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Andrade FG, Feliciano SVM, Sardou-Cezar I, Brisson GD, dos Santos-Bueno FV, Vianna DT, Marques LVC, Terra-Granado E, Zalcberg I, Santos MDO, Costa JT, Noronha EP, Thuler LCS, Wiemels JL, Pombo-de-Oliveira MS. Pediatric Acute Promyelocytic Leukemia: Epidemiology, Molecular Features, and Importance of GST-Theta 1 in Chemotherapy Response and Outcome. Front Oncol 2021; 11:642744. [PMID: 33816294 PMCID: PMC8017304 DOI: 10.3389/fonc.2021.642744] [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: 12/16/2020] [Accepted: 02/08/2021] [Indexed: 11/23/2022] Open
Abstract
Previous studies have suggested a variation in the incidence of acute promyelocytic leukemia (APL) among the geographic regions with relatively higher percentages in the Latin American population. We aimed to explore the population burden of pediatric APL, gathering information from the population-based cancer registry (PBCR) and the diagnosis of APL obtained through incident cases from a hospital-based cohort. The homozygous deletion in glutathione S-transferases (GSTs) leads to a loss of enzyme detoxification activity, possibly affecting the treatment response. Mutations in the RAS pathway genes are also considered to be a key component of the disease both in the pathogenesis and in the outcomes. We have assessed mutations in a RAS-MAP kinase pathway (FLT3, PTPN11, and K-/NRAS) and GST variant predisposition risk in the outcome. Out of the 805 children and adolescents with acute myeloid leukemia (AML) who are registered in the PBCR, 35 (4.3%) were APL cases. The age-adjusted incidence rate (AAIR) was 0.03 per 100,000 person-years. One-hundred and sixty-three patients with APL were studied out of 931 AML cases (17.5%) from a hospital-based cohort. Mutations in FLT3, KRAS, and NRAS accounted for 52.1% of the cases. Patients with APL presented a 5-year probability of the overall survival (OS) of 67.3 ± 5.8%. A GST-theta 1 (GSTT1) null genotype conferred adverse prognosis, with an estimated hazard ratio of 2.8, 95% confidence interval (CI) 1.2-6.9. We speculate that the GSTT1 polymorphism is associated with therapeutics and would allow better OS of patients with APL with a GSTT1 null genotype.
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Affiliation(s)
- Francianne G. Andrade
- Pediatric Hematology-Oncology Program, Research Center, Instituto Nacional de Câncer, Rio de Janeiro, Brazil
| | - Suellen V. M. Feliciano
- Pediatric Hematology-Oncology Program, Research Center, Instituto Nacional de Câncer, Rio de Janeiro, Brazil
| | - Ingrid Sardou-Cezar
- Pediatric Hematology-Oncology Program, Research Center, Instituto Nacional de Câncer, Rio de Janeiro, Brazil
| | - Gisele D. Brisson
- Pediatric Hematology-Oncology Program, Research Center, Instituto Nacional de Câncer, Rio de Janeiro, Brazil
| | - Filipe V. dos Santos-Bueno
- Pediatric Hematology-Oncology Program, Research Center, Instituto Nacional de Câncer, Rio de Janeiro, Brazil
| | - Danielle T. Vianna
- Laboratory of Molecular Biology, Bone Marrow Transplantation Center, Instituto Nacional de Câncer, Rio de Janeiro, Brazil
| | - Luísa V. C. Marques
- Pediatric Hematology-Oncology Program, Research Center, Instituto Nacional de Câncer, Rio de Janeiro, Brazil
| | - Eugênia Terra-Granado
- Pediatric Hematology-Oncology Program, Research Center, Instituto Nacional de Câncer, Rio de Janeiro, Brazil
| | - Ilana Zalcberg
- Laboratory of Molecular Biology, Bone Marrow Transplantation Center, Instituto Nacional de Câncer, Rio de Janeiro, Brazil
| | - Marceli de O. Santos
- Surveillance and Prevention, Instituto Nacional de Cancer, Rio de Janeiro, Brazil
| | - Juliana T. Costa
- Department of Pediatric Hematology-Oncology, Hospital Martagão Gesteira, Salvador, Brazil
| | - Elda P. Noronha
- Pediatric Hematology-Oncology Program, Research Center, Instituto Nacional de Câncer, Rio de Janeiro, Brazil
| | - Luiz C. S. Thuler
- Clinical Research Department, Research Center, Instituto Nacional de Câncer, Rio de Janeiro, Brazil
| | - Joseph L. Wiemels
- Center for Genetic Epidemiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Maria S. Pombo-de-Oliveira
- Pediatric Hematology-Oncology Program, Research Center, Instituto Nacional de Câncer, Rio de Janeiro, Brazil
