Factors affecting thrombohemorrhagic early death in patients with acute promyelocytic leukemia treated with arsenic trioxide alone

Factors associated with thrombo-hemorrhagic deaths in patients with Acute Promyelocytic leukemia treated with Arsenic Trioxide and all-trans retinoic acid

Acute Promyelocytic Leukemia (APL) is associated with excellent long-term outcomes. However, early mortality due to coagulopathy remains a challenge. In this study we examined the bleeding and thrombotic manifestations, as well as incidence of Early Death secondary to thrombosis/hemorrhage (ED-TH) in patients with APL. Early death (ED) was defined as death occurring within 30 days of induction therapy. Two-hundred forty-eight patients were included in the study. Overall, 57 patients had evidence of a major bleed/thrombosis at presentation or during induction therapy, including 44 patients with a major bleed, 8 patients with thrombosis and 5 patients with both evidence of thrombosis and a major bleed. Forty patients (16.1%) had ED, of which 21 had ED-TH. The cumulative incidence of death due to thrombo-hemorrhagic complications at 30 days was 8.4%. On univariate analysis, increasing Prothrombin time (PT)(p-<0.001), white blood cell count (p < 0.001) and activated Partial thromboplastin time (aPTT) (p < 0.001) were statistically significantly associated with increased risk of ED-TH. However, on multivariate analysis, only increasing PT (p-0.025) and aPTT (p-0.041) were significantly associated with increased risk of ED-TH.

The Coagulopathy of Acute Promyelocytic Leukemia: An Updated Review of Pathophysiology, Risk Stratification, and Clinical Management

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.

Short-term exposure to some heavy metals carried with PM10 and cardiovascular system biomarkers during dust storm

This study aimed to evaluate the effect of short-term exposure to heavy metals (HM) extracted from PM₁₀ on CB in workers' population in an outdoor space located in southern Iran during a dust storm. At first, 44 healthy and non-smoking workers were selected. Then PM₁₀ and Blood samples were collected before and after the dust storm. Finally, HMs associated with PM₁₀ measured by ICP-MS and its effect on the CB, including fibrinogen, CRP, TNF-α, and BP were estimated by ANOVA, Pearson correlation, and Odd Ratio (OR) in SPSS23. Based on the results, the concentration of PM₁₀ and extracted HM such as Cr, As, and Cd was higher than the WHO/EPA standards in dust storms they increased the CB and BP remarkably. Moreover, the level of fibrinogen, blood pressure (BP) and TNF-α in dust storms were higher than in normal conditions (p < 0.05, OR > 3). In addition, As and Cd decreased fibrinogen concentration and systolic BP, respectively. Whereas, TNF-α was associated with concentration of Pb (R = - 0.85) on normal days. Consequently, the HM on PM₁₀ such as As, interferes with the level of investigated CB. These results considered a potential risk for the residents in the southern regions of Iran.

Value of the FDP/FIB ratio in predicting early severe bleeding events in patients with newly diagnosed acute promyelocytic leukemia

Severe bleeding is the leading cause of early death in patients with newly diagnosed acute promyelocytic leukemia (APL). However, there are no means for hemorrhagic risk stratification in APL. This study aimed to identify optimized predictors of severe bleeding events related to APL. A total of 109 consecutive patients with newly diagnosed APL from January 2015 to April 2022 were retrospectively investigated. A systematic review of computer-based patient medical records was conducted to obtain clinical date, including baseline characteristics, routine blood examination findings, coagulation and fibrinolysis indexes, and bleeding events. Among the 109 patients, 89 were classified into the no-severe bleeding group, while 20 had severe bleeding. Compared with the patients with no severe bleeding, the patients with severe bleeding had significantly higher circulating leukemic cell percentages, disseminated intravascular coagulation (DIC) scores, D-dimer (D-D) levels, and fibrin degradation product (FDP) levels. They also had lower fibrinogen (FIB) levels and a longer prothrombin time. Multivariate analysis revealed that the circulating leukemic cell percentage (OR = 1.040, CI = 1.008-1.072, P = 0.012), FIB level (OR = 0.101, CI = 0.011-0.896, P = 0.040), and FDP level (OR = 1.012, CI = 1.000-1.024, P = 0.047) were independent risk factors for severe bleeding. FDP/FIB, D-D/FIB, and seven meaningful indicators in the single-factor analysis were included in the receiver operating characteristic (ROC) curve analysis. The results showed that FDP/FIB was the best indicator for predicting severe bleeding related to newly diagnosed APL. The area under the ROC curve of FDP/FIB was 0.915, and the best cutoff value was 61.77, with 100% sensitivity and 74.2% specificity. Statistical analysis showed a higher incidence of severe bleeding and higher DIC scores when FDP/FIB was >61.77 in APL patients. FDP/FIB has obvious advantages in predicting the degree of bleeding associated with primary promyelocytic leukemia; the greater the FDP/FIB value, the more severe the bleeding. The risk of severe bleeding was the highest when FDP/FIB > 61.77.

