimed at
evaluating the effects of statins and aspirin in CLL patients receiving
chemoimmunotherapy is warranted.
Young Kwang Chae
Division of Cancer Medicine,
The University of Texas MD Anderson Cancer Center,
Houston, TX
Long Trinh
Department of Leukemia, Division of Cancer Medicine,
The University of Texas MD Anderson Cancer Center,
Houston, TX
Preetesh Jain
Department of Leukemia, Division of Cancer Medicine,
The University of Texas MD Anderson Cancer Center,
Houston, TX
Xuemei Wang
Department of Biostatistics, Division of Quantitative Sciences,
The University of Texas MD Anderson Cancer Center,
Houston, TX
Uri Rozovski
Department of Leukemia, Division of Cancer Medicine,
The University of Texas MD Anderson Cancer Center,
Houston, TX
William G. Wierda
Department of Leukemia, Division of Cancer Medicine,
The University of Texas MD Anderson Cancer Center,
Houston, TX
Michael J. Keating
Department of Leukemia, Division of Cancer Medicine,
The University of Texas MD Anderson Cancer Center,
Houston, TX
Zeev Estrov
Department of Leukemia, Division of Cancer Medicine,
The University of Texas MD Anderson Cancer Center,
Houston, TX
From www.bloodjournal.org by guest on June 18, 2017. For personal use only.
BLOOD, 27 FEBRUARY 2014 x VOLUME 123, NUMBER 9
CORRESPONDENCE
1425
Figure 1. Kaplan-Meier estimates for PFS and OS
by aspirin and statin use. Patients receiving both
statins and aspirin (n 5 20) had a median PFS (A) and
OS (B) of 6.1 years and 9.2 years compared with 1.6
years and 3.7 years for patients on neither medication
(n 5 221) (PFS P 5 .003; OS P 5 .05). The number of
events per total number of patients is denoted in the
box. The P value was derived from a log-rank test.
Y.K.C. and L.T. contributed equally to this study.
Contribution: Y.K.C. and L.T. designed and performed research and analyzed
data, and wrote the manuscript; X.W. performed statistical analysis; J.P., U.R.,
and W.G.W. revised the manuscript; and M.J.K. and Z.E. designed and
supervised research and revised the manuscript.
Conflict-of-interest disclosure: The authors declare no competing financial
interests.
Correspondence: Zeev Estrov, Department of Leukemia, The University of
Texas MD Anderson Cancer Center, 1400 Holcombe Blvd, Unit 428, Houston,
TX 77030; e-mail: [email protected].
References
1. Nielsen SF, Nordestgaard BG, Bojesen SE. Statin use and reduced cancerrelated mortality. N Engl J Med. 2012;367(19):1792-1802.
2. Thun MJ, Jacobs EJ, Patrono C. The role of aspirin in cancer prevention. Nat
Rev Clin Oncol. 2012;9(5):259-267.
3. Bellosillo B, Piqué M, Barragán M, et al. Aspirin and salicylate induce apoptosis
and activation of caspases in B-cell chronic lymphocytic leukemia cells. Blood.
1998;92(4):1406-1414.
4. Chapman-Shimshoni D, Yuklea M, Radnay J, Shapiro H, Lishner M.
Simvastatin induces apoptosis of B-CLL cells by activation of mitochondrial
caspase 9. Exp Hematol. 2003;31(9):779-783.
5. Bracci PM. Use of 3-hydroxy-3-methylglutaryl Coenzyme-A Reductase
Inhibitors (statins), Genetic Polymorphisms in Immunomodulatory and
Inflammatory Pathways and Risk of Non-Hodgkin Lymphoma [dissertation].
Berkeley, CA: University of California, Berkeley; 2007.
6. Kasum CM, Blair CK, Folsom AR, Ross JA. Non-steroidal anti-inflammatory
drug use and risk of adult leukemia. Cancer Epidemiol Biomarkers Prev. 2003;
12(6):534-537.
7. Friedman DR, Magura LA, Warren HA, Harrison JD, Diehl LF, Weinberg JB.
Statin use and need for therapy in chronic lymphocytic leukemia. Leuk
Lymphoma. 2010;51(12):2295-2298.
8. Shanafelt TD, Rabe KG, Kay NE, et al. Statin and non-steroidal anti-inflammatory
drug use in relation to clinical outcome among patients with Rai stage 0 chronic
lymphocytic leukemia. Leuk Lymphoma. 2010;51(7):1233-1240.
From www.bloodjournal.org by guest on June 18, 2017. For personal use only.
1426
CORRESPONDENCE
9. Wierda W, O’Brien S, Wen S, et al. Chemoimmunotherapy with fludarabine,
cyclophosphamide, and rituximab for relapsed and refractory chronic
lymphocytic leukemia. J Clin Oncol. 2005;23(18):4070-4078.
10. Podhorecka M, Halicka D, Klimek P, Kowal M, Chocholska S, Dmoszynska
A. Simvastatin and purine analogs have a synergic effect on apoptosis of
BLOOD, 27 FEBRUARY 2014 x VOLUME 123, NUMBER 9
chronic lymphocytic leukemia cells. Ann Hematol. 2010;89(11):
1115-1124.
