1
|
Kantarjian H, Borthakur G, Daver N, DiNardo CD, Issa G, Jabbour E, Kadia T, Sasaki K, Short NJ, Yilmaz M, Ravandi F. Current status and research directions in acute myeloid leukemia. Blood Cancer J 2024; 14:163. [PMID: 39300079 DOI: 10.1038/s41408-024-01143-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Revised: 08/31/2024] [Accepted: 09/05/2024] [Indexed: 09/22/2024] Open
Abstract
The understanding of the molecular pathobiology of acute myeloid leukemia (AML) has spurred the identification of therapeutic targets and the development of corresponding novel targeted therapies. Since 2017, twelve agents have been approved for the treatment of AML subsets: the BCL2 inhibitor venetoclax; the CD33 antibody drug conjugate gemtuzumab ozogamicin; three FLT3 inhibitors (midostaurin, gilteritinib, quizartinib); three IDH inhibitors (ivosidenib and olutasidenib targeting IDH1 mutations; enasidenib targeting IDH2 mutations); two oral hypomethylating agents (oral poorly absorbable azacitidine; fully absorbable decitabine-cedazuridine [latter approved as an alternative to parenteral hypomethylating agents in myelodysplastic syndrome and chronic myelomonocytic leukemia but commonly used in AML]); and CPX-351 (encapsulated liposomal 5:1 molar ratio of cytarabine and daunorubicin), and glasdegib (hedgehog inhibitor). Other targeted therapies (menin inhibitors, CD123 antibody-drug conjugates) are showing promising results. To achieve optimal results in such a rare and heterogeneous entity as AML requires expertise, familiarity with this rare cancer, and the access to, and delivery of disparate therapies under rigorous supportive care conditions. In this review, we update the standard-of-care and investigational therapies and outline promising current and future research directions.
Collapse
Affiliation(s)
- Hagop Kantarjian
- From the Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA.
| | - Gautam Borthakur
- From the Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | - Naval Daver
- From the Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | - Courtney D DiNardo
- From the Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | - Ghayas Issa
- From the Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | - Elias Jabbour
- From the Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | - Tapan Kadia
- From the Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | - Koji Sasaki
- From the Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | - Nicholas J Short
- From the Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | - Musa Yilmaz
- From the Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | - Farhad Ravandi
- From the Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| |
Collapse
|
2
|
Hermsen J, Hambley B. The Coagulopathy of Acute Promyelocytic Leukemia: An Updated Review of Pathophysiology, Risk Stratification, and Clinical Management. Cancers (Basel) 2023; 15:3477. [PMID: 37444587 DOI: 10.3390/cancers15133477] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 06/21/2023] [Accepted: 06/28/2023] [Indexed: 07/15/2023] Open
Abstract
Acute promyelocytic leukemia (APL) has a well-established mechanism and a long-term prognosis that exceeds that of any other acute leukemia. These improving outcomes are due, in part, to all-trans retinoic acid (ATRA) and arsenic trioxide (ATO), two targeted and highly active agents in this disease. However, there remains a considerable morbidity and mortality risk in APL secondary to clinically significant hemorrhagic and/or thrombotic events. Prevention and treatment of these coagulopathic complications remain significant impediments to further progress in optimizing outcomes for patients with APL. Moreover, the relative rarity of APL hinders adequately powered randomized controlled trials for evaluating APL coagulopathy management strategies. This review draws from peer-reviewed works falling between initial descriptions of APL in 1957 and work published prior to January 2023 and provides an updated overview of the pathophysiology of hemorrhagic and thrombotic complications in APL, outlines risk stratification parameters, and compiles current clinical best practices. An improved understanding of the pathophysiologic mechanisms driving hemorrhage and thrombosis along with the completion of well-designed trials of management strategies will assist clinicians in developing interventions that mitigate these devastating complications in an otherwise largely curable disease.
Collapse
Affiliation(s)
- Jack Hermsen
- University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Bryan Hambley
- Division of Hematology/Oncology, Department of Internal Medicine, University of Cincinnati, 3125 Eden Ave, Cincinnati, OH 45267, USA
| |
Collapse
|
3
|
Liposomal formulation of new arsenic schiff base complex as drug delivery agent in the treatment of acute promyelocytic leukemia and quantum chemical and docking calculations. J Drug Deliv Sci Technol 2022. [DOI: 10.1016/j.jddst.2022.103600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
4
|
Baysal M, Gürsoy V, Hunutlu FC, Erkan B, Demirci U, Bas V, Gulsaran SK, Pinar IE, Ersal T, Kirkizlar TA, Atli EI, Kirkizlar HO, Ümit EG, Gürkan H, Ozkocaman V, Ozkalemkas F, Demir AM, Ali R. The evaluation of risk factors leading to early deaths in patients with acute promyelocytic leukemia: a retrospective study. Ann Hematol 2022; 101:1049-1057. [PMID: 35190843 DOI: 10.1007/s00277-022-04798-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 02/14/2022] [Indexed: 11/28/2022]
Abstract
Acute promyelocytic leukemia (APL) differs from other forms of acute myeloid leukemia (AML), including coagulopathy, hemorrhage, disseminated intravascular coagulation (DIC), and treatment success with all-trans retinoic acid (ATRA). Despite ATRA, early deaths (ED) are still common in APL. Here, we evaluated factors associated with ED and applicability of scoring systems used to diagnose DIC. Ninety-one APL patients (55 females, 36 males, and median age 40 years) were included. ED was defined as deaths attributable to any cause between day of diagnosis and following 30th day. DIC was assessed based on DIC scoring system released by the International Society of Thrombosis and Hemostasis (ISTH) and Chinese Diagnostic Scoring System (CDSS). Patients' median follow-up time was 49.2 months, and ED developed in 14 (15.4% of) cases. Patients succumbing to ED had higher levels of the Eastern Cooperative Oncology Group Performance Status (ECOG PS), lactate dehydrogenase (LDH), and ISTH DIC, and lower fibrinogen levels (p <0.05). In multivariate Cox regression analysis, age >55 and ECOG PS ≥2 rates were revealed to be associated with ED. Based on ISTH and CDSS scores, DIC was reported in 47.3 and 58.2% of the patients, respectively. Despite advances in APL, ED is still a major obstacle. Besides the prompt recognition and correction of coagulopathy, those at high ED risk are recommended to be detected rapidly. Implementation of local treatment plans and creating awareness should be achieved in hematological centers. Common utilization of ATRA and arsenic trioxide (ATO) may be beneficial to overcome ED and coagulopathy in APL patients.
Collapse
Affiliation(s)
- Mehmet Baysal
- Division of Hematology Edirne, Department of Internal Medicine, Trakya University School of Medicine, Balkan Campus, 22030, Edirne, Turkey.
| | - Vildan Gürsoy
- Division of Hematology, Department of Internal Medicine, Uludag University School of Medicine, Bursa, Turkey
| | - Fazil Cagri Hunutlu
- Department of Internal Medicine, Uludag University School of Medicine, Bursa, Turkey
| | - Buket Erkan
- Department of Internal Medicine, Uludag University School of Medicine, Bursa, Turkey
| | - Ufuk Demirci
- Division of Hematology Edirne, Department of Internal Medicine, Trakya University School of Medicine, Balkan Campus, 22030, Edirne, Turkey
| | - Volkan Bas
- Division of Hematology Edirne, Department of Internal Medicine, Trakya University School of Medicine, Balkan Campus, 22030, Edirne, Turkey
| | - Sedanur Karaman Gulsaran
- Division of Hematology Edirne, Department of Internal Medicine, Trakya University School of Medicine, Balkan Campus, 22030, Edirne, Turkey
| | - Ibrahim Ethem Pinar
- Division of Hematology, Department of Internal Medicine, Uludag University School of Medicine, Bursa, Turkey
| | - Tuba Ersal
- Division of Hematology, Department of Internal Medicine, Uludag University School of Medicine, Bursa, Turkey
| | - Tugcan Alp Kirkizlar
- Division of Hematology Edirne, Department of Internal Medicine, Trakya University School of Medicine, Balkan Campus, 22030, Edirne, Turkey
| | - Emine Ikbal Atli
- Department of Medical Genetics, Trakya University School of Medicine, Edirne, Turkey
| | - Hakki Onur Kirkizlar
- Division of Hematology Edirne, Department of Internal Medicine, Trakya University School of Medicine, Balkan Campus, 22030, Edirne, Turkey
| | - Elif G Ümit
- Division of Hematology Edirne, Department of Internal Medicine, Trakya University School of Medicine, Balkan Campus, 22030, Edirne, Turkey
| | - Hakan Gürkan
- Department of Medical Genetics, Trakya University School of Medicine, Edirne, Turkey
| | - Vildan Ozkocaman
- Division of Hematology, Department of Internal Medicine, Uludag University School of Medicine, Bursa, Turkey
| | - Fahir Ozkalemkas
- Division of Hematology, Department of Internal Medicine, Uludag University School of Medicine, Bursa, Turkey
| | - Ahmet Muzaffer Demir
- Division of Hematology Edirne, Department of Internal Medicine, Trakya University School of Medicine, Balkan Campus, 22030, Edirne, Turkey
| | - Ridvan Ali
- Division of Hematology, Department of Internal Medicine, Uludag University School of Medicine, Bursa, Turkey
| |
Collapse
|
5
|
Sanz MA, Barragán E. History of Acute Promyelocytic Leukemia. Clin Hematol Int 2021; 3:142-152. [PMID: 34938986 PMCID: PMC8690702 DOI: 10.2991/chi.k.210703.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 06/03/2021] [Indexed: 12/24/2022] Open
Abstract
In this article, we discuss the history of acute promyelocytic leukemia (APL) from the pre-therapeutic era, which began after its recognition by Hillestad in 1947 as a nosological entity, to the present day. It is a paradigmatic history that has transformed the “most malignant leukemia form” into the most curable one. The identification of a balanced reciprocal translocation between chromosomes 15 and 17, resulting in fusion between the promyelocytic leukemia gene and the retinoic acid receptor alpha, has been crucial in understanding the mechanisms of leukemogenesis, and responsible for the peculiar response to targeted therapy with all-trans retinoic acid (ATRA) and arsenic trioxide (ATO). We review the milestones that marked successive therapeutic advances, beginning with the introduction of the first successful chemotherapy in the early 1970s, followed by a subsequent incorporation of ATRA and ATO in the late 1980s and early 1990s which have revolutionized the treatment of this disease. Over the past two decades, treatment optimization has relied on the combination of ATRA, ATO, and chemotherapy according to risk-adapted approaches, which together with improvements in supportive therapy have paved the way for cure for most patients with APL.