Acute promyelocytic leukaemia: population-based study of epidemiology and outcome with ATRA and oral-ATO from 1991 to 2021

BACKGROUND

The epidemiology and treatment of acute promyelocytic leukaemia (APL) are changing. We have incorporated oral arsenic trioxide (oral-ATO) into induction/maintenance.

METHODS

Newly-diagnosed APL from 1991 to 2021 divided into three 10-year periods were studied to define its epidemiology and how oral-ATO impacted on its outcome. Primary endpoints included APL incidence, early deaths (ED, first 30 days), and overall survival (OS). Secondary endpoints included post-30-day OS, relapse-free survival (RFS), and incidence of second cancers.

RESULTS

APL occurred in 374 males and 387 females at a median age of 44 (1-97) years. Annual incidences increased progressively, averaging 0.32 per 100,000 people. All-trans retinoic acid (ATRA)-based and oral-ATO-based regimens were used in 469 and 282 patients. There were 144 EDs, occurring almost exclusively in ATRA-based inductions (N = 139), being more with males, age > 50 years, leucocyte > 10 × 10⁹/L, diagnosis during 1991-2009 and fewer with oral-ATO-based regimens. After a median of 75 (interquartile range: 14-161) months, 5-year and 10-year OS were 68.1% and 63.3%, inferior with males, age > 50 years, leucocyte > 10 × 10⁹/L, high-risk Sanz score and superior with oral-ATO-based regimens. Factoring out EDs, 5-year and 10-year post-30-day OS were 84.0% and 78.1%, inferior with males and superior with oral-ATO-based regimens. In 607 CR1 patients, the 5-year RFS was 83.8%, superior with diagnosis in 2010-2021 and oral-ATO-based regimens. Second cancers developed in 21 patients, unrelated to oral-ATO-based regimens.

CONCLUSIONS

There was an increasing incidence of APL, and all survivals were superior with the use of oral-ATO-based regimens. This study formed part of the Acute Promyelocytic Leukaemia Asian Consortium Project (ClinicalTrials.gov identifier: NCT04251754).

Effect of Therapeutically Related Drugs on Coagulation-Anticoagulation Balance in Acute Promyelocytic Leukemia

Acute promyelocytic leukemia (APL) usually presents with a series of coagulation-anticoagulation disturbance. Early administration of All-trans retinoic acid (ATRA) can reduce the risk of bleeding, but the potential for thrombosis needs to be addressed in some cases. The role of arsenic agent in correcting coagulation disorder remains to be studied, but oral arsenic agent shows potential advantages in coagulation recovery compared with intravenous agent, and chemotherapy can aggravate the progress of coagulation disease. In addition to early application of ATRA, avoiding invasive procedures and transfusion support can reduce the risk of bleeding. Whether the administration of heparin, thrombomodulin, recombinant factor VIIa or antifibrinolytics reduces the risk of bleeding and thrombosis associated with APL remains to be further explored, and their routine use outside of clinical trials is not recommended. This article reviews the effects of related drugs on coagulation-anticoagulation balance in APL patients.

The evaluation of risk factors leading to early deaths in patients with acute promyelocytic leukemia: a retrospective study

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.

