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Santolaria A, Perales A, Montesinos P, Sanz MA. Acute Promyelocytic Leukemia during Pregnancy: A Systematic Review of the Literature. Cancers (Basel) 2020; 12:cancers12040968. [PMID: 32295152 PMCID: PMC7225915 DOI: 10.3390/cancers12040968] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/04/2020] [Accepted: 04/07/2020] [Indexed: 11/16/2022] Open
Abstract
The management of pregnant women with acute promyelocytic leukemia (APL) is a challenging situation where limited evidence-based information is available. We performed a systematic literature review to analyze the outcomes reported for both mother and fetus when APL is diagnosed during pregnancy. PubMed, Scopus and Web of Science databases were systematically searched to identify studies reporting cases of APL during pregnancy. Sixty-six articles met the eligibility criteria (53 single case reports). Ninety-two patients were eligible for induction therapy, with most them being treated with all-trans retinoic acid alone (32%) or combined with chemotherapy (43%), while the remaining patients received chemotherapy alone. Three patients were treated with arsenic-based regimens after delivery. Overall complete remission rate was 89%, with no statistically significant differences according to the type of induction and gestational age. During the first trimester, women were more likely to experience spontaneous and induced abortion compared to those during the second trimester (88% vs. 30%) (p < 0.0001), while only one patient diagnosed during the third trimester terminated in stillbirth. Twelve of 16 infants with neonatal complications had respiratory distress syndrome. Except two early deaths (Potter’s syndrome and pulmonary hemorrhage), all neonates evolved favorably. This study confirms that gestational age does not affect the results in the mother, but is closely related to fetal viability. Our results may be useful for the process of decision making that requires the involvement of the patient, hematologist, obstetrician and neonatologist.
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Affiliation(s)
- Andrea Santolaria
- Department of Obstetrics and Gynecology, Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain; (A.S.); (A.P.)
| | - Alfredo Perales
- Department of Obstetrics and Gynecology, Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain; (A.S.); (A.P.)
- Department of Obstetrics and Gynecology, University of Valencia, 46010 Valencia, Spain
| | - Pau Montesinos
- Department of Hematology, Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain;
- Centro de Investigación Biomédica en Red de Cáncer, Instituto Carlos III, 28029 Madrid, Spain
| | - Miguel A. Sanz
- Department of Hematology, Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain;
- Centro de Investigación Biomédica en Red de Cáncer, Instituto Carlos III, 28029 Madrid, Spain
- Department of Medicine, University of Valencia, 46010 Valencia, Spain
- Correspondence:
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Yang R, Qian SX, Chen C. [Treatment of acute promyelocytic leukemia during pregnancy]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2019; 40:439-442. [PMID: 31207714 PMCID: PMC7342234 DOI: 10.3760/cma.j.issn.0253-2727.2019.05.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- R Yang
- Hangzhou Hospital Affiliated to Nanjing Medical University, Hangzhou 310006, China
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Delgado-Lamas JL, GarcéS-Ruiz OM. Acute Promyelocytic Leukemia in Late Pregnancy. Successful Treatment with All-Trans-Retinoic Acid (ATRA) and Chemotherapy. Hematology 2016; 4:415-8. [DOI: 10.1080/10245332.1999.11746466] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- José Luis Delgado-Lamas
- Hematology Department, Hospital de Especialidades, Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, México
| | - Oscar Miguel GarcéS-Ruiz
- Hematology Department, Hospital de Especialidades, Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, México
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Verma V, Giri S, Manandhar S, Pathak R, Bhatt VR. Acute promyelocytic leukemia during pregnancy: a systematic analysis of outcome. Leuk Lymphoma 2015; 57:616-22. [PMID: 26110880 DOI: 10.3109/10428194.2015.1065977] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The outcomes of acute promyelocytic leukemia (APL) in pregnancy are largely unknown. The MEDLINE database was systematically searched to obtain 43 articles with 71 patients with new-onset APL during pregnancy. Induction therapy included various regimens of all-trans retinoic acid (ATRA), cytarabine, and anthracycline and resulted in a complete remission rate of 93%. Obstetric and fetal complications included pre-term deliveries (46%), spontaneous/therapeutic abortion/intrauterine death (33.3%) and other neonatal complications (25.9%). Mothers diagnosed in the first trimester were more likely to experience obstetric (p < 0.01) and fetal (p < 0.01) complications. To our knowledge, this is the largest systematic review of APL in pregnancy. The vast majority of APL patients in pregnancy may achieve remission with initial induction therapy. APL or its therapy in pregnancy, however, is associated with a high risk of fetal and obstetrical complications. The results of our study may help in patient counseling and informed decision-making.
