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Could a citrus keep the haematologist away?

Anaemia has long been recognized as one of the most impor-

tant prognostic factors in chronic lymphocytic leukaemia

(CLL) (Binet et al, 1981). Many mechanisms can cause anae-

mia in CLL including bone marrow infiltration, auto-immu-

nity, cytotoxic therapy, hypersplenism, inflammation, iron

deficiency and poor nutritional status (Mauro et al, 2002).

Among nutritional causes of anaemia, vitamin B9 and vita-

min B12 deficiencies are often sought, whereas vitamin C

deficiency (hypovitaminosis C) is underestimated (Fain,

2004). Vitamin C, also known as ascorbic acid (AA), is one

of the four main antioxidants (AA, vitamin E, selenium and

b-carotene) available in human alimentation (Fain, 2004).

The pathophysiology of CLL may involve oxidative stress

(Sarmento-Ribeiro et al, 2012). Because of its role in pre-

venting anaemia and its ability to degrade free radicals and

oxidants, we hypothesized that hypovitaminosis C level could

be associated with Binet stage C. Herein, we report a single-

centre study comparing the blood level of vitamin C in

patients with Binet stage A and Binet stage C CLL.

Between June 2012 and November 2012, we performed a

prospective exploratory study of the vitamin C plasma level

in patients followed for CLL at the Department of Hema-

tology of University Hospital of Tours. In order to com-

pare vitamin C plasma level between low and high burden

of disease, we randomly selected 40 patients with Binet

stage A CLL and 40 patients with Binet stage C CLL (Binet

et al, 1981). The only exclusion criterion was ongoing vita-

min C supplementation. The following baseline demograph-

ical and clinical data were recorded for all of the study

patients: age, sex, weight, size, performance status and date

of CLL diagnosis. The following blood tests were performed

in patients who provided an informed consent: complete

blood cell count, reticulocytes, aspartate aminotransferase,

serum creatinine level, thyroid-stimulating hormone (TSH),

C-reactive protein (CRP), serum iron level, transferrin satu-

ration, ferritin, albumin, folic acid, vitamin B12 and vita-

min C serum levels. To protect AA from light and air

alteration, blood samples were collected in tubes encased in

foil. Results are expressed as mean and confidence intervals.

Wilcoxon’s test was used to test the comparisons between

the two groups. A P value of less than 0�05 was considered

significant.

Baseline data and biological test results of the patients are

presented in Table I. Stage C patients had lower haemoglo-

bin level than stage A patients (107 g/l, vs. 134 g/l,

respectively, P < 0�00005). Anaemia was mostly normocytic,

normochromic and hyporegenerative. Platelet count was also

lower in stage C patients than in stage A patients

(111 9 109/l, vs. 200 9 109/l, respectively, P < 0�00005).Thyroid, liver and renal functions, as well as vitamin B9 and

serum iron levels, were normal in both groups. CRP and fer-

ritin levels were significantly higher in patients with Stage C

(10�0 mg/l, vs. 3�0 mg/l, and 431 lg/l, vs. 117 lg/l, respec-tively, P < 0�05 for both comparisons). There was no statisti-

cal difference in Vitamin B12 level between the two groups.

Vitamin C level was significantly higher in stage A patients

than in stage C patients (58�7 lmol/l, vs. 37�7 lmol/l,

P < 0�00005). In total, 22 CLL patients (27�5%) had hypovi-

taminosis C including three stage A patients (7�5%) and 19

stage C patients (47�5%).

298 ª 2014 John Wiley & Sons LtdBritish Journal of Haematology, 2014, 166, 292–308

Correspondence

To our knowledge, this study is the first to measure the

frequency of hypovitaminosis C in CLL patients, and to

detect an association between stage C and a lower level of

Vitamin C.

Previous studies of vitamin levels reported low levels of

vitamin D in CLL. Two groups reported that vitamin D defi-

ciency is associated with inferior time-to-first-treatment and

overall survival (Shanafelt et al, 2011; Molica et al, 2012).

Our work highlights the fact that hypovitaminosis C is

underestimated in CLL patients. As a known cause of anae-

mia and fatigue, practitioners should consider screening their

patients for vitamin C deficiency. When needed, careful sup-

plementation should be provided together with close surveil-

lance because vitamin C intake may increase markers of

haemolysis in patients with sickle cell anaemia or kidney

stone formation (Arruda et al, 2013; Thomas et al, 2013).

However, the reason for this deficiency remains unclear. Sev-

eral assumptions can be proposed to explain the low blood

levels in CLL: poor nutritional status with low vitamin C

intake, reduced vitamin C absorption, or an increased intra-

cellular uptake of vitamin C by tumour cells (Fain, 2004).

