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Song X, Chi C, Gao W, Sun W, Liu Y, Zhang X, Huang X, Zhu J, Wang Y. Biochemical risk factors and outcomes of acute promyelocytic leukemia patients with thrombotic events: a matched pair analysis. J Thromb Thrombolysis 2024; 57:828-841. [PMID: 38700714 DOI: 10.1007/s11239-024-02988-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/18/2024] [Indexed: 07/10/2024]
Abstract
Acute promyelocytic leukemia (APL) stands out as a distinctive form of acute leukemia, exhibiting a higher occurrence of thrombotic events when contrasted with other leukemia subtypes. Since thrombosis is a relatively rare but unfavorable condition with poor prognostic implications, it is crucial to determine the risk factors for thrombotic events in APL(thrombosis in large venous or arterial from onset to differentiation therapy in 30d). We performed a retrospective study involving 950 APL patients between January 2000 and October 2022, from which 123 were excluded by younger than 16 years of age, 95 were excluded by incomplete data, and 6 were excluded by thrombosis related to CVC or PICC. A total of 23 APL patients with thrombosis for inclusion in our analysis were performed a 1:5 ratio matching based on sex (perfect match) and age (within 5 years) to patients without thrombosis. These patients were continuously monitored in the outpatient department over a period of 5 years. We meticulously examined clinical and laboratory data to pinpoint the risk factors related to thrombotic events in APL. Our primary clinical endpoints were all-cause mortality and achieving complete remission, while secondary clinical outcomes included APL relapse. Thrombotic events were observed in 2.4% (23/950) of APL patients. Compared to patients without thrombosis, patients with thrombosis had higher lactate dehydrogenase (LDH) [313 (223, 486) vs. 233 (188, 367) U/L, p = 0.020], higher indirect bilirubin [11.2 (7.4, 18.6) vs.8.3 (6.0, 10.7) umol/L, p = 0.004], higher creatinine [72 (62, 85) vs. 63 (54, 74) umol/L, p = 0.026], higher CD2 expression (65.2 vs. 15.2%, p < 0.001), higher CD15 expression (60.9 vs. 24.3%, p = 0.001), and PML/RARαisoforms (p < 0.001). Multivariate-logistic-regression analysis revealed several factors that were markedly related to thrombosis, including LDH (OR≈1.003, CIs≈1.000-1.006, p = 0.021), indirect bilirubin (OR≈1.084, CIs≈1.000-1.188, p = 0.043), CD2 expression positive (OR≈16.629, CIs≈4.001-62.832, p < 0.001), and CD15 expression positive (OR≈7.747, CIs≈2.005-29.941, p = 0.003). The S-type (OR≈0.012, CIs≈0.000-0.310, p = 0.008) and L-type (OR≈0.033, CIs≈0.002-0.609, p = 0.022) PML/RARα isoforms were negatively associated with thrombosis. Kaplan-Meier curves indicated that the survival rates were remarkably varied between APL patients with and without thrombosis (HR:21.34, p < 0.001). LDH and indirect bilirubin are variables significantly associated with thrombosis in APL, S-type and L-type PML/RARαisoforms exhibit a negative association with thrombotic events. The thrombotic events of APL can predict the subsequent survival of thrombosis. The findings of our study have the potential to facilitate early detection of thrombosis and enhance the prognosis for individuals with APL who develop thrombosis. Further validation of our findings will be essential through future prospective or multicenter studies.
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Affiliation(s)
- Xiaojing Song
- Department of Emergency, Peking University People's Hospital, Beijing, 100044, China
| | - Cheng Chi
- Department of Emergency, Peking University People's Hospital, Beijing, 100044, China
| | - Weibo Gao
- Department of Emergency, Peking University People's Hospital, Beijing, 100044, China
| | - Wei Sun
- Department of Hematology, Peking University People's Hospital, Beijing, 100044, China
| | - Yang Liu
- Department of Hematology, Peking University People's Hospital, Beijing, 100044, China
| | - Xiaohui Zhang
- Department of Hematology, Peking University People's Hospital, Beijing, 100044, China
| | - Xiaojun Huang
- Department of Hematology, Peking University People's Hospital, Beijing, 100044, China
| | - Jihong Zhu
- Department of Emergency, Peking University People's Hospital, Beijing, 100044, China.
| | - Yu Wang
- Department of Hematology, Peking University People's Hospital, Beijing, 100044, China.
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de Figueiredo-Pontes LL, Catto LFB, Chauffaille MDLLF, Pagnano KBB, Madeira MIA, Nunes EC, Hamerschlak N, de Andrade Silva MC, Carneiro TX, Bortolheiro TC, de Freitas TT, Bittencourt RI, Maranhão Fagundes E, Magalhães Rego E. Diagnosis and management of acute promyelocytic leukemia: Brazilian consensus guidelines 2024 on behalf of the Brazilian Association of Hematology, Hemotherapy and Cellular Therapy. Hematol Transfus Cell Ther 2024:S2531-1379(24)00253-0. [PMID: 38890097 DOI: 10.1016/j.htct.2024.05.002] [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: 05/06/2024] [Accepted: 05/06/2024] [Indexed: 06/20/2024] Open
Abstract
Improvements in clinical assessment have occurred since the last published recommendations on the diagnosis and treatment of acute promyelocytic leukemia in 2013. Here, a committee of specialists of the Brazilian Association of Hematology, Hemotherapy and Cellular Therapy presents a comprehensive review on the current knowledge, focusing on the advances in diagnosis, risk assessment, and frontline and salvage therapy. The concept of urgent diagnosis is explored as well as the management of critical situations such as coagulopathy and differentiation syndrome. Recent adjustments in risk stratification based on white blood cell counts only are presented together with the incorporation of chemo-free regimens for non-high-risk patients. Special conditions such as acute promyelocytic leukemia in children, the elderly and pregnant women are discussed. Finally, acute promyelocytic leukemia is presented as a highly curable disease because of the real possibility of targeted therapy towards differentiation, and, paradoxically, as a serious and urgent condition that deserves prompt recognition and management to avoid early mortality.
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Affiliation(s)
| | - Luiz Fernando Bazzo Catto
- Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil; Translational Stem Cell Biology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | | | | | - Maria Isabel Ayrosa Madeira
- Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | - Elenaide Coutinho Nunes
- Unidade de Hematologia e Oncologia do Hospital das Clínicas da Universidade Federal do Paraná, Curitiba, PR, Brazil and Instituto Pasquini de Hematologia e Transplante, Hospital Nossa Senhora das Graças, Curitiba, PR, Brazil
| | | | | | | | - Teresa Cristina Bortolheiro
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Irmandade da Santa Casa de São Paulo da Santa Casa de São Paulo, São Paulo, SP, Brazil
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Hisada Y. Dysregulated hemostasis in acute promyelocytic leukemia. Int J Hematol 2024; 119:526-531. [PMID: 38341391 DOI: 10.1007/s12185-024-03708-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 12/26/2023] [Accepted: 01/04/2024] [Indexed: 02/12/2024]
Abstract
Acute promyelocytic leukemia (APL) is associated with a high incidence of early death, which occurs within 30 days of diagnosis. The major cause of early death in APL is severe bleeding, particularly intracranial bleeding. Although APL is known to be associated with activation of coagulation, hyperfibrinolysis, and thrombocytopenia, the precise mechanisms that cause bleeding have not yet been elucidated. I propose that a combination of four pathways may contribute to bleeding in APL: (1) tissue factor, (2) the urokinase plasminogen activator/urokinase plasminogen activator receptor, (3) the annexin A2/S100A100/tissue plasminogen activator, and (4) the podoplanin/C-type lectin-like receptor 2. A better understanding of these pathways will identify new biomarkers to determine which APL patients are at high risk of bleeding and allow the development of new treatments for APL-associated bleeding.
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Affiliation(s)
- Yohei Hisada
- UNC Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, 116 Manning Drive, 8004 Mary Ellen Jones Bldg, Campus Box #7035, Chapel Hill, NC, 27599, USA.