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Affiliation(s)
- Vivek Verma
- a Department of Radiation Oncology , University of Nebraska Medical Center , Omaha , NE , USA
| | - Smith Giri
- b Department of Internal Medicine , University of Tennessee Health Science Center , Memphis , TN , USA
| | - Samyak Manandhar
- c Department of Medicine , University of Pittsburgh Medical Center - Mercy Hospital , Pittsburgh , PA , USA
| | - Ranjan Pathak
- d Department of Internal Medicine , Reading Health System , West Reading , PA , USA
| | - Vijaya Raj Bhatt
- e Department of Internal Medicine , Division of Hematology/Oncology, University of Nebraska Medical Center , Omaha , NE , USA
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Abstract
Although acute myeloid leukemia (AML) mostly occurs in older patients, it could be seen in women of childbearing age. It is therefore not surprising that in some patients, the management of AML will be complicated by a coexistent pregnancy. However, the association of leukemia and pregnancy is uncommon. Its incidence is estimated to be 1 in 75,000-100,000 pregnancies. During pregnancy, most leukemias are acute: two-thirds are myeloid and one-third are lymphoblastic. There is no standard approach for this clinical dilemma, in part because of variables such as the type of AML, the seriousness of the symptoms, and the patient's personal beliefs. In many cases, the diagnostic workup has to be altered because of the pregnancy, and often available treatments have varying risks to the fetus. While chemotherapy is reported to have some risks during the first trimester, it is admitted that it can be administered safely during the second and the third trimesters.
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Affiliation(s)
- Xavier Thomas
- Hospices Civils de Lyon, Hematology Department, Lyon-Sud Hospital, Pierre Bénite, France
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Pagnano KBB, Rego EM, Rohr S, Chauffaille MDL, Jacomo RH, Bittencourt R, Firmato AB, Fagundes EM, Melo RAM, Bernardo W. Guidelines on the diagnosis and treatment for acute promyelocytic leukemia: Associação Brasileira de Hematologia, Hemoterapia e Terapia Celular Guidelines Project: Associação Médica Brasileira - 2013. Rev Bras Hematol Hemoter 2014; 36:71-89. [PMID: 24624041 PMCID: PMC3948671 DOI: 10.5581/1516-8484.20140018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2013] [Indexed: 12/15/2022] Open
Affiliation(s)
| | | | - Sandra Rohr
- Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | | | | | - Rosane Bittencourt
- Universidade Federal do Rio Grande do Sul (UFGRS), Porto Alegre, RS, Brazil
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Azim HA, Pavlidis N, Peccatori FA. Treatment of the pregnant mother with cancer: A systematic review on the use of cytotoxic, endocrine, targeted agents and immunotherapy during pregnancy. Part II: Hematological tumors. Cancer Treat Rev 2010; 36:110-21. [DOI: 10.1016/j.ctrv.2009.11.004] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2009] [Revised: 11/09/2009] [Accepted: 11/15/2009] [Indexed: 11/28/2022]
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Abstract
Management of the pregnant patient with acute promyelocytic leukemia (APL) is a challenge. Immediate treatment of APL is critical, as it is an oncologic emergency, with a high risk of morbidity and mortality associated with disseminated intravascular coagulation. However, administration of chemotherapy and differentiating agents in pregnancy is controversial because of potential teratogenic effects. In addition, complications associated with APL, including retinoic acid syndrome, add to the complexity of management. To better understand how to manage this complex patient care situation, we searched the PubMed database (January 1972-May 2008) for English-language articles about maternal and fetal outcomes resulting from APL treatment during pregnancy. A total of 42 cases from 35 articles were identified: 12 first-trimester, 21 second-trimester, and 9 third-trimester cases. The most commonly administered agents were all-trans-retinoic acid (ATRA), anthracyclines, and antimetabolites. Complete remission was reported in 35 (83%) of 42 patients. Administration of ATRA or chemotherapy in the first trimester was associated with an increased risk of fetal malformations and spontaneous abortion, whereas administration in the second and third trimesters was associated with relatively favorable fetal outcomes. The overall treatment of the pregnant patient with APL should include a discussion about pregnancy termination, especially if APL is diagnosed in the first trimester. If the pregnancy is to continue, then the appropriate chemotherapy regimen needs to be determined. Frequent fetal monitoring, along with aggressive management of potential APL-related complications, is necessary to allow for optimal maternal and fetal outcomes.
