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Abstract
Acute promyelocytic leukaemia (APL) is a rare subtype of acute myeloid leukaemia. The outcome of paediatric APL has improved substantially over the past 20 years; cure rates above 80% are expected when all-trans retinoic acid (ATRA) is given with anthracycline-based regimens. The presenting features of paediatric APL may include severe bleeding and thrombotic complications, which contribute to the high early death rate. The incidence of leucocytosis and the microgranular subtype is greater in paediatric than adult APL, and children experience greater ATRA-related toxicity. It is crucial to begin ATRA therapy and intensive platelet and fibrinogen replacement on first suspicion of APL. Recent risk-adapted therapeutic trials have shown that patients at greater risk of relapse benefit from the introduction of high-dose cytarabine during consolidation. Combination therapy with ATRA and arsenic trioxide provides very effective frontline treatment and may reduce the need for subsequent anthracycline therapy.
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Affiliation(s)
- Oussama Abla
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Raul C. Ribeiro
- Department of Oncology and International Outreach Program, Saint Jude Children’s Research Hospital, Memphis, USA
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2
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Akoz AG, Dagdas S, Ozet G, Ceran F, Yilmaz M. Isolated central nervous system relapse during cytologic and molecular hematologic remission in two patients with acute promyelocytic leukemia. Hematology 2013; 12:419-22. [PMID: 17852441 DOI: 10.1080/10245330701442472] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Extramedullary involvement in the absence of bone marrow disease is rare in patients with acute promyelocytic leukemia (APL). We report two patients with APL who had central nervous system (CNS) relapse without evidence of cytologic and molecular disease of bone marrow after all-trans-retinoic acid (ATRA) treatment. Both of the patients were treated successfully with combination of intrathecal chemotherapy and radiotherapy with or without systemic chemotherapy. Although increasing number of cases with extramedullary involvement of APL after ATRA including therapy have been reported, further studies with a large series of patients are necessary to determine whether ATRA increases the risk of development of extramedullary involvement of disease in patients with APL.
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Affiliation(s)
- Ayla Gokmen Akoz
- Department of Hematology, Karaelmas University Medical School, Zonguldak, Turkey.
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Zou XL, Zeng K, Xie LP, Wang L, Chen M, Liu T, Niu T. Acute promyelocytic leukemia with Flt3-TKD and WT1 mutations relapsing in a testicle and followed by systemic relapse. Acta Haematol 2013; 130:223-9. [PMID: 23816818 DOI: 10.1159/000351054] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 03/17/2013] [Indexed: 12/22/2022]
Abstract
Extramedullary relapse is a rare phenomenon in patients with acute promyelocytic leukemia (APL), especially that derived from urogenital systems like the testicles. In this report, we describe an APL patient who had received standard induction/maintenance therapy resulting in durable remission for 4.5 years, when he presented with a unilateral testicular mass confirmed as myeloid sarcoma; this was followed by systemic relapse of APL. Retrospective analysis of the involved blood and bone marrow samples at the time of the initial diagnosis revealed a rare point mutation of FLT3-TKD and a novel mutation of WT1. These mutations were detected recurrently throughout the course of the disease. After reinduction therapy with arsenic trioxide and all-trans retinoic acid combined with daunorubicin, complete hematological remission was achieved for the ensuing salvage allogeneic hematopoietic stem cell transplant.
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Affiliation(s)
- Xing-li Zou
- Department of Hematology and Research Laboratory of Hematology, West China Hospital, Sichuan University, Chengdu, PR China
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Extramedullary disease in acute promyelocytic leukemia: two-in-one disease. Mediterr J Hematol Infect Dis 2011; 3:e2011066. [PMID: 22220263 PMCID: PMC3248343 DOI: 10.4084/mjhid.2011.066] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2011] [Accepted: 11/27/2011] [Indexed: 11/08/2022] Open
Abstract
In acute promyelocytic leukemia (APL), extramedullary disease (EMD) is particularly rare and shows special clinical and biological features. It is estimated that about 3-5% of APL patients will suffer extramedullary relapse. The most common site of EMD in APL is the central nervous system (CNS). At present, there are still many issues of EMD in APL needing further clarification, including pathogenesis, risk factors, prognosis and treatment. A better understanding of the biological mechanisms underlying EMD is important to be able to devise more effective CNS prophylaxis and induction-consolidation therapeutic strategies.
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Promyelocytic sarcoma of the spine: a case report and review of the literature. Adv Hematol 2010; 2010:137608. [PMID: 20339529 PMCID: PMC2843861 DOI: 10.1155/2010/137608] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2009] [Accepted: 01/15/2010] [Indexed: 12/17/2022] Open
Abstract
Myeloid sarcoma (MS, previously named granulocytic sarcoma or chloroma) is a rare extramedullary tumour of immature myeloid cells. It can be present before, concurrently with, or after the diagnosis of acute myeloid leukemia. MS is extremely uncommon in acute promyelocytic leukemia (APL). In the case described here, MS was the sole site of APL relapse and the cause of spinal cord compression. The patient presented with neurologic symptoms due to a paravertebral mass of MS after 7 years of complete remission. He was treated with excision of the mass followed by local radiotherapy. Systemic treatment was also given with combined arsenic trioxide and all-trans retinoic acid and the patient was able to achieve a second prolonged clinical and molecular remission.