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Gurnari C, Voso MT, Girardi K, Mastronuzzi A, Strocchio L. Acute Promyelocytic Leukemia in Children: A Model of Precision Medicine and Chemotherapy-Free Therapy. Int J Mol Sci 2021; 22:ijms22020642. [PMID: 33440683 PMCID: PMC7826974 DOI: 10.3390/ijms22020642] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 01/07/2021] [Accepted: 01/08/2021] [Indexed: 12/12/2022] Open
Abstract
Acute promyelocytic leukemia (APL) represents a paradigm of precision medicine. Indeed, in the last decades, the introduction of all-trans retinoic acid (ATRA) and arsenic trioxide (ATO) completely revolutionized the therapeutic approach to this previously highly fatal disorder. This entirely chemotherapy-free treatment, which provided excellent survival rates, has been initially validated in adults and, recently, translated in the pediatric setting. This review summarizes currently available data on the use of ATRA and ATO combination in pediatric APL, providing a particular focus on peculiar issues and challenges, such as the occurrence of pseudotumor cerebri and death during induction (early death), as well as the advantage offered by the ATO/ATRA combination in sparing long-term sequelae.
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Affiliation(s)
- Carmelo Gurnari
- Department of Pediatric Hemato-Oncology and Cell and Gene Therapy, Istituto di Ricovero e Cura a Carattere Scientifico Bambino Gesù Children’s Hospital, 00165 Rome, Italy; (C.G.); (K.G.); (A.M.)
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, 00133 Rome, Italy;
- Immunology, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, 00133 Rome, Italy
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Maria Teresa Voso
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, 00133 Rome, Italy;
- Laboratorio di Neuro-Oncoematologia, Fondazione Santa Lucia, 00179 Rome, Italy
| | - Katia Girardi
- Department of Pediatric Hemato-Oncology and Cell and Gene Therapy, Istituto di Ricovero e Cura a Carattere Scientifico Bambino Gesù Children’s Hospital, 00165 Rome, Italy; (C.G.); (K.G.); (A.M.)
| | - Angela Mastronuzzi
- Department of Pediatric Hemato-Oncology and Cell and Gene Therapy, Istituto di Ricovero e Cura a Carattere Scientifico Bambino Gesù Children’s Hospital, 00165 Rome, Italy; (C.G.); (K.G.); (A.M.)
| | - Luisa Strocchio
- Department of Pediatric Hemato-Oncology and Cell and Gene Therapy, Istituto di Ricovero e Cura a Carattere Scientifico Bambino Gesù Children’s Hospital, 00165 Rome, Italy; (C.G.); (K.G.); (A.M.)
- Correspondence:
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Jastaniah W, Alsultan A, Al Daama S, Ballourah W, Bayoumy M, Al-Anzi F, Al Shareef O, Abrar MB, Al Sudairy R, Al Ghemlas I. Clinical characteristics and outcome of childhood acute promyelocitic leukemia (APL) in Saudi Arabia: a multicenter SAPHOS leukemia group study. ACTA ACUST UNITED AC 2017; 23:316-323. [PMID: 29212418 DOI: 10.1080/10245332.2017.1412380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Acute promyelocytic leukemia (APL) is a rare form of acute myelogenous leukemia (AML). Survival rates exceed 80% in developed countries. Successful treatments rely on all-trans retinoic acid with anthracycline-based chemotherapy. Availability of modern care and public knowledge play important roles in pediatric APL survival. METHOD A cytogenetic diagnosis of APL was confirmed in 30 (14.5%) out of 207 children consecutively diagnosed with de novo AML between January 2005 and December 2012 at nine cancer care centers in Saudi Arabia. Patients were treated based on the standard protocol used by the center following the PETHEMA or the C9710 treatment protocols. We modeled 5-year overall survival (OS), event-free survival (EFS) and cumulative incidence of relapse (CIR) vs. treatment and potential covariates of age at diagnosis, involvement of central nervous system (CNS), and white blood cell (WBC) levels. RESULTS The median age was 10.4 years with a male:female ratio of 1.9. WBC was 10 × 109/l or greater in 57% and CNS involvement was confirmed in 13%. OS, EFS, and CIR were 74 ± 12%, 55 ± 19%, and, 36 ± 17% respectively. No significant difference was found by treatment protocol. WBC levels were significantly prognostic for all negative events, but treatment with C9710 significantly ameliorated negative WBC effects. Overall outcomes were comparable to those reported in developed countries. CONCLUSIONS Access to modern care is likely to be a critical factor in successful and comparable outcomes of childhood APL across the globe. In the present study, utilizing a cytarabine-containing protocol improved outcome of high-risk pediatric patients with APL.