Analysis of risk factors for early death in patients with acute promyelocytic leukaemia treated with arsenic trioxide

To date, no specific studies have evaluated early death (ED) in patients with acute promyelocytic leukaemia (APL) homogeneously treated with arsenic trioxide induction therapy and investigated according to the white blood cell (WBC) count at onset. Such patients were retrospectively analysed in this study, including 314 patients with a WBC count ≤ 10 × 10⁹/L (standard-risk (SR) group) and 144 with a WBC count > 10 × 10⁹/L (high-risk (HR) group). The baseline clinical characteristics and risk factors for ED were compared between the two groups. The incidence of fibrinogen < 1.0 g/L and elevated serum uric acid, aspartate aminotransferase and creatinine levels were higher in the HR group than in the SR group (P = 0.001; P < 0.001; P < 0.001; P = 0.044, respectively). The ED rate was significantly higher in the HR group than in the SR group (29.17% vs. 10.83%, P < 0.001). The main cause of ED was bleeding, followed by infection and differentiation syndrome (DS) in the HR group, while it was bleeding, followed by DS and infection in the SR group. Male sex, age > 50 years old, and fibrinogen < 1.0 g/L were independent risk factors for ED in the SR group. Increased serum creatinine levels, decreased albumin levels, and fibrinogen < 1.0 g/L were independent risk factors for ED in the HR group. Overall, the incidence of ED was higher in the HR group, and the baseline clinical characteristics, causes, times, and predictors of ED in the HR group differed from those in the SR group.

Predictive factors for differentiating thrombohemorrhagic disorders in high-risk acute promyelocytic leukemia

INTRODUCTION

Acute promyelocytic leukemia (APL) is often accompanied by potentially fatal coagulopathy, especially in high-risk APL. Bleeding, particularly severe bleeding is the leading cause of early death (ED). Meanwhile, thrombosis, the other major coagulopathic complication, is being increasingly recognized. However, predictors of thrombohemorrhagic disorders are still not well investigated.

MATERIALS AND METHODS

In this study, we retrospectively studied 83 patients with high-risk APL and categorized them into severe bleeding, thrombosis and no evident events groups.

RESULTS

Severe bleeding was observed in 15 patients, nearly half of whom died of hemorrhage, while thrombosis was observed in 12 patients. Risk factor analysis showed that high WBC (>58.76 × 10⁹/L) (p = 0.001) and prolonged PT (>17.7 s) (p = 0.015) could be independent predictors for severe bleeding, while high WBC/D-dimer>5.12 (p = 0.002) and low D-dimer/FIB<5.14 (p = 0.03) could be independent predictors for thrombosis in high-risk APL patients. Moreover, there are significant differences in WBC/D-dimer and D-dimer/FIB between DIC and Non-DIC groups (p < 0.001). Notably, we found that the WBC/D-dimer was dramatically higher in the thrombotic group than in the other two groups at the time of admission or during the first week of induction therapy.

CONCLUSIONS

High WBC and prolonged PT could predict severe bleeding in high-risk APL patients, while high WBC/D-dimer and low D-dimer/FIB could be independent predictors for thrombosis. For high-risk APL, WBC/D-dimer and D-dimer/FIB are also beneficial in the diagnosis of DIC. WBC/D-dimer might help early identification of thrombosis at the time of admission or during the first week of induction therapy.

Characteristics and predictors of early hospital deaths in newly diagnosed APL: a 13-year population-wide study

