1
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Singh S, Mustari AP, Lad D, Parkhi M, Vinay K. Oral ulcers and cutaneous rash as manifestations of differentiation syndrome in acute promyelocytic leukaemia. Indian J Dermatol Venereol Leprol 2022; 89:449-452. [PMID: 36688898 DOI: 10.25259/ijdvl_576_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 09/01/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Sukhdeep Singh
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Akash P Mustari
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepesh Lad
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Mayur Parkhi
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Keshavamurthy Vinay
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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2
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Krause JR, Fathima S, Mayer RR, Snipes GJ. An unusual myeloid sarcoma. Proc AMIA Symp 2021; 35:252-253. [DOI: 10.1080/08998280.2021.1995108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- John R. Krause
- Section of Hematopathology, Department of Pathology, Baylor University Medical Center, Dallas, Texas
| | - Samreen Fathima
- Section of Hematopathology, Department of Pathology, Baylor University Medical Center, Dallas, Texas
| | - Rory Richard Mayer
- Department of Neurosurgery, Baylor University Medical Center, Dallas, Texas
| | - George J. Snipes
- Department of Neuropathology, Baylor University Medical Center, Dallas, Texas
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3
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Molica M, Mazzone C, Ottone T, Niscola P, Abruzzese E, Fratoni S, Voso MT, de Fabritiis P. Case Report: Very Late, Atypical Extra-Medullary Relapse in a Patient With Acute Promyelocytic Leukemia (APL) Rescued With a Transplant-Free Approach. Front Oncol 2021; 11:699886. [PMID: 34268125 PMCID: PMC8276173 DOI: 10.3389/fonc.2021.699886] [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: 04/24/2021] [Accepted: 06/11/2021] [Indexed: 12/01/2022] Open
Abstract
Relapses of acute promyelocytic leukemia (APL) beyond 7 years from the first molecular remission are exceptional, and it is unclear whether these relapses represent a new, therapy-related leukemia rather than a delayed relapse of the original leukemic clone. The increase extra-medullary relapses (ER) in the era of all-trans retinoic acid (ATRA) therapy suggests a potential correlation between ATRA therapy and ER, and several potential explanations have been proposed. The gold standard post-remission approach, particularly for patients in late relapse, has not yet been established. The benefit of a transplant approach has been questioned in this setting because continuing ATRA-arsenic trioxide (ATO) might be curative. Here we report on the case of an APL patient who relapsed 9 years after achieving her first molecular complete remission (mCR) and who showed an atypical isolated localization at nodal sites, including the into- and peri-parotid glands. Genomic PML/RARa breakpoint analysis detected the same bcr3 PML/RARa hybrid gene in DNA purified from bone marrow and lymph nodes, suggesting that the relapse was because of the reemergence of the initial clone. This case shows that APL, treated with ATRA and cytotoxic drugs, may still emerge in extra-medullary sites even after a very prolonged mCR and could be salvaged with an ATO-based protocol, not including a transplant approach.
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Affiliation(s)
| | | | - Tiziana Ottone
- Department of Biomedicine and Prevention, University Tor Vergata, Rome, Italy
| | | | | | - Stefano Fratoni
- Surgical Pathology, Hematopathology Unit, St. Eugenio Hospital, Rome, Italy
| | - Maria Teresa Voso
- Department of Biomedicine and Prevention, University Tor Vergata, Rome, Italy
| | - Paolo de Fabritiis
- Haematology Unit, St. Eugenio Hospital, Rome, Italy
- Department of Biomedicine and Prevention, University Tor Vergata, Rome, Italy
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4
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Gill HS, Yim R, Kumana CR, Tse E, Kwong YL. Oral arsenic trioxide, all-trans retinoic acid, and ascorbic acid maintenance after first complete remission in acute promyelocytic leukemia: Long-term results and unique prognostic indicators. Cancer 2020; 126:3244-3254. [PMID: 32365228 DOI: 10.1002/cncr.32937] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/04/2020] [Accepted: 04/06/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The role of arsenic trioxide (As2 O3 ) in the maintenance of first complete remission (CR1) in acute promyelocytic leukemia (APL) is unclear. METHODS A total of 129 consecutive adult patients with APL of all risk categories who achieved CR1 with conventional induction (all-trans retinoic acid [ATRA]/daunorubicin) and consolidation (daunorubicin/cytarabine [induction daunorubicin and consolidation omitted for age ≥70 years]) underwent maintenance comprising ATRA (45 mg/m2 /day), oral As2 O3 (10 mg/day), and ascorbic acid (1 g/day) (AAA) for 2 weeks every 2 months for 2 years. RESULTS Over a 17-year period from August 1, 2002, to July 31, 2019, 63 men and 66 women (median age, 46 years [range, 18-82 years]) received AAA maintenance, which was already completed in 117 patients. At a median follow-up of 100 months (range, 8-215 months), 17 patients (13%) developed first relapse (R1) (hematologic, n = 14; molecular, n = 3) after a median of 19 months (range, 7-96 months) from CR1. Two R1 patients had concomitant central nervous system (CNS) involvement. All patients achieved CR2 with oral As2 O3 -based salvage. Five patients had a subsequent relapse and died. Eight patients died of unrelated causes while still in CR1. The 5-year and 10-year rates of relapse-free survival (RFS) were 89% and 85%, respectively. The 5-year and 10-year rates of overall survival (OS) were 94% and 87%, respectively. Multivariate analysis showed that inferior RFS was associated with FLT3-ITD (P = .005) and CNS involvement on presentation (P = .004), and inferior OS was associated with therapy-related APL (P = .03), FLT3-ITD (P = .03), and relapse (P = .03). The safety profile was favorable, with no grade 3/4 organ toxicities. CONCLUSION CR1 maintenance with AAA is safe and results in favorable long-term survival in patients with APL.
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Affiliation(s)
- Harinder S Gill
- Department of Medicine, University of Hong Kong, Hong Kong, China
| | - Rita Yim
- Department of Medicine, University of Hong Kong, Hong Kong, China
| | - Cyrus R Kumana
- Department of Medicine, University of Hong Kong, Hong Kong, China
| | - Eric Tse
- Department of Medicine, University of Hong Kong, Hong Kong, China
| | - Yok-Lam Kwong
- Department of Medicine, University of Hong Kong, Hong Kong, China
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5
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Osumi T, Watanabe A, Okamura K, Nakabayashi K, Yoshida M, Tsujimoto SI, Uchiyama M, Takahashi H, Tomizawa D, Hata K, Kiyokawa N, Kato M. Acute promyelocytic leukemia with a cryptic insertion of RARA into TBL1XR1. Genes Chromosomes Cancer 2019; 58:820-823. [PMID: 31350930 DOI: 10.1002/gcc.22791] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 07/10/2019] [Accepted: 07/11/2019] [Indexed: 01/22/2023] Open
Abstract
Acute promyelocytic leukemia (APL) is cytogenetically characterized by the t(15;17) (q24;q21), although cases without this translocation exist. These cases are referred to as "cryptic" or "masked" translocations. Additionally, fewer than 5% of APL cases have another partner gene fused to the RARA gene. The TBL1XR1-RARA fusion gene has recently been reported as a novel RARA-associated fusion gene. We report a case with TBL1XR1-RARA and a masked translocation that was not detected by conventional tests for RARA-associated translocations. Three-year-old girl was diagnosed with APL based morphological findings, although conventional tests for RARA-associated chimeric genes were negative. She received all-trans retinoic acid treatment, but that was not effective. She achieved a complete remission (CR) by conventional multidrug chemotherapy, but had extramedullary relapse 2 years after onset. She underwent cord blood transplantation (CBT) in her second CR and is currently alive. To investigate the underlying pathogenesis of this unique case, we performed whole-genome sequencing and found a cryptic insertion of RARA gene into the TBL1XR1 gene. The transcript of the chimeric gene, TBL1XR1-RARA, was confirmed as an in-frame fusion by RT-PCR. In conclusion, we found using next-generation sequencing (NGS) a TBL1XR1-RARA fusion in a child with variant APL without the classic karyotype. Cryptic insertion could also occur in cases other than APL with PML-RARA. Variant APL has many variants and NGS analysis should therefore be considered for APL variant cases, even for those without RARA translocation detected by conventional analysis.