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Affiliation(s)
- Wasil Jastaniah
- a Department of Pediatrics, Faculty of Medicine , Umm Al-Qura University , Makkah , Saudi Arabia.,b Princess Noorah Oncology Center , King Saud Bin Abdulaziz University and King Abdulaziz Medical City , Jeddah , Saudi Arabia
| | - Abdulrahman Alsultan
- c Department of Pediatrics , College of Medicine, King Saud University , Riyadh , Saudi Arabia
| | - Saad Al Daama
- d King Fahad Specialist Hospital , Dammam , Saudi Arabia
| | | | - Mohamed Bayoumy
- f King Faisal Specialist Hospital & Research Center , Jeddah , Saudi Arabia
| | - Faisal Al-Anzi
- g Prince Faisal Bin Bandar Cancer Center , Qaseem , Saudi Arabia
| | - Omar Al Shareef
- h Prince Sultan Military Medical City , Riyadh , Saudi Arabia
| | - Mohammed Burhan Abrar
- b Princess Noorah Oncology Center , King Saud Bin Abdulaziz University and King Abdulaziz Medical City , Jeddah , Saudi Arabia
| | - Reem Al Sudairy
- i Department of Pediatric Hematology/Oncology , King Abdullah specialized Children's Hospital, King Abdulaziz Medical City , Riyadh , Saudi Arabia
| | - Ibrahim Al Ghemlas
- j Faculty of Medicine Alfaisal University , Riyadh , Saudi Arabia.,k King Faisal Specialist Hospital & Research Center , Riyadh , Saudi Arabia
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Zhang L, Samad A, Pombo-de-Oliveira MS, Scelo G, Smith MT, Feusner J, Wiemels JL, Metayer C. Global characteristics of childhood acute promyelocytic leukemia. Blood Rev 2015; 29:101-25. [PMID: 25445717 PMCID: PMC4379131 DOI: 10.1016/j.blre.2014.09.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Revised: 09/21/2014] [Accepted: 09/23/2014] [Indexed: 12/29/2022]
Abstract
Acute promyelocytic leukemia (APL) comprises approximately 5-10% of childhood acute myeloid leukemia (AML) cases in the US. While variation in this percentage among other populations was noted previously, global patterns of childhood APL have not been thoroughly characterized. In this comprehensive review of childhood APL, we examined its geographic pattern and the potential contribution of environmental factors to observed variation. In 142 studies (spanning >60 countries) identified, variation was apparent-de novo APL represented from 2% (Switzerland) to >50% (Nicaragua) of childhood AML in different geographic regions. Because a limited number of previous studies addressed specific environmental exposures that potentially underlie childhood APL development, we gathered 28 childhood cases of therapy-related APL, which exemplified associations between prior exposures to chemotherapeutic drugs/radiation and APL diagnosis. Future population-based studies examining childhood APL patterns and the potential association with specific environmental exposures and other risk factors are needed.
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Affiliation(s)
- L Zhang
- School of Public Health, University of California, Berkeley, USA.
| | - A Samad
- School of Public Health, University of California, Berkeley, USA.
| | - M S Pombo-de-Oliveira
- Pediatric Hematology-Oncology Program, Research Center-National Institute of Cancer, Rio de Janeiro, Brazil.
| | - G Scelo
- International Agency for Research on Cancer (IARC), Lyon, France.
| | - M T Smith
- School of Public Health, University of California, Berkeley, USA.
| | - J Feusner
- Department of Hematology, Children's Hospital and Research Center Oakland, Oakland, USA.
| | - J L Wiemels
- Department of Epidemiology and Biostatistics, University of California, San Francisco, USA.
| | - C Metayer
- School of Public Health, University of California, Berkeley, USA.