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Hisada Y, Kawano T, Archibald SJ, Welch JS, Reeves BN, Mackman N. Tissue factor activates the coagulation cascade in mouse models of acute promyelocytic leukemia. Blood Adv 2023; 7:5458-5469. [PMID: 37450381 PMCID: PMC10515313 DOI: 10.1182/bloodadvances.2023010466] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 07/03/2023] [Accepted: 07/03/2023] [Indexed: 07/18/2023] Open
Abstract
Acute promyelocytic leukemia (APL) is associated with a high risk of bleeding and thrombosis. APL patients have an activated coagulation system, hyperfibrinolysis, and thrombocytopenia. APL cells express tissue factor (TF), a receptor and cofactor for factor VII/VIIa. This study had 2 goals. Firstly, we measured biomarkers of coagulation and fibrinolysis activation as well as platelet counts and bleeding in both mouse xenograft and allograft models of APL. Secondly, we determined the effect of inhibiting TF on the activation of coagulation in these models. We observed increased levels of plasma thrombin-antithrombin complexes (TAT), D-dimer, and plasmin-antiplasmin complexes, reduced platelet counts, and increased tail bleeding in both mouse models of APL. Fibrinogen levels decreased in the xenograft model but not in the allograft model. In contrast, the red blood cell count decreased in the allograft model but not in the xenograft model. Inhibition of APL-derived human TF with an anti-human TF monoclonal antibody reduced the level of TAT, increased platelet count, and normalized tail bleeding in a xenograft model. Inhibition of all sources of TF (APL cells and host cells) in the allograft model with a rat anti-mouse TF monoclonal antibody decreased the levels of TAT but did not affect the platelet count. Our study demonstrates that TF plays a central role in the activation of coagulation in both the xenograft and allograft mouse models of APL. These APL mouse models can be used to investigate the mechanisms of coagulopathy and thrombocytopenia in APL.
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Affiliation(s)
- Yohei Hisada
- University of North Carolina Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Tomohiro Kawano
- University of North Carolina Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Sierra J. Archibald
- University of North Carolina Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - John S. Welch
- Division of Oncology, Department of Internal Medicine, Washington University in St. Louis, St. Louis, MO
| | - Brandi N. Reeves
- University of North Carolina Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Nigel Mackman
- University of North Carolina Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Matsuda K, Oyama T, Maki H, Nakazaki K, Yasunaga M, Honda A, Masamoto Y, Kurokawa M. Prompt Initiation of Conventional Chemotherapy to Avoid Early Death in Patients with Newly Diagnosed Acute Promyelocytic Leukemia. Intern Med 2023; 62:2181-2185. [PMID: 36476552 PMCID: PMC10465272 DOI: 10.2169/internalmedicine.0937-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 11/02/2022] [Indexed: 12/12/2022] Open
Abstract
Objective Compared to prospective trials, the early death rate of newly diagnosed acute promyelocytic leukemia (APL) in the real-world clinical setting is higher. However, the early death rate was heterogeneous according to the reported institutes. Thus, the therapeutic approach at each institute may be important for preventing early death. This study evaluated the management strategy for untreated APL in our institute to avoid early death. Methods We identified consecutive 21 patients with untreated APL who received induction therapy including all-trans retinoic acid (ATRA) between July 2007 and December 2021 at the University of Tokyo Hospital. Results As therapeutic approaches, 16 patients (76%) received ATRA administration on the day of admission, and the remaining 5 received ATRA within 4 days from admission. Notably, all patients received conventional chemotherapy added to ATRA at a median of 1 day from admission (range: 0-9 days). As clinical outcomes, no patient died during induction therapy for untreated APL, and all achieved complete molecular remission. Conclusion Compared to the previous nationwide survey, a higher proportion of patients at our institute received conventional chemotherapy in addition to ATRA, and it was initiated more promptly, which may have helped prevent early death.
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Affiliation(s)
- Kensuke Matsuda
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Takashi Oyama
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Hiroaki Maki
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Kumi Nakazaki
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Megumi Yasunaga
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Akira Honda
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Yosuke Masamoto
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Mineo Kurokawa
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Japan
- Department of Cell Therapy and Transplantation Medicine, The University of Tokyo Hospital, Japan
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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.
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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
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Institutional factors associated with early mortality of newly diagnosed acute promyelocytic leukemia. Blood Cancer J 2022; 12:167. [PMID: 36522307 PMCID: PMC9755312 DOI: 10.1038/s41408-022-00767-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 11/30/2022] [Accepted: 12/02/2022] [Indexed: 12/23/2022] Open
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8
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Thakur W, Anwar N, Fatima N, Jamal A, Rizvi QA, Borhany M. Coagulation Abnormalities and Risk Assessment in Acute Promyelocytic Leukemia: An Experience From a Resource-Constraint Country. Cureus 2022; 14:e26026. [PMID: 35865439 PMCID: PMC9293264 DOI: 10.7759/cureus.26026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2022] [Indexed: 11/10/2022] Open
Abstract
Introduction The objective of the study was to assess the impact of coagulopathy in risk-stratified acute promyelocytic leukemia (APML) patients irrespective of bleeding manifestation. Patients and methods This was a cross-sectional study design conducted at the National Institute of Blood Diseases and Bone Marrow Transplantation (NIBD & BMT) from November 2019 to December 2021. A total of 62 patients between three years to 74 years of age of either gender and treatment-naive cases of APML were included in the study. Morphological diagnosis was made on bone marrow samples, and confirmation was done by karyotyping/fluorescence in situ hybridization (FISH) and/or polymerase chain reaction (PCR). Complete blood count (CBC), prothrombin time (PT), activated partial thromboplastin time (APTT), D-dimer, and fibrinogen levels were done for bleeding risk assessment. Cases other than APML and cases on treatment were excluded from the study. Results A total of 85 APML patients were registered at our institute. Among them, 62 (73%) were included in the analysis as per the inclusion criteria of the study. The median age was 32 (3-74) years, with a male predominance of 34 (55%). According to the Sanz score, 18 (29%) patients were noted to have low risk; however, 22 (35.4%) patients were found to have an intermediate-risk disease and 22 (35.4%) patients had high-risk disease. There was positive bleeding history among 44 (71%) patients, followed by fever in 28 (45%) patients. Raised PT, APTT, and D-dimer were found in 46 (74%), 38 (61%), and 52(83.8%) patients, respectively. Low fibrinogen levels were observed among 16 (26%) patients. The association of risk stratification and bleeding history with CBC and coagulation parameters was observed. Platelet count and total leucocyte count were noted to be significantly associated with risk stratification. However, there was no association observed between the rest of the parameters with risk stratification and bleeding. Conclusion The results of our study suggest that regardless of bleeding symptoms, coagulation parameters must be investigated at the time of diagnosis in patients with suspected APML, and in addition to all-trans-retinoic acid (ATRA), transfusion of fresh frozen plasma should be done. It has clinical value, and adding it to the algorithm of treatment would be beneficial to the patients in the developing world, where resources are already meager.
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Asadbeigi S, Zhou Y. Interdisciplinary Quality Improvement Led by the Molecular Pathology Laboratory Expedites Diagnosis of Acute Promyelocytic Leukemia. Am J Clin Pathol 2022; 157:381-389. [PMID: 34546330 DOI: 10.1093/ajcp/aqab137] [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: 02/19/2021] [Accepted: 07/21/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Acute promyelocytic leukemia (APL) requires emergent treatment while definitive laboratory results are pending. Following the death of a patient whose diagnosis was delayed, we sought to improve our institution's workflow by using the EPIDEM (Exploration, Promotion, Implementation, Documentation, Evaluation, Modification) quality improvement model. METHODS APL is confirmed by identifying translocation t(15;17)(q24;q21) PML-RARA by using either molecular or cytogenetic methods on peripheral blood or bone marrow specimens. We used the EPIDEM model to decrease the turnaround time (TAT) of molecular diagnosis by improving communication and developing reflex testing. We additionally compared 32 APL cases against a control group of 18 suspected APL cases. RESULTS Our review of 687 multiplex polymerase chain reaction orders and 33 PML-RARA orders (January 2012 to April 2021) showed an initial TAT decrease from 4.48 days to 2.71 days (P < .0001), which further decreased to 0.64 days (P < .0001) after implementation of the PML-RARA qualitative assay. Compared with patients suspected of having APL, patients with confirmed APL had higher dimerized plasmin fragment D (P = .0145), lower fibrinogen (P ≤ .0001), and lower WBC (P ≤ .0001). CONCLUSIONS By using the EPIDEM model, with its emphasis on local context, culture, and resources, improved communication and workflow changes enabled us to reduce the time needed to diagnose APL to 0.64 days and identify potential locally derived screening cutoffs.