Collapse
Affiliation(s)
- Miguel A Sanz
- Department of Hematology, Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - Eva Barragán
- Clinical Laboratory, Hospital Universitari i Politècnic La Fe, Valencia, Spain.,Centro de Investigación Biomédica en Red de Cáncer, Carlos III Institute, Madrid, Spain
| |
Collapse
|
6
|
Ferrara F, Molica M, Bernardi M. Drug treatment options for acute promyelocytic leukemia. Expert Opin Pharmacother 2021; 23:117-127. [PMID: 34348549 DOI: 10.1080/14656566.2021.1961744] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Until the late 1980s, acute promyelocytic leukemia (APL) was the most rapidly fatal leukemia; however, nowadays, it is a curable disease with survival rates exceeding 90-95%. The improvement of APL outcome is mainly due to two agents, which target the typical translocation t(15;17) and its fusion transcript PML-RARα responsible for initiating and maintaining the disease: all-trans retinoic acid (ATRA) and arsenic trioxide (ATO). The story of APL represents a pioneering model for the development of precision medicine and curative chemotherapy-free approaches for acute leukemia. AREA COVERED The authors examine the major advances in the treatment of patients with APL focusing on three different eras: 1) the pre-ATRA era; 2) the ATRA era; 3) the ATO era. EXPERT OPINION The combination of ATRA and ATO is effective and curative for the majority of APL patients. It has been approved for low/intermediate risk cases while an experimental trial with a minimal addition of chemotherapy for high-risk ones is ongoing. Disease relapse is infrequent and can be cured with ATRA-ATO rechallenging, with or without subsequent transplantation depending on the interval between complete remission and relapse. New therapeutic landscapes contemplate the use of an oral chemo-free ATRA-ATO combination, implementing treatment as outpatient care, thus increasing quality of life and decreasing medical costs.
Collapse
Affiliation(s)
| | | | - Massimo Bernardi
- Haematology and BMT Unit IRCCS San Raffaele Scientific Institute via Olgettina 60, Milan
| |
Collapse
|
7
|
Dhakal P, Lyden E, Rajasurya V, Zeidan AM, Chaulagain C, Gundabolu K, Bhatt VR. Early mortality and overall survival in acute promyelocytic leukemia: do real-world data match results of the clinical trials? Leuk Lymphoma 2021; 62:1949-1957. [PMID: 33711907 PMCID: PMC9429085 DOI: 10.1080/10428194.2021.1894651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 02/11/2021] [Accepted: 02/15/2021] [Indexed: 10/21/2022]
Abstract
Acute promyelocytic leukemia (APL) boasts overall survival (OS) of >90% at 3 years and early mortality of <5% in recent clinical trials. Using a large National Cancer Database, we performed analysis of 7190 adults with APL to determine whether one-month mortality and OS of patients with APL treated in real-world practices mirror outcomes noted in clinical trials. Only 64% of total patients received multi-agent therapy; 32% received either single-agent therapy or no therapy at all. One-month mortality was 6% for patients ≤18 years, 6% for 19-40 years, 10% for 41-60 years, and 21% for >60 years. OS at 1- and 3-year were 81% and 75%, respectively. In a multivariate analysis, age ≤ 40 years, treatment at academic center, use of multi-agent therapy, and diagnosis after 2009 conferred better OS. In this largest database study in APL till date, we demonstrated an overall improvement in OS over time but challenges still exist in translating successes of clinical trials to real-world practices.
Collapse
Affiliation(s)
- Prajwal Dhakal
- Department of Internal Medicine, Division of Oncology and Hematology, University of Nebraska Medical Center, Omaha, NE, USA
- Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE, USA
| | - Elizabeth Lyden
- Department of Biostatics, University of Nebraska Medical Center, Omaha, NE, USA
| | - Venkat Rajasurya
- Department of Pulmonary Critical Care, Multicare Health System, Puyallup, WA, USA
| | - Amer M. Zeidan
- Department of Internal Medicine, Section of Hematology, Yale University School of Medicine and Yale Cancer Center, New Haven, CT, USA
| | - Chakra Chaulagain
- Department of Hematology and Oncology, Maroone Cancer Center, Cleveland Clinic Florida, Weston, FL, USA
| | - Krishna Gundabolu
- Department of Internal Medicine, Division of Oncology and Hematology, University of Nebraska Medical Center, Omaha, NE, USA
- Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE, USA
| | - Vijaya Raj Bhatt
- Department of Internal Medicine, Division of Oncology and Hematology, University of Nebraska Medical Center, Omaha, NE, USA
- Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE, USA
| |
Collapse
|
8
|
Real-life outcomes of unselected acute promyelocytic leukemia patients: a single-center 14-year experience. ACTA ACUST UNITED AC 2021; 58:138-145. [PMID: 32452194 DOI: 10.2478/rjim-2020-0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND After the inclusion of all-trans retinoic acid (ATRA) into the treatment of Acute Promyelocytic leukemia (APL), a notable improvement concerning the survival rates of patients with APL has been observed. However, the population-based studies demonstrated that there was no marked improvement in the survival of patients after the 2000s. We aim to describe the clinical response and prognosis of adult patients diagnosed with APL and examine the change in these outcomes by the time period of diagnosis. METHODS We retrospectively reviewed thirty-six unselected APL patients who were diagnosed between September 2003 and February 2016. RESULTS The probability of survival at two years was 58%, while disease-free survival (DFS) was 87%. The overall early death (ED) rate was 33% and remain stable over time [42% in 2003-2009 vs. 24% in 2010-2016 (p=.20)]. In addition, the 2-year overall survival (OS) rates were 47% in 2003-2009 and 70% in 2010-2016 (p=.29), and no differences were noted. Univariate analyses showed possible predictors of poor OS were defined as leukocytosis (≥10x109/L), high Sanz score, hemorrhage, infection, disseminated intravascular coagulopathy (DIC) at presentation and microgranular morphologic subtype. CONCLUSIONS This study shows that long-term survival remains low in APL patients, particularly related to a high ED rate. Initiatives to reduce ED are exceedingly substantial for improving the survival in APL.
Collapse
|
9
|
Kantarjian HM, Short NJ, Fathi AT, Marcucci G, Ravandi F, Tallman M, Wang ES, Wei AH. Acute Myeloid Leukemia: Historical Perspective and Progress in Research and Therapy Over 5 Decades. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 21:580-597. [PMID: 34176779 DOI: 10.1016/j.clml.2021.05.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/20/2021] [Accepted: 05/22/2021] [Indexed: 12/17/2022]
Abstract
With the Food and Drug Administration approval of 9 agents for different acute myeloid leukemia (AML) indications, the prognosis and management of AML is evolving rapidly. Herein, we review the important milestones in the history of AML research and therapy, discuss insights regarding prognostic assessment and prediction of treatment outcome, detail practical supportive care measures, and summarize the current treatment landscape and areas of evolving research.
Collapse
Affiliation(s)
| | - Nicholas J Short
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | - Amir T Fathi
- Leukemia Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Guido Marcucci
- Gehr Family Center for Leukemia Research City of Hope, Duarte, CA, USA
| | - Farhad Ravandi
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | - Martin Tallman
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY, USA
| | - Eunice S Wang
- Leukemia Service, Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Andrew H Wei
- Department of Clinical Hematology, The Alfred Hospital and Monash University, Melbourne, Australia
| |
Collapse
|
10
|
Zapata-Canto N, Aguilar M, Arana L, Montano E, Ramos-Penafiel C, De la Pena JA, Alvarez-Vera JL, Espitia-Rios E, Perez Zuniga JM, Hernandez-Ruiz E, Cervera E, Espinoza-Zamora R, Sosa-Espinoza A, Solis-Poblano JC, Demichelis R, Gomez-Almaguer D, Barrera E, Mijangos J, Solis-Armenta R, de Jesus Perez O, Herrera M, Diaz-Vargas G, Cabrera-Garcia A, Flores-Jimenez JA, Morales-Adrian J, Ramirez-Romero EF, Ceballos-Lopez A, Guillermo VA, Manuel MS, Lourdes EJLC, Ojeda-Tovar J, Gomez-Perdomo G, Alvarado-Ibarra M. Acute Promyelocytic Leukemia: A Long-Term Retrospective Study in Mexico. J Hematol 2021; 10:53-63. [PMID: 34007366 PMCID: PMC8110230 DOI: 10.14740/jh773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 04/20/2021] [Indexed: 11/11/2022] Open
Abstract
Background The present retrospective study reviewed acute promyelocytic leukemia (APL) cases recorded in Mexico between January 2007 and January 2017. The primary objective of the study was to evaluate overall survival (OS) in Mexican patients with APL. Secondary objective was to evaluate the impact of induction treatment with different anthracyclines on OS, event-free survival (EFS) and complications in this patient population. Methods The medical charts of patients referred to medical institutions in Mexico from January 2007 through January 2017 for the treatment of suspected APL were reviewed retrospectively. Patients aged 15 - 75 years, in whom the diagnosis of APL was confirmed, who had an Eastern Cooperative Group performance status of 0 - 2, and who were eligible for combined treatment with intensive chemotherapy and all-trans retinoic acid (ATRA), were included in the study. Study participants received induction and consolidation treatment with ATRA plus either daunorubicin or idarubicin, followed by 2 years of single-agent ATRA as maintenance therapy. Patients who were unable to pay for ATRA treatment received anthracycline-based induction and consolidation, with methotrexate plus mercaptopurine as maintenance therapy. Results A total of 360 patients from 21 public and private hospitals were included in the study. The median age of the population was 37 years, and 51% were male. Of the 360 patients, 205 (57%) vs. 155 (43%) received daunorubicin vs. idarubicin as induction treatment for APL. ATRA was administered to 201 (98%) patients in the daunorubicin group vs. 138 (89%) in the idarubicin group (P = 0.001), and was initiated at diagnosis in 92% vs. 73% of recipients, respectively (P = 0.0001). At 150 months, OS and EFS for the entire population were 84% and 79%, respectively. Both OS (90% vs. 76%, P = 0.003) and EFS (85% vs. 72%, P = 0.001) were significantly prolonged in daunorubicin vs. idarubicin recipients. Rates of complications were similar in the two groups. Conclusions As arsenic trioxide (ATO) is not currently available in Mexico, anthracycline plus ATRA is the mainstay of treatment for APL here. Our results confirm the efficacy of this strategy, with high OS and EFS rates being observed 12.5 years after diagnosis.
