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de Figueiredo-Pontes LL, Catto LFB, Chauffaille MDLLF, Pagnano KBB, Madeira MIA, Nunes EC, Hamerschlak N, de Andrade Silva MC, Carneiro TX, Bortolheiro TC, de Freitas TT, Bittencourt RI, Maranhão Fagundes E, Magalhães Rego E. Diagnosis and management of acute promyelocytic leukemia: Brazilian consensus guidelines 2024 on behalf of the Brazilian Association of Hematology, Hemotherapy and Cellular Therapy. Hematol Transfus Cell Ther 2024; 46:553-569. [PMID: 38890097 DOI: 10.1016/j.htct.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 05/06/2024] [Indexed: 06/20/2024] Open
Abstract
Improvements in clinical assessment have occurred since the last published recommendations on the diagnosis and treatment of acute promyelocytic leukemia in 2013. Here, a committee of specialists of the Brazilian Association of Hematology, Hemotherapy and Cellular Therapy presents a comprehensive review on the current knowledge, focusing on the advances in diagnosis, risk assessment, and frontline and salvage therapy. The concept of urgent diagnosis is explored as well as the management of critical situations such as coagulopathy and differentiation syndrome. Recent adjustments in risk stratification based on white blood cell counts only are presented together with the incorporation of chemo-free regimens for non-high-risk patients. Special conditions such as acute promyelocytic leukemia in children, the elderly and pregnant women are discussed. Finally, acute promyelocytic leukemia is presented as a highly curable disease because of the real possibility of targeted therapy towards differentiation, and, paradoxically, as a serious and urgent condition that deserves prompt recognition and management to avoid early mortality.
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Affiliation(s)
| | - Luiz Fernando Bazzo Catto
- Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil; Translational Stem Cell Biology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | | | | | - Maria Isabel Ayrosa Madeira
- Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | - Elenaide Coutinho Nunes
- Unidade de Hematologia e Oncologia do Hospital das Clínicas da Universidade Federal do Paraná, Curitiba, PR, Brazil and Instituto Pasquini de Hematologia e Transplante, Hospital Nossa Senhora das Graças, Curitiba, PR, Brazil
| | | | | | | | - Teresa Cristina Bortolheiro
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Irmandade da Santa Casa de São Paulo da Santa Casa de São Paulo, São Paulo, SP, Brazil
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Smith MB, Griffiths EA, Thompson JE, Wang ES, Wetzler M, Freyer CW. High pseudotumor cerebri incidence in tretinoin and arsenic treated acute promyelocytic leukemia and the role of topiramate after acetazolamide failure. Leuk Res Rep 2014; 3:62-6. [PMID: 25180154 PMCID: PMC4145165 DOI: 10.1016/j.lrr.2014.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Revised: 07/09/2014] [Accepted: 07/14/2014] [Indexed: 12/28/2022] Open
Abstract
Dual differentiation therapy with arsenic trioxide and tretinoin (all-trans-retinoic acid; ATRA) for the management of low and intermediate risk acute promyelocytic leukemia has recently been recommended by the National Comprehensive Cancer Network. Some less common toxicities of the combination may have yet to be fully realized. Of ten patients we have treated thus far, five (50%) have developed pseudotumor cerebri. In one patient, temporary discontinuation of ATRA and initiation of acetazolamide controlled symptoms. In four patients, topiramate was substituted for acetazolamide to relieve symptoms and allow ATRA dose re-escalation. We conclude that providers should monitor for pseudotumor cerebri and consider topiramate if acetazolamide fails. We identify five cases of pseudotumor cerebri during arsenic and tretinoin therapy. We report four cases of pseudotumor cerebri successfully treated with topiramate. Topiramate may have a role in the management of pseudotumor cerebri. Addition of arsenic trioxide to tretinoin may potentiate pseudotumor cerebri.