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Affiliation(s)
- Sepideh Asadbeigi
- Department of Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, USA
- Department of Dermatology, Northwestern University, Chicago, IL, USA
| | - Yaolin Zhou
- Department of Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, USA
- Department of Pathology and Laboratory Medicine, Eastern Carolina University, Greenville, NC, USA
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10
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Wang Y, Hou W, Li H, Tian X, Li J, Hu T, Shi D, Zhang Y. Analysis of risk factors for early death in patients with acute promyelocytic leukaemia treated with arsenic trioxide. Ann Hematol 2022; 101:1039-1047. [PMID: 35174404 DOI: 10.1007/s00277-022-04788-w] [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: 08/29/2021] [Accepted: 02/07/2022] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Yuan Wang
- Department of Hematology, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, People's Republic of China
| | - Wenyi Hou
- Department of Hematology, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, People's Republic of China
| | - Haitao Li
- Department of Hematology, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, People's Republic of China
| | - Xuanyu Tian
- Department of Oncology, The Yuechi People's Hospital, Guangan, 638373, People's Republic of China
| | - Jinqiao Li
- Department of Hematology, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, People's Republic of China
| | - Tianming Hu
- Department of Hematology, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, People's Republic of China
| | - Deli Shi
- Department of Hematology, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, People's Republic of China
| | - Yingmei Zhang
- Department of Central Laboratory, The First Affiliated Hospital of Harbin Medical University, No. 23, Youzheng Street, Nangang District, Harbin, 150001, People's Republic of China. .,Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, People's Republic of China.
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Sabljic N, Pantic N, Virijevic M, Bukumiric Z, Novakovic T, Pravdic Z, Rajic J, Vidovic A, Suvajdzic N, Jaradeh M, Fareed J, Antic D, Mitrovic M. Application of Rotational Thromboelastometry in Patients with Acute Promyelocytic Leukemia. Clin Appl Thromb Hemost 2022; 28:10760296221119809. [PMID: 35942712 PMCID: PMC9373117 DOI: 10.1177/10760296221119809] [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] [Indexed: 11/17/2022] Open
Abstract
Introduction Hemorrhagic early death (HED) remains a major cause of treatment failure
among patients with acute promyelocytic leukemia (APL). We aimed to
investigate the prognostic potential of rotational thromboelastometry
(ROTEM) for bleeding in patients with APL. Materials and Methods 31 newly-diagnosed APL patients (median age of 40 years; 14 female/17 male)
that underwent treatment at the Clinic of Hematology UCCS from 2016-2020
with all-trans retinoic acid and anthracyclines were recruited. CBCs
(complete blood count), conventional coagulation tests (CCTs), and ROTEM
parameters obtained before treatment initiation were evaluated. Results All patients demonstrated at least one ROTEM parameter out of the reference
range. ROTEM parameters associated with significant hemorrhage were EXTEM
clotting time (CT) (P = 0.041) and INTEM amplitude 10 (A10) (P = 0.039),
however, only EXTEM CT (P = 0.036) was associated with HED. Among CBCs and
CCTs, only platelets were associated with significant bleeding (P = 0.015),
while D-dimer was associated with both bleeding and HED (P = 0.001 and
P = 0.002, respectively). Conclusion Our results indicate that ROTEM parameters may reveal hypocoagulability in
APL patients and have the potential to improve current hemorrhage prognostic
methods. Additionally, these results suggest the combination of ROTEM and
CCTs might be useful in identifying patients at risk for HED.
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Affiliation(s)
- Nikica Sabljic
- Clinic of Hematology, 63740University Clinical Center of Serbia, Belgrade, Serbia
| | - Nikola Pantic
- Clinic of Hematology, 63740University Clinical Center of Serbia, Belgrade, Serbia
| | - Marijana Virijevic
- Clinic of Hematology, 63740University Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, 54801University of Belgrade, Belgrade, Serbia
| | - Zoran Bukumiric
- Faculty of Medicine, 54801University of Belgrade, Belgrade, Serbia.,Faculty of Medicine, Institute for medical statistics and informatics, 54801University of Belgrade, Beograd, Serbia
| | - Tina Novakovic
- Clinic of Vascular Surgery, 63740University Clinical Center of Serbia, Belgrade, Serbia
| | - Zlatko Pravdic
- Clinic of Hematology, 63740University Clinical Center of Serbia, Belgrade, Serbia
| | - Jovan Rajic
- Clinic of Hematology, 63740University Clinical Center of Serbia, Belgrade, Serbia
| | - Ana Vidovic
- Clinic of Hematology, 63740University Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, 54801University of Belgrade, Belgrade, Serbia
| | - Nada Suvajdzic
- Clinic of Hematology, 63740University Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, 54801University of Belgrade, Belgrade, Serbia
| | - Mark Jaradeh
- Department of Molecular Pharmacology & Neuroscience, 25815Loyola University Medical Center, Maywood, USA
| | - Jawed Fareed
- Department of Molecular Pharmacology & Neuroscience, 25815Loyola University Medical Center, Maywood, USA
| | - Darko Antic
- Clinic of Hematology, 63740University Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, 54801University of Belgrade, Belgrade, Serbia
| | - Mirjana Mitrovic
- Clinic of Hematology, 63740University Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, 54801University of Belgrade, Belgrade, Serbia
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Hambley BC, Tomuleasa C, Ghiaur G. Coagulopathy in Acute Promyelocytic Leukemia: Can We Go Beyond Supportive Care? Front Med (Lausanne) 2021; 8:722614. [PMID: 34485349 PMCID: PMC8415964 DOI: 10.3389/fmed.2021.722614] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 07/26/2021] [Indexed: 11/24/2022] Open
Abstract
Acute promyelocytic leukemia (APL) is characterized by frequent complications due to a distinct coagulopathy. While advances in treatments have improved long-term survival, hemorrhagic and thrombotic complications remain the most common causes of death and morbidity. Improved understanding of the mechanisms of the coagulopathy associated with APL may lead to therapeutic interventions to mitigate the risk of hemorrhage and thrombosis.
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Affiliation(s)
- Bryan C Hambley
- Division of Hematology/Oncology, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Ciprian Tomuleasa
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania.,Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj Napoca, Romania.,Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Gabriel Ghiaur
- Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania.,Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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13
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Sanz MA, Montesinos P. Advances in the management of coagulopathy in acute promyelocytic leukemia. Thromb Res 2021; 191 Suppl 1:S63-S67. [PMID: 32736781 DOI: 10.1016/s0049-3848(20)30399-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 01/13/2020] [Accepted: 01/14/2020] [Indexed: 12/13/2022]
Abstract
Since the introduction of all-trans retinoic acid and, more recently, arsenic trioxide into the therapy of acute promyelocytic leukemia (APL), significant improvements in patient outcomes have been achieved, and this disease has become the most curable subtype of acute myeloid leukemia. However, while primary leukemia resistance has virtually disappeared, a sizable fraction of APL patients still die before or during induction therapy. Hemorrhagic death still remains the major problem during this early phase of treatment and, to a lesser extent, deaths due to infection, differentiation syndrome and other causes. Patients with APL typically present with a range of laboratory abnormalities consistent with the diagnosis of disseminated intravascular coagulation and hyperfibrinolysis. This APL-associated coagulopathy, as a result of a dysregulation of the hemostatic system due to the imbalance between procoagulant, anticoagulant and profibrinolytic mechanisms, may show a variety of clinical manifestations, ranging from minimal bleeding or localized thrombosis to lethal or life-threatening hemorrhages or thrombotic events that sometimes occur concomitantly. Hemorrhagic events are the most common cause of death associated with APL coagulopathy, but thrombosis, a less recognized and probably underestimated life-threatening manifestation of the thrombo-hemorrhagic syndrome, is also a non-negligible cause of morbidity and mortality in patients with APL. In this article, we aim to discuss recent advances in the knowledge of pathogenesis, predictors of thrombo-hemorrhagic events, management of coagulopathy associated with APL and the controversial issues that still persist.