Collapse
Affiliation(s)
| | - Manuel Aguilar
- Instituto Nacional de Cancerologia, Ciudad de Mexico, Mexico
| | - Luara Arana
- Hospital 20 de Noviembre ISSSTE, Ciudad de Mexico, Mexico
| | - Efren Montano
- Hospital 20 de Noviembre ISSSTE, Ciudad de Mexico, Mexico
| | | | | | | | | | | | | | - Eduardo Cervera
- Instituto Nacional de Cancerologia, Ciudad de Mexico, Mexico
| | | | | | | | - Roberta Demichelis
- Instituto Nacional de la Nutricion Salvador Zubiran, Ciudad de Mexico, Mexico
| | | | - Esperanza Barrera
- Hospital Civil de Guadalajara "Fray Antonio Alcande", Guadalajara, Jalisco, Mexico
| | | | | | | | - Miguel Herrera
- Hospital Lomas de San Luis Potosi, San Luis Potosi, Mexico
| | | | | | | | | | | | | | | | | | | | - Juan Ojeda-Tovar
- Hospital Regional de Alta Especialidad del Bajio, Guanajuato, Mexico
| | - Gladys Gomez-Perdomo
- Centro Estatal de Cancerologia Dr. Miguel Dorantes Mesa, Xalapa Veracruz, Mexico
| | | |
Collapse
|
11
|
Sidhom JW, Siddarthan IJ, Lai BS, Luo A, Hambley BC, Bynum J, Duffield AS, Streiff MB, Moliterno AR, Imus P, Gocke CB, Gondek LP, DeZern AE, Baras AS, Kickler T, Levis MJ, Shenderov E. Deep learning for diagnosis of acute promyelocytic leukemia via recognition of genomically imprinted morphologic features. NPJ Precis Oncol 2021; 5:38. [PMID: 33990660 PMCID: PMC8121867 DOI: 10.1038/s41698-021-00179-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 04/16/2021] [Indexed: 12/16/2022] Open
Abstract
Acute promyelocytic leukemia (APL) is a subtype of acute myeloid leukemia (AML), classified by a translocation between chromosomes 15 and 17 [t(15;17)], that is considered a true oncologic emergency though appropriate therapy is considered curative. Therapy is often initiated on clinical suspicion, informed by both clinical presentation as well as direct visualization of the peripheral smear. We hypothesized that genomic imprinting of morphologic features learned by deep learning pattern recognition would have greater discriminatory power and consistency compared to humans, thereby facilitating identification of t(15;17) positive APL. By applying both cell-level and patient-level classification linked to t(15;17) PML/RARA ground-truth, we demonstrate that deep learning is capable of distinguishing APL in both discovery and prospective independent cohort of patients. Furthermore, we extract learned information from the trained network to identify previously undescribed morphological features of APL. The deep learning method we describe herein potentially allows a rapid, explainable, and accurate physician-aid for diagnosing APL at the time of presentation in any resource-poor or -rich medical setting given the universally available peripheral smear.
Collapse
Affiliation(s)
- John-William Sidhom
- Bloomberg Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ingharan J Siddarthan
- Bloomberg Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bo-Shiun Lai
- Bloomberg Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Adam Luo
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bryan C Hambley
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jennifer Bynum
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amy S Duffield
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Hematopathology Service, Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michael B Streiff
- Division of Hematology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alison R Moliterno
- Division of Hematology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Philip Imus
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christian B Gocke
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lukasz P Gondek
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amy E DeZern
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alexander S Baras
- Bloomberg Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Thomas Kickler
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mark J Levis
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Eugene Shenderov
- Bloomberg Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| |
Collapse
|
12
|
Kantarjian HM, Kadia TM, DiNardo CD, Welch MA, Ravandi F. Acute myeloid leukemia: Treatment and research outlook for 2021 and the MD Anderson approach. Cancer 2021; 127:1186-1207. [PMID: 33734442 DOI: 10.1002/cncr.33477] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 12/31/2020] [Accepted: 01/11/2021] [Indexed: 12/17/2022]
Abstract
The unraveling of the pathophysiology of acute myeloid leukemia (AML) has resulted in rapid translation of the information into clinical practice. After more than 40 years of slow progress in AML research, the US Food and Drug Administration has approved nine agents for different AML treatment indications since 2017. In this review, we detail the progress that has been made in the research and treatment of AML, citing key publications related to AML research and therapy in the English literature since 2000. The notable subsets of AML include acute promyelocytic leukemia (APL), core-binding factor AML (CBF-AML), AML in younger patients fit for intensive chemotherapy, and AML in older/unfit patients (usually at the age cutoff of 60-70 years). We also consider within each subset whether the AML is primary or secondary (therapy-related, evolving from untreated or treated myelodysplastic syndrome or myeloproliferative neoplasm). In APL, therapy with all-trans retinoic acid and arsenic trioxide results in estimated 10-year survival rates of ≥80%. Treatment of CBF-AML with fludarabine, high-dose cytarabine, and gemtuzumab ozogamicin (GO) results in estimated 10-year survival rates of ≥75%. In younger/fit patients, the "3+7" regimen (3 days of daunorubicin + 7 days of cytarabine) produces less favorable results (estimated 5-year survival rates of 35%; worse in real-world experience); regimens that incorporate high-dose cytarabine, adenosine nucleoside analogs, and GO are producing better results. Adding venetoclax, FLT3, and IDH inhibitors into these regimens has resulted in encouraging preliminary data. In older/unfit patients, low-intensity therapy with hypomethylating agents (HMAs) and venetoclax is now the new standard of care. Better low-intensity regimens incorporating cladribine, low-dose cytarabine, and other targeted therapies (FLT3 and IDH inhibitors) are emerging. Maintenance therapy now has a definite role in the treatment of AML, and oral HMAs with potential treatment benefits are also available. In conclusion, AML therapy is evolving rapidly and treatment results are improving in all AML subsets as novel agents and strategies are incorporated into traditional AML chemotherapy. LAY SUMMARY: Ongoing research in acute myeloid leukemia (AML) is progressing rapidly. Since 2017, the US Food and Drug Administration has approved 10 drugs for different AML indications. This review updates the research and treatment pathways for AML.
Collapse
Affiliation(s)
| | - Tapan M Kadia
- Department of Leukemia, MD Anderson Cancer Center, Houston, Texas
| | | | - Mary Alma Welch
- Department of Leukemia, MD Anderson Cancer Center, Houston, Texas
| | - Farhad Ravandi
- Department of Leukemia, MD Anderson Cancer Center, Houston, Texas
| |
Collapse
|
13
|
Kantarjian H, Kadia T, DiNardo C, Daver N, Borthakur G, Jabbour E, Garcia-Manero G, Konopleva M, Ravandi F. Acute myeloid leukemia: current progress and future directions. Blood Cancer J 2021; 11:41. [PMID: 33619261 PMCID: PMC7900255 DOI: 10.1038/s41408-021-00425-3] [Citation(s) in RCA: 336] [Impact Index Per Article: 112.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/14/2020] [Accepted: 01/18/2021] [Indexed: 12/12/2022] Open
Abstract
Progress in the understanding of the biology and therapy of acute myeloid leukemia (AML) is occurring rapidly. Since 2017, nine agents have been approved for various indications in AML. These included several targeted therapies like venetoclax, FLT3 inhibitors, IDH inhibitors, and others. The management of AML is complicated, highlighting the need for expertise in order to deliver optimal therapy and achieve optimal outcomes. The multiple subentities in AML require very different therapies. In this review, we summarize the important pathophysiologies driving AML, review current therapies in standard practice, and address present and future research directions.
Collapse
Affiliation(s)
- Hagop Kantarjian
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA.
| | - Tapan Kadia
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | - Courtney DiNardo
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | - Naval Daver
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | - Gautam Borthakur
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | - Elias Jabbour
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | | | - Marina Konopleva
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | - Farhad Ravandi
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| |
Collapse
|
14
|
Xu ZL, Huang XJ. Therapeutic Approaches for Acute Promyelocytic Leukaemia: Moving Towards an Orally Chemotherapy-Free Era. Front Oncol 2020; 10:586004. [PMID: 33194735 PMCID: PMC7606937 DOI: 10.3389/fonc.2020.586004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 09/30/2020] [Indexed: 12/18/2022] Open
Abstract
The treatment of acute promyelocytic leukaemia (APL) has evolved dramatically over the past several decades, making the disease a highly curable form of acute leukaemia. The discoveries of all-trans retinoic acid (ATRA) and arsenic trioxide (ATO) were landmark events, leading to historic revolutions in the treatment of APL. One major change was from chemotherapy-based to chemotherapy-free treatment regimens, and the combination of ATRA plus ATO without chemotherapy has been recommended as the standard therapy for non-high-risk APL. The other major change was from the intravenous administration of medicine in the hospital to a largely home-based oral approach, which is a more cost-effective and convenient treatment model. In this review, we focus on the evolution of therapeutic approaches for APL, as well as the challenges that remain with the current approaches.