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Affiliation(s)
- Tomoo Osumi
- Department of Pediatric Hematology and Oncology Research, Research Institute, National Center for Child Health and Development, Tokyo, Japan.,Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Akihiro Watanabe
- Department of Pediatrics, Niigata Cancer Center Hospital, Niigata, Japan
| | - Kohji Okamura
- Department of Systems BioMedicine, Research Institute, National Center for Child Health and Development, Tokyo, Japan
| | - Kazuhiko Nakabayashi
- Department of Maternal-Fetal Biology, Research Institute, National Center for Child Health and Development, Tokyo, Japan
| | - Masanori Yoshida
- Department of Pediatric Hematology and Oncology Research, Research Institute, National Center for Child Health and Development, Tokyo, Japan.,Department of Pediatrics, Yokohama City University, Yokohama, Japan
| | - Shin-Ichi Tsujimoto
- Department of Pediatric Hematology and Oncology Research, Research Institute, National Center for Child Health and Development, Tokyo, Japan.,Department of Pediatrics, Yokohama City University, Yokohama, Japan
| | - Meri Uchiyama
- Department of Pediatric Hematology and Oncology Research, Research Institute, National Center for Child Health and Development, Tokyo, Japan
| | - Hiroyuki Takahashi
- Department of Pediatrics, Toho University Omori Medical Center, Tokyo, Japan
| | - Daisuke Tomizawa
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Kenichiro Hata
- Department of Maternal-Fetal Biology, Research Institute, National Center for Child Health and Development, Tokyo, Japan
| | - Nobutaka Kiyokawa
- Department of Pediatric Hematology and Oncology Research, Research Institute, National Center for Child Health and Development, Tokyo, Japan
| | - Motohiro Kato
- Department of Pediatric Hematology and Oncology Research, Research Institute, National Center for Child Health and Development, Tokyo, Japan.,Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
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6
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Management of patients with acute promyelocytic leukemia. Leukemia 2018; 32:1277-1294. [DOI: 10.1038/s41375-018-0139-4] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 04/08/2018] [Accepted: 04/11/2018] [Indexed: 01/10/2023]
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7
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Gill H, Yim R, Lee HKK, Mak V, Lin SY, Kho B, Yip SF, Lau JSM, Li W, Ip HW, Hwang YY, Chan TSY, Tse E, Au WY, Kumana CR, Kwong YL. Long-term outcome of relapsed acute promyelocytic leukemia treated with oral arsenic trioxide-based reinduction and maintenance regimens: A 15-year prospective study. Cancer 2018; 124:2316-2326. [PMID: 29579321 DOI: 10.1002/cncr.31327] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 01/30/2018] [Accepted: 02/13/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND For patients who have acute promyelocytic leukemia (APL) in second complete remission (CR2), optimal postremission strategies remain undefined. METHODS The role of an oral arsenic trioxide (As2 O3 )-based regimen in the management of patients who had APL in CR2 was examined. RESULTS Seventy-three patients with APL in first relapse (R1) were studied. Oral As2 O3 -based reinduction resulted uniformly in CR2, irrespective of previous As2 O3 exposure. All patients received oral As2 O3 -based maintenance in CR2. At a median follow-up of 94 months (range, 9-205 months), 43 patients (58.9%) were still in CR2, and 49 (67.1%) had finished the planned 2-year CR2 maintenance with all-trans retinoic acid, oral As2 O3 , and ascorbic acid. Reinduction and maintenance treatments were well tolerated. Grade 1 and 2 headache occurred in 20 patients (27.4%). Hepatotoxicity, all in the form of transaminitis, occurred in 35 patients (47.9%; grade 1 and 2, n = 26; grade 3 and 4, n = 9). Three patients had self-limiting QTc prolongation. The 10-year leukemia-free survival rate was 56.8%. Thirty patients developed R2. Oral As2 O3 -based reinduction led to CR3 in 27 patients (90%). Post-CR3 strategies included autologous hematopoietic stem cell transplantation and oral As2 O3 maintenance. At a post-CR3 follow-up of 30 months (range, 3-166 months), 11 patients were still in CR3. The 5-year and 10-year overall survival rates in the R1 cohort were 79.5% and 67.3%, respectively. Prior receipt of oral As2 O3 maintenance in CR1 was the only risk factor for inferior leukemia-free survival. Central nervous system involvement occurred in 15 patients, including 5 who remained alive. Relapse during oral As2 O3 therapy was the only significant risk factor for central nervous system involvement. CONCLUSIONS For patients with relapsed APL, As2 O3 remained effective despite repeated As2 O3 exposures. Oral As2 O3 maintenance was an effective postremission strategy for CR2. Cancer 2018;124:2316-26. © 2018 American Cancer Society.
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Affiliation(s)
- Harinder Gill
- Department of Medicine, Queen Mary Hospital, Hong Kong, China
| | - Rita Yim
- Department of Medicine, Queen Mary Hospital, Hong Kong, China
| | - Harold K K Lee
- Department of Medicine, Princess Margaret Hospital, Hong Kong, China
| | - Vivien Mak
- Department of Medicine, Princess Margaret Hospital, Hong Kong, China
| | - Shek-Ying Lin
- Department of Medicine, United Christian Hospital, Hong Kong, China
| | - Bonnie Kho
- Department of Medicine, Pamela Youde Eastern Hospital, Hong Kong, China
| | - Sze-Fai Yip
- Department of Medicine, Tuen Mun Hospital, Hong Kong, China
| | - June S M Lau
- Department of Medicine, Queen Elizabeth Hospital, Hong Kong, China
| | - Wah Li
- Department of Clinical Oncology, Prince of Wales Hospital, Hong Kong, China
| | - Ho-Wan Ip
- Department of Pathology, Queen Mary Hospital, Hong Kong, China
| | - Yu-Yan Hwang
- Department of Medicine, Queen Mary Hospital, Hong Kong, China
| | - Thomas S Y Chan
- Department of Medicine, Queen Mary Hospital, Hong Kong, China
| | - Eric Tse
- Department of Medicine, Queen Mary Hospital, Hong Kong, China
| | | | - Cyrus R Kumana
- Department of Medicine, Queen Mary Hospital, Hong Kong, China
| | - Yok-Lam Kwong
- Department of Medicine, Queen Mary Hospital, Hong Kong, China
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8
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Zhang Y, Hou J, Ge F, Cao F, Li H, Wang P, Xu M, Song P, Li X, Wang S, Li J, Han X, Zhao Y, Su Y, Li Y, Fan S, Li L, Zhou J. Integrating microRNA and mRNA expression profiles of acute promyelocytic leukemia cells to explore the occurrence mechanisms of differentiation syndrome. Oncotarget 2018; 7:73509-73524. [PMID: 27634874 PMCID: PMC5341995 DOI: 10.18632/oncotarget.11989] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 09/02/2016] [Indexed: 01/25/2023] Open
Abstract
The pathogenesis of therapy-induced differentiation syndrome (DS) in patients with acute promyelocytic leukemia (APL) remains unclear. In this study, mRNA and microRNA (miRNA) expression profiling of peripheral blood APL cells from patients complicated with vs. without DS were integratively analyzed to explore the mechanisms underlying arsenic trioxide treatment-associated DS. By integrating the differentially expressed data with the data of differentially expressed microRNAs and their computationally predicted target genes, as well as the data of transcription factors and differentially expressed target microRNAs obtained from a literature search, a DS-related genetic regulatory network was constructed. Then using an EAGLE algorithm in clusterViz, the network was subdivided into 10 modules. Using the Kyoto Encyclopedia of Genes and Genomes (KEGG) database the modules were annotated functionally, and three functionally active modules were recognized. The further in-depth analyses on the annotated functions of the three modules and the expression and roles of the related genes revealed that proliferation, differentiation, apoptosis and infiltration capability of APL cells might play important roles in the DS pathogenesis. The results could improve our understanding of DS pathogenesis from a more overall perspective, and could provide new clues for future research.