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Affiliation(s)
- Miguel A Sanz
- Hospital Universitario y Politécnico La Fe, Valencia, Spain.
| | - Pau Montesinos
- Hospital Universitario y Politécnico La Fe, Valencia, Spain
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14
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Pei Y, Shi M, Song J, Niu X, Wei S, Dou L, Xiao M, Li D, Xu F, Bai Y, Sun K. Absolute Circulating Leukemic Cells as a Risk Factor for Early Bleeding Events in Patients with Non-High-Risk Acute Promyelocytic Leukemia. Cancer Manag Res 2021; 13:4135-4146. [PMID: 34045900 PMCID: PMC8149285 DOI: 10.2147/cmar.s309138] [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: 03/02/2021] [Accepted: 04/25/2021] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Yanru Pei
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Henan, People's Republic of China
| | - Mingyue Shi
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Henan, People's Republic of China
| | - Juanjuan Song
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Henan, People's Republic of China
| | - Xiaona Niu
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Henan, People's Republic of China
| | - Shengjie Wei
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Henan, People's Republic of China
| | - Liurui Dou
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Henan, People's Republic of China
| | - Mengyu Xiao
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Henan, People's Republic of China
| | - Dan Li
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Henan, People's Republic of China
| | - Fangfang Xu
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Henan, People's Republic of China
| | - Yanliang Bai
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Henan, People's Republic of China
| | - Kai Sun
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Henan, People's Republic of China
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15
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Wang TF, Makar RS, Antic D, Levy JH, Douketis JD, Connors JM, Carrier M, Zwicker JI. Management of hemostatic complications in acute leukemia: Guidance from the SSC of the ISTH. J Thromb Haemost 2020; 18:3174-3183. [PMID: 33433069 PMCID: PMC7909744 DOI: 10.1111/jth.15074] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/17/2020] [Accepted: 08/20/2020] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Tzu-Fei Wang
- Department of Medicine, University of Ottawa at The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Robert S. Makar
- Blood Transfusion Service, Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Darko Antic
- Clinic for Hematology, Clinical Center Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Jerrold H. Levy
- Departments of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC, USA
| | | | - Jean M. Connors
- Division of Hematology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Marc Carrier
- Department of Medicine, University of Ottawa at The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Jeffrey I. Zwicker
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
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16
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Predictors of early death, serious hemorrhage, and differentiation syndrome in Japanese patients with acute promyelocytic leukemia. Ann Hematol 2020; 99:2787-2800. [PMID: 32879992 DOI: 10.1007/s00277-020-04245-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 08/28/2020] [Indexed: 12/18/2022]
Abstract
Significant advancements have been achieved with regard to the outcomes of acute promyelocytic leukemia (APL) patients through the introduction of all-trans retinoic acid; however, early hemorrhagic death and differentiation syndrome remain the major causes of remission induction failure in patients with APL. To investigate early death, serious hemorrhage, and differentiation syndrome during remission induction therapy in terms of incidence, risk factors, influence on outcomes, and prophylactic effects of several new anticoagulants, the results of 344 patients enrolled in the Acute Promyelocytic Leukemia 204 study conducted by the Japan Adult Leukemia Study Group were analyzed. Early death was observed in 16 patients (4.7%), of whom 14 had serious hemorrhage and 2 had differentiation syndrome. Serious hemorrhage and differentiation syndrome of grade 2 or higher were observed in 21 and 54 patients, respectively. Patients who achieved complete remission had a 7-year disease-free survival of 84.8% if they did not experience serious hemorrhage and 40.0% if they experienced serious hemorrhage during remission induction therapy (P = 0.001). Risk factor analyses showed that higher white blood cell count was associated with early death, higher white blood cell count and lower platelet count with serious hemorrhage, and leukocytosis during induction therapy and higher body surface area with differentiation syndrome. In conclusion, these results indicate that patients with such high-risk features may benefit from more intensive supportive care. The hemorrhagic risk was not relieved by the introduction of new anticoagulants. Further studies are required to establish the predictive impact of body surface area on differentiation syndrome. This trial is registered with UMIN-CTR as C000000154 on September 13, 2005.
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17
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Chu T, Wang H, Lv X, Qi J, Tang Y, Fan Y, Qiu H, Tang X, Fu C, Ruan C, Han Y, Wu DP. Investigation of fibrinogen in early bleeding of patients with newly diagnosed acute promyelocytic leukemia. Platelets 2020; 32:677-683. [PMID: 32799612 DOI: 10.1080/09537104.2020.1799969] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Early hemorrhagic death remains a major cause of treatment failure in acute promyelocytic leukemia (APL). This study investigated the role of fibrinogen concentrations in early hemorrhage and overall survival (OS) of APL patients. Laboratory and clinical data, including fibrinogen concentrations and other coagulation indexes, bleeding events, and survival data, of 198 patients newly diagnosed with APL from February 2012 to December 2017 were extracted from patient records and retrospectively investigated. Patients with moderate/severe bleeding had significantly lower median fibrinogen concentrations (p = .023), higher Chinese disseminated intravascular coagulation scoring system (CDSS) (p < .001), and were more often female (p = .034) than patients with no such bleeding. Additionally, patients with fibrinogen <1.0 g/L and 1.0-1.6 g/L had significantly higher moderate/severe bleeding rates than those with fibrinogen >1.6 g/L (p = .015; p = .023). However, moderate/severe (p = .088) and severe bleeding rates (p = .063) were comparable for patients with fibrinogen <1.0 g/L and 1.0-1.6 g/L. Multivariate analysis showed that fibrinogen ≤1.6 g/L (p = .036), platelet counts ≤10 × 109/L (p = .037), and CDSS scores ≥5 (p = .023) were independent risk factors for moderate/severe bleeding. Survival analysis indicated that moderate/severe bleeding (p = .018), fibrinogen ≤1.6 g/L combined with prothrombin time >12.8 s (p = .005), age ≥60 years (p = .001), and CDSS ≥5 (p = .044) were independent predictors of 1-year OS. Fibrinogen ≤1.6 g/L may be an independent risk factor for early bleeding in newly treated patients with APL and is associated with a worse 1-year OS. Increasing fibrinogen to >1.6 g/L may help to prevent bleeding.