Collapse
Affiliation(s)
| | - Xiao-Jun Huang
- Peking University People’s Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| |
Collapse
|
15
|
Thomas X. Acute Promyelocytic Leukemia: A History over 60 Years-From the Most Malignant to the most Curable Form of Acute Leukemia. Oncol Ther 2019; 7:33-65. [PMID: 32700196 PMCID: PMC7360001 DOI: 10.1007/s40487-018-0091-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Indexed: 02/07/2023] Open
Abstract
Acute promyelocytic leukemia (APL) is a distinct subtype of acute myeloid leukemia (AML) that is cytogenetically characterized by a balanced reciprocal translocation between chromosomes 15 and 17, which results in the fusion of the promyelocytic leukemia (PML) and retinoic acid receptor alpha (RARα) genes. Because patients with APL present a tendency for severe bleeding, often resulting in an early fatal course, APL was historically considered to be one of the most fatal forms of acute leukemia. However, therapeutic advances, including anthracycline- and cytarabine-based chemotherapy, have significantly improved the outcomes of APL patients. Due to the further introduction of all-trans retinoic acid (ATRA) and-more recently-the development of arsenic trioxide (ATO)-containing regimens, APL is currently the most curable form of AML in adults. Treatment with these new agents has introduced the concept of cure through targeted therapy. With the advent of revolutionary ATRA-ATO combination therapies, chemotherapy can now be safely omitted from the treatment of low-risk APL patients. In this article, we review the six-decade history of APL, from its initial characterization to the era of chemotherapy-free ATRA-ATO, a model of cancer-targeted therapy.
Collapse
Affiliation(s)
- Xavier Thomas
- Hospices Civils de Lyon, Hematology Department, Lyon-Sud University Hospital, Pierre Bénite, France.
| |
Collapse
|
16
|
Pallavi R, Mazzarella L, Pelicci PG. Advances in precision epigenetic treatment for acute promyelocytic leukemia. EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2019. [DOI: 10.1080/23808993.2019.1612238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Rani Pallavi
- Department of Experimental Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Luca Mazzarella
- Department of Experimental Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
- Division of Innovative Therapies, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Pier Giuseppe Pelicci
- Department of Experimental Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| |
Collapse
|
17
|
Salamero O, Martínez-Cuadrón D, Sobas M, Benavente C, Vives S, De la Serna J, Pérez-Encinas M, Escoda L, Gil C, Brunet S, Ramos F, Esteve J, Amigo M, Krsnik I, Manso F, Arias J, González-Campos J, Serrano J, Oleksiuk J, Barrios M, García-Boyero R, Novo A, Sanz MA, Montesinos P. Real life outcomes of patients aged ≥75 years old with acute promyelocytic leukemia: experience of the PETHEMA registry. Leuk Lymphoma 2019; 60:2720-2732. [PMID: 31068052 DOI: 10.1080/10428194.2019.1607327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Acute promyelocytic leukemia is infrequent among patients aged ≥75 years old, a population that is rarely eligible for clinical protocols. This study aims to analyze the treatment strategies and clinical outcomes of very old APL patients reported to the international PETHEMA registry. Between 1997 and 2017, among 2501 APL cases registered 120 were ≥75 years old. Treatment approaches were: AIDA regimen, 79 patients; ATRA alone, 23; 16, supportive care (SC) and 2, other strategies. Patients treated with AIDA were younger, had better ECOG and lower leukocytes. Complete remission (CR) was achieved in 65% of AIDA-group vs. 45% in the ATRA-group, being infections followed by bleeding the most frequent causes of induction death. Patients in CR after AIDA showed 3-year DFS of 73%. Our real-life series of very old APL patients provides a reference basis for future treatment strategies aiming to improve clinical outcomes in this challenging population.
Collapse
Affiliation(s)
- Olga Salamero
- UAB-Medicine Department, Hospital Universitario Vall d'Hebron, VHIO, Barcelona, Spain
| | - David Martínez-Cuadrón
- Hospital Universitari i Politècnic La Fe, Valencia, Spain.,CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Marta Sobas
- Department of Hematology, Blood Neoplasms and Bone Marrow Transplantation, Wroclaw Medical University, Wroclaw, Poland
| | | | - Susana Vives
- ICO-Hospital Universitari Germans Trias i Pujol, Jose Carreras Research Institute, Badalona, Spain
| | | | | | | | | | - Salut Brunet
- Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | | | | | | | - Félix Manso
- Hospital General de Albacete, Albacete, Spain
| | - Jesús Arias
- Hospital Universitario Lucus Augusti, Lugo, Spain
| | | | | | | | - Manuel Barrios
- Hospital Regional Universitario Carlos Haya, Málaga, Spain
| | | | - Andrés Novo
- Hospital Universitari Son Espases, Palma, Spain
| | - Miguel A Sanz
- Hospital Universitari i Politècnic La Fe, Valencia, Spain.,CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Pau Montesinos
- Hospital Universitari i Politècnic La Fe, Valencia, Spain.,CIBERONC, Instituto Carlos III, Madrid, Spain
| | | |
Collapse
|
18
|
David S, Mathews V. Mechanisms and management of coagulopathy in acute promyelocytic leukemia. Thromb Res 2018; 164 Suppl 1:S82-S88. [PMID: 29703489 DOI: 10.1016/j.thromres.2018.01.041] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 01/24/2018] [Indexed: 11/28/2022]
Abstract
Acute promyelocytic leukemia (APL) is a subtype of leukemia which is associated with unique and distinctive coagulopathy. In the absence of treatment it is rapidly fatal and even after initiation of therapy the major cause of early mortality is related to hemorrhagic complications. The coagulopathy can be exacerbated with the start of treatment. In the absence of early hemorrhage related deaths the probability of cure exceeds 90% in low and intermediate risk patients and 80% even in high risk patients, highlighting the importance of understanding the pathophysiology of this complication and instituting prompt and appropriate management strategies. The coagulopathy in APL is complex and results from a combination of thrombocytopenia, disseminated intravascular coagulation and hyperfibronlysis. Recently the effect of all-trans retinioc acid (ATRA) induced ETosis on exacerbating coagulopathy in the first few days after starting therapy with this agent raises the potential for potentially novel strategies to reduce the risk of hemorrhage. Currently management is mainly related to rapid initiation of therapy with ATRA along with appropriate and adequate replacement of blood products to correct the coagulopathy. There is limited role for the use of low dose anti-coagulants and anti-fibrinolytic agents in the initial management of this disease. There is limited data on the use of rFVIIa or the use of global tests of hemostasis in the management of this condition.
Collapse
Affiliation(s)
- Sachin David
- Department of Haematology, Christian Medical College, Vellore, India
| | - Vikram Mathews
- Department of Haematology, Christian Medical College, Vellore, India.
| |
Collapse
|
19
|
Pikman Y, Stegmaier K. Targeted therapy for fusion-driven high-risk acute leukemia. Blood 2018; 132:1241-1247. [PMID: 30049809 PMCID: PMC6148448 DOI: 10.1182/blood-2018-04-784157] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 07/14/2018] [Indexed: 11/20/2022] Open
Abstract
Despite continued progress in drug development for acute leukemias, outcomes for patients with some subtypes have not changed significantly in the last decade. Recurrent chromosomal translocations have long been recognized as driver events in leukemia, and many of these oncogenic fusions portend high-risk disease. Improved understanding of the molecular underpinnings of these fusions, coupled with novel chemistry approaches, now provide new opportunity for therapeutic inroads into the treatment of leukemia driven by these fusions.
Collapse
Affiliation(s)
- Yana Pikman
- Division of Hematology/Oncology, Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston Children's Hospital, Boston, MA; and
| | - Kimberly Stegmaier
- Division of Hematology/Oncology, Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston Children's Hospital, Boston, MA; and
- Broad Institute of Massachusetts Institute of Technology and Harvard University, Cambridge, MA
| |
Collapse
|
20
|
McCulloch D, Brown C, Iland H. Retinoic acid and arsenic trioxide in the treatment of acute promyelocytic leukemia: current perspectives. Onco Targets Ther 2017; 10:1585-1601. [PMID: 28352191 PMCID: PMC5359123 DOI: 10.2147/ott.s100513] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Acute promyelocytic leukemia (APL) is a distinct subtype of acute myeloid leukemia (AML) with a unique morphological appearance, associated coagulopathy and canonical balanced translocation of genetic material between chromosomes 15 and 17. APL was first described as a distinct subtype of AML in 1957 by Dr Leif Hillestad who recognized the pattern of an acute leukemia associated with fibrinolysis, hypofibrinogenemia and catastrophic hemorrhage. In the intervening years, the characteristic morphology of APL has been described fully with both classical hypergranular and variant microgranular forms. Both are characterized by a balanced translocation between the long arms of chromosomes 15 and 17, [t(15;17)(q24;q21)], giving rise to a unique fusion gene PML-RARA and an abnormal chimeric transcription factor (PML-RARA), which disrupts normal myeloid differentiation programs. The success of current treatments for APL is in marked contrast to the vast majority of patients with non-promyelocytic AML. The overall prognosis in non-promyelocytic AML is poor, and although there has been an improvement in overall survival in patients aged <60 years, only 30%-40% of younger patients are still alive 5 years after diagnosis. APL therapy has diverged from standard AML therapy through the empirical discovery of two agents that directly target the molecular basis of the disease. The evolution of treatment over the last 4 decades to include all-trans retinoic acid and arsenic trioxide, with chemotherapy limited to patients with high-risk disease, has led to complete remission in 90%-100% of patients in trials and rates of overall survival between 86% and 97%.
Collapse
Affiliation(s)
- Derek McCulloch
- Institute of Hematology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Christina Brown
- Institute of Hematology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Harry Iland
- Institute of Hematology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| |
Collapse
|
21
|
Kantarjian H. Acute myeloid leukemia--major progress over four decades and glimpses into the future. Am J Hematol 2016; 91:131-45. [PMID: 26598393 DOI: 10.1002/ajh.24246] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 11/18/2015] [Indexed: 12/17/2022]
Abstract
In this Review, the progress in research and therapy of acute myeloid leukemia is detailed.