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Vega-Ruiz A, Faderl S, Estrov Z, Pierce S, Cortes J, Kantarjian H, Ravandi F. Incidence of extramedullary disease in patients with acute promyelocytic leukemia: a single-institution experience. Int J Hematol 2009; 89:489-496. [PMID: 19340529 DOI: 10.1007/s12185-009-0291-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2008] [Revised: 03/06/2009] [Accepted: 03/10/2009] [Indexed: 02/02/2023]
Abstract
Using current treatment regimens, over 90% of patients with acute promyelocytic leukemia will achieve complete remission (CR). However, approximately 30% of these patients will relapse, including a small proportion who will develop extramedullary disease (EMD). In this study, we investigated the incidence of EMD in 263 patients with APL who were treated at our institution from January 1990 to May 2008. With a median follow-up of 31 months (range 2 days-203 months), 8 (3%) patients developed EMD. The most commonly affected site was the central nervous system (n = 7). Before developing EMD, one patient had achieved CR with a chemotherapy-only regimen, six patients had achieved CR with all-trans-retinoic acid (ATRA)-based regimens, and one patient had achieved CR with an ATRA plus arsenic trioxide (ATO)-based regimen. The EMD conferred a poor prognosis; five patients died within 4 months of developing EMD. The molecular status did not predict EMD; four patients had a negative PCR for the PML-RARA transcripts prior to relapse with EMD. In conclusion, the incidence of EMD is low. We were unable to identify any specific factors that could predict the development of EMD.
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Affiliation(s)
- Arturo Vega-Ruiz
- Department of Leukemia, Unit 428, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Stefan Faderl
- Department of Leukemia, Unit 428, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Zeev Estrov
- Department of Leukemia, Unit 428, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Sherry Pierce
- Department of Leukemia, Unit 428, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Jorge Cortes
- Department of Leukemia, Unit 428, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Hagop Kantarjian
- Department of Leukemia, Unit 428, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Farhad Ravandi
- Department of Leukemia, Unit 428, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.
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Long-term efficacy and safety of all-trans retinoic acid/arsenic trioxide-based therapy in newly diagnosed acute promyelocytic leukemia. Proc Natl Acad Sci U S A 2009; 106:3342-7. [PMID: 19225113 DOI: 10.1073/pnas.0813280106] [Citation(s) in RCA: 327] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
All-trans retinoic acid (ATRA)/arsenic trioxide (ATO) combination-based therapy has benefitted newly diagnosed acute promyelocytic leukemia (APL) in short-term studies, but the long-term efficacy and safety remained unclear. From April 2001, we have followed 85 patients administrated ATRA/ATO with a median follow-up of 70 months. Eighty patients (94.1%) entered complete remission (CR). Kaplan-Meier estimates of the 5-year event-free survival (EFS) and overall survival (OS) for all patients were 89.2% +/- 3.4% and 91.7% +/- 3.0%, respectively, and the 5-year relapse-free survival (RFS) and OS for patients who achieved CR (n = 80) were 94.8% +/- 2.5% and 97.4% +/- 1.8%, respectively. Upon ATRA/ATO, prognosis was not influenced by initial white blood cell count, distinct PML-RARalpha types, or FLT3 mutations. The toxicity profile was mild and reversible. No secondary carcinoma was observed, and 24 months after the last dose of ATRA/ATO, patients had urine arsenic concentrations well below the safety limit. These results demonstrate the high efficacy and minimal toxicity of ATRA/ATO treatment for newly diagnosed APL in long-term follow-up, suggesting a potential frontline therapy for de novo APL.
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Ko MW, Tamhankar MA, Volpe NJ, Porter D, McGrath C, Galetta SL. Acute promyelocytic leukemic involvement of the optic nerves following mitoxantrone treatment for multiple sclerosis. J Neurol Sci 2008; 273:144-7. [PMID: 18687447 DOI: 10.1016/j.jns.2008.06.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2008] [Revised: 06/19/2008] [Accepted: 06/24/2008] [Indexed: 11/24/2022]
Abstract
Mitoxantrone, the first immunosuppressant to receive FDA approval for treatment of worsening relapsing-remitting, secondary progressive, and progressive-relapsing multiple sclerosis (MS) is a DNA topoisomerase II inhibitor that has been associated with the development of acute promyelocytic myelogenous leukemia (APML). Central nervous system APML is a rare site of extramedullary involvement following mitoxantrone therapy. We report a patient with history of multiple sclerosis who developed bilateral optic nerve involvement as the primary manifestation of APML relapse following mitoxantrone treatment.