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Affiliation(s)
- Tiantian Chu
- Jiangsu Institute of Hematology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Hong Wang
- Jiangsu Institute of Hematology, First Affiliated Hospital of Soochow University, Suzhou, China.,National Clinical Research Center for Hematologic Diseases, Suzhou, China.,State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China.,Institute of Blood and Marrow Transplantation, Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Xin Lv
- Jiangsu Institute of Hematology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jiaqian Qi
- Jiangsu Institute of Hematology, First Affiliated Hospital of Soochow University, Suzhou, China.,National Clinical Research Center for Hematologic Diseases, Suzhou, China.,State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China.,Institute of Blood and Marrow Transplantation, Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Yaqiong Tang
- Jiangsu Institute of Hematology, First Affiliated Hospital of Soochow University, Suzhou, China.,National Clinical Research Center for Hematologic Diseases, Suzhou, China.,State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China.,Institute of Blood and Marrow Transplantation, Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Yi Fan
- Jiangsu Institute of Hematology, First Affiliated Hospital of Soochow University, Suzhou, China.,National Clinical Research Center for Hematologic Diseases, Suzhou, China.,State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China.,Institute of Blood and Marrow Transplantation, Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Huiying Qiu
- Jiangsu Institute of Hematology, First Affiliated Hospital of Soochow University, Suzhou, China.,National Clinical Research Center for Hematologic Diseases, Suzhou, China.,State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China.,Institute of Blood and Marrow Transplantation, Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Xiaowen Tang
- Jiangsu Institute of Hematology, First Affiliated Hospital of Soochow University, Suzhou, China.,National Clinical Research Center for Hematologic Diseases, Suzhou, China.,State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China.,Institute of Blood and Marrow Transplantation, Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Chengcheng Fu
- Jiangsu Institute of Hematology, First Affiliated Hospital of Soochow University, Suzhou, China.,National Clinical Research Center for Hematologic Diseases, Suzhou, China.,State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China.,Institute of Blood and Marrow Transplantation, Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Changgeng Ruan
- Jiangsu Institute of Hematology, First Affiliated Hospital of Soochow University, Suzhou, China.,National Clinical Research Center for Hematologic Diseases, Suzhou, China.,State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China.,Institute of Blood and Marrow Transplantation, Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Yue Han
- Jiangsu Institute of Hematology, First Affiliated Hospital of Soochow University, Suzhou, China.,National Clinical Research Center for Hematologic Diseases, Suzhou, China.,State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China.,Institute of Blood and Marrow Transplantation, Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - De-Pei Wu
- Jiangsu Institute of Hematology, First Affiliated Hospital of Soochow University, Suzhou, China.,National Clinical Research Center for Hematologic Diseases, Suzhou, China.,State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China.,Institute of Blood and Marrow Transplantation, Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
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18
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Gurnari C, Breccia M, Di Giuliano F, Scalzulli E, Divona M, Piciocchi A, Cicconi L, De Bellis E, Venditti A, Del Principe MI, Arcese W, Lo-Coco F, Garaci F, Voso MT. Early intracranial haemorrhages in acute promyelocytic leukaemia: analysis of neuroradiological and clinico-biological parameters. Br J Haematol 2020; 193:129-132. [PMID: 32808672 DOI: 10.1111/bjh.17018] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 07/09/2020] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Carmelo Gurnari
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Massimo Breccia
- Department of Translational and Precision Medicine, University 'La Sapienza' of Rome, Rome, Italy
| | - Francesca Di Giuliano
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Emilia Scalzulli
- Department of Translational and Precision Medicine, University 'La Sapienza' of Rome, Rome, Italy
| | - Mariadomenica Divona
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy.,Saint Camillus International, University of Health Sciences, Rome, Italy
| | | | - Laura Cicconi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Eleonora De Bellis
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Adriano Venditti
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | | | - William Arcese
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Francesco Lo-Coco
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Francesco Garaci
- Neuroradiology Unit, Department of Biomedicine and Preventio, University of Rome "Tor Vergata", Rome, Italy.,San Raffaele Cassino, Cassino, Italy
| | - Maria Teresa Voso
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy.,Laboratorio di Neuro-Oncoematologia, Fondazione Santa Lucia, Rome, Italy
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19
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Naymagon L, Mascarenhas J. Hemorrhage in acute promyelocytic leukemia: Can it be predicted and prevented? Leuk Res 2020; 94:106356. [PMID: 32445941 DOI: 10.1016/j.leukres.2020.106356] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/11/2020] [Accepted: 04/17/2020] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Leonard Naymagon
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States.
| | - John Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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20
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Guo Z, Chen X, Tan Y, Xu Z, Xu L. Coagulopathy in cytogenetically and molecularly distinct acute leukemias at diagnosis: Comprehensive study. Blood Cells Mol Dis 2020; 81:102393. [DOI: 10.1016/j.bcmd.2019.102393] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 11/20/2019] [Accepted: 11/28/2019] [Indexed: 11/24/2022]
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21
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Jin B, Zhang Y, Hou W, Cao F, Lu M, Yang H, Tian X, Wang Y, Hou J, Fu J, Li H, Zhou J. Comparative analysis of causes and predictors of early death in elderly and young patients with acute promyelocytic leukemia treated with arsenic trioxide. J Cancer Res Clin Oncol 2019; 146:485-492. [DOI: 10.1007/s00432-019-03076-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 11/01/2019] [Indexed: 02/07/2023]
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22
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Hou W, Zhang Y, Jin B, Cao W, Lu M, Yan L, Yang H, Tian X, Hou J, Fu J, Zhao H, Li H, Zhou J. Factors affecting thrombohemorrhagic early death in patients with acute promyelocytic leukemia treated with arsenic trioxide alone. Blood Cells Mol Dis 2019; 79:102351. [PMID: 31400712 DOI: 10.1016/j.bcmd.2019.102351] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 07/31/2019] [Indexed: 11/18/2022]
Abstract
Acute promyelocytic leukemia (APL) is often accompanied by a potentially devastating coagulopathy. Predictors of thrombohemorrhagic early death (TH-ED)/early bleeding death are not well characterized. In this retrospective study, eleven baseline clinical variables that can be assessed easily and promptly were chosen for evaluation in a cohort of 364 patients with APL who were administered arsenic trioxide (ATO) alone as remission induction therapy. TH-ED was defined as death from bleeding or thrombosis within 30 days after hospital admission. Cox proportional hazards regression model was used for both the univariate and multivariate analyses. Totally, 53 patients died from severe bleeding (51 cases) or thrombosis (2 cases), and at 30 days the cumulative incidences of TH-ED were 14.6%. Six independent risk factors for TH-ED were identified, including relapse, male, white blood cell (WBC) count above 10 × 109/L, fibrinogen level below 1 g/L, D-dimer level above 4 mg/L and increased creatinine level. Increased creatinine level was the most powerful risk factor, followed by WBC count > 10 × 109/L. This study identified risk factors for TH-ED in a large cohort of patients with APL, which enriched clinical information on identifying patients at high risk of TH-ED.
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Affiliation(s)
- Wenyi Hou
- Department of Hematology, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, PR China
| | - Yingmei Zhang
- Department of Central Laboratory, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, PR China
| | - Bo Jin
- Department of Hematology, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, PR China
| | - Weifan Cao
- College of Life Science Northeast Forest University, Harbin 150040, PR China
| | - Ming Lu
- Maternal and Child Health Care Hospital of Heilongjiang Province, Harbin 150030, PR China
| | - Liru Yan
- Department of Carders Outpatient Service, The Fourth Affiliated Hospital of Harbin Medical University, Harbin 150001, PR China
| | - Huiyuan Yang
- Department of Hematology, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, PR China
| | - Xuanyu Tian
- Department of Hematology, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, PR China
| | - Jinxiao Hou
- Department of Hematology, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, PR China
| | - Jinyue Fu
- Department of Hematology, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, PR China
| | - Hongli Zhao
- Department of Hematology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin 150001, PR China
| | - Haitao Li
- Department of Hematology, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, PR China
| | - Jin Zhou
- Department of Hematology, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, PR China; Department of Central Laboratory, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, PR China.
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23
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Fibrinogen consumption and use of heparin are risk factors for delayed bleeding during acute promyelocytic leukemia induction. Leuk Res 2019; 83:106174. [PMID: 31255938 DOI: 10.1016/j.leukres.2019.106174] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 06/17/2019] [Accepted: 06/18/2019] [Indexed: 11/22/2022]
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24
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Naymagon L, Moshier E, Tremblay D, Mascarenhas J. Predictors of early hemorrhage in acute promyelocytic leukemia. Leuk Lymphoma 2019; 60:2394-2403. [PMID: 30849255 DOI: 10.1080/10428194.2019.1581187] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Fatal hemorrhage is the most common cause of induction failure and death among patients with acute promyelocytic leukemia (APL). However, there remains no established means of hemorrhagic risk stratification in APL. In this single center retrospective study of 43 patients treated for APL group-based trajectory modeling was used to identify laboratory trends associated with major bleeding. Bleeding risk was significantly associated with particular trends in white blood cell count (WBC) and lactate dehydrogenase level (LDH). Specifically, patients who presented with high WBC and/or LDH, and whose WBC and/or LDH then proceeded to uptrend during the initial days of induction, were significantly more likely to experience major bleeding (p = .0111 and p = .0143, respectively). Additionally, there appeared to be a temporal association between WBC and LDH trends and major bleeding events. Among nonlaboratory variables, differentiation syndrome (DS) was significantly associated with major bleeding (p = .00149).