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Affiliation(s)
- Yingmei Zhang
- Central Laboratory, The First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Jinxiao Hou
- Department of Hematology, The First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Fei Ge
- Department of Hematology, The First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Fenglin Cao
- Central Laboratory, The First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Haitao Li
- Department of Hematology, The First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Ping Wang
- Department of Hematology, The First Affiliated Hospital, Harbin Medical University, Harbin, China.,Department of Neonatology, The First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Mengyuan Xu
- Department of Hematology, The First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Peng Song
- Central Laboratory, The First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Xiaoxia Li
- Department of Hematology, The First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Shuye Wang
- Department of Hematology, The First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Jinmei Li
- Department of Hematology, The First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Xueying Han
- Department of Hematology, The First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Yanhong Zhao
- Department of Hematology, The First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Yanhua Su
- Department of Hematology, The First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Yinghua Li
- Department of Hematology, The First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Shengjin Fan
- Department of Hematology, The First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Limin Li
- Department of Hematology, The First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Jin Zhou
- Central Laboratory, The First Affiliated Hospital, Harbin Medical University, Harbin, China.,Department of Hematology, The First Affiliated Hospital, Harbin Medical University, Harbin, China
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9
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Collinge E, Tigaud I, Balme B, Gerland LM, Sujobert P, Carlioz V, Salles G, Thomas X, Paubelle E. Case report: Purulent transformation of granulocytic sarcoma: An unusual pattern of differentiation in acute promyelocytic leukemia. Medicine (Baltimore) 2018; 97:e9657. [PMID: 29465554 PMCID: PMC5841987 DOI: 10.1097/md.0000000000009657] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Acute promyelocytic leukemia (APL) is a curable subtype of acute myeloid leukemia. APL is currently treated with combination of all-trans retinoic acid (ATRA) and arsenic trioxide (ATO) resulting in the induction of apoptosis and differentiation of the leukemic cells. Differentiation syndrome (so-called ATRA syndrome) is the main life-threatening complication of induction therapy with these differentiating agents. PATIENT CONCERNS Herein, we report the case of a 49-year-old woman diagnosed with APL with, concomitantly, a bulky cutaneous lesion of 10 cm diameter with a red-to-purple background and a necrotic center, localized on her abdomen. DIAGNOSES After 10 days of treatment, the cutaneous lesion became purulent. Fluorescence in situ hybridization (FISH) analysis performed on this pus confirmed the presence of malignant features in the involved granulocytes proving their origin from the differentiation of leukemic APL cells, as all the analyzed nuclei showed 2 promyelocytic leukemia (PML)-retinoic acid receptor-a (RARA) fusions signals. INTERVENTION The association by ATRA and ATO was continued. OUTCOME Eventually, the evolution was favorable with healing in three weeks. LESSONS This case report therefore highlights the differentiation phenomenon of promyelocytic blasts within promyelocytic sarcoma with the ATRA-ATO combination and the efficacy of this drug association in resolving both the malignant sarcoma and a secondary local infection.
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Affiliation(s)
- Elodie Collinge
- Department of Hematology, CHU UCL Namur, Belgium
- Department of Hematology
| | | | | | | | | | - Violette Carlioz
- Department of Dermatology, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud
| | | | | | - Etienne Paubelle
- Laboratory of Hematology
- LBMC, ENS, CNRS UMR5239, Faculté de Médecine Lyon Sud, Pierre-Bénite, France
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10
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Liu TT, Zeng KE, Wang L, Liu T, Niu T. Acute promyelocytic leukemia harbouring rare FLT3-TKD and WT1 mutations: A case report. Oncol Lett 2015; 10:1858-1862. [PMID: 26622765 DOI: 10.3892/ol.2015.3437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Accepted: 05/12/2015] [Indexed: 02/05/2023] Open
Abstract
The involvement of the central nervous system (CNS) is rare in acute promyelocytic leukemia (APL). The present study reported the case of a 34-year-old male patient with APL that possessed a rare point mutation (p.Asn841Gly, c.2523C>A) in the tyrosine kinase domain of the FMS-like tyrosine kinase 3 (FLT3) gene and a novel Wilm tumor gene mutation (c.1209_1210insT/p.K404X). The patient suffered central nervous system and systemic relapses twice during systemic and intrathecal chemotherapy. At present, the patient is undergoing alternative induction and consolidation therapies, including the administration of FLT3 inhibitor, tetraarsenic tetrasulfide and novel cytotherapy, and is prepared for salvage allogeneic hematopoietic stem cell transplantion (allo-HSCT). The present study indicated that patients with APL that are at a high risk of relapse and unfavorable gene mutations should receive immediate allo-HSCT, whenever possible.
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Affiliation(s)
- Ting-Ting Liu
- Department of Hematology and Research Laboratory of Hematology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China ; Department of Internal Medicine, Fourth Hospital of West China, Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - K E Zeng
- Department of Hematology and Research Laboratory of Hematology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Lin Wang
- Department of Pathology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Ting Liu
- Department of Hematology and Research Laboratory of Hematology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Ting Niu
- Department of Hematology and Research Laboratory of Hematology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
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11
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Mishra J, Gupta M. Cerebrospinal fluid involvement in acute promyelocytic leukaemia at presentation. BMJ Case Rep 2015; 2015:bcr-2014-208418. [PMID: 25754165 DOI: 10.1136/bcr-2014-208418] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
In acute promyelocytic leukaemia (APL), extramedullary disease (EMD) is rare but can occur in those who relapse following therapy. Although the most common site of EMD in APL is central nervous system (CNS) and skin, CNS involvement in recently diagnosed patients with APL is very rare and rarely described. We report cerebrospinal fluid involvement in a case of APL, on day 3 of induction therapy.
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Affiliation(s)
- Jyoti Mishra
- Department of Pathology, School of Medical Sciences and Research, Greater Noida, Uttar Pradesh, India
| | - Mayank Gupta
- Department of General Pathology, Christian Medical College, Vellore, Tamil Nadu, India
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12
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Ohanian M, Rozovski U, Ravandi F, Garcia-Manero G, Jabbour E, Kantarjian HM, Estrov Z. Very high levels of lactate dehydrogenase at diagnosis predict central nervous system relapse in acute promyelocytic leukaemia. Br J Haematol 2014; 169:595-7. [PMID: 25413673 DOI: 10.1111/bjh.13230] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Maro Ohanian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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13
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Ganzel C, Douer D. Extramedullary disease in APL: a real phenomenon to contend with or not? Best Pract Res Clin Haematol 2014; 27:63-8. [PMID: 24907018 DOI: 10.1016/j.beha.2014.04.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
In the last 2 decades an increasing number of patients reported with extramedullary involvement among relapsed acute promyelocytic leukemia (APL) patients. Several investigators related this phenomenon to the relatively new treatment of all-trans-retinoic-acid (ATRA). In this review article we will examine what has been reported in the medical literature on extramedullary disease in APL: the common sites to be involved, the clinical risk factors to its development, the role of ATRA and arsenic tri-oxide and the recommended treatment.
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Affiliation(s)
- Chezi Ganzel
- Shaare Zedek Medical Center, Jerusalem, Israel; Leukemia Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
| | - Dan Douer
- Leukemia Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; Weil Cornell Medical College, NYC, USA.
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14
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Ovcharenko A, Granot G, Shpilberg O, Raanani P. Retinoic acid induces adhesion and migration in NB4 cells through Pyk2 signaling. Leuk Res 2013; 37:956-62. [PMID: 23587524 DOI: 10.1016/j.leukres.2013.03.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Revised: 02/03/2013] [Accepted: 03/17/2013] [Indexed: 12/21/2022]
Abstract
Since the introduction of all-trans-retinoic acid (ATRA) treatment for acute promyelocytic leukemia (APL) there has been increasing concern about extramedullary disease (EMD) progression despite favorable response in the bone marrow. We postulated that ATRA treatment enhances migration and adhesion abilities possibly enabling APL cells to inhabit extramedullary sites. We revealed an increase in adhesion, migration and invasion capabilities of NB4 cells following ATRA treatment. ATRA induced upregulation of Pyk2 mRNA, protein and phosphorylation levels and enhanced Pyk2 interaction with paxillin and vinculin. Pyk2 inhibition resulted in a reduction of NB4 cell adhesion and migration following ATRA treatment. These results indicate that in vitro Pyk2 might function to regulate cell adhesion and motility following ATRA treatment and its upregulated expression may contribute to EMD development in APL patients.