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Affiliation(s)
- Morgan B Smith
- Department of Pharmacy, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263, United States
| | - Elizabeth A Griffiths
- Leukemia Section, Department of Medicine, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263, United States
| | - James E Thompson
- Leukemia Section, Department of Medicine, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263, United States
| | - Eunice S Wang
- Leukemia Section, Department of Medicine, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263, United States
| | - Meir Wetzler
- Leukemia Section, Department of Medicine, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263, United States
| | - Craig W Freyer
- Department of Pharmacy, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263, United States
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Pagnano KBB, Rego EM, Rohr S, de Lourdes Chauffaille M, Jacomo RH, Bittencourt R, Firmato AB, Fagundes EM, Moraes Melo RA, Bernardo W. Guidelines on the diagnosis and treatment for acute promyelocytic leukemia: Associação Brasileira de Hematologia, Hemoterapia e Terapia Celular Guidelines Project: Associação Médica Brasileira - 2013. Rev Bras Hematol Hemoter 2014; 36:71-92. [PMID: 24624041 PMCID: PMC3948671 DOI: 10.5581/1516-8484.20140018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2013] [Indexed: 12/15/2022] Open
Affiliation(s)
| | | | - Sandra Rohr
- Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | | | | | - Rosane Bittencourt
- Universidade Federal do Rio Grande do Sul (UFGRS), Porto Alegre, RS, Brazil
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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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Au WY, Hon C, Yau K, Lai WW, Fong BM, Tam S, Kwong YL. Two cases of monocular visual loss during oral arsenic trioxide therapy of acute promyelocytic leukemia. Am J Hematol 2009; 84:699. [PMID: 19705432 DOI: 10.1002/ajh.21505] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Lipton J, Joffe S, Ullrich NJ. CNS relapse of acute myelogenous leukemia masquerading as pseudotumor cerebri. Pediatr Neurol 2008; 39:355-7. [PMID: 18940560 DOI: 10.1016/j.pediatrneurol.2008.07.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2008] [Revised: 07/21/2008] [Accepted: 07/23/2008] [Indexed: 10/21/2022]
Abstract
An 18-year-old man in remission from acute myelogenous leukemia 3 years after a bone marrow transplant presented with signs of pseudotumor cerebri, including headache, visual changes, and papilledema. He manifested elevated opening pressure on lumbar puncture and positive cytology, with a concurrent normal bone marrow aspirate and biopsy. He was diagnosed with an isolated central nervous system relapse of acute myeloid leukemia. Although the precise etiology remains elusive, this case demonstrates that pseudotumor cerebri must remain within the differential diagnosis after other complications are excluded, particularly in persons with underlying hematologic malignancies.
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Affiliation(s)
- Jonathan Lipton
- Department of Neurology, Children's Hospital Boston, Boston, Massachusetts, 02115, USA
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Cashin R, Burry L, Peckham K, Reynolds S, Seki JT. Acute renal failure, gastrointestinal bleeding, and cardiac arrhythmia after administration of arsenic trioxide for acute promyelocytic leukemia. Am J Health Syst Pharm 2008; 65:941-6. [DOI: 10.2146/ajhp060616] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Richard Cashin
- Pharmacy, David Thompson Health Region, Red Deer, Alberta, Canada
| | - Lisa Burry
- Department of Pharmacy, and Associate Scientist, Department of Medicine, Mount Sinai Hospital University, University of Toronto, Toronto, Ontario
| | - Kenneth Peckham
- Hematology Services, Princess Margaret Hospital, University Health Network (UHN), Toronto
| | - Stuart Reynolds
- UHN, Toronto, and Staff Intensivist, Mount Sinai Hospital, Toronto
| | - Jack T. Seki
- Princess Margaret Hospital, UHN, and Assistant Professor, Pharm.D. Program, University of Toronto, Toronto
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Abstract
Arsenic trioxide (As2O3) has been used medicinally for thousands of years. Its therapeutic use in leukaemia was described a century ago. Recent rekindling in the interest of As2O3 is due to its high efficacy in acute promyelocytic leukaemia (APL). As2O3 has also been tested clinically in other blood and solid cancers. Most studies have used intravenous As2O3, although an oral As2O3 is equally efficacious. Side effects of As2O3 are usually minor, including skin reactions, gastrointestinal upset, and hepatitis. These respond to symptomatic treatment or temporary drug cessation, and do not compromise subsequent treatment with As2O3. During induction therapy in APL, a leucocytosis may occasionally occur, which can be associated with fluid accumulation and pulmonary infiltration. The condition is similar to the APL differentiation syndrome during treatment with all-trans retinoic acid, and responds to cytoreductive treatment and corticosteroids. Intravenous As2O3 treatment leads to QT prolongation. In the presence of underlying cardiopulmonary diseases or electrolyte disturbances, particularly hypokalaemia and hypomagnesaemia, serious arrhythmias may develop, with torsades du pointes reported in 1% of cases. This may be related to a dose-dependent arsenic-mediated inhibition of potassium ion channels that compromises cardiac repolarization. Because of slow intestinal absorption, oral-As2O3 gives a lower plasma arsenic concentration, which is associated with lesser QT prolongation and hence a more favorable cardiac safety profile. As2O3 does not appear to enter the central nervous system. However, if the blood brain barrier is breached, elemental arsenic may enter the cerebrospinal fluid. As2O3 is predominantly excreted in the kidneys, and dose adjustment is required when renal function is impaired.