Despite therapeutic advances, early death (ED) remains a major factor curtailing survival of acute promyelocytic leukemia (APL). Studies examining factors that cause early death (ED; within 30 days of admission) and the correlation of survival with the timing of administration of all-trans retinoic acid (ATRA) and hemostatic parameters are scarce. We performed a cohort analysis of nonselect patients with newly diagnosed APL who presented to the health care system in Hong Kong, where oral arsenic trioxide was used. From 1 January 2007 to 30 April 2020, 358 patients (median age, 47 [1-97] years) with newly diagnosed APL were identified. ED occurred in 56 patients (16%): 11 (3%) died in the first 2 days after admission (intracranial hemorrhage [ICH], n = 6; APL-differentiation syndrome [APL-DS], n = 4; infection, n = 1); 22 (6%) died within 3 to 7 days (ICH, n = 12; APL-DS, n = 8; infections, n = 2), and 23 (6%) died within 8 to 30 days (ICH, n = 7; APL-DS, n = 11; infection, n = 5). Factors significantly associated with ED by multivariate analysis included male sex (P = .01); presenting leukocyte count ≥10 × 109/L (P = .03); fibrinogen <1.5 g/L (P = .02); and ATRA administration >24 hours after hospital admission (P < .001). After a median follow-up of 47 (0-166) months, the 5- and 10-year overall survival (OS) was 68.6% and 61.2%, respectively. Excluding EDs, the 5- and 10-year post-30-day OS improved to 81.3% and 72.5%. Early administration of ATRA (<24 hours) and vigorous correction of hemostatic abnormalities, including hypofibrinogenemia, are key to reducing ED.

Absolute Circulating Leukemic Cells as a Risk Factor for Early Bleeding Events in Patients with Non-High-Risk Acute Promyelocytic Leukemia

Background

Hemorrhagic complications are the most common cause of early death in patients with APL and remain a major challenge in the management of APL. Early fatal bleeding events occur not only in high-risk but also in non-high-risk acute promyelocytic leukemia (APL) patients with normal or low WBC counts.

Objectives and Methods

To demonstrate the role of the absolute number of circulating leukemic cells in early bleeding events in APL patients. Clinical and laboratory characteristics of 149 patients newly diagnosed with APL were obtained from medical records and retrospectively investigated.

Results

In this study, circulating absolute leukemic cells were positively correlated with the WBC count (r=0.9813, p<0.001) in all patients with APL, and importantly, they were strongly associated with significant bleeding events in non-high-risk patients. Multivariate logistic regression analysis showed that the absolute number of leukemia cells was an independent risk factor for significant bleeding events in APL patients. A cut-off value of 2.59×10⁹/L for circulating leukemic cells to predict significant bleeding events in APL patients was obtained by ROC curve analysis. We further confirmed that the significant bleeding rate of patients with non-high-risk APL was statistically increased when the absolute number of circulating leukemic cells was ≥2.59×10⁹/L.

Conclusion

Circulating leukemic cell content has great clinical value for predicting early bleeding events in APL patients, especially in non-high-risk APL.

[Analysis of early death factors and prognosis of acute promyelocytic leukemia]

目的

总结初诊急性早幼粒细胞白血病（APL）早期死亡患者的临床特征，分析早期死亡的危险因素和直接死亡原因，同时对患者进行生存分析。

方法

回顾性分析2011年1月至2017年12月苏州大学附属第一医院、苏州大学附属第一医院广慈分院、苏州弘慈血液病医院收治的368例初诊APL患者的临床特征，分析早期死亡的独立危险因素，比较出血性早期死亡与非出血性早期死亡患者的临床特征，并对所有APL患者进行生存分析。

结果

368例初诊APL患者中早期死亡31例，早期病死率为8.4%，从诊断至死亡的中位时间为7（0~29）d。比较早期死亡患者与非早期死亡患者的临床特征，应用Logistic回归模型进行多因素分析显示，年龄≥50岁和初诊时WBC≥10×10⁹/L为初诊APL患者发生早期死亡的独立危险因素（P值均<0.01）。31例早期死亡患者中有27例（87.1%）的直接死亡原因为出血，出血是<50岁患者的唯一死亡原因，≥50岁患者的主要死亡原因。比较出血性早期死亡患者与非出血性早期死亡患者的临床特征，提示出血性早期死亡患者的中位年龄和间接胆红素水平较非出血性早期死亡患者低（P<0.05）。所有患者中位随访时间为41.0（0.3~101.4）个月。2年总生存（OS）率为（93.5±1.3）%，5年OS率为（91.0±1.5）%。2年无病生存（DFS）率为（98.8±0.6）%，5年DFS率为（97.1±0.9）%。≥50岁与<50岁患者的2年OS率分别为79.3%和94.2%（P=0.000）；2年DFS率分别为92.3%和98.1%（P=0.023）。高危患者与非高危患者的2年OS率分别为77.3%和96.7%（P=0.000）；2年DFS率分别为94.0%和98.4%（P=0.139）。

