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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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Masetti R, Muratore E, Leardini D, Baccelli F, Pession A, Prete A, Locatelli F. Chemotherapy-free treatment for acute promyelocytic leukemia: the pediatric view of a revolutionary tale. Front Oncol 2023; 13:1135350. [PMID: 37124521 PMCID: PMC10145906 DOI: 10.3389/fonc.2023.1135350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 03/27/2023] [Indexed: 05/02/2023] Open
Abstract
The addition of all-trans retinoic acid (ATRA) to the standard anthracycline-base chemotherapy has revolutionized the treatment of acute promyelocytic leukemia (APL) over the last decades, becoming a model for precision medicine. The protocols based on the combination of ATRA and chemotherapy allowed obtaining excellent response rates both for children and adults. However, the persistence of anthracycline chemotherapy as a backbone was a matter of concern for both acute and long-term complications. Efforts in reducing anthracycline cumulative dose or even eliminating anthracycline have been pursued in more recent pediatric protocols thanks to the introduction of arsenic trioxide (ATO). The impressive results of the ATRA/ATO combinations led to the introduction of protocols completely chemotherapy-free for standard-risk adult patients as the standard of care, whereas pediatric chemo-free protocols are still currently under evaluation. In this Review, we will critically retrace the history of this unique revolution in precision medicine, discussing the peculiar advantages for pediatric patients with APL.
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Affiliation(s)
- Riccardo Masetti
- Pediatric Oncology and Hematology “Lalla Seràgnoli”, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Edoardo Muratore
- Pediatric Oncology and Hematology “Lalla Seràgnoli”, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- *Correspondence: Edoardo Muratore,
| | - Davide Leardini
- Pediatric Oncology and Hematology “Lalla Seràgnoli”, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesco Baccelli
- Pediatric Oncology and Hematology “Lalla Seràgnoli”, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andrea Pession
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Arcangelo Prete
- Pediatric Oncology and Hematology “Lalla Seràgnoli”, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Franco Locatelli
- Department of Pediatric Hematology/Oncology and Cell and Gene Therapy, IRCCS Ospedale Pediatric Bambino Gesù, Rome, Italy
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Gurnari C, Divona M, Voso MT. What are the considerations for the pharmacotherapeutic management of acute promyelocytic leukemia in children? Expert Opin Pharmacother 2021; 23:289-294. [PMID: 34842028 DOI: 10.1080/14656566.2021.2006182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Carmelo Gurnari
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy.,Translational Hematology and Oncology Research Department, Taussig Cancer Center, Cleveland Clinic, OH, USA
| | - Mariadomenica Divona
- Laboratory of Advanced Diagnostics in Oncohematology, Hematology Department, Tor Vergata Hospital, Rome, Italy
| | - Maria Teresa Voso
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy.,Department of Neuro-Oncohematology, Rome, Italy
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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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Chien N, Varghese C, Green TN, Chan G, Theakston E, Eaddy N, Doocey R, Berkahn L, Hawkins T, Browett PJ, Kalev-Zylinska ML. Treatment outcomes of patients with acute promyelocytic leukaemia between 2000 and 2017, a retrospective, single centre experience. Leuk Res 2020; 93:106358. [PMID: 32380366 DOI: 10.1016/j.leukres.2020.106358] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/19/2020] [Accepted: 04/20/2020] [Indexed: 02/06/2023]
Abstract
All-trans retinoic acid (ATRA) and arsenic trioxide (ATO) are effective induction therapy for acute promyelocytic leukaemia (APL). However, early thrombo-haemorrhagic complications and mortality remain high. We aimed to investigate how the timing of ATRA initiation and the inclusion of ATO influence patient outcomes. Clinical records were retrospectively reviewed for all patients treated for APL in a single, tertiary centre during 2000-2017. Among 70 patients with APL, 36 (51.4%) presented with thrombo-haemorrhagic complications, and four (5.8%) died within 30 days. The median time to ATRA initiation was 11.2 (range 0-104) h from the time of admission. Patients requiring more transfusions started on ATRA sooner (P = 0.04). Patients with adverse early events did not start ATRA later (P = 0.99). Nevertheless, patients that required additional tests for diagnosis (PML immunofluorescence or molecular) started on ATRA later (28.5 versus 5.3 h; P < 0.0001), and had more thrombo-haemorrhagic complications (P = 0.04). Long-term survival was actually better in patients who started ATRA later (P = 0.03), which is likely explained by higher proportion of low risk patients in this group. Patients treated with ATO (n = 23) maintained higher fibrinogen levels and required less transfusions during induction (P < 0.05), with no disease-related deaths in this group over a median follow-up time of 37.8 months (interquartile range 44.9 months). In summary, fast ATRA initiation reduces early but not late adverse events in APL patients, and the inclusion of ATO helps further improve both early and late outcomes in APL.
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Affiliation(s)
- Nicole Chien
- Department of Haematology, Auckland City Hospital, Auckland, New Zealand
| | - Chris Varghese
- Department of Molecular Medicine and Pathology, School of Medical Sciences, University of Auckland, Auckland, New Zealand
| | - Taryn N Green
- Department of Molecular Medicine and Pathology, School of Medical Sciences, University of Auckland, Auckland, New Zealand
| | - George Chan
- Department of Haematology, Auckland City Hospital, Auckland, New Zealand; Department of Molecular Medicine and Pathology, School of Medical Sciences, University of Auckland, Auckland, New Zealand; Department of Pathology and Laboratory Medicine, LabPlus Haematology, Auckland City Hospital, Auckland, New Zealand
| | - Edward Theakston
- Department of Pathology and Laboratory Medicine, LabPlus Haematology, Auckland City Hospital, Auckland, New Zealand
| | - Nicola Eaddy
- Department of Haematology, Auckland City Hospital, Auckland, New Zealand
| | - Richard Doocey
- Department of Haematology, Auckland City Hospital, Auckland, New Zealand
| | - Leanne Berkahn
- Department of Haematology, Auckland City Hospital, Auckland, New Zealand
| | - Timothy Hawkins
- Department of Haematology, Auckland City Hospital, Auckland, New Zealand
| | - Peter J Browett
- Department of Haematology, Auckland City Hospital, Auckland, New Zealand; Department of Molecular Medicine and Pathology, School of Medical Sciences, University of Auckland, Auckland, New Zealand; Department of Pathology and Laboratory Medicine, LabPlus Haematology, Auckland City Hospital, Auckland, New Zealand
| | - Maggie L Kalev-Zylinska
- Department of Molecular Medicine and Pathology, School of Medical Sciences, University of Auckland, Auckland, New Zealand; Department of Pathology and Laboratory Medicine, LabPlus Haematology, Auckland City Hospital, Auckland, New Zealand.
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