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Affiliation(s)
- Leonard Naymagon
- Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai Tisch Cancer Institute , New York , NY , USA
| | - Erin Moshier
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai Tisch Cancer Institute , New York , NY , USA
| | - Douglas Tremblay
- Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai Tisch Cancer Institute , New York , NY , USA
| | - John Mascarenhas
- Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai Tisch Cancer Institute , New York , NY , USA
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Mantha S, Tallman MS, Devlin SM, Soff GA. Predictive factors of fatal bleeding in acute promyelocytic leukemia. Thromb Res 2018; 164 Suppl 1:S98-S102. [PMID: 29703492 DOI: 10.1016/j.thromres.2018.01.038] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 01/19/2018] [Accepted: 01/22/2018] [Indexed: 02/08/2023]
Abstract
Acute promyelocytic leukemia (APL) is associated with a profound coagulopathy. Based on retrospective assessments, several potential risk factors for hemorrhagic morbidity and mortality have emerged. Several studies have shown elevated white blood cell (WBC) count at presentation to be a robust predictor of bleeding events. Other clinical and laboratory parameters have been evaluated with variable association with hemorrhagic morbidity or mortality. These include ECOG performance status, age, morphological subtype, platelet count, peripheral blood blast count, ethnicity, body mass index, prothrombin time, activated partial thromboplastin time, lactate dehydrogenase, d-dimers, creatinine and fibrinogen levels. Unfortunately, most of those assessments were based on a small patient sample and the results have been at times contradictory in terms of which parameters are independent predictors. More recently, two large retrospective studies have reported on the issue. They included data from several international trials of chemotherapy for APL, one on adults and the other focused on the pediatric population. Importantly, both analyses found that WBC count at presentation is the main predictor of early hemorrhagic death and early thrombo-hemorrhagic death, respectively. Much remains to be done if the rate of induction mortality in APL is going to be reduced significantly. One approach would be to incorporate the known risk factors for early hemorrhagic death into a risk stratification system and devise personalized transfusion interventions to meet an individual patient's risk, which could be evaluated in future randomized trials.
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Affiliation(s)
- Simon Mantha
- Department of Medicine, Hematology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Martin S Tallman
- Department of Medicine, Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sean M Devlin
- Department of Epidemiology-Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Gerald A Soff
- Department of Medicine, Hematology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Zhang Y, Hou W, Wang P, Hou J, HuiyuanYang, Zhao H, Jin B, Sun J, Cao F, Zhao Y, Li H, Ge F, Fu J, Zhou J. Development of a risk grading system to identify patients with acute promyelocytic leukemia at high risk of early death. Cancer Manag Res 2018; 10:3619-3627. [PMID: 30271210 PMCID: PMC6149832 DOI: 10.2147/cmar.s167686] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background Early death (ED) rate in acute promyelocytic leukemia (APL) remains high. Some studies have identified prognostic factors capable of predicting ED, whereas no risk rating system for ED has been reported in the literature. In this study, a risk classification system was built to identify subgroup at high risk of ED among patients with APL. Methods Totally, 364 consecutive APL patients who received arsenic trioxide as induction therapy were included. Ten baseline clinical characteristics were selected for analysis, and they were de novo/relapse, age, sex, white blood cell count, platelet count, serum fibrinogen, creatinine, uric acid, aspartate aminotransferase, and albumin. Using a training cohort (N=275), a multivariable logistic regression model was constructed, which was internally validated by the bootstrap method and externally validated using an independent cohort (N=89). Based on the model, a risk classification system was designed. Then, all patients were regrouped into de novo (N=285) and relapse (N=79) cohorts and the model and risk classification system were applied to both cohorts. Results The constructed model included 8 variables without platelet count and sex. The model had excellent discriminatory ability (optimism-corrected area under the receiver operator characteristic curve=0.816±0.028 in the training cohort and area under the receiver operator characteristic curve=0.798 in the independent cohort) and fit well for both the training and independent data sets (Hosmer-Lemeshow test, P=0.718 and 0.25, respectively). The optimism-corrected calibration slope was 0.817±0.12. The risk classification system could identify a subgroup comprising ~25% of patients at high risk of ED in both the training and independent cohorts (OR=0.140, P<0.001 and OR=0.224, P=0.027, respectively). The risk classification system could effectively identify patient subgroups at high risk of ED in not only de novo but also relapse cohorts (OR=0.233, P<0.001 and OR=0.105, P=0.001, respectively). Conclusion All the results highlight the high practical value of the risk classification system.
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Affiliation(s)
- Yingmei Zhang
- Department of Central Laboratory, The First Affiliated Hospital, Harbin Medical University, Harbin, People's Republic of China,
| | - Wenyi Hou
- Department of Hematology, The First Affiliated Hospital, Harbin Medical University, Harbin, People's Republic of China,
| | - Ping Wang
- Department of Hematology, The First Affiliated Hospital, Harbin Medical University, Harbin, People's Republic of China, .,Department of Neonatology, The First Affiliated Hospital, Harbin Medical University, Harbin, People's Republic of China
| | - Jinxiao Hou
- Department of Hematology, The First Affiliated Hospital, Harbin Medical University, Harbin, People's Republic of China,
| | - HuiyuanYang
- Department of Hematology, The First Affiliated Hospital, Harbin Medical University, Harbin, People's Republic of China,
| | - Hongli Zhao
- Department of Hematology, The First Affiliated Hospital, Harbin Medical University, Harbin, People's Republic of China, .,Department of Hematology, The Fourth Affiliated Hospital, Harbin Medical University, Harbin, People's Republic of China
| | - Bo Jin
- Department of Hematology, The First Affiliated Hospital, Harbin Medical University, Harbin, People's Republic of China,
| | - Jiayue Sun
- Department of Hematology, The First Affiliated Hospital, Harbin Medical University, Harbin, People's Republic of China,
| | - Fenglin Cao
- Department of Central Laboratory, The First Affiliated Hospital, Harbin Medical University, Harbin, People's Republic of China,
| | - Yanqiu Zhao
- Department of Hematology, The First Affiliated Hospital, Harbin Medical University, Harbin, People's Republic of China,
| | - Haitao Li
- Department of Hematology, The First Affiliated Hospital, Harbin Medical University, Harbin, People's Republic of China,
| | - Fei Ge
- Department of Hematology, The First Affiliated Hospital, Harbin Medical University, Harbin, People's Republic of China,
| | - Jinyue Fu
- Department of Hematology, The First Affiliated Hospital, Harbin Medical University, Harbin, People's Republic of China,
| | - Jin Zhou
- Department of Central Laboratory, The First Affiliated Hospital, Harbin Medical University, Harbin, People's Republic of China, .,Department of Hematology, The First Affiliated Hospital, Harbin Medical University, Harbin, People's Republic of China,
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Basophil-lineage commitment in acute promyelocytic leukemia predicts for severe bleeding after starting therapy. Mod Pathol 2018; 31:1318-1331. [PMID: 29572500 DOI: 10.1038/s41379-018-0038-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 01/24/2018] [Accepted: 01/26/2018] [Indexed: 02/04/2023]
Abstract
Severe hemorrhagic events occur in a significant fraction of acute promyelocytic leukemia patients, either at presentation and/or early after starting therapy, leading to treatment failure and early deaths. However, identification of independent predictors for high-risk of severe bleeding at diagnosis, remains a challenge. Here, we investigated the immunophenotype of bone marrow leukemic cells from 109 newly diagnosed acute promyelocytic leukemia patients, particularly focusing on the identification of basophil-related features, and their potential association with severe bleeding episodes and patient overall survival.From all phenotypes investigated on leukemic cells, expression of the CD203c and/or CD22 basophil-associated markers showed the strongest association with the occurrence and severity of bleeding (p ≤ 0.007); moreover, aberrant expression of CD7, coexpression of CD34+/CD7+ and lack of CD71 was also more frequently found among patients with (mild and severe) bleeding at baseline and/or after starting treatment (p ≤ 0.009). Multivariate analysis showed that CD203c expression (hazard ratio: 26.4; p = 0.003) and older age (hazard ratio: 5.4; p = 0.03) were the best independent predictors for cumulative incidence of severe bleeding after starting therapy. In addition, CD203c expression on leukemic cells (hazard ratio: 4.4; p = 0.01), low fibrinogen levels (hazard ratio: 8.8; p = 0.001), older age (hazard ratio: 9.0; p = 0.002), and high leukocyte count (hazard ratio: 5.6; p = 0.02) were the most informative independent predictors for overall survival.In summary, our results show that the presence of basophil-associated phenotypic characteristics on leukemic cells from acute promyelocytic leukemia patients at diagnosis is a powerful independent predictor for severe bleeding and overall survival, which might contribute in the future to (early) risk-adapted therapy decisions.