结论

年龄≥50岁和WBC≥10×10⁹/L是APL患者早期死亡的独立危险因素；高危和低危APL的早期病死率有差异而DFS率差异无统计学意义。

Management of hemostatic complications in acute leukemia: Guidance from the SSC of the ISTH

Patients with acute leukemia frequently develop thrombocytopenia and hemostatic complications caused by coagulopathy. Coagulopathy complicates the management of these patients and can lead to significant morbidity and mortality. This guidance document aims to review and provide guidance on the management of hemostatic complications in adult patients with acute leukemia, addressing four main issues, including platelet transfusion, disseminated intravascular coagulation, L-asparaginase-related hypofibrinogenemia, and the use of antifibrinolytic agents.

Early intracranial haemorrhages in acute promyelocytic leukaemia: analysis of neuroradiological and clinico-biological parameters

Acute promyelocytic leukaemia (APL) represents a modern success of precision medicine. However, fatalities occurring within the first 30 days of induction treatment, in particular intracranial haemorrhage (ICH), remain the main causes of death. We studied the clinico-biological characteristics of 13 patients with APL who experienced ICH. Compared to 85 patients without this complication, patients with ICH were older and more frequently had high-risk APL. Moreover, positivity for the 'swirl' sign at neuroradiological imaging and hydrocephalus were predictors of a fatal outcome, together with lower fibrinogen, prolonged international normalized ratio (INR) and higher lactate dehydrogenase levels.

The prognostic value of plasma fibrinogen level in patients with acute myeloid leukemia: a systematic review and meta-analysis

Increasing evidence has revealed that plasma fibrinogen levels may serve as prognostic indicators in patients with acute myeloid leukemia (AML), yet the exact association is still elusive. We conducted a systematic review and meta-analysis of all available studies concerning the relationship between plasma fibrinogen level and survival in AML patients. The pooled hazard ratio (HR) and 95% confidence intervals (CIs) for overall survival (OS) were calculated to evaluate the effect. A random-effect model was applied and the robustness of the pooled results was confirmed by subgroup and sensitivity analysis. A total of 9 studies were eligible to assess the association between plasma fibrinogen level and prognosis in AML. Among these investigations above, 5 studies adopted OS as their outcome indicator and were selected for the final meta-analysis. The pooled result suggested that plasma fibrinogen level was significantly relevant to increased mortality risk in AML patients (HR = 1.21, 95% CI: 1.01-1.44, p = .000, I²=85.4%). In conclusion, high plasma fibrinogen level may independently predict worse OS in patients with AML.

Hemorrhage in acute promyelocytic leukemia: Can it be predicted and prevented?

Hemorrhagic death is the leading cause of treatment failure in acute promyelocytic leukemia (APL). Our ability to identify patients at greatest risk of hemorrhage, and to actively prevent hemorrhage, remains limited. Nevertheless, some data is available to guide contemporary clinical practice and future investigation. Circulating disease burden, best represented by the peripheral WBC / blast count, is the most consistent predictor of major and fatal bleeding risk. In contrast, laboratory markers of disseminated intravascular coagulation (DIC) appear to be poor predictors. A number of interventions have been posited to reduce bleeding risk. Prompt initiation of all-trans retinoic acid (ATRA), avoidance of invasive procedures, transfusion support, and cytoreduction all have theoretical merit. Though they lack strong evidence to support their benefit with respect to bleeding, they are associated with limited risks, and are therefore advisable. Low-dose therapeutic heparin and antifibrinolytics have not shown the ability to positively modify bleeding risk, and heparin has been associated with harm. Thrombomodulin has shown promise in limited retrospective studies however further prospective data are needed. rFVIIa may have a role in cases of life-threatening bleeding however evidence is largely anecdotal. Additional studies evaluating the above interventions, and investigating other potential interventions are needed.