Collapse
Affiliation(s)
- Hagop Kantarjian
- Department of Leukemia; MD Anderson Cancer Center; Houston Texas
| |
Collapse
|
22
|
Acute promyelocytic leukemia: where did we start, where are we now, and the future. Blood Cancer J 2015; 5:e304. [PMID: 25885425 PMCID: PMC4450325 DOI: 10.1038/bcj.2015.25] [Citation(s) in RCA: 181] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 02/13/2015] [Indexed: 01/07/2023] Open
Abstract
Historically, acute promyelocytic leukemia (APL) was considered to be one of the most fatal forms of acute leukemia with poor outcomes before the introduction of the vitamin A derivative all-trans retinoic acid (ATRA). With considerable advances in therapy, including the introduction of ATRA initially as a single agent and then in combination with anthracyclines, and more recently by development of arsenic trioxide (ATO)-containing regimens, APL is now characterized by complete remission rates of 90% and cure rates of ∼80%, even higher among low-risk patients. Furthermore, with ATRA-ATO combinations, chemotherapy may safely be omitted in low-risk patients. The disease is now considered to be the most curable subtype of acute myeloid leukemia (AML) in adults. Nevertheless, APL remains associated with a significant incidence of early death related to the characteristic bleeding diathesis. Early death, rather than resistant disease so common in all other subtypes of AML, has emerged as the major cause of treatment failure.
Collapse
|
23
|
Lancet JE. Postremission Therapy in Acute Promyelocytic Leukemia: Room for Improvement? J Clin Oncol 2014; 32:3692-6. [DOI: 10.1200/jco.2014.56.5549] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
24
|
Arsenic trioxide induces oxidative stress, DNA damage, and mitochondrial pathway of apoptosis in human leukemia (HL-60) cells. JOURNAL OF EXPERIMENTAL & CLINICAL CANCER RESEARCH : CR 2014; 33:42. [PMID: 24887205 PMCID: PMC4049373 DOI: 10.1186/1756-9966-33-42] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 05/11/2014] [Indexed: 01/03/2023]
Abstract
Background Acute promyelocytic leukemia (APL) is a subtype of acute myeloid leukemia (AML), which accounts for approximately 10% of all acute myloid leukemia cases. It is a blood cancer that is formed by chromosomal mutation. Each year in the United States, APL affects about 1,500 patients of all age groups and causes approximately 1.2% of cancer deaths. Arsenic trioxide (ATO) has been used successfully for treatment of APL patients, and both induction and consolidated therapy have resulted in complete remission. Recently published studies from our laboratory have demonstrated that ATO pharmacology as an anti-leukemic drug is associated with cytotoxic and genotoxic effects in leukemia cells. Methods In the present study, we further investigated the detailed molecular mechanism of ATO-mediated intrinsic pathway of apoptosis; using HL-60 cells as a test model. Oxidative stress was assessed by spectrophotometric measurements of MDA and GSH levels while genotoxicity was determined by single cell gel electrophoresis (Comet assay). Apoptosis pathway was analyzed by Western blot analysis of Bax, Bcl2 and caspase 3 expression, as well as immunocytochemistry and confocal imaging of Bax and Cyt c translocation and mitochondrial membrane potential depolarization. Results ATO significantly (p < 0.05) induces oxidative stress, DNA damage, and caspase 3 activityin HL-60 cells in a dose-dependent manner. It also activated the intrinsic pathway of apoptosis by significantly modulating (p < 0.05) the expression and translocation of apoptotic molecules and decreasing the mitochondrial membrane potential in leukemia cells. Conclusion Taken together, our research demonstrated that ATO induces mitochondrial pathway of apoptosis in HL-60 cells. This apoptotic signaling is modulated via oxidative stress, DNA damage, and change in mitochondrial membrane potential, translocation and upregulation of apoptotic proteins leading programmed cell death.
Collapse
|
25
|
Kwaan HC, Cull EH. The coagulopathy in acute promyelocytic leukaemia – What have we learned in the past twenty years. Best Pract Res Clin Haematol 2014; 27:11-8. [DOI: 10.1016/j.beha.2014.04.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
26
|
Zhou GB, Chen SJ, Chen Z. Acute promyelocytic leukemia: A model of molecular target based therapy. Hematology 2013; 10 Suppl 1:270-80. [PMID: 16188687 DOI: 10.1080/10245330512331390519] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Leukemia, a group of hematological malignancies characterized by clonal expansion of hematopoietic cells with uncontrolled proliferation, decreased apoptosis and blocked differentiation, is one of the most notorious enemies of mankind which accounts for some 300,000 new cases and 222,000 deaths each year worldwide. Leukemia can be divided into acute or chronic, lymphoid or myeloid types, based on the disease progression and hematopoietic lineages involved 5. The responses of leukemia to therapies differ from one type or subtype to another. Hence, to improve the clinical outcome, the therapeutic strategies should be disease pathogenesis-based and individualized. The close collaboration between bench and bedside may not only shed new lights on leukemogenesis, gain insights into therapeutic mechanisms, but also provide opportunities for designing more rational therapies. The development of curative approaches for acute promyelocytic leukemia (APL) may serve as a paradigm.
Collapse
Affiliation(s)
- Guang-Biao Zhou
- Shanghai Institute of Hematology, Rui Jin Hospital Affiliated to Shanghai Second Medical University 197, Rui Jin Road II, Shanghai, 200025, China
| | | | | |
Collapse
|
27
|
Larsen AM, Leinøe EB, Johansson PI, Birgens H, Ostrowski SR. High syndecan-1 levels in acute myeloid leukemia are associated with bleeding, thrombocytopathy, endothelial cell damage, and leukocytosis. Leuk Res 2013; 37:777-83. [DOI: 10.1016/j.leukres.2013.02.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Revised: 02/14/2013] [Accepted: 02/17/2013] [Indexed: 10/27/2022]
|
28
|
Park J, Jurcic JG, Rosenblat T, Tallman MS. Emerging new approaches for the treatment of acute promyelocytic leukemia. Ther Adv Hematol 2013; 2:335-52. [PMID: 23556100 DOI: 10.1177/2040620711410773] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
The introduction of all-trans retinoic acid (ATRA) in the late 1980s combined with anthracycline-based chemotherapy has revolutionized the prognosis of acute promyelocytic leukemia (APL) with more than 90% complete response rates and cure rates of approximately 80%. The subsequent advent of arsenic trioxide (ATO) in 1990s and progress in the treatment of APL have changed its course from a highly fatal to a highly curable disease. Despite the dramatic improvement in clinical outcome of APL, treatment failure still occurs due most often to early death. Relapse has become increasingly less frequent, most commonly occurring in patients with high-risk disease. A major focus of research for the past decade has been to develop risk-adapted and rationally targeted nonchemotherapy treatment strategies to reduce treatment-related morbidity and mortality to low- and intermediate-risk or older patients while targeting more intensive or alternative therapy to those patients at most risk of relapse. In this review, emerging new approaches to APL treatment with special emhasis on strategies to reduce early deaths, risk-adapted therapy during induction, consolidation and maintenance, as well as an overview of current and future clinical trials in APL will be discussed.
Collapse
Affiliation(s)
- Jae Park
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY, USA
| | | | | | | |
Collapse
|
29
|
Chen Y, Kantarjian H, Wang H, Cortes J, Ravandi F. Acute promyelocytic leukemia: a population-based study on incidence and survival in the United States, 1975-2008. Cancer 2012; 118:5811-8. [PMID: 22707337 PMCID: PMC4180246 DOI: 10.1002/cncr.27623] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Revised: 03/20/2012] [Accepted: 04/02/2012] [Indexed: 11/07/2022]
Abstract
BACKGROUND With the introduction of all-trans retinoic acid and arsenic trioxide, the management of acute promyelocytic leukemia (APL) has changed dramatically. We performed a population-based study of APL in the United States to determine its incidence and relative survival (RS) during a 34-year period. METHODS We identified 1397 patients diagnosed with APL between 1975 and 2008 in the Surveillance, Epidemiology, and End Results database. Patients were categorized into 4 age groups and 3 calendar periods. As a comparison, we also reviewed the outcome of APL patients treated at our institution during approximately the same time interval. RESULTS The incidences of APL increased with time period and patient age. Short- and long-term RS improved with each calendar period, with the greatest improvement occurring between 1991 and 1999; 5-year RS rates were 0.18 for patients diagnosed in 1975-1990, 0.52 in 1991-1999, and 0.64 in 2000-2008. Age was an important predictor of survival. For example, the 5-year RS rate in patients diagnosed in 2000-2008 was 0.38 for patients aged ≥ 60 years and 0.73 and 0.75 for patients aged <20 years and 20-39 years, respectively. Similar treads of improvements in the survival were observed in APL patients treated at our institution. CONCLUSIONS The incidence of APL has increased, especially in the last decade. Clinical outcome improved remarkably in patients with APL diagnosed from 1991 to 1999, mainly because of the increased use of all-trans retinoic acid.
Collapse
Affiliation(s)
- Yiming Chen
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Texas
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Texas
| | - Haijun Wang
- The University of Texas MD Anderson Cancer Center; Texas, Children Hospital
| | - Jorge Cortes
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Texas
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Texas
| |
Collapse
|
30
|
Elemam O, Abdelmoety D. Acute promyelocytic leukemia, study of predictive factors for Differentiation Syndrome, single center experience. J Egypt Natl Canc Inst 2012; 25:13-9. [PMID: 23499202 DOI: 10.1016/j.jnci.2012.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Revised: 10/18/2012] [Accepted: 10/24/2012] [Indexed: 12/12/2022] Open
Abstract
Reports about patients with acute promyelocytic leukemia from the Middle East are few; in this study we are reporting our single center experience of treating 29 patients over 6years. Acute promyelocytic leukemia treatment response is markedly improved after the introduction of ATRA. Treatment related complication is still an important issue particularly Differentiation Syndrome. Prediction to its occurrence has been tried by other groups. We aimed to study all the possible predictive factors of acute promyelocytic leukemia. Our chemotherapy induction protocol is AIDA protocol which includes ATRA 45mg/m(2)/d in divided doses every12h, and Idarubicin 12mg/m(2)/d IV on days 3, 5, 7, and 9. Differentiation Syndrome occurred in 48.3% of patients and was mainly presented by pulmonary symptoms in 55.2%, 6 cases died during induction. None of the predictive factors studied showed a statistically significant difference between patients who developed Differentiation Syndrome and those who did not. Differentiation Syndrome did not affect overall survival. Cox regression showed an inverse yet a non significant association between PETHEMA and overall survival probability (P=0.168). In conclusion, Differentiation Syndrome has no clear predictive factor to date. The best approach is to hold ATRA and give dexamethasone which is quite effective as reported in the literature. PETHEMA risk model has a moderately significant prognostic value.