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Abstract
This study aimed to compare the efficacy of thromboelastography (TEG) and conventional coagulation methods in predicting hemorrhage risk in patients with leukemia.A total of 226 patients diagnosed with leukemia were included and divided into bleeding and nonbleeding groups. All patients had their blood samples taken for TEG test to measure the reaction time (R time), alpha (α angle), and maximum amplitude (MA) as well as measure platelet count (PLT), prothrombin time, and activated partial thromboplastin time. Patients were followed up for bleeding episodes.The multivariate analysis showed that PLT [odds ratio (OR) = 0.993] and MA (OR = 0.921) have better association with bleeding risk. Receiver operating characteristic (ROC) analysis showed that the combination of PLT and MA (AUC = 0.824) was better for hemorrhage risk prediction than PLT [area under the curve (AUC) = 0.730] and MA (AUC = 0.819) alone.The combination of TEG and conventional coagulation methods could help in assessing the risk of hemorrhage in patients with leukemia.
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Affiliation(s)
- Hang-xing Bao
- Zhejiang Provincial Hospital of TCM, First Clinical Medical College of Zhejiang Chinese Medical University
| | - Jing Du
- Department of Laboratory Medicine, Zhejiang Provincial People's Hospital of Hangzhou Medical College, Hangzhou, China
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Determinants of fatal bleeding during induction therapy for acute promyelocytic leukemia in the ATRA era. Blood 2017; 129:1763-1767. [PMID: 28082441 DOI: 10.1182/blood-2016-10-747170] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 01/02/2017] [Indexed: 11/20/2022] Open
Abstract
Acute promyelocytic leukemia (APL) is commonly complicated by a complex coagulopathy. Uncertainty remains as to which markers of bleeding risk are independent predictors. Drawing from 5 large clinical trials that included all-trans retinoic acid (ATRA) as part of induction, we assessed known determinants of bleeding at baseline and evaluated them as potential predictors of hemorrhagic death (HD) in the first 30 days of treatment. The studies included were ALLG APML3 (single arm of ATRA + idarubicin ± prednisone), ALLG APML4 (single arm of ATRA + idarubicin + arsenic trioxide + prednisone), CALGB C9710 (single arm of ATRA + cytarabine + daunorubicin), Eastern Cooperative Oncology Group-American College of Radiology Imaging Network (ECOG-ACRIN) E2491 (intergroup I0129, consisting of daunorubicin + cytarabine vs ATRA), and SWOG S0521 (single-arm induction of ATRA + cytarabine + daunorubicin). A total of 1009 patients were included in the original trials, of which 995 had sufficient data to be included in our multivariate analysis. In this final cohort, there were 37 HD cases during the first 30 days following induction, for an estimated cumulative incidence of 3.7% (95% confidence interval [CI], 2.6% to 5.0%). Using multivariate Cox proportional hazards regression, the hazard ratio of HD in the first 30 days was 2.17 (95% CI, 0.84-5.62) for an ECOG performance status of 3-4 vs 0-2 and 5.20 (95% CI, 2.70-10.02) for a white blood cell count of ≥20 000/μL vs <20 000/μL. In this large cohort of APL patients, high white blood cell count emerged as an independent predictor of early HD.
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Pei RZ, Si T, Lu Y, Zhang PS, Liu XH, Ye PP, Chen D, Du XH, Ma JX, Jin J. [Clinical features and prognostic analysis of high-risk acute promyelocytic leukemia patients]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2016; 37:360-5. [PMID: 27210868 PMCID: PMC7348312 DOI: 10.3760/cma.j.issn.0253-2727.2016.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To investigate the clinical features and outcomes of high-risk acute promyelocytic leukemia (APL) patients. METHODS A retrospective analysis was conducted to compare the clinical characteristics and prognosis of 118 high-risk APL patients (WBC≥10 × 10(9)/L) and 234 low and intermedia-risk patients (WBC <10×10(9)/L) from January 2003 to April 2015, who were treated in the First Affiliated Hospital of Zhejiang University and Yinzhou People's Hospital affiliated to Medical College of Ningbo University. RESULTS The initial platelet counts of high-risk APL were significantly lower than that of low and intermediate-risk groups (P=0.003); the major type of PML-RARα isoforms in high-risk patients was short-form (51.8% vs 28.2%, P <0.001); the early death (ED) rate of high-risk patients was higher than low and intermedia-risk patients (20.3% vs 2.6%, P<0.001); in contrast, the complete remission (CR) rate and 5 years estimated overall survival (OS) rate of the former were lower than the latter (76.3% vs 94.9%, P <0.001; 74.2% vs 93.7%, P <0.001). However, the CR rate (P=0.682) and 5 years estimated OS rate (P=0.481) did not have difference when the ED patients were excluded. The 5 years estimated relapse-free survival (RFS) and central nervous system (CNS) relapse were 82.7%, 9.4%, respectively, which were lower than low and intermediate-risk groups (87.8%, 1.4% ) with statistic difference (P=0.048, 0.002). High-dose cytarabine and intrathecal chemotherapy may reduce the risk of CNS relapse. CONCLUSION The outcomes of high-risk APL patients were worse than low and intermediate-risk group owing to the high ED rate and CNS relapse, it was important to decrease the ED rate and emphasis the CNS prophylaxis for high-risk APL patients.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - J Jin
- Department & Institute of Hematology, The First Affiliated Hospital of Zhejiang University, The Key Laboratory of Hematologic Tumor (Diagnose and Treatment) of Zhejiang Province, Hangzhou 310003, China
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The role of thromboelastography in predicting bleeding risk and guiding the administration of platelet transfusions in hematological patients: a cohort study. Ann Hematol 2016; 95:1163-8. [DOI: 10.1007/s00277-016-2658-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 03/29/2016] [Indexed: 01/28/2023]
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Jurisic V, Radenkovic S, Konjevic G. The Actual Role of LDH as Tumor Marker, Biochemical and Clinical Aspects. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 867:115-24. [PMID: 26530363 DOI: 10.1007/978-94-017-7215-0_8] [Citation(s) in RCA: 157] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Lactate dehydrogenase (LDH) among many biochemical parameters represents a very valuable enzyme in patients with cancer with possibility for easy routine measurement in many clinical laboratories. Previous studies where mostly based on investigated LDH in serum of patients with cancer with aims to estimate their clinical significance. The new directions in investigation of LDH where based on the principle that tumor cells release intracellular enzymes trough damaged cell membrane, that is mostly consequence in intracellular mitochondrial machinery alteration, and apoptosis deregulation. This consideration can be used not only in-vitro assays, but also in respect to clinical characteristics of tumor patients. Based on new techniques of molecular biology it is shown that intracellular characteristics of LDH enzyme are very sensitive indicators of the cellular metabolic state, aerobic or anaerobic direction of glycolysis, activation status and malignant transformation. Using different molecular analyses it is very useful to analyzed intracellular LDH activity in different cell line and tumor tissues obtained from patients, not only to understanding complexity in cancer biochemistry but also in early clinical diagnosis. Based on understandings of the LDH altered metabolism, new therapy option is created with aims to blocking certain metabolic pathways and stop tumors growth.