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Treatment of paediatric APL: how does the therapeutic approach differ from adults? Best Pract Res Clin Haematol 2014; 27:69-78. [PMID: 24907019 DOI: 10.1016/j.beha.2014.04.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Acute promyelocytic leukaemia (APL) in children and adolescents shares many features with APL in adults. There are important distinctions, however, between these age groups in the presentation, complications and treatment outcomes. Paediatric patients are more likely to present with high risk features including elevated WBC count or microgranular variant (M3v). Yet the early death rate is lower in paediatric patients compared to adult patients. Overall outcomes such as CR, OS and EFS appear similar in paediatric and adult patients treated on similar regimens except that very young children may have a higher risk of relapse. While contemporary studies have clearly demonstrated improved survival in adults receiving ATO therapy, currently there is more limited data on the role of ATO in paediatric patients. Here we highlight the similarities and important distinctions between paediatric and adult APL while reviewing available data on treatment of paediatric APL.
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Tedesco J, Qualtieri J, Head D, Savani BN, Reddy N. High Prevalence of Obesity in Acute Promyelocytic Leukemia (APL): Implications for Differentiating Agents in APL and Metabolic Syndrome. Ther Adv Hematol 2013; 2:141-5. [PMID: 23556085 DOI: 10.1177/2040620711408490] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Between January 1999 and December 2008, 469 patients treated for acute myeloid leukemia (AML) were included in this single-institution study. METHODS We performed a case-control analysis to study the rate of obesity among patients with acute promyelocytic leukemia (APL) and non-APL AML. RESULTS A total of 81% of APL patients analyzed were obese compared with 41.7% in the non-APL group (p < 0.001). Body mass index (BMI) >30 was seen in 57% of APL patients compared with 31% for the non-APL group (p = 0.01). Neither obesity nor the chemotherapy dosing based on ideal body weight affected survival. CONCLUSIONS Our findings generate the hypothesis that APL and metabolic syndromes may share a common pathogenic pathway via retinoic acid receptors (RARs), the ligand-controlled transcription factors that function as heterodimers with retinoid X receptors (RXRs) to regulate cell growth and survival. If this link is confirmed in larger studies, our data will instigate further studies using RXR and RAR modulators as a preventive strategy among obese individuals.
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Affiliation(s)
- Jason Tedesco
- Department of Pathology, Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
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Yoo ES. Recent advances in the diagnosis and management of childhood acute promyelocytic leukemia. KOREAN JOURNAL OF PEDIATRICS 2011; 54:95-105. [PMID: 21738538 PMCID: PMC3121002 DOI: 10.3345/kjp.2011.54.3.95] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Accepted: 03/07/2011] [Indexed: 02/07/2023]
Abstract
Since the successful introduction of all-trans-retinoic acid (ATRA) and its combination with anthracycline-containing chemotherapy, the prognosis for acute promyelocytic leukemia (APL) has markedly improved. With ATRA and anthracycline-based-chemotherapy, the complete remission rate is greater than 90%, and the long-term survival rate is 70-89%. Moreover, arsenic trioxide (ATO), which was introduced for APL treatment in 1994, resulted in excellent remission rates in relapsed patients with APL, and more recently, several clinical studies have been designed to explore its role in initial therapy either alone or in combination with ATRA. APL is a rare disease in children and is frequently associated with hyperleukocytosis, which is a marker for higher risk of relapse and an increased incidence of microgranular morphology. The frequency of occurrence of the promyelocytic leukemia/retinoic acid receptor-alpha (PML/RARα) isoforms bcr 2 and bcr 3 is higher in children than in adults. Although recent clinical studies have reported comparable long-term survival rates in patients with APL, therapy for APL in children is challenging because of the risk of early death and the potential long-term cardiac toxicity resulting from the need to use high doses of anthracyclines. Additional prospective, randomized, large clinical trials are needed to address several issues in pediatric APL and to possibly minimize or eliminate the need for chemotherapy by combining ATRA and ATO. In this review article, we discuss the molecular pathogenesis, diagnostic progress, and most recent therapeutic advances in the treatment of children with APL.