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Affiliation(s)
- Adelina Ovcharenko
- Felsenstein Medical Research Center, Tel Aviv University, Petah Tikva, Israel
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15
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Gupta V, Gonsalves W, Patnaik M, Gangat N. Central nervous system relapse in acute promyelocytic leukemia: a single institution experience. Leuk Lymphoma 2013; 54:2728-30. [PMID: 23469963 DOI: 10.3109/10428194.2013.782609] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Vinay Gupta
- Department of Hematology, Mayo Clinic Rochester , Rochester, MN , USA
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16
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Kyaw TZ, Maniam JAS, Bee PC, Chin EF, Nadarajan VS, Shanmugam H, Kadir KAA. Myeloid sarcoma: an unusual presentation of acute promyelocytic leukemia causing spinal cord compression. Turk J Haematol 2012; 29:278-82. [PMID: 24744674 PMCID: PMC3986755 DOI: 10.5505/tjh.2012.94809] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Accepted: 08/22/2011] [Indexed: 12/12/2022] Open
Abstract
Acute promyelocytic leukemia with concurrent myeloid sarcoma is a rare clinical event. Herein we describe a patient that presented with back pain and bilateral leg weakness caused by spinal cord compression due to extramedullary deposition of leukemic cells. Acute promyelocytic leukemia was suspected based on immunophenotypic findings of malignant cells in bone marrow aspirate. The diagnosis was confirmed by the presence of PML-RARα fusion copies. MRI showed multiple hyperintense changes on the vertebral bodies, together with intraspinal masses causing spinal cord compression. The patient immediately underwent radiotherapy, and was treated with all-trans retinoic acid and idarubicin. Reassessment MRI showed complete resolution of all intraspinal masses and the disappearance of most of the bony lesions. Post-treatment bone marrow aspirate showed complete hematological and molecular remission. The motor power of his legs fully recovered from 0/5 to 5/5; however, sensory loss below the T4 level persisted.
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Affiliation(s)
- Tay Za Kyaw
- University of Malaya, Faculty of Medicine, Department of Pathology, Kuala Lumpur, Malaysia
| | - Jayaranee A S Maniam
- University of Malaya, Faculty of Medicine, Department of Pathology, Kuala Lumpur, Malaysia
| | - Ping Chong Bee
- University of Malaya, Faculty of Medicine, Department of Medicine, Kuala Lumpur, Malaysia
| | - Edmund Fui Chin
- University of Malaya, Faculty of Medicine, Department of Medicine, Kuala Lumpur, Malaysia
| | | | - Hemalatha Shanmugam
- University of Malaya, Faculty of Medicine, Department of Pathology, Kuala Lumpur, Malaysia
| | - Khairul Azmi Abd Kadir
- University of Malaya, Faculty of Medicine, Department of Radiology, Kuala Lumpur, Malaysia
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17
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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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18
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The differentiation syndrome in patients with acute promyelocytic leukemia: experience of the pethema group and review of the literature. Mediterr J Hematol Infect Dis 2011; 3:e2011059. [PMID: 22220256 PMCID: PMC3248336 DOI: 10.4084/mjhid.2011.059] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Accepted: 11/16/2011] [Indexed: 01/01/2023] Open
Abstract
Differentiation syndrome (DS), formerly known as retinoic acid syndrome, is the main life-threatening complication of therapy with differentiating agents (all-trans retinoic acid [ATRA] or arsenic trioxide [ATO]) in patients with acute promyelocytic leukemia (APL). The differentiation of leukemic blasts and promyelocytes induced by ATRA and/or ATO may lead to cellular migration, endothelial activation, and release of interleukins and vascular factors responsible of tissue damage. Roughly one quarter of patients with APL undergoing induction therapy will develop the DS, characterized by unexplained fever, acute respiratory distress with interstitial pulmonary infiltrates, and/or a vascular capillary leak syndrome leading to acute renal failure. Although the development of the DS, particularly of the severe form, is still associated with a significant increase in morbidity and mortality during induction, the early administration of high-dose dexamethasone at the onset of the first symptoms seems likely to have dramatically reduced the mortality rate of this complication. In this article, we will review the clinical features, incidence, prognostic factors, management, and outcome of the DS reported in the scientific literature. We will make focus in the experience of the three consecutive Programa Español de Tratamientos en Hematología trials (PETHEMA LPA96, LPA99, and LPA2005), in which more than one thousand patients were treated with ATRA plus idarubicin for induction.
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19
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Thomas X, Chelghoum Y. Promyelocytic sarcoma of the sternum: a case report and review of the literature. THE KOREAN JOURNAL OF HEMATOLOGY 2011; 46:52-6. [PMID: 21461306 PMCID: PMC3065629 DOI: 10.5045/kjh.2011.46.1.52] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/06/2010] [Revised: 01/31/2011] [Accepted: 01/31/2011] [Indexed: 11/17/2022]
Abstract
This study reports a case of promyelocytic sarcoma that developed as a solitary sternal mass without any clinical evidence of acute promyelocytic leukemia. The case presented the diagnostic difficulties common to all aleukemic granulocytic sarcomas, and diagnosis was made possible by local identification of the PML/RARα fusion gene by fluorescent in situ hybridization. The patient was treated by surgery followed by chemotherapy plus all-trans retinoic acid therapy and local radiotherapy.
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Affiliation(s)
- Xavier Thomas
- Department of Hematology, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
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20
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Imaizumi M, Tawa A, Hanada R, Tsuchida M, Tabuchi K, Kigasawa H, Kobayashi R, Morimoto A, Nakayama H, Hamamoto K, Kudo K, Yabe H, Horibe K, Tsuchiya S, Tsukimoto I. Prospective study of a therapeutic regimen with all-trans retinoic acid and anthracyclines in combination of cytarabine in children with acute promyelocytic leukaemia: the Japanese childhood acute myeloid leukaemia cooperative study. Br J Haematol 2011; 152:89-98. [PMID: 20735397 DOI: 10.1111/j.1365-2141.2010.08332.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In childhood acute promyelocytic leukaemia (APL), the efficacy of therapy combining cytarabine with all-trans retinoic acid (ATRA) and anthracyclines remains unclear in terms of long-term prognosis. Between August 1997 and March 2004, 58 children with APL (median age: 11 years) were enrolled into an acute myeloid leukaemia (AML) study (AML99-M3) and followed up for a median time of 86 months. The regimen included ATRA and anthracyclines combined with cytarabine in both induction and consolidation. In induction, two patients died of haemorrhage and four patients developed retinoic acid syndrome. Of 58 patients, 56 (96·6%) achieved complete remission, two of whom relapsed in the bone marrow after 15 and 19 months respectively. Sepsis was a major complication, with an incidence of 5·6-10·9% in the consolidation blocks, from which all but one of patients recovered. Consequently, 7-year overall and event-free survival rates were 93·1% and 91·4% respectively, and cumulative incidence of relapse plateaued at 3·6% after 2 years. Follow-up survey of 54 patients revealed no patients with late cardiotoxicity or secondary malignancy, except one with asymptomatic prolongation of QTc interval. This study suggests that the combination of cytarabine with ATRA and anthracycline-based therapy may have useful implications in the perspective of long-term prognosis and late adverse effects for childhood APL.
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Affiliation(s)
- Masue Imaizumi
- Department of Haematology and Oncology, Miyagi Children's Hospital, Sendai, Japan.
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21
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Kim SH, Yun J, Kim HJ, Kim CK, Park SK, Hong DS. Long-term survival in a patient with acute promyelocytic leukemia with isolated meningeal relapse. THE KOREAN JOURNAL OF HEMATOLOGY 2010; 45:208-10. [PMID: 21120212 PMCID: PMC2983040 DOI: 10.5045/kjh.2010.45.3.208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2010] [Revised: 08/03/2010] [Accepted: 09/02/2010] [Indexed: 11/30/2022]
Abstract
The meningeal involvement is rare in acute promyelocytic leukemia. We experienced a 39-year-old woman who achieved complete remission with all-trans retinoic acid, idarubicin and cytarabine therapy. Several months later, she complained of non-specific headache. Her complete blood cell count was normal, but magnetic resonance image of brain revealed focal meningeal enhancement and cerebrospinal fluid showed leukemic promyelocytes and PML/RARA rearrangement. Bone marrow study showed hematologic, cytogenetic and molecular remission. She was treated with intrathecal and systemic chemotherapy and whole brain radiotherapy. The patient has survived for 68 months since the last systemic chemotherapy.