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Affiliation(s)
- Melissa W Ko
- Department of Neurology, State University of New York Upstate Medical University, Syracuse, NY, United States.
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Kesari S, Drappatz J, Akar S, Vergilio JA, Wen PY, Soiffer RJ, Stone RM, DeAngelo DJ. Recurrent Acute Promyelocytic Leukemia Presenting As a Sacral Nerve Root Mass. J Clin Oncol 2008; 26:3279-81. [DOI: 10.1200/jco.2007.15.6729] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Santosh Kesari
- Department of Neurology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA
| | - Jan Drappatz
- Department of Neurology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA
| | - Serra Akar
- Dana-Farber Cancer Institute, Boston, MA; Hacettepe University School of Medicine, Ankara, Turkey
| | - Jo-Anne Vergilio
- Department of Pathology, Brigham and Women's Hospital; Harvard Medical School, Boston, MA
| | - Patrick Y. Wen
- Department of Neurology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA
| | - Robert J. Soiffer
- Department of Pathology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA
| | - Richard M. Stone
- Department of Pathology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA
| | - Daniel J. DeAngelo
- Department of Pathology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA
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Abstract
Central nervous system (CNS) involvement is rare in acute promyelocytic leukemia (APL). The majority of CNS relapses occur in patients with hyperleukocytosis at presentation, and the optimal management of such patients is still controversial. We describe a 13-year-old boy with APL who developed an isolated CNS relapse after first-line treatment with all-trans retinoic acid and chemotherapy. A second remission was achieved with a regimen consisting of intrathecal chemotherapy, intravenous high-dose cytarabine, and oral 6-mercaptopurine. All-trans retinoic acid was avoided owing to severe complications during initial therapy. The patient remains in molecular remission at 9 months after autologous stem cell transplant. Prognostic factors of CNS relapse in children with APL are needed to define the indications for CNS prophylaxis in this group of patients.
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Raanani P, Shpilberg O, Ben-Bassat I. Extramedullary disease and targeted therapies for hematological malignancies—is the association real? Ann Oncol 2007; 18:7-12. [PMID: 16790518 DOI: 10.1093/annonc/mdl129] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
During the past years targeted therapies have gained a major role in the treatment of cancer patients, including those with hematological malignancies. Extramedullary involvement is a rare manifestation of acute and chronic leukemias and of multiple myeloma. Nevertheless, with the expanding use of targeted treatments there is an impression that the incidence of extramedullary relapses is increasing. We reviewed the reports on this phenomenon in patients treated with all-trans-retinoic acid and arsenic trioxide for acute promyelocytic leukemia, thalidomide and bortezomib for multiple myeloma and imatinib for chronic myeloid leukemia. The pathogenetic mechanisms suggested are: life prolongation by these treatments allowing for disease progression arising from dormant cells; poor penetration of the drugs to sanctuary sites like the central nervous system; the requirement of some of these drugs, especially thalidomide, for the marrow microenvironment to exert their action; and finally, a possible active role for some of the drugs, like all-trans-retinoic acid. Since the use of these targeted therapies is expanding we should be aware of this association.
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Affiliation(s)
- P Raanani
- Institute of Hematology, Rabin Medical Center, Beilinson Campus, Petah-Tikva.
| | - O Shpilberg
- Institute of Hematology, Rabin Medical Center, Beilinson Campus, Petah-Tikva
| | - I Ben-Bassat
- Institute of Hematology, The Chaim Sheba Medical Center, Tel-Hashomer and Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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12
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Bae SH, Ryoo HM, Cho HS, Lee JL, Lee KH, Hyun MS. Meningeal relapse in a patient with acute promyelocytic leukemia: a case report and review of the literature. J Korean Med Sci 2004; 19:311-4. [PMID: 15082912 PMCID: PMC2822320 DOI: 10.3346/jkms.2004.19.2.311] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The involvement of central nervous system is rare in acute promyelocytic leukemia (APL). We report a APL patient of a 41 yr-old Korean male who presented with fever and petechia. Complete molecular remission was achieved with all-trans retinoic acid (ATRA), idarubicin, and cytarabine. Ten months later, he complained of a mild headache. The results of the physical examination and the complete blood counts were normal. The examination of cerebrospinal fluid showed the presence of promyelocyte. Bone marrow studies showed cytogenetic remission but with molecular relapse. He was treated with intrathecal and systemic chemotherapy.
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Affiliation(s)
- Sung Hwa Bae
- Department of Internal Medicine, Daegu Catholic University College of Medicine, Daegu, Korea
| | - Hun Mo Ryoo
- Department of Internal Medicine, Daegu Catholic University College of Medicine, Daegu, Korea
| | - Hee Soon Cho
- Department of Laboratory Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Jae Lyun Lee
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Kyung Hee Lee
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Myung Soo Hyun
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
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