Collapse
Affiliation(s)
- Omyma Elemam
- Department of Medical Oncology, Oncology Center, Mansoura University, Egypt
| | | |
Collapse
|
31
|
Abstract
Genetic and epigenetic events within a cell which promote a block in normal development or differentiation coupled with unregulated proliferation are hallmarks of neoplastic transformation. Differentiation therapy involves the use of agents with the ability to induce differentiation in cells that have lost this ability, i.e. cancer cells. The promise of differentiation-based therapy as a viable treatment modality is perhaps best characterized by the addition of retinoids in the treatment of acute promyelocytic leukemia (APML) revolutionizing the management of APML and dramatically improving survival. However, interest and application of differentiationbased therapy for the treatment of solid malignancies have lagged due to deficiencies in our understanding of differentiation pathways in solid malignancies. Over the past decade, a differentiation-based developmental model for solid tumors has emerged providing insights into the biology of various solid tumors as well as identification of targetable pathways capable of re-activating blocked terminal differentiation programs. Furthermore, a variety of agents including retinoids, histone deacetylase inhibitors (HDACI), PPARγ agonists, and others, currently in use for a variety of malignancies, have been shown to induce differentiation in solid tumors. Herein we discuss the relevancy of differentiation-based therapies in solid tumors, using soft tissue sarcomas (STS) as a biologic and clinical model, and review the preclinical data to support its role as a promising modality of therapy for the treatment of solid tumors.
Collapse
Affiliation(s)
- Filemon Dela Cruz
- Division of Pediatric Oncology, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | | |
Collapse
|
32
|
Yildirim R, Gundogdu M, Ozbıcer A, Kiki I, Erdem F, Dogan H. Acute promyelocytic leukemia, centre, experience, Turkey. Transfus Apher Sci 2012; 48:45-9. [PMID: 22892289 DOI: 10.1016/j.transci.2012.06.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2011] [Revised: 06/06/2012] [Accepted: 06/29/2012] [Indexed: 01/03/2023]
Abstract
Acute promyelocytic leukemia (APL) is a specific type of acute myeloid leukemia (AML) and has distinct hematopathologic, cytogenetic, clinical and molecular features. This study was a retrospective review of 18 adult patients (10 male, 8 female; mean age of 32.17 ± 5.66 (15-61 years) with APL at our department from January 2006 to December 2011. Following induction therapy, 17 patients achieved CR, 1 of 18 patients died of result bleeding within thirty-sixth hours of admission. In two of 18 patients developed RAS. The relapse rate was 27% (5/18). Fourteen of 18 patients (77%) have been followed in remission. APL is a malignancy requiring quick diagnosis, efficient treatment and supportive care system. ATO, one of the important therapy option in the treatment of APL, cannot be obtained easily in developing countries. This may lead to an increase in the mortality rates. The studies should be made with more number of patients and a longer period of time for accurate results.
Collapse
Affiliation(s)
- Rahsan Yildirim
- Department of Hematology, Medical School, Ataturk University, Erzurum, Turkey.
| | | | | | | | | | | |
Collapse
|
33
|
Choudhry A, DeLoughery TG. Bleeding and thrombosis in acute promyelocytic leukemia. Am J Hematol 2012; 87:596-603. [PMID: 22549696 DOI: 10.1002/ajh.23158] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Revised: 01/31/2012] [Accepted: 02/04/2012] [Indexed: 11/11/2022]
Abstract
Acute promyelocytic leukemia (APL) has evolved from being a deadly to a highly curable disease, due to targeted molecular therapy with all-trans retinoic acid (ATRA). As a result, the incidence of early hemorrhagic deaths for which APL is notorious has reduced to 5-10% as reported in clinical trials. These results are not replicated outside of clinical trials as is evident from recent population-based registries. High incidence of early hemorrhagic deaths remains the greatest contributor to treatment failure in this otherwise curable leukemia. Additionally, thrombosis is now being increasingly recognized in APL patients and may be associated with ATRA usage.
Collapse
Affiliation(s)
- Aditi Choudhry
- Legacy Emanuel and Legacy Good Samaritan Hospitals Internal Medicine Residency Training Program, 3181 SW Sam Jackson Park Road, Portland, OR 97201-3098, USA
| | | |
Collapse
|
34
|
Epidemiology, diagnosis and treatment of acute promyelocytic leukemia in children: the experience in china. Mediterr J Hematol Infect Dis 2012; 4:e2012012. [PMID: 22550558 PMCID: PMC3340987 DOI: 10.4084/mjhid.2012.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Accepted: 02/11/2011] [Indexed: 11/08/2022] Open
Abstract
Acute promyelocytic leukemia (APL) is the subtype of acute myeloid leukemia characterized by an accumulation of abnormal promyelocytes in bone marrow, a severe bleeding tendency and the presence of the chromosomal translocation t(15;17) or variants. APL, the most fatal type of leukemia two decades ago, is highly curable with current treatment strategies. There is evidence that the incidence of APL varies across ethnic groups and that genetic factors play a role in the etiology of APL. And there are some difference between children and adults in APL.1-3 The limited data of children available in many developing countries suggest that the rate of early mortality is high and that long-term survival is poor. Death from bleeding and infection during chemotherapy, relapse and treatment abandonment are among the main cause of treatment failure in APL children as well in adults.2 The status of children APL treatment in China has not been described in general.Here we describe the epidemiology and treatment of APL in children in China. In addition, we review the results of a survey of its clinical manifestations and outcome in China.
Collapse
|
35
|
Powell BL. Arsenic trioxide in acute promyelocytic leukemia: potion not poison. Expert Rev Anticancer Ther 2012; 11:1317-9. [PMID: 21929304 DOI: 10.1586/era.11.128] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
36
|
Abstract
The leukemias and lymphomas represent a heterogenous group of hematologic malignancies with protean manifestations. Neurologic sequelae of the diseases have been recognized almost since the time the conditions were first described in the mid-1800s. Although our understanding of the various presentations of these blood disorders has evolved along with our knowledge of the malignancies, accurate diagnosis can still be difficult. It is critical for neurologists to have a high index of clinical suspicion to appropriately recognize the heralding features. This review focuses on the relevant clinical neurologic features and diagnostic studies to identify leukemias and lymphomas affecting the nervous system.
Collapse
|
37
|
Suárez-Cuenca JA, Arellano-Sánchez JL, Scherling-Ocampo AA, Sánchez-Hernández G, Pérez-Guevara D, Chalapud-Revelo JR. Rapidly progressing, fatal and acute promyelocytic leukaemia that initially manifested as a painful third molar: a case report. J Med Case Rep 2009; 3:102. [PMID: 19946580 PMCID: PMC2783043 DOI: 10.1186/1752-1947-3-102] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2008] [Accepted: 11/03/2009] [Indexed: 11/21/2022] Open
Abstract
Introduction Acute promyelocytic leukaemia, an uncommon and devastating subtype of leukaemia, is highly prevalent in Latin American populations. The disease may be detected by a dentist since oral signs are often the initial manifestation. However, despite several cases describing oral manifestations of acute promyelocytic leukaemia and genetic analysis, reports of acute promyelocytic leukaemia in Hispanic populations are scarce. The identification of third molar pain as an initial clinical manifestation is also uncommon. This is the first known case involving these particular features. Case presentation A 24-year-old Latin American man without relevant antecedents consulted a dentist for pain in his third molar. After two dental extractions, the patient experienced increased pain, poor healing, jaw enlargement and bleeding. A physical examination later revealed that the patient had pallor, jaw enlargement, ecchymoses and gingival haemorrhage. Laboratory findings showed pancytopaenia, delayed coagulation times, hypoalbuminaemia and elevated lactate dehydrogenase. Splenomegaly was detected on ultrasonography. Peripheral blood and bone marrow analyses revealed a hypercellular infiltrate of atypical promyelocytic cells. Cytogenetic analysis showing genetic translocation t(15;17) further confirmed acute promyelocytic leukaemia. Despite early chemotherapy, the patient died within one week due to intracranial bleeding secondary to disseminated intravascular coagulation. Conclusion The description of this unusual presentation of acute promyelocytic leukaemia, the diagnostic difficulties and the fatal outcome are particularly directed toward dental surgery practitioners to emphasise the importance of clinical assessment and preoperative evaluation as a minimal clinically-oriented routine. This case may also be of particular interest to haematologists, since the patient's cytogenetic analysis, clinical course and therapeutic response are well documented.
Collapse
Affiliation(s)
- Juan A Suárez-Cuenca
- Department of Internal Medicine, Ticomán General Hospital, SSDF Mexico City, Mexico
| | | | | | | | | | | |
Collapse
|
38
|
Stein E, McMahon B, Kwaan H, Altman JK, Frankfurt O, Tallman MS. The coagulopathy of acute promyelocytic leukaemia revisited. Best Pract Res Clin Haematol 2009; 22:153-63. [PMID: 19285282 DOI: 10.1016/j.beha.2008.12.007] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Since the initial description of the disease, the life-threatening coagulopathy associated with acute promyelocytic leukaemia (APL) has been the defining clinical characteristic. Historically, this uncommon subtype of acute myeloid leukaemia has been associated with a high mortality rate during induction therapy, most frequently attributable to haemorrhage. Since the introduction of all-trans retinoic acid (ATRA) into the therapy of all patients with APL, disease-free survival and overall survival have improved dramatically, such that the disease is now highly curable. However, induction mortality remains a major problem and haemorrhage still accounts for the majority of such early deaths. Pathogenesis of the coagulopathy is complex and includes disseminated intravascular coagulation (DIC), fibrinolysis and proteolysis. As a result, while the predominant clinical manifestation of the coagulopathy is haemorrhage, thromboembolic events may occur both at presentation and during therapy. A major recent finding is the high expression of annexin II in the leukaemic cells from patients with APL. Annexin II is a protein with high affinity for plasminogen and tissue-type plasminogen activator (tPA), and also acts as a cofactor for plasminogen activation by tPA. As a result, both plasminogen and tPA are increased on the cell surface of the leukaemic cell, increasing plasmin activity. Annexin II is expressed in high amounts in cerebral microvascular endothelial cells, perhaps accounting for the relatively high incidence of intracranial haemorrhage in APL compared with other sites. Microparticles are cell-derived membrane fragments originating from normal cells or released from malignant cells involved in activating coagulation. Recent studies have found that microparticles containing tissue factor, tPA, plasminogen activator inhibitor-1 and annexin II have been found in the plasma of APL patients, suggesting a role in pathogenesis of the coagulopathy. Treatment of the coagulopathy remains primarily supportive. Aggressive transfusions of platelets and cryoprecipitate appear to be important. There is no clear role for the routine use of heparin or antifibrinolytic therapy. The most important factor may be the early introduction of ATRA at the first suspicion of a diagnosis of APL, before it is confirmed genetically.