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Affiliation(s)
- Daisy Yang
- Department of Pharmacy, University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA
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Murrin RJA, Adjetey V, Harrison P, Warwick A. Acute promyelocytic leukaemia presenting as postpartum haemorrhage. ACTA ACUST UNITED AC 2004; 26:233-7. [PMID: 15163324 DOI: 10.1111/j.1365-2257.2004.00609.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Acute leukaemia is encountered rarely in obstetric practice, occurring once in every 100,000 pregnancies. Such cases are usually diagnosed in the second and third trimesters. We describe a patient who developed a postpartum haemorrhage (PPH) as the presenting feature of acute promyelocytic leukaemia, which, to the best of our knowledge, has not been reported previously.
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Affiliation(s)
- R J A Murrin
- Department of Haematology, Russells Hall Hospital, Dudley, West Mids, UK
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Consoli U, Figuera A, Milone G, Meli CR, Guido G, Indelicato F, Moschetti G, Leotta S, Tornello A, Poidomani M, Murgano P, Pinto V, Giustolisi R. Acute promyelocytic leukemia during pregnancy: report of 3 cases. Int J Hematol 2004; 79:31-6. [PMID: 14979475 DOI: 10.1007/bf02983530] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Acute promyelocytic leukemia (APL) is characterized by onset at a young age and a life-threatening hemorrhagic diathesis, which is attributed to a disseminated intravascular coagulation (DIC)-like coagulopathy. The discovery of all-trans-retinoic acid has changed the course of APL treatment by reducing the onset of DIC and inducing a complete and durable remission in more than 90% of patients. The occurrence of APL during pregnancy is not a frequent event, but the management of these patients raises many therapeutic and ethical dilemmas and requires a careful clinical case evaluation of fetal and maternal risk, coagulation status, the parents' wishes, and therapeutic options. Here we describe 3 patients with APL diagnosed during pregnancy. Clinical data and the therapeutic approaches are presented. In the discussion, we analyze clinical decisions and therapeutic options and compare our cases with those found in the literature.
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Affiliation(s)
- Ugo Consoli
- Chair and Division of Haematology with Bone Marrow Transplantation Unit, University of Catania, Catania, Italy.
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12
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Cohen M, Bertram CP. Section Review: Oncologic, Endocrine & Metabolic: New advances in the treatment of acute promyelocytic leukaemia. Expert Opin Investig Drugs 1996. [DOI: 10.1517/13543784.5.6.695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Lin CP, Huang MJ, Liu HJ, Chang IY, Tsai CH. Successful treatment of acute promyelocytic leukemia in a pregnant Jehovah's Witness with all-trans retinoic acid, rhG-CSF, and erythropoietin. Am J Hematol 1996; 51:251-2. [PMID: 8619417 DOI: 10.1002/(sici)1096-8652(199603)51:3<251::aid-ajh20>3.0.co;2-i] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Abstract
BACKGROUND Acute promyelocytic leukemia (APL) is an uncommon form of acute myeloid leukemia usually associated with disseminated intravascular coagulation (DIC). Pregnancy in patients with APL requires special consideration to maximize the probability of survival of both mother and fetus. METHODS A patient with APL diagnosed during pregnancy who developed DIC is described. Obstetric and oncologic management of this difficult patient is discussed, and a pertinent literature review of pregnancy in APL is presented. RESULTS Of 23 pregnancies in patients with APL reported in the literature (including the present patient), 19 yielded live births, including 8 of 12 who received chemotherapy during late pregnancy and all 3 patients who received all-trans-retinoic acid (ATRA) during late pregnancy. Chemotherapy or ATRA induced complete remission in 72% of treated patients. CONCLUSIONS Proper management of pregnant patients with APL usually results in a live birth and complete remission of the mother's leukemia, despite the potentially devastating consequences of DIC, which is present at diagnosis in most patients.
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Affiliation(s)
- M A Hoffman
- Department of Oncology, Montefiore Medical Center, Bronx, NY 10467, USA
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Nakamura K, Dan K, Iwakiri R, Gomi S, Nomura T. Successful treatment of acute promyelocytic leukemia in pregnancy with all-trans retinoic acid. Ann Hematol 1995; 71:263-4. [PMID: 7492630 DOI: 10.1007/bf01744377] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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