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Affiliation(s)
- Se Hyung Kim
- Department of Hematology-Oncology, Soonchunhyang University College of Medicine, Bucheon, Korea
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22
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Kumar B, Sharma V, Chopra A, Mahapatra M, Kumar R, Mathur S, Sazawal S, Kumar S, Saxena R. Central nervous system involvement at second relapse in acute promyelocytic leukemia treated with ATRA and chemotherapy. Leuk Res 2010; 34:e264-5. [DOI: 10.1016/j.leukres.2010.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Revised: 04/14/2010] [Accepted: 04/25/2010] [Indexed: 11/29/2022]
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23
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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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24
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Kakimoto T, Takahashi Y, Watanabe H, Matsuzawa M, Sanada Y, Suzuki K, Mihara A, Yoshida S, Nakazato T. Primary multiple cerebral invasion in acute promyelocytic leukemia dramatically worsened by all-trans retinoic acid. Leuk Res 2009; 34:e137-9. [PMID: 20015546 DOI: 10.1016/j.leukres.2009.11.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2009] [Revised: 11/16/2009] [Accepted: 11/18/2009] [Indexed: 12/17/2022]
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25
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Montesinos P, Díaz-Mediavilla J, Debén G, Prates V, Tormo M, Rubio V, Pérez I, Fernández I, Viguria M, Rayón C, González J, de la Serna J, Esteve J, Bergua JM, Rivas C, González M, González JD, Negri S, Brunet S, Lowenberg B, Sanz MA. Central nervous system involvement at first relapse in patients with acute promyelocytic leukemia treated with all-trans retinoic acid and anthracycline monochemotherapy without intrathecal prophylaxis. Haematologica 2009; 94:1242-9. [PMID: 19608685 DOI: 10.3324/haematol.2009.007872] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The prevalence of and risk factors for central nervous system recurrence in patients with acute promyelocytic leukemia are not well established and remain a controversial matter. DESIGN AND METHODS Between 1996 and 2005, 739 patients with newly diagnosed acute promyelocytic leukemia enrolled in two consecutive trials (PETHEMA LPA96 and LPA99) received induction therapy with all-trans retinoic acid and idarubicin. Consolidation therapy comprised three courses of anthracycline monochemotherapy (LPA96), with all-trans retinoic acid and reinforced doses of idarubicin in patients with an intermediate or high risk of relapse (LPA99). Central nervous system prophylaxis was not given. RESULTS Central nervous system relapse was documented in 11 patients. The 5-year cumulative incidence of central nervous system relapse was 1.7% (LPA96 3.2% and LPA99 1.2%; p=0.09). The cumulative incidence was 0%, 0.8%, and 5.5% in low-, intermediate-, and high-risk patients, respectively. Relapse risk score (p=0.0001) and the occurrence of central nervous system hemorrhage during induction (5-year cumulative incidence 18.7%, p=0.006) were independent risk factors for central nervous system relapse. CONCLUSIONS This study shows a low incidence of central nervous system relapse in patients with acute promyelocytic leukemia following therapy with all-trans retinoic acid and anthracycline without specific central nervous system prophylaxis. Central nervous system relapse was significantly associated with high white blood cell counts and prior central nervous system hemorrhage, which emerged as independent prognostic factors.
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Affiliation(s)
- Pau Montesinos
- Hematology Department, Hospital Universitario La Fe, Avda. Campanar 21, Valencia, Spain
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26
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Chow J, Feusner J. Isolated central nervous system recurrence of acute promyelocytic leukemia in children. Pediatr Blood Cancer 2009; 52:11-3. [PMID: 18816805 DOI: 10.1002/pbc.21608] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The incidence of isolated central nervous system (iCNS) relapse in pediatric acute promyelocytic leukemia (APL) is debated. We analyzed the literature, focusing on clinical trials reported since the advent of ATRA use. Only 2/218 (0.92%) good risk patients (diagnostic WBC <10,000/microl) had truly iCNS relapse. This incidence does not support the use of intrathecal CNS prophylaxis for all children with APL. We also identified multiple deficiencies in these reports. Additional reporting of these events could provide insight into the true incidence and pathogenesis of iCNS relapse and might allow for identification of risk factors associated with such extramedullary relapse.
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Affiliation(s)
- Jessica Chow
- Department of Public Health, University of California, Berkeley, California, USA
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27
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Differentiation syndrome in patients with acute promyelocytic leukemia treated with all-trans retinoic acid and anthracycline chemotherapy: characteristics, outcome, and prognostic factors. Blood 2008; 113:775-83. [PMID: 18945964 DOI: 10.1182/blood-2008-07-168617] [Citation(s) in RCA: 230] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Differentiation syndrome (DS) can be a life-threatening complication in patients with acute promyelocytic leukemia (APL) undergoing induction therapy with all-trans retinoic acid (ATRA). Detailed knowledge about DS has remained limited. We present an analysis of the incidence, characteristics, prognostic factors, and outcome of 739 APL patients treated with ATRA plus idarubicin in 2 consecutive trials (Programa Español de Tratamientos en Hematología [PETHEMA] LPA96 and LPA99). Overall, 183 patients (24.8%) experienced DS, 93 with a severe form (12.6%) and 90 with a moderate form (12.2%). Severe but not moderate DS was associated with an increase in mortality. A bimodal incidence of DS was observed, with peaks occurring in the first and third weeks after the start of ATRA therapy. A multivariate analysis indicated that a WBC count greater than 5 x 10(9)/L and an abnormal serum creatinine level correlated with an increased risk of developing severe DS. Patients receiving systematic prednisone prophylaxis (LPA99 trial) in contrast to those receiving selective prophylaxis with dexamethasone (LPA96 trial) had a lower incidence of severe DS. Patients developing severe DS showed a reduced 7-year relapse-free survival in the LPA96 trial (60% vs 85%, P = .003), but this difference was not apparent in the LPA99 trial (86% vs 88%).
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28
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Worch J, Ritter J, Frühwald MC. Presentation of acute promyelocytic leukemia as granulocytic sarcoma. Pediatr Blood Cancer 2008; 50:657-60. [PMID: 17437290 DOI: 10.1002/pbc.21190] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Granulocytic sarcoma (GS) is a localized tumor composed of immature myeloid cells. This extramedullary tumor can present before, concurrent with or after the diagnosis of acute myeloid leukemia. GS is extremely uncommon in acute promyelocytic leukemia (APL). As a proportion of patients never develop systemic disease, correct and timely diagnosis may be rather difficult, but is a prerequisite for optimal outcome. GS should be considered in the differential diagnosis of children with unusual bone lesions. We describe a patient with GS who presented with symptoms mimicking osteomyelytis or rheumatoid disease.
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MESH Headings
- Adolescent
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Arthritis, Psoriatic/diagnosis
- Biomarkers, Tumor/analysis
- Diagnostic Errors
- Female
- Humans
- Leukemia, Promyelocytic, Acute/complications
- Leukemia, Promyelocytic, Acute/diagnosis
- Leukemia, Promyelocytic, Acute/drug therapy
- Oncogene Proteins, Fusion/analysis
- Osteolysis/etiology
- Osteomyelitis/diagnosis
- Remission Induction
- Sarcoma, Myeloid/drug therapy
- Sarcoma, Myeloid/etiology
- Shoulder Pain/etiology
- Tretinoin/administration & dosage
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Affiliation(s)
- Jennifer Worch
- University Children's Hospital Muenster, Department of Pediatric Hematology and Oncology, Muenster, Germany
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29
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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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30
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Abstract
Current treatment for acute promyelocytic leukemia (APL) usually includes an induction phase with all-trans retinoic acid (ATRA) and anthracycline-based chemotherapy, followed by a consolidation phase of anthracycline-based chemotherapy and maintenance therapy with ATRA with or without low-dose chemotherapy for 1-2 years. This treatment strategy results in a high complete remission (CR) rate of about 90% and an overall survival rate of 80%. About 5%-30% of patients relapse, mainly patients with high-risk APL. Relapse at extramedullary sites, which occurs in approximately 3%-5% of patients, is emerging as a new issue. Treatment of relapsed/advanced APL includes the use of arsenic trioxide (ATO), gemtuzumab ozogamicin, and hematopoietic stem cell transplantation. ATO is currently the most effective therapeutic agent in relapsed APL. Hematopoietic stem cell transplantation is becoming a common strategy after achieving remission with ATO. Autologous transplant appears to have a more favorable outcome than allogeneic transplant in this setting, particularly when carried out during second remission, primarily because of significantly higher treatment-related mortality with allogeneic transplants. Allogeneic transplant, however, should be strongly considered for patients who remain molecularly positive. Future directions for APL therapy should include developing agents that can prevent relapse, particularly for high-risk patients. Other future treatment strategies may include use of ATO administered concomitantly or sequentially with chemotherapy, gemtuzumab or FLT-3 inhibitors that may obviate the need for autologous transplantation, and posttransplant maintenance perhaps with FLT-3 inhibitors.