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Affiliation(s)
- Vladimir Jurisic
- Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia.
| | | | - Gordana Konjevic
- Institute of Oncology and Radiology of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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Whatʼs new in the pathogenesis of the coagulopathy in acute promyelocytic leukemia? Curr Opin Hematol 2016; 23:121-6. [DOI: 10.1097/moh.0000000000000221] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Christersson C, Wallentin L, Andersson U, Alexander JH, Ansell J, De Caterina R, Gersh BJ, Granger CB, Hanna M, Horowitz JD, Huber K, Husted S, Hylek EM, Lopes RD, Siegbahn A. D-dimer and risk of thromboembolic and bleeding events in patients with atrial fibrillation--observations from the ARISTOTLE trial. J Thromb Haemost 2014; 12:1401-12. [PMID: 24942912 DOI: 10.1111/jth.12638] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 05/12/2014] [Indexed: 01/17/2023]
Abstract
BACKGROUND D-dimer is related to adverse outcomes in arterial and venous thromboembolic diseases. OBJECTIVES To evaluate the predictive value of D-dimer level for stroke, other cardiovascular events, and bleeds, in patients with atrial fibrillation (AF) treated with oral anticoagulation with apixaban or warfarin; and to evaluate the relationship between the D-dimer levels at baseline and the treatment effect of apixaban vs. warfarin. METHODS In the ARISTOTLE trial, 18 201 patients with AF were randomized to apixaban or warfarin. D-dimer was analyzed in 14 878 patients at randomization. The cohort was separated into two groups; not receiving vitamin K antagonist (VKA) treatment and receiving VKA treatment at randomization. RESULTS Higher D-dimer levels were associated with increased frequencies of stroke or systemic embolism (hazard ratio [HR] [Q4 vs. Q1] 1.72, 95% confidence interval [CI] 1.14-2.59, P = 0.003), death (HR [Q4 vs. Q1] 4.04, 95% CI 3.06-5.33) and major bleeding (HR [Q4 vs. Q1] 2.47, 95% CI 1.77-3.45, P < 0.0001) in the no-VKA group. Similar results were obtained in the on-VKA group. Adding D-dimer level to the CHADS2 score improved the C-index from 0.646 to 0.655 for stroke or systemic embolism, and from 0.598 to 0.662 for death, in the no-VKA group. D-dimer level improved the HAS-BLED score for prediction of major bleeds, with an increase in the C-index from 0.610 to 0.641. There were no significant interactions between efficacy and safety of study treatment and D-dimer level. CONCLUSION In anticoagulated patients with AF, the level of D-dimer is related to the risk of stroke, death, and bleeding, and adds to the predictive value of clinical risk scores. The benefits of apixaban were consistent, regardless of the baseline D-dimer level.
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Affiliation(s)
- C Christersson
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
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Li J, Zhu H, Hu J, Mi J, Chen S, Chen Z, Wang Z. Progress in the treatment of acute promyelocytic leukemia: optimization and obstruction. Int J Hematol 2014; 100:38-50. [DOI: 10.1007/s12185-014-1603-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Revised: 05/13/2014] [Accepted: 05/20/2014] [Indexed: 11/29/2022]
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Pagnano KBB, Rego EM, Rohr S, Chauffaille MDL, Jacomo RH, Bittencourt R, Firmato AB, Fagundes EM, Melo RAM, Bernardo W. Guidelines on the diagnosis and treatment for acute promyelocytic leukemia: Associação Brasileira de Hematologia, Hemoterapia e Terapia Celular Guidelines Project: Associação Médica Brasileira - 2013. Rev Bras Hematol Hemoter 2014; 36:71-89. [PMID: 24624041 PMCID: PMC3948671 DOI: 10.5581/1516-8484.20140018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2013] [Indexed: 12/15/2022] Open
Affiliation(s)
| | | | - Sandra Rohr
- Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | | | | | - Rosane Bittencourt
- Universidade Federal do Rio Grande do Sul (UFGRS), Porto Alegre, RS, Brazil
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Matsushita T, Watanabe J, Honda G, Mimuro J, Takahashi H, Tsuji H, Eguchi Y, Kitajima I, Sakata Y. Thrombomodulin alfa treatment in patients with acute promyelocytic leukemia and disseminated intravascular coagulation: a retrospective analysis of an open-label, multicenter, post-marketing surveillance study cohort. Thromb Res 2014; 133:772-81. [PMID: 24636871 DOI: 10.1016/j.thromres.2014.02.025] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Revised: 02/09/2014] [Accepted: 02/25/2014] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Patients with acute promyelocytic leukemia (APL) can develop disseminated intravascular coagulation (DIC) that results in life-threatening hemorrhagic complications. Studies regarding the safety and efficacy of thrombomodulin alfa (TM-α; recombinant human soluble thrombomodulin) in patients with APL and DIC are limited. MATERIALS AND METHODS A retrospective evaluation was performed on a cohort of 172 patients with APL from an open-label, multicenter, post-marketing surveillance study of TM-α. RESULTS Of the 172 patients, 31 were relapse/refractory APL patients, and 141 were newly diagnosed APL patients. Within the first 30 days, 24 patients (14.0%) died, and six of those deaths (3.5%) were due to hemorrhage. In total, 12 patients (7.0%) had severe hemorrhagic complications. Both the early death rate due to hemorrhage as well as the severe hemorrhage rate did not exceed those in some recent population-based studies of patients with APL. Forty-nine patients received TM-α prior to the initiation of antileukemic treatment, and one patient experienced hemorrhagic early death (ED), suggesting that early TM-α treatment appeared to result in a reduction in the hemorrhagic ED rate. Moreover, TM-α improved coagulopathy regardless of concomitant all-trans retinoic acid treatment. CONCLUSIONS This study confirmed the safety and efficacy of TM-α in daily clinical practice for patients with APL and DIC. TM-α appeared to reduce hemorrhagic early deaths due to DIC in patients with APL who were receiving antileukemic treatment.
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Affiliation(s)
- Tadashi Matsushita
- Department of Transfusion Medicine, Nagoya University Hospital, Aichi, Japan; The Japanese Society on Thrombosis and Hemostasis Post-Marketing Surveillance Committee for Recomodulin(®) Injection, Japan.
| | | | - Goichi Honda
- ART Project, Asahi Kasei Pharma Corporation, Tokyo, Japan
| | - Jun Mimuro
- Division of Cell and Molecular Medicine, Center for Molecular Medicine, Jichi Medical University, School of Medicine, Tochigi, Japan; The Japanese Society on Thrombosis and Hemostasis Post-Marketing Surveillance Committee for Recomodulin(®) Injection, Japan
| | - Hoyu Takahashi
- Department of Internal Medicine, Niigata Prefectural Kamo Hospital, Niigata, Japan; The Japanese Society on Thrombosis and Hemostasis Post-Marketing Surveillance Committee for Recomodulin(®) Injection, Japan
| | - Hajime Tsuji
- Department of Blood Transfusion, Kyoto Prefectural University of Medicine, Kyoto, Japan; The Japanese Society on Thrombosis and Hemostasis Post-Marketing Surveillance Committee for Recomodulin(®) Injection, Japan
| | - Yutaka Eguchi
- Critical and Intensive Care Medicine, Shiga University of Medical Science, Shiga, Japan; The Japanese Society on Thrombosis and Hemostasis Post-Marketing Surveillance Committee for Recomodulin(®) Injection, Japan
| | - Isao Kitajima
- Department of Clinical Laboratory and Molecular Pathology, Graduate School of Medical and Pharmaceutical Science, University of Toyama, Toyama, Japan; The Japanese Society on Thrombosis and Hemostasis Post-Marketing Surveillance Committee for Recomodulin(®) Injection, Japan
| | - Yoichi Sakata
- Division of Cell and Molecular Medicine, Center for Molecular Medicine, Jichi Medical University, School of Medicine, Tochigi, Japan; The Japanese Society on Thrombosis and Hemostasis Post-Marketing Surveillance Committee for Recomodulin(®) Injection, Japan
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Mitrovic M, Suvajdzic N, Bogdanovic A, Kurtovic NK, Sretenovic A, Elezovic I, Tomin D. International Society of Thrombosis and Hemostasis Scoring System for disseminated intravascular coagulation ≥6: a new predictor of hemorrhagic early death in acute promyelocytic leukemia. Med Oncol 2013; 30:478. [DOI: 10.1007/s12032-013-0478-y] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2012] [Accepted: 01/20/2013] [Indexed: 11/28/2022]
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Chang H, Kuo MC, Shih LY, Dunn P, Wang PN, Wu JH, Lin TL, Hung YS, Tang TC. Clinical bleeding events and laboratory coagulation profiles in acute promyelocytic leukemia. Eur J Haematol 2012; 88:321-8. [DOI: 10.1111/j.1600-0609.2011.01747.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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