Collapse
Affiliation(s)
- Eytan Stein
- Northwestern University Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center, Division of Hematology Oncology, 676 N. St. Clair Street Suite 850, Chicago, IL 60611, USA
| | | | | | | | | | | |
Collapse
|
39
|
Fenaux P, Vandenbossche-Simon L, Pollet JP, Nelken B, Zandecki M, Bauters F. Acute Promyelocytic Leukemia in Children: a Report on Eleven Cases. Leuk Lymphoma 2009; 2:399-405. [DOI: 10.3109/10428199009069293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
|
40
|
Fenaux P, Pollet JP, Vandenbossche-simon L, Morel P, Zandecki M, Jouet JP, Bauters F. Treatment of Acute Promyelocytic Leukemia: A Report of 70 Cases. Leuk Lymphoma 2009; 4:239-48. [DOI: 10.3109/10428199109068072] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
|
41
|
|
42
|
Thomas X, Archimbaud E, Treille-ritouet D, Fiere D. Prognostic Factors in Acute Promyelocytic Leukemia: A Retrospective Study of 67 Cases. Leuk Lymphoma 2009; 4:249-56. [DOI: 10.3109/10428199109068073] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
43
|
Chim CS, Kwong YL. Adverse prognostic impact ofCDKN2Bhyper-methylationin acute promyelocytic leukemia. Leuk Lymphoma 2009; 47:815-25. [PMID: 16753865 DOI: 10.1080/10428190500513827] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The use of all-trans retinoic acid (ATRA) has markedly improved the survival of patients with acute promyelocytic leukemia (APL), making it potentially curable. However, the identification of prognostic markers predictive of durable remission remains an important aspect in risk-adjusted treatment algorithms. High presentation leucocyte count has been found to correlate with inferior disease-free-survival (DFS). However, recent studies have also shown aberrant promoter methylation of the CDKN2B (alias p15) gene to be a negative prognostic factor. Promoter methylation results in the formation of a repressor complex, leading to chromatin compaction and suppression of gene expression and is, therefore, an alternative mechanism of gene inactivation. CDKN2B, a cyclin-dependent kinase inhibitor, is a tumor suppressor gene inhibiting cell cycle progression. The CpG island inside the CDKN2B promoter is hyper-methylated in approximately 50 - 60% of APL patients. CDKN2B methylation correlates negatively with DFS. As methylation-induced inactivation of CDKN2B pre-disposes to unchecked cellular proliferation, CDKN2B hyper-methylation is also associated with high presentation leucocyte count. Multivariate analysis in several studies, however, has shown that the negative prognostic impact of CDKN2B methylation is independent of its association with high leucocyte counts. Therefore, CDKN2B methylation is a potential prognostic factor that may be incorporated into a risk-stratified therapeutic strategy, which aims at achieving a cure with optimal amounts of treatment.
Collapse
Affiliation(s)
- Chor-Sang Chim
- Department of Medicine, University of Hong Kong, Hong Kong, PR China
| | | |
Collapse
|
44
|
Kelaidi C, Chevret S, De Botton S, Raffoux E, Guerci A, Thomas X, Pigneux A, Lamy T, Rigal-Huguet F, Meyer-Monard S, Chevallier P, Maloisel F, Deconinck E, Ferrant A, Fegueux N, Ifrah N, Sanz M, Dombret H, Fenaux P, Adès L. Improved Outcome of Acute Promyelocytic Leukemia With High WBC Counts Over the Last 15 Years: The European APL Group Experience. J Clin Oncol 2009; 27:2668-76. [PMID: 19414681 DOI: 10.1200/jco.2008.18.4119] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PurposeAcute promyelocytic leukemia (APL) with pretreatment WBC counts greater than 10,000/μL is still considered to carry a poorer prognosis than APL with WBC lower than 10,000/mL. We evaluated outcome improvement in such patients in recent years.Patients and MethodsNine hundred two patients with APL, including 204 patients and 68 patients with WBC counts more than 10,000/μL and more than 50,000/μL, respectively, were enrolled between 1993 and 2005 in two successive randomized trials of the European APL group (APL 93 and APL 2000) that tested, in particular, the modalities of combination of all-trans retinoic acid (ATRA) and chemotherapy, maintenance treatment, escalating doses of cytarabine, early administration of dexamethasone, and CNS prophylaxis.ResultsBetween the APL 93 and 2000 trials, the complete response (CR) rate increased from 89.6% to 93%, and the 5-year cumulative incidence of relapse (CIR) decreased from 40% to 9.5% in patients with WBC counts of 10,000 to 50,000/μL. In patients with WBC counts more than 50,000/μL, the CR rate increased from 82% to 91%, and 5-year CIR decreased from 59% to 24%. Whereas in the APL 93 trial, increased WBC counts were significantly associated with higher CIR and shorter survival, this was not the case in the APL 2000 trial. In patients with increased WBC counts, enrollment onto the APL 2000 trial (v APL 93) and combined maintenance with ATRA and chemotherapy were associated with significantly lower CIR and better survival.ConclusionOutcome of APL with high WBC count has markedly improved over the years as a result of fewer early deaths and fewer relapses. Better initial supportive care and combined maintenance treatment have contributed to this improvement.
Collapse
Affiliation(s)
- Charikleia Kelaidi
- From the European APL group, L'Institut National de la Santé et de la Recherche Médicale U848, Villejuif, France
| | - Sylvie Chevret
- From the European APL group, L'Institut National de la Santé et de la Recherche Médicale U848, Villejuif, France
| | - Stéphane De Botton
- From the European APL group, L'Institut National de la Santé et de la Recherche Médicale U848, Villejuif, France
| | - Emmanuel Raffoux
- From the European APL group, L'Institut National de la Santé et de la Recherche Médicale U848, Villejuif, France
| | - Agnès Guerci
- From the European APL group, L'Institut National de la Santé et de la Recherche Médicale U848, Villejuif, France
| | - Xavier Thomas
- From the European APL group, L'Institut National de la Santé et de la Recherche Médicale U848, Villejuif, France
| | - Arnaud Pigneux
- From the European APL group, L'Institut National de la Santé et de la Recherche Médicale U848, Villejuif, France
| | - Thierry Lamy
- From the European APL group, L'Institut National de la Santé et de la Recherche Médicale U848, Villejuif, France
| | - Françoise Rigal-Huguet
- From the European APL group, L'Institut National de la Santé et de la Recherche Médicale U848, Villejuif, France
| | - Sandrine Meyer-Monard
- From the European APL group, L'Institut National de la Santé et de la Recherche Médicale U848, Villejuif, France
| | - Patrice Chevallier
- From the European APL group, L'Institut National de la Santé et de la Recherche Médicale U848, Villejuif, France
| | - Frédéric Maloisel
- From the European APL group, L'Institut National de la Santé et de la Recherche Médicale U848, Villejuif, France
| | - Erick Deconinck
- From the European APL group, L'Institut National de la Santé et de la Recherche Médicale U848, Villejuif, France
| | - Augustin Ferrant
- From the European APL group, L'Institut National de la Santé et de la Recherche Médicale U848, Villejuif, France
| | - Nathalie Fegueux
- From the European APL group, L'Institut National de la Santé et de la Recherche Médicale U848, Villejuif, France
| | - Norbert Ifrah
- From the European APL group, L'Institut National de la Santé et de la Recherche Médicale U848, Villejuif, France
| | - Miguel Sanz
- From the European APL group, L'Institut National de la Santé et de la Recherche Médicale U848, Villejuif, France
| | - Hervé Dombret
- From the European APL group, L'Institut National de la Santé et de la Recherche Médicale U848, Villejuif, France
| | - Pierre Fenaux
- From the European APL group, L'Institut National de la Santé et de la Recherche Médicale U848, Villejuif, France
| | - Lionel Adès
- From the European APL group, L'Institut National de la Santé et de la Recherche Médicale U848, Villejuif, France
| |
Collapse
|
45
|
Causes and prognostic factors of remission induction failure in patients with acute promyelocytic leukemia treated with all-trans retinoic acid and idarubicin. Blood 2008; 111:3395-402. [PMID: 18195095 DOI: 10.1182/blood-2007-07-100669] [Citation(s) in RCA: 246] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
An understanding of the prognostic factors associated with the various forms of induction mortality in patients with acute promyelocytic leukemia (APL) has remained remarkably limited. This study reports the incidence, time of occurrence, and prognostic factors of the major categories of induction failure in a series of 732 patients of all ages (range, 2-83 years) with newly diagnosed APL who received all-trans retinoic acid (ATRA) plus idarubicin as induction therapy in 2 consecutive studies of the Programa de Estudio y Tratamiento de las Hemopatias Malignas (PETHEMA) Group. Complete remission was attained in 666 patients (91%). All the 66 induction failures were due to induction death. Hemorrhage was the most common cause of induction death (5%), followed by infection (2.3%) and differentiation syndrome (1.4%). Multivariate analysis identified specific and distinct pretreatment characteristics to correlate with an increased risk of death caused by hemorrhage (abnormal creatinine level, increased peripheral blast counts, and presence of coagulopathy), infection (age >60 years, male sex, and fever at presentation), and differentiation syndrome (Eastern Cooperative Oncology Group [ECOG] score >1 and low albumin levels), respectively. These data furnish clinically relevant information that might be useful for designing more appropriately risk-adapted treatment protocols aimed at reducing the considerable problem of induction mortality in APL.