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MESH Headings
- Aminoglycosides/therapeutic use
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Humanized
- Antineoplastic Agents/therapeutic use
- Arsenic Trioxide
- Arsenicals/therapeutic use
- Clinical Trials as Topic
- Gemtuzumab
- Hematopoietic Stem Cell Transplantation
- Humans
- Leukemia, Promyelocytic, Acute/drug therapy
- Leukemia, Promyelocytic, Acute/genetics
- Multicenter Studies as Topic
- Neoplasm Recurrence, Local/drug therapy
- Oxides/therapeutic use
- Transplantation, Autologous
- Transplantation, Homologous
- fms-Like Tyrosine Kinase 3/antagonists & inhibitors
- fms-Like Tyrosine Kinase 3/genetics
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Affiliation(s)
- Martin S Tallman
- Northwestern University Feinberg School of Medicine, Division of Hematology-Oncology, Robert H. Lurie Comprehensive Cancer Center, 676 N St. Clair Street, Suite 850, Chicago, IL 60611, USA.
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31
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Abstract
We review the role of all-trans retinoic acid (ATRA) in the treatment of acute promyelocytic leukemia (APL). The combination of ATRA and conventional anthracycline-ARA-C chemotherapy (CT) has clearly demonstrated its superiority over CT alone (in terms of relapse and survival) in newly diagnosed APL. Combination treatment probably also reduces the incidence of initial failures, and complete remission (CR) rates greater than 90% are now regularly reported in large multicenter trials. Some randomized studies strongly suggest that prolonged maintenance treatment (for 1 or 2 years) with ATRA and low-dose CT, and possibly very early introduction of anthracycline CT during induction treatment, may reduce the incidence of relapse. With those treatments, the relapse risk appears to be only 10%-15%, although it remains greater in patients who initially have high white blood cell counts (often associated with variant M3 morphology, short bcr3 isoform, etc.) and patients with residual disease detectable by RT-PCR at the end of consolidation courses. In those patients, addition of arsenic derivatives to induction or consolidation treatment (or both treatments together) may prove useful and is currently being tested. ATRA syndrome (now generally called APL differentiation syndrome, as it is also seen with arsenic derivatives) remains the major side effect of ATRA treatment. It occurs in 10%-15% of patients and is currently fatal in at least 10% of them. Rapid onset of CT or high dose steroids (or both) should improve its outcome. A sizeable proportion of APL patients who relapse after ATRA and CT can be durably salvaged by the same treatment followed by allogeneic or autologous stem cell transplantation, provided the transplant (in the autologous setting) is RT-PCR-negative. However, in relapsing APL arsenic derivatives (mainly arsenic trioxide) are now considered to be the reference treatment. Some of the current issues with ATRA treatment in newly diagnosed APL include whether ATRA has a role during consolidation treatment and whether arabinoside (AraC) is required in addition to anthracyclines in the chemotherapy combined to ATRA.
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Affiliation(s)
- P Fenaux
- Service d'Hématologie Clinique, Hôpital Avicenne, Paris 13 University, 93000 Bobigny, France.
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32
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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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33
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Latagliata R, Carmosino I, Breccia M, Minni A, Testi A, Iorio N, Lo-Coco F, Avvisati G, Petti MC, Mandelli F, Cimino G. Late relapses in acute promyelocytic leukaemia. Acta Haematol 2006; 117:106-8. [PMID: 17135723 DOI: 10.1159/000097385] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2006] [Accepted: 07/14/2006] [Indexed: 11/19/2022]
Abstract
From January 1988 to December 1997, among 53 acute promyelocytic leukaemia patients in 1st complete remission (CR) after 5 years from diagnosis, we observed 5 late relapses (9.4%) after 60, 61, 71, 101 and 155 months from diagnosis; 3 of those late relapses (7.7%) occurred among 39 patients previously treated with all-trans-retinoic acid. An involvement of the mastoid occurred in 3/5 patients (60%), compared with 2/32 patients (6.3%) at an early relapse (p < 0.02). As to the treatment of the late relapse, 1 patient received all-trans-retinoic acid alone followed by allogeneic transplantation and 4 patients were treated according to the GIMEMA 0191 protocol. All patients achieved a 2nd CR and are still alive: 4 in the 2nd molecular CR after 6, 33, 34 and 115 months; 1 relapsed after 15 months and is now in the 3rd CR. In conclusion, a late relapse occurred in a sizeable fraction of acute promyelocytic leukaemia patients: the high rate of ear involvement might be explained considering the ear as a 'disease sanctuary'.
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Affiliation(s)
- Roberto Latagliata
- Dipartimento di Biotecnologie Umane e Ematologia, Università La Sapienza, Roma, Italia.
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Liesveld JL. Acute promyelocytic leukemia-mobile and infiltrative. Leuk Res 2006; 31:5-7. [PMID: 16978695 DOI: 10.1016/j.leukres.2006.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2006] [Revised: 05/25/2006] [Accepted: 05/30/2006] [Indexed: 11/29/2022]
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de Botton S, Sanz MA, Chevret S, Dombret H, Martin G, Thomas X, Mediavilla JD, Recher C, Ades L, Quesnel B, Brault P, Fey M, Wandt H, Machover D, Guerci A, Maloisel F, Stoppa AM, Rayon C, Ribera JM, Chomienne C, Degos L, Fenaux P. Extramedullary relapse in acute promyelocytic leukemia treated with all-trans retinoic acid and chemotherapy. Leukemia 2006; 20:35-41. [PMID: 16307026 DOI: 10.1038/sj.leu.2404006] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
We analyzed the incidence, presenting features, risk factors of extramedullary (EM) relapse occurring in acute promyelocytic leukemia (APL) treated with all-trans retinoic acid (ATRA) and chemotherapy by using a competing-risk method. In total, 740/ 806 (92%) patients included in three multicenter trials (APL91, APL93 trials and PETHEMA 96) achieved CR, of whom 169 (23%) relapsed, including 10 EM relapses. Nine relapses involved the central nervous system (CNS) and one the skin, of which two were isolated EM relapse. In patients with EM disease, median WBC count was 26950/mm3 (7700-162000). The 3-year cumulative incidence of EM disease at first relapse was 5.0%. Univariate analysis identified age <45 years (P=0.05), bcr3 PML-RARalpha isoform (P= 0.0003) and high WBC counts (> or = 10,000/ mm3) (P<0.0001) as risk factors for EM relapse. In multivariate analysis, only high WBC count remained significant (P= 0.001). Patients with EM relapse had a poorer outcome since median survival from EM relapse was 6.7 months as compared to 26.3 months for isolated BM relapse (P=0.04). In conclusion, EM relapse in APL occurs more frequently in patients with increased WBC counts (> or = 10,000/mm3) and carries a poor prognosis. Whether CNS prophylaxis should be systematically performed in patients with WBC > or = 10,000/mm3 at diagnosis remains to be established.
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Kai T, Kimura H, Shiga Y, Ogawa K, Sato H, Maruyama Y. Recurrent extramedullary relapse of acute promyelocytic leukemia after allogeneic stem cell transplantation: successful treatment by arsenic trioxide in combination with local radiotherapy. Int J Hematol 2006; 83:337-40. [PMID: 16757435 DOI: 10.1532/ijh97.05167] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Isolated extramedullary relapse is rare in patients with acute promyelocytic leukemia (APL) after allogeneic stem cell transplantation (SCT), and an optimal therapy for it has not been established. We describe a patient with APL who developed serially occurring extramedullary disease (EMD) after SCT. We confirmed that EMD had arisen from the recipient's APL blasts by detecting t(15;17) and PML/RARalpha from the tumor cell suspension. The patient displayed EMD 4 times at different sites. Administration of all-trans retinoic acid with local radiotherapy and with chemotherapy for the first to third EMDs resulted in regression of the tumors. However, these regimens did not prevent the subsequent occurrence of new EMD. For the fourth EMD, intravenous administration of arsenic trioxide followed by local radiotherapy resulted in the disappearance of EMD, and no further EMD has developed to date. In the present case, the bone marrow was in morphologic and molecular remission during the course of recurrent EMD. The accumulation of detailed cases is needed to elucidate the pathogenesis, predisposing factors, and optimal therapy for EMD in APL after SCT.
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MESH Headings
- Antineoplastic Agents/administration & dosage
- Arsenic Trioxide
- Arsenicals/administration & dosage
- Chromosomes, Human, Pair 15/genetics
- Chromosomes, Human, Pair 17/genetics
- Combined Modality Therapy
- Female
- Humans
- Leukemia, Promyelocytic, Acute/diagnostic imaging
- Leukemia, Promyelocytic, Acute/genetics
- Leukemia, Promyelocytic, Acute/therapy
- Middle Aged
- Neoplasm Proteins/genetics
- Oncogene Proteins, Fusion/genetics
- Oxides/administration & dosage
- Radiography
- Recurrence
- Remission Induction
- Sarcoma, Myeloid/diagnostic imaging
- Sarcoma, Myeloid/genetics
- Sarcoma, Myeloid/therapy
- Stem Cell Transplantation/adverse effects
- Translocation, Genetic/genetics
- Transplantation, Homologous
- Tretinoin/administration & dosage
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Affiliation(s)
- Tatsuyuki Kai
- Hematology, Kita-Fukushima Medical Center, Fukushima, Japan.
