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Araji G, Mustafa A, Niazi M, Wei C, Sharma R, Abu-Baker S, Khattar G, El-Sayegh S, Odaimi M. Acute cardiovascular complications of disseminated intravascular coagulation in acute myeloid leukemia. Thromb Res 2024; 239:109042. [PMID: 38796899 DOI: 10.1016/j.thromres.2024.109042] [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: 04/11/2024] [Revised: 05/12/2024] [Accepted: 05/23/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Disseminated intravascular coagulation (DIC) is a common complication of all leukemia subtypes, but it is an especially prominent feature of Acute Myeloid Leukemias (AML). DIC complicating AML can lead to a variety of complications, however, its association with acute cardiovascular complications has not been reported before. METHODS National Inpatient Sample Database was used to procure individuals with AML, and baseline demographics and comorbidities were collected using ICD-10-DM codes. Patients were stratified into those with and without DIC. Greedy propensity matching using R was performed to match the two cohorts in 1:1 ratio on age, gender, and fifteen other baseline comorbidities. Univariate analysis pre and post-match along with binary logistic regression analysis post-match were used to analyze outcomes. RESULTS Out of a total of 37,344 patients with AML, 996 had DIC. DIC patients were younger, predominantly males, and had lower prevalence of baseline cardiovascular comorbidities. DIC patients had statistically significant higher mortality (30.2 % vs 7.8 %), acute myocardial infarction (5.1 % vs 1.8 %), acute pulmonary edema (2.3 % vs 0.7 %), cardiac arrest (6.4 % vs 0.9 %), and acute DVT/PE (6.6 % vs 2.7 %). Logistic regression model after matching showed similar outcomes along with significantly higher rates of acute heart failure in DIC patients. CONCLUSION These findings highlight the importance of close cardiovascular monitoring and prompt recognition of complications in AML patients