Collapse
|
46
|
Zhou GB, Zhang J, Wang ZY, Chen SJ, Chen Z. Treatment of acute promyelocytic leukaemia with all-trans retinoic acid and arsenic trioxide: a paradigm of synergistic molecular targeting therapy. Philos Trans R Soc Lond B Biol Sci 2007; 362:959-71. [PMID: 17317642 PMCID: PMC2435563 DOI: 10.1098/rstb.2007.2026] [Citation(s) in RCA: 106] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
To turn a disease from highly fatal to highly curable is extremely difficult, especially when the disease is a type of cancer. However, we can gain some insight into how this can be done by looking back over the 50-year history of taming acute promyelocytic leukaemia (APL). APL is the M3 type of acute myeloid leukaemia characterized by an accumulation of abnormal promyelocytes in bone marrow, a severe bleeding tendency and the presence of the chromosomal translocation t(15;17) or variants. APL was considered the most fatal type of acute leukaemia five decades ago and the treatment of APL was a nightmare for physicians. Great efforts have been made by scientists worldwide to conquer this disease. The first use of chemotherapy (CT) was unsuccessful due to lack of supportive care and cytotoxic-agent-related exacerbated coagulopathy. The first breakthrough came from the use of anthracyclines which improved the complete remission (CR) rate, though the 5-year overall survival could only be attained in a small proportion of patients. A rational and intriguing hypothesis, to induce differentiation of APL cells rather than killing them, was raised in the 1970s. Laudably, the use of all-trans retinoic acid (ATRA) in treating APL resulted in terminal differentiation of APL cells and a 90-95% CR rate of patients, turning differentiation therapy in cancer treatment from hypothesis to practice. The combination of ATRA with CT further improved the 5-year overall survival. When arsenic trioxide (ATO) was used to treat relapsed APL not only the patients but also the ancient drug were revived. ATO exerts dose-dependent dual effects on APL cells: at low concentration, ATO induces partial differentiation, while at relatively high concentration, it triggers apoptosis. Of note, both ATRA and ATO trigger catabolism of the PML-RARalpha fusion protein which is the key player in APL leukaemogenesis generated from t(15;17), targeting the RARalpha (retinoic acid receptor alpha) or promyelocytic leukaemia (PML) moieties, respectively. Hence, in treating APL both ATRA and ATO represent paradigms for molecularly targeted therapy. At molecular level, ATRA and ATO synergistically modulate multiple downstream pathways/cascades. Strikingly, a clearance of PML-RARalpha transcript in an earlier and more thorough manner, and a higher quality remission and survival in newly diagnosed APL are achieved when ATRA is combined with ATO, as compared to either monotherapy, making APL a curable disease. Thus, the story of APL can serve as a model for the development of curative approaches for disease; it suggests that molecularly synergistic targeted therapies are powerful tools in cancer, and dissection of disease pathogenesis or anatomy of the cancer genome is critical in developing molecular target-based therapies.
Collapse
Affiliation(s)
- Guang-Biao Zhou
- State Key Laboratory of Medical Genomics, Shanghai Institute of Hematology, Ruijin Hospital Affiliated to Shanghai JiaoTong University School of Medicine (SJTUSM)197, Ruijin Road II, Shanghai 200025, People's Republic of China
- Guangzhou Institute of Biomedicine and Health, Chinese Academy of SciencesGuangzhou Sciences Park, Guangzhou 510663, People's Republic of China
| | - Ji Zhang
- State Key Laboratory of Medical Genomics, Shanghai Institute of Hematology, Ruijin Hospital Affiliated to Shanghai JiaoTong University School of Medicine (SJTUSM)197, Ruijin Road II, Shanghai 200025, People's Republic of China
- Institute of Health Science, SJTUSM and Shanghai Institutes of Biological Sciences, CASSouth Chongqing Road, Shanghai 200025, People's Republic of China
| | - Zhen-Yi Wang
- State Key Laboratory of Medical Genomics, Shanghai Institute of Hematology, Ruijin Hospital Affiliated to Shanghai JiaoTong University School of Medicine (SJTUSM)197, Ruijin Road II, Shanghai 200025, People's Republic of China
| | - Sai-Juan Chen
- State Key Laboratory of Medical Genomics, Shanghai Institute of Hematology, Ruijin Hospital Affiliated to Shanghai JiaoTong University School of Medicine (SJTUSM)197, Ruijin Road II, Shanghai 200025, People's Republic of China
| | - Zhu Chen
- State Key Laboratory of Medical Genomics, Shanghai Institute of Hematology, Ruijin Hospital Affiliated to Shanghai JiaoTong University School of Medicine (SJTUSM)197, Ruijin Road II, Shanghai 200025, People's Republic of China
- Author for correspondence ()
| |
Collapse
|
47
|
Abstract
Acute promyelocytic leukemia (APL) is a rare subtype of acute myeloid leukemia (AML) for which a number of targeted therapies have been developed. The "targets" have included both genotypic and phenotypic features of the disease. The application of monoclonal antibodies (MAbs) to this disease to date have been limited to a relatively small number of studies where this therapy has been used to supplement effective approaches to the disease. The preliminary results have been promising, and further development of this modality as an effective adjunct to existing treatment regimens will most certainly occur in the near future.
Collapse
Affiliation(s)
- P G Maslak
- Memorial Sloan-Kettering Cancer Center and Weill Medical College of Cornell University, New York, NY 10021, USA.
| | | | | |
Collapse
|
48
|
Abstract
We review the role of all-trans retinoic acid (ATRA) in the treatment of acute promyelocytic leukemia (APL). The combination of ATRA and conventional anthracycline-ARA-C chemotherapy (CT) has clearly demonstrated its superiority over CT alone (in terms of relapse and survival) in newly diagnosed APL. Combination treatment probably also reduces the incidence of initial failures, and complete remission (CR) rates greater than 90% are now regularly reported in large multicenter trials. Some randomized studies strongly suggest that prolonged maintenance treatment (for 1 or 2 years) with ATRA and low-dose CT, and possibly very early introduction of anthracycline CT during induction treatment, may reduce the incidence of relapse. With those treatments, the relapse risk appears to be only 10%-15%, although it remains greater in patients who initially have high white blood cell counts (often associated with variant M3 morphology, short bcr3 isoform, etc.) and patients with residual disease detectable by RT-PCR at the end of consolidation courses. In those patients, addition of arsenic derivatives to induction or consolidation treatment (or both treatments together) may prove useful and is currently being tested. ATRA syndrome (now generally called APL differentiation syndrome, as it is also seen with arsenic derivatives) remains the major side effect of ATRA treatment. It occurs in 10%-15% of patients and is currently fatal in at least 10% of them. Rapid onset of CT or high dose steroids (or both) should improve its outcome. A sizeable proportion of APL patients who relapse after ATRA and CT can be durably salvaged by the same treatment followed by allogeneic or autologous stem cell transplantation, provided the transplant (in the autologous setting) is RT-PCR-negative. However, in relapsing APL arsenic derivatives (mainly arsenic trioxide) are now considered to be the reference treatment. Some of the current issues with ATRA treatment in newly diagnosed APL include whether ATRA has a role during consolidation treatment and whether arabinoside (AraC) is required in addition to anthracyclines in the chemotherapy combined to ATRA.
Collapse
Affiliation(s)
- P Fenaux
- Service d'Hématologie Clinique, Hôpital Avicenne, Paris 13 University, 93000 Bobigny, France.
| | | | | |
Collapse
|
49
|
Kim H, Lee JH, Choi SJ, Lee JH, Seol M, Lee YS, Kim WK, Lee JS, Lee KH. Risk score model for fatal intracranial hemorrhage in acute leukemia. Leukemia 2006; 20:770-6. [PMID: 16525500 DOI: 10.1038/sj.leu.2404148] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
To build a risk score (RS) model of fatal intracranial hemorrhage (FICH) in patients with acute leukemia, we retrospectively assessed risk factors in 792 patients newly diagnosed with acute leukemia, 41 of whom had analyzable FICH. We found that female gender (relative risk (RR) = 5.234, P<0.001), acute promyelocytic leukemia (RR = 4.057, P = 0.003), leukocytosis (RR = 3.301, P = 0.004), thrombocytopenia (RR = 3.283, P = 0.005) and prolonged prothrombin time (RR = 3.291, P = 0.016) were significantly associated with occurrence of FICH in multivariate analysis. To calculate RS for FICH, one point was assigned for each risk factor, making the RS between 0 and 5. The RS model segregated patients into three prognostic groups: a low-risk group (LRG) for RS of 0 or 1; an intermediate-risk group (IRG) for RS of 2 or 3; and a high-risk group (HRG) for RS of 4 or 5. Expectation of FICH was well correlated with risk groups (all P-values < 0.001). Overall survival was significantly shorter in the HRG compared with the LRG. The RS model we constructed to predict the occurrence of FICH will be verified through prospective studies.
Collapse
Affiliation(s)
- H Kim
- Division of Hematology-Oncology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | | | | | | | | | | | | | | | | |
Collapse
|
50
|
Yi HG, Lim JH, Kim JS, Park HJ, Moon Y, Lee MH, Nahm CH, Kim CS. Ten-year Experience on Acute Promyelocytic Leukemia at Inha University Hospital. THE KOREAN JOURNAL OF HEMATOLOGY 2006. [DOI: 10.5045/kjh.2006.41.4.289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Hyeon Gyu Yi
- Department of Internal Medicine, Inha University Hospital and College of Medicine, Incheon, Korea
| | - Joo Han Lim
- Department of Internal Medicine, Inha University Hospital and College of Medicine, Incheon, Korea
| | - Jin Soo Kim
- Department of Internal Medicine, Inha University Hospital and College of Medicine, Incheon, Korea
| | - Hyun Joo Park
- Department of Internal Medicine, Inha University Hospital and College of Medicine, Incheon, Korea
| | - Yeonsook Moon
- Department of Laboratory Medicine, Inha University Hospital and College of Medicine, Incheon, Korea
| | - Moon Hee Lee
- Department of Internal Medicine, Inha University Hospital and College of Medicine, Incheon, Korea
| | - Chung Hyun Nahm
- Department of Laboratory Medicine, Inha University Hospital and College of Medicine, Incheon, Korea
| | - Chul Soo Kim
- Department of Internal Medicine, Inha University Hospital and College of Medicine, Incheon, Korea
| |
Collapse
|