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Lengfelder E, Saussele S, Weisser A, Büchner T, Hehlmann R. Treatment concepts of acute promyelocytic leukemia. Crit Rev Oncol Hematol 2005; 56:261-74. [PMID: 16236522 DOI: 10.1016/j.critrevonc.2004.08.009] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2004] [Revised: 07/30/2004] [Accepted: 08/06/2004] [Indexed: 01/14/2023] Open
Abstract
In the past, acute promyelocytic leukemia (APL) was associated with a high risk of early mortality resulting from severe coagulopathy, frequently inducing fatal cerebral hemorrhage. With the introduction of the differentiating agent all-trans retinioc acid (ATRA) APL has changed to the best curable subtype of acute myeloid leukemia (AML). With ATRA and chemotherapy approximately 70-80% of patients with newly diagnosed APL achieve long-term remission and are probably cured. PML/RARalpha, the molecular fusion transcript of the specific translocation t(15;17) represents not only the target for ATRA but also permits a precise diagnosis and provides a marker for the identification of minimal residual or recurrent disease (MRD). During the last decade, substantial progress has been made with regard to the recognition of prognostic factors and the optimization of the combination of ATRA and chemotherapy. Remaining questions are the role of arsenic and of ara-C in first line therapy of APL as well as the indication of maintenance therapy in the individual patient. Several treatment options exist for patients with APL who have relapsed after ATRA and chemotherapy. Approximately 50% of the patients in first relapse can achieve long-lasting second remission and might be cured with salvage regimens. Currently, arsenic compounds and transplantation procedures seem to be the most promising options in relapsed disease. The role of CD33 antibodies has to be determined in future studies. Refining the molecular monitoring of MRD by quantitative RT-PCR, better elucidation of the biologic mechanisms, and the identification of prognostic factors might be helpful to make further progress in the treatment of APL.
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MESH Headings
- Antineoplastic Agents/administration & dosage
- Antineoplastic Agents/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/administration & dosage
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Arsenic Trioxide
- Arsenicals/administration & dosage
- Arsenicals/adverse effects
- Hemorrhage/chemically induced
- Humans
- Leukemia, Promyelocytic, Acute/complications
- Leukemia, Promyelocytic, Acute/genetics
- Leukemia, Promyelocytic, Acute/therapy
- Neoplasm Proteins/genetics
- Neoplasm, Residual
- Oncogene Proteins, Fusion/genetics
- Oxides/administration & dosage
- Oxides/adverse effects
- Prognosis
- Recurrence
- Risk Factors
- Stem Cell Transplantation
- Thrombosis/chemically induced
- Translocation, Genetic
- Transplantation, Homologous
- Tretinoin/administration & dosage
- Tretinoin/adverse effects
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Affiliation(s)
- Eva Lengfelder
- Medizinische Universitätsklinik, Klinikum Mannheim, Fakultät für Klinische Medizin Mannheim der Universität Heidelberg, Wiesbadener Str. 7-11, 68305 Mannheim, Germany.
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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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Soignet S, Maslak P. Therapy of acute promyelocytic leukemia. ADVANCES IN PHARMACOLOGY (SAN DIEGO, CALIF.) 2004; 51:35-58. [PMID: 15464904 DOI: 10.1016/s1054-3589(04)51002-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
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41
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Tallman MS, Rowe JM. Long-term follow-up and potential for cure in acute promyelocytic leukaemia. Best Pract Res Clin Haematol 2003; 16:535-43. [PMID: 12935968 DOI: 10.1016/s1521-6926(03)00058-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Acute promyelocytic leukaemia (APL) may be characterized simultaneously as the most potentially rapidly fatal human acute leukaemia if untreated, yet the most frequently cured acute leukaemia if promptly diagnosed and treated without delay. Co-operative group and single-institution studies which include large numbers of patients with relatively long follow-up demonstrate that, with all-trans retinoic acid (ATRA) plus anthracycline-based chemotherapy, the majority of newly-diagnosed patients appear cured of their disease. The 5-year disease-free survival rates range from 75 to 85%. Early death is still observed in approximately 10% of patients and remains a difficult obstacle to increasing the cure rate. Prognostic factors which identify patients at high risk for recurrence are becoming increasingly recognized. Older age (over age 55-60 years), elevated white blood cell count at presentation (higher than 5,000-10,000/microl), and expression of CD56 unfavourably influence outcome. The treatment of such patients remains a challenge, although it is important to note that APL is the only type of AML in which a significant proportion of older patients may be cured. Because more patients are cured of their disease, potential long-term consequences may become increasingly recognized. These include the emergence of extramedullary disease, the development of secondary myelodysplasia or acute myeloid leukaemia and the potential for late-onset cardiac toxicity.
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Affiliation(s)
- Martin S Tallman
- Division of Hematology/Oncology, School of Medicine, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg, 676 N. St Clair, Suite 850, Chicago, IL 60611, USA.
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Abstract
The vitamin A derivative, all-trans retinoic acid (ATRA), induces differentiation of leukaemic promyelocytes in patients with acute promyelocytic leukaemia (APL). As a result, the majority of patients achieve complete remission either with ATRA alone or with combined ATRA and chemotherapy. The most important complication is the retinoic acid syndrome, which is usually successfully treated with the early administration of dexamethasone. Prospective randomized trials have shown that ATRA is better than conventional chemotherapy in newly diagnosed patients, that ATRA combined with chemotherapy confers an advantage with respect to relapse rate, compared to ATRA alone for induction followed by chemotherapy for consolidation, and that maintenance therapy with ATRA or ATRA plus low-dose chemotherapy is beneficial. The presence of adverse prognostic factors, including older age, presenting white blood cell count and platelet count, expression of CD56 and presence of mutations in the FLT3 gene, identify patients at risk for relapse for whom new strategies are needed.
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Affiliation(s)
- Giuseppe Avvisati
- Hematology, University Campus Bio-Medico, Via Emilio Longoni 83, Roma 00159, Italy.
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Abstract
Acute promyelocytic leukaemia (APL) is characterised by the fusion gene transcript PML-RAR-alpha and is now the most frequently curable acute leukaemia in adults if promptly diagnosed and adequately treated. The clinical presentation is associated with a haemorrhagic diathesis and the blasts almost always have Auer rods. Poor prognostic factors include older age, elevated white blood cell count, low platelet count, and CD56 expression. The introduction of all-trans retinoic acid (ATRA), which leads to the differentiation of leukaemic blasts into mature granulocytes has been the major breakthrough in the treatment of APL. Induction treatment with concurrent ATRA and chemotherapy leads to a rapid resolution of the characteristic life-threatening coagulopathy, high complete remission rates and excellent survival rates, compared to chemotherapy alone. However, treatment with ATRA is associated with the retinoic acid syndrome (RAS), which is a major toxicity and may lead to mortality. The role of cytarabine as a part of initial induction regimen remains unclear. After achievement of complete remission (CR), there is a definitive role of maintenance therapy with ATRA with or without low-dose chemotherapy. In relapsed patients, arsenic trioxide is considered the treatment of choice. However, the best postremission treatment for patients with second CR remains unknown. With the continued improvement in the field of stem cell transplantation, it may play an important role in the few patients with relapsed/refractory disease or those in second CR.
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Affiliation(s)
- Simrit Parmar
- Division of Hematology-Oncology, Northwestern University Feinberg School of Medicine, Robert H Lurie Comprehensive Cancer Center, 676 North St. Clair, Suite 850, Chicago, IL 60611, USA
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Abstract
Retinoid therapy for acute promyelocytic leukemia (APL) is one of the major achievements of leukemia research in the last 15 years. Use of all trans retinoic acid (ATRA) has changed the prognosis of APL from a fatal leukemia to a highly curable disease. This case-based review examines the available clinical and scientific data to form evidence-based decisions in the management of APL. The main aim of this review is to highlight recent progress made in the management of APL and address the role of maintenance therapy, prognostic factors for relapse and treatment of relapsed disease.
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Affiliation(s)
- Vikas Gupta
- Department of Medical Oncology and Hematology, Princess Margaret Hospital, University of Toronto, Toronto, Canada; M5G 2M9.