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Affiliation(s)
- Wing-Yan Au
- Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong, China.
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9
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Abstract
Arsenic trioxide (As(2)O(3)) for leukaemia treatment was described a century ago. Recent resurgence in the use of arsenic trioxide is related to its high efficacy in acute promyelocytic leukaemia (APL). Most arsenic trioxide preparations are intravenous, although an oral formulation is similarly efficacious. Side effects of arsenic trioxide are usually minor, including skin reactions, gastrointestinal upset, and reversible increases in transaminases. During therapy, a leukocytosis occasionally occurs, which may be complicated by fluid accumulation and pulmonary infiltration. Arsenic trioxide causes an asymptomatic QT prolongation in most patients. However, if concomitant cardiopulmonary diseases or electrolyte disturbances are present, more sinister arrhythmias may develop. Therefore, before commencement of arsenic trioxide therapy, a full cardiac assessment and avoidance of drugs that prolong QT interval should be instituted. Arsenic trioxide is partly renally excreted and, therefore, dose adjustment is required when renal function is impaired. In addition to its use in APL, arsenic trioxide is now tested in other malignancies, notably multiple myeloma.
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Affiliation(s)
- Yok-Lam Kwong
- University of Hong Kong, Department of Medicine, Queen Mary Hospital, Pokfulam Road, Hong Kong.
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Evens AM, Tallman MS, Gartenhaus RB. The potential of arsenic trioxide in the treatment of malignant disease: past, present, and future. Leuk Res 2004; 28:891-900. [PMID: 15234563 DOI: 10.1016/j.leukres.2004.01.011] [Citation(s) in RCA: 132] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2004] [Revised: 01/22/2004] [Accepted: 01/26/2004] [Indexed: 11/18/2022]
Abstract
Arsenic trioxide (As2O3) is an effective therapy for acute promyelocytic leukemia (APL), and there has been promising activity noted in other hematologic and solid tumors. The mechanism of action of As2O3 such as differentiation and apoptosis has prompted study into combination therapy. Furthermore, the connection of the sensitivity of diseases such as APL and multiple myeloma to oxidative damage has allowed the investigation of pharmacologic modulation of the cellular redox state for potentiation of As2O3. Continued study of As2O3 as a single-agent and in combination therapy will allow identification of the safest and most effective treatment regimens for malignant disease.
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Affiliation(s)
- Andrew M Evens
- Department of Medicine, Divison of Hematology/Oncology, Northwestern University, Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center, 676 N. St. Clair, Suite 850, Chicago, IL 60611, USA
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Abstract
PURPOSE OF REVIEW To discuss the current standard in diagnosis and treatment of pseudotumor cerebri (PTC), the syndrome of increased intracranial pressure without a brain tumor. Since PTC is a diagnosis of exclusion, the differential diagnostic work-up is of special importance. RECENT FINDINGS Modern imaging techniques have facilitated the differential diagnosis of PTC. Various therapeutic options are available to prevent irreversible visual loss. New treatment modalities are being explored, but the standard therapy has undergone little change in the past years. SUMMARY PTC, a potentially blinding disease, most commonly manifests with headache and slightly blurred vision due to papilledema. This review seeks to present a methodical approach to its diagnosis and treatment.
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Affiliation(s)
- Michaela K Mathews
- Wills Eye Hospital, Neuro-Ophthalmology Service, Philadelphia, PA 19107, USA.
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Lam MS, Ignoffo RJ. Arsenic trioxide for the treatment of acute promyelocytic leukemia. CANCER PRACTICE 2001; 9:155-7. [PMID: 11879303 DOI: 10.1046/j.1523-5394.2001.009003155.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- M S Lam
- School of Clinical Pharmacy, University of California, San Francisco, California, USA
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