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Affiliation(s)
- Eun Sun Yoo
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Ewha Womans University, School of Medicine, Seoul, Korea
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Population-based incidence of childhood leukaemias and lymphomas in Spain (1993-2002). Eur J Cancer Prev 2011; 19:247-55. [PMID: 20395866 DOI: 10.1097/cej.0b013e328339e2f3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The aim of this study was to estimate the incidence of leukaemias and lymphomas in children according to the International Classification of Childhood Cancer third edition (ICCC-3) in the population covered by the Girona, Valencia, and Zaragoza population-based cancer registries and compare it with the incidence rates in other European countries. All haematological malignancies (HMs) registered between 1993 and 2002 in children below 15 years of age were included in the study. Pathological and haematological diagnoses were reviewed, recoded according to International Classification of Diseases for Oncology-3 and reclassified on the basis of ICCC-3. Sex and age-adjusted incidence rates were calculated, using the world population as standard. Five hundred and seventy-one HMs were registered in the Girona, Valencia and Zaragoza Cancer Registries during the study period. According to ICCC-3, precursor cell leukaemias were the most frequent HMs in children and constituted 60% of all HMs (an age-adjusted incidence rate of 42.7 per million children-years). The second most frequent childhood HM was Hodgkin lymphoma (11.2% of all HMs), yielding an age-adjusted standardized incidence rate of 6.3 per million children-years. With regard to myeloid lineage, acute myeloid leukaemias were the most frequent with a rate of 7.9 per million children-years. The standardized incidence rates for lymphoid leukaemia (1.19) and Burkitt lymphoma (3.94) were statistically higher than the rates observed in Europe. Compared with European data, Spain has a high incidence of lymphoid leukaemias and lymphomas. In particular, a high incidence of Burkitt lymphoma was observed. The causes of this geographical variation are still unknown.
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Abstract
Acute promyelocytic leukemia is the first malignant disease highly curable with targeted therapy directed at a unique molecular abnormality. The characteristic bleeding diathesis is the most notorious manifestation of the disease, which historically has accounted for a high mortality rate during induction. Acute promyelocytic leukemia is one of the few hematologic diseases that must be recognized under the microscope by the practicing hematologist because early institution of all-trans retinoic acid (ATRA) at the first suspicion of the disease before confirmation of the diagnosis and aggressive blood product support are critical to reduce early mortality. ATRA plus anthracycline-based chemotherapy for induction and consolidation followed by maintenance ATRA with low-dose chemotherapy is currently the standard of care. However, the combination of ATRA and arsenic trioxide, with minimal chemotherapy to control leukocytosis, is very effective therapy for newly diagnosed patients. This combination may replace conventional approaches for most, if not all, patients in the very near future. Acute promyelocytic leukemia should be considered in any patient with newly diagnosed acute myeloid leukemia because the treatment is urgent and different from all other subtypes.
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Management of acute promyelocytic leukemia: recommendations from an expert panel on behalf of the European LeukemiaNet. Blood 2008; 113:1875-91. [PMID: 18812465 DOI: 10.1182/blood-2008-04-150250] [Citation(s) in RCA: 594] [Impact Index Per Article: 37.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The introduction of all-trans retinoic acid (ATRA) and, more recently, arsenic trioxide (ATO) into the therapy of acute promyelocytic leukemia (APL) has revolutionized the management and outcome of this disease. Several treatment strategies using these agents, usually in combination with chemotherapy, but also without or with minimal use of cytotoxic agents, have provided excellent therapeutic results. Cure of APL patients, however, is also dependent on peculiar aspects related to the management and supportive measures that are crucial to counteract life-threatening complications associated with the disease biology and molecularly targeted treatment. The European LeukemiaNet recently appointed an international panel of experts to develop evidence- and expert opinion-based guidelines on the diagnosis and management of APL. Together with providing current indications on genetic diagnosis, modern risk-adapted front-line therapy and salvage treatment, the review contains specific recommendations for the identification and management of most important complications such as the bleeding disorder, APL differentiation syndrome, QT prolongation and other ATRA- and ATO-related toxicities, as well as for molecular assessment of response to treatment. Finally, the approach to special situations is also discussed, including management of APL in children, elderly patients, and pregnant women.
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