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Abstract
Abstract
The therapeutic approach to the patient with acute myeloid leukemia (AML) currently evolves toward new frontiers. This is particularly apparent from the entree of high-throughput diagnostic technologies and the identification of prognostic and therapeutic targets, the introduction of therapies in genetically defined subgroups of AML, as well as the influx of investigational approaches and novel drugs into the pipeline of clinical trials that target pathogenetic mechanisms of the disease.
In Section I, Dr. Bob Löwenberg reviews current issues in the clinical practice of the management of adults with AML, including those of older age. Dr. Löwenberg describes upcoming possibilities for predicting prognosis in defined subsets by molecular markers and reviews experimental strategies to improve remission induction and postinduction treatment.
In Section II, Dr. James Griffin reviews the mechanisms that lead to activation of tyrosine kinases by mutations in AML, the consequences of that activation for the cell, and the opportunities for targeted therapy and discusses some examples of developing novel drugs (tyrosine kinase inhibitors) and their effectiveness in AML (FLT3).
In Section III, Dr. Martin Tallman describes the evaluation and management of patients with acute promyelocytic leukemia, a notable example of therapeutic progress in a molecularly defined entity of leukemia. Dr. Tallman focuses on the molecular genetics of APL, current curative treatment strategies and approaches for patients with relapsed and refractory disease. In addition, areas of controversy regarding treatment are addressed.
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Breccia M, Carmosino I, Diverio D, De Santis S, De Propris MS, Romano A, Petti MC, Mandelli F, Lo-Coco F. Early detection of meningeal localization in acute promyelocytic leukaemia patients with high presenting leucocyte count. Br J Haematol 2003; 120:266-70. [PMID: 12542484 DOI: 10.1046/j.1365-2141.2003.04056.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Extramedullary relapse occurs infrequently in acute promyelocytic leukaemia (APL) but has been increasingly reported after the advent of all-trans retinoic acid (ATRA) treatment, probably as a consequence of improved patient survival. We describe our single centre experience of six APL patients who had disease localization in the central nervous system (CNS). In three patients, clinical symptoms (headache and/or nausea) that presented during follow-up led to the performance of a lumbar puncture and detection of overt CNS infiltration. Two of these patients had simultaneous haematological relapse and one was in molecular remission when CNS leukaemia was documented. One patient with no local symptoms showed CNS infiltration at the time of molecular relapse. Following the introduction of routine lumbar puncture, carried out after front-line induction in all newly diagnosed patients with white blood cell count (WBC) greater than 10 x 109/l, two additional patients in molecular remission with no local symptoms were found to have initial APL localization in the CNS. Presenting features included in 6/6 patients an elevated WBC count (> 10 x 109/l) and a predominance of the PML/RAR bcr3 type (5/6 patients) and of microgranular morphology (5/6 patients). Our findings highlight the importance of carrying out lumbar puncture in APL patients presenting with high-risk features.
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Affiliation(s)
- Massimo Breccia
- Department of Cellular Biotechnologies and Haematology, University La Sapienza of Rome, Italy
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Burry LD, Seki JT. CNS relapses of acute promyelocytic leukemia after all-trans retinoic acid. Ann Pharmacother 2002; 36:1900-6. [PMID: 12452754 DOI: 10.1345/aph.1a471] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVE To review the role of all-trans retinoic acid (ATRA) and arsenic trioxide in central nervous system (CNS) relapses of acute promyelocytic leukemia (APL). CASE SUMMARY A 69-year-old white man diagnosed with APL presented with bleeding diathesis. His molecular and cytogenetic studies were positive for promyelocytic leukemia-retinoic acid receptoralpha (PML-RARalpha) and t(15;17) transformation. Complete molecular and cytogenetic remission was achieved with ATRA, daunorubicin, and cytarabine. Within 6 months, the patient was readmitted for investigation of severe global headaches and an ataxic gait. His peripheral blood and cerebral spinal fluid were positive for PML-RARalpha fusion protein. Intrathecal chemotherapy and radiation, as well as ATRA, were the main treatment modalities provided. Molecular and cytogenetic remission was again obtained. Three months later, a second relapse occurred in the CNS and the peripheral blood. DISCUSSION APL is typically treated with anthacycline-based chemotherapy and ATRA. Approximately 85-95% of patients achieve complete remission (CR); however, the relapse rate has been reported to be about 30-40%. A thorough literature search (MEDLINE, EMBASE, CANCERLIT, 1966-January 2002) revealed only 54 cases of extramedullary disease, of which 35 involved the CNS. CONCLUSIONS The introduction of ATRA has improved patient survival dramatically. APL relapse, in general, has been in part attributable to repetitive or prolonged exposure to ATRA and the possibility of additional chromosomal changes, making the disease more refractory to treat. Given the evidence, one could argue that, with repeated ATRA treatment, CR duration may be shortened. However, limited data are available to guide the appropriate management of APL relapsed to the CNS with either ATRA, chemotherapy, or arsenic trioxide. In our opinion, treatment using arsenic trioxide is an unconventional option worthy of exploring.
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Affiliation(s)
- Lisa D Burry
- Mt. Sinai Hospital, University of Toronto, Ontario, Canada
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Breccia M, Petti MC, Testi AM, Specchia G, Ferrara F, Diverio D, Romano A, Guerrisi V, Greco A, Fiorella ML, de Vincentiis M, Mandelli F, Lo Coco F. Ear involvement in acute promyelocytic leukemia at relapse: a disease-associated 'sanctuary'? Leukemia 2002; 16:1127-30. [PMID: 12040443 DOI: 10.1038/sj.leu.2402497] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2001] [Accepted: 02/01/2002] [Indexed: 01/27/2023]
Abstract
Extramedullary (EM) involvement occurs infrequently in acute promyelocytic leukemia (APL) and usually involves skin and CNS. We describe seven patients (four observed at a single institution) who relapsed in various sites of the auditory apparatus, including the external canal and middle ear (temporal bone). Front-line treatment included ATRA and chemotherapy (six patients) or chemotherapy alone (one patient). Three patients had concomitant hematologic relapse, two had molecular relapse and two were in hematologic and molecular remission when ear localization was documented. Local symptoms that stimulated further diagnostic studies included ear bleeding/discharge in the first patient, but were mild in the others (hypoacusia, five patients; earache, two patients). Ear involvement by leukemia was documented by histological and/or molecular studies after local surgery in five cases, and by CT scan or NMR in the remaining patients. We suggest that the ear might represent a specific sanctuary for disease involvement in APL.
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Affiliation(s)
- M Breccia
- Department of Cellular Biotechnologies, University La Sapienza, Rome, Italy
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Patriarca F, Filì C, Geromin A, Sperotto A, Prosdocimo S, Fanin R. Activity of all-trans-retinoic acid in a case of central nervous system extramedullary relapse of acute promyelocytic leukemia. Eur J Haematol 2002; 68:310-3. [PMID: 12144538 DOI: 10.1034/j.1600-0609.2002.01660.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
We describe a patient with an acute promyelocytic leukemia (APL) previously treated with two courses of cytarabin, idarubicin and all-trans retinoic acid (ATRA), who presented a medullary and meningeal relapse after 8 months of complete remission. A diagnosis of central nervous system (CNS) involvement was based on the appearance of APL blasts in the cerebrospinal fluid (CSF); magnetic resonance (MR) imaging was negative. The neurological symptoms were not evident at the time of recognition of the medullary recurrence, but appeared a few days later, when the patient had already received a reinduction treatment. When the CSF was first examined, showing atypical promyelocytes, there was no excess of blasts on bone-marrow examination. The patient was treated with ATRA and intrathecal administrations of cytoxic drugs, achieving a complete long-lasting CNS remission. The appearance of mature myeloid cells in the CSF during this treatment suggested a possible differentiating effect of ATRA towards extramedullary relapse.
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Affiliation(s)
- Francesca Patriarca
- Division of Hematology, Department of Bone Marrow Transplantation, Udine University Hospital, P. le S. Maria della Misericordia, I-13300 Udine, Italy.
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50
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Tallman MS. Retinoic acid syndrome: a problem of the past? Leukemia 2002; 16:160-1. [PMID: 11840279 DOI: 10.1038/sj.leu.2402344] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2001] [Accepted: 10/01/2001] [Indexed: 11/09/2022]
Affiliation(s)
- M S Tallman
- Division of Hematology-Oncology, Northwestern University Medical School, and the Robert H Lurie Comprehensive Cancer Center, Chicago, IL, USA
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