These results also raise the question of the possible role of

vitamin C in the progression and the treatment of the dis-

ease. Our work has some limitations that prevent us from

drawing the conclusion that a low vitamin C blood level

leads to disease progression. First, dietary differences were

not evaluated. Second, we arbitrarily compared two groups

of patients at different stages of the disease, which leads to

expected differences in performance status, albumin levels,

and inflammatory markers, such as ferritin and CRP. More-

over a low vitamin C blood level could result from disease

progression. However, a recent in vitro study found that both

arsenic trioxide (ATO) and vitamin C mediated cytotoxicity

on CLL B lymphocytes and emphasized the ability of vitamin

C to increase the efficacy of ATO (Biswas et al, 2010).

Vitamin C derivatives have been recently reported as a

‘promising new class of anti-cancer drugs, either alone or in

combination with other molecules’, and vitamin C showed

efficiency in a phase I clinical trial in biopsy-proven

advanced and/or progressing metastatic solid tumours

(Bordignon et al, 2013; Stephenson et al, 2013). Thus, we

believe that clinical trials and experimental studies should be

performed to determine if vitamin C supplementation could

indeed maintain stage A CLL quiescence and/or enhance

treatment efficacy in patients needing anticancer therapy.

Acknowledgments

BC, CD, LB, MS, FC, SL, ME, HB, PV, FM, PC and EG per-

formed the research. BC, CD, LB, EG, SL, ME designed the

research study. BC, CD, FC, MS, FM, HB, PV, PC and EG

analysed the data. BC and EG wrote the paper.

Table I. Characteristics of Stage A and Stage C CLL patients included in the study.

Characteristic

Stage A

N = 40

Stage C

N = 40 P

Gender (Male/Female) 25/15 25/15 NS

Age (years) 70 � 3 71 � 3 NS

Caucasian 40 40 NS

Disease duration (years) 6 � 2 8 � 2 NS

Body mass index (20�0–25�0 kg/m2) 26�4 � 0�99 25�4 � 1�22 NS

Performance Status 0�52 � 0�20 1�45 � 0�27 ***

Haemoglobin (115–160 g/l) 134 � 4�0 107 � 6�0 ***

Haematocrit (37–47%) 39�9 � 1�1 32 � 1�9 ***

Mean corpuscular volume (80–100 fl) 94�5 � 1�7 99�9 � 2�9 **

Mean corpuscular haemoglobin concentration (320–360 g/l) 333 � 20 332 � 4�0 NS

Platelet count (150–400 9 109/l) 200 � 17 111 � 19 ***

White blood cell count (4–10 9 109/l) 37�0 � 12�6 50�2 � 31�4 NS

Lymphocyte count (1-4 9 109/l) 30�3 � 12�1 45�5 � 31�3 NS

Reticulocytes (80–100 9 109/l) 43�0 � 6�4 61�4 � 21�7 NS

Thyroid-stimulating hormone (0�2–3�4 miu/l) 1�60 � 0�11 1�47 � 0�36 NS

Folic Acid (6–39 nmol/l) 16�1 � 1�8 23�3 � 6�9 NS

Vitamin B12 (142–725 pmol/l) 312�9 � 40�2 429�8 � 78�7 NS

Serum iron (10–30 lmol/l) 15�0 � 1�2 16�0 � 3�6 NS

Transferrin saturation (25–35%) 25�0 � 2�3 31�5 � 8�5 ***

Ferritin (10–300 lg/l) 117 � 33 431 � 199 *

Creatinine (60–100 lmol/l) 106�6 � 7�7 97�1 � 8�5 *

Aspartate transaminase (0–30 iu/l) 23 � 2 27 � 5 NS

C-reactive protein (0–6 mg/l) 3�0 � 1�5 10�0 � 5�5 *

Albumin (40–48 g/l) 43�9 � 0�7 40�0 � 1�9 **

Vitamin C (26�1–84�6 lmol/l) 58�7 � 7�5 37�7 � 8�3 ***

Normal ranges are indicated in parentheses. NS = P > 0�05; *P < 0�05; **P < 0�005; ***P < 0�001.

ª 2014 John Wiley & Sons Ltd 299British Journal of Haematology, 2014, 166, 292–308

Correspondence

Conflict of interest

The authors have no competing interests.

Benjamin Chaigne1,2

Caroline Dartigeas1

Lotfi Benboubker1

Franc�ois Chaumier1,3

Marjan Ertault1

S�everine Lissandre1

Marion Stacoffe1

Franc�ois Maillot2

H�el�ene Blasco4

Patrick Vourc’h4

Philippe Colombat1,3

Emmanuel Gyan1,3

1Service d’h�ematologie et th�erapie cellulaire, Centre hospitalier universi-

taire de Tours, 2Service de m�edecine interne, Centre hospitalier univers-

itaire de Tours, 3UMR CNRS 7292, Universit�e Franc�ois Rabelais, and4Service de biochimie et de biologie mol�eculaire, Centre hospitalier uni-

versitaire de Tours, Tours, France

E-mail: emmanuel.gyan@univ-tours.fr

Keywords: vitamin C, chronic lymphocytic leukaemia, ascorbic

acid, anaemia

First published online 20 March 2014

doi: 10.1111/bjh.12840

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Correspondence