© 2014 by The American Society of Hematology
To the editor:
Mutations in GATA2 are rare in juvenile myelomonocytic leukemia
GATA2 encodes a transcription factor that regulates hematopoiesis
and vascular development, and germline mutations cause MonoMAC
syndrome,1,2 Emberger syndrome,3 and some cases of mild chronic
neutropenia.4 Patients with each of these disorders are predisposed to
myelodysplastic syndrome (MDS) and acute myeloid leukemia that is
frequently associated with somatic acquisition of monosomy 7.5,6
Juvenile myelomonocytic leukemia (JMML) is an aggressive
childhood malignancy with overlapping features of an MDS and
myeloproliferative neoplasm (MPN) that is caused by mutations
that aberrantly activate Ras/MAPK signaling. Mutations in NF1,
NRAS, KRAS, PTPN11, and CBL are found in 85% to 90% of newly
diagnosed patients.7,8 Given the frequent occurrence of somatic
monosomy 7 in JMML7 as well as the fact that there are several
germline syndromes that predispose children to developing both
transient and aggressive forms of JMML, we hypothesized that
mutations in GATA2 play a role in its development.
Specimens from 57 patients with JMML were screened for GATA2
mutations. Patient samples and clinical data were collected from
the Children’s Oncology Group trial AAML0122.9 DNA was
extracted from peripheral blood or bone marrow as per previous
protocols and whole genome amplified using Qiagen REPLI-g
kits. We performed bidirectional Sanger sequencing (Beckman
Coulter Genomics, Danvers, MA) of the entire coding region of
GATA2 (NM_001145661.1) and aligned the sequences using
CLC software (CLC Bio, Aarhus, Denmark). Only missense, splice
site, or nonsense mutations were evaluated using SIFT (Sorting
Tolerant from Intolerant)10 to predict the impact of identified mutations on the structure and function in the resultant protein.
GATA2 was mutated in only 1 of 57 JMML specimens. Peripheral
blood from patient J384 contained a nonsense point mutation
(Figure 1) at c.988C.T (R330X), which has been reported as a
germline mutation in patients with mild chronic neutropenia.4
Patient J384 also carried a second missense point mutation at
c.962T.G (L321R), which was predicted to be damaging by
SIFT, PolyPhen 2.0, and Mutation Assessor. Subcloning of the
mutant amplicon using a TA cloning kit with pCR 2.1 vector
(Invitrogen) followed by directed sequencing of individually
transformed colonies revealed that the 2 sequence variants only
occurred in a trans configuration. Out of 40 amplicons sequenced,
20 displayed the c.988C.T transition, 16 had the c.962T.G variant,
and 4 were wild-type. We therefore hypothesize that c.988C.T
was inherited as a germline event, whereas c.962T.G represents
a somatic acquisition. Unfortunately, granulocyte-macrophage
progenitor colonies at diagnosis were not available for analysis,
nor was parental DNA. Previous studies of patient J384 revealed
a subclonal KRAS G12D mutation (c.35G.A) as well as monosomy 7
in his JMML bone marrow.
Patient J384 met the World Health Organization diagnostic
criteria for JMML based on having splenomegaly, an absolute
monocyte count .1000 (1 3 109/mL), ,20% bone marrow blasts,
absence of t(9;22) or BCR/ABL, and presence of myeloid precursors in peripheral blood with a white blood cell count .10 000
(10 3 109/mL).9 However, he also possessed features less common
in JMML, including older age at diagnosis (4 years and 10 months)
and, in particular, a normal response in myeloid progenitor cells to
the cytokine granulocyte-macrophage colony-stimulating factor in
methylcellulose culture, which is rarely seen in JMML.11
We speculate that a somatic “second hit” in the normal GATA2
allele accelerated the onset of MDS in patient J384, with monosomy 7
and the oncogenic KRAS mutation cooperating to drive clonal
Figure 1. Identification of 2 distinct GATA2 mutations in patient J384. (A) Bidirectional sequencing of patient sample J384 revealed 2 distinct sequence variants
in both the forward (shown here) and reverse strands. Sequencing of 40 individual colony
picks after subcloning revealed that each sequence variant occurred in a trans configuration
(CP9 and CP13 are shown here as examples). In addition, 10% of colony picks (ie, CP32)
revealed a wild-type sequence, indicating that at least 1 of the 2 variants was a somatic
event. (B) Schematic representation of the GATA2 gene highlighting the proposed
germline and somatic mutations identified in patient J384. Both mutations are present in
coding region 3, which translates to the zinc finger 1 region of the protein.
From www.bloodjournal.org by guest on June 18, 2017. For personal use only.
2014 123: 1424-1426
doi:10.1182/blood-2013-07-517102
Statin and aspirin use is associated with improved outcome of FCR
therapy in relapsed/refractory chronic lymphocytic leukemia
Young Kwang Chae, Long Trinh, Preetesh Jain, Xuemei Wang, Uri Rozovski, William G. Wierda,
Michael J. Keating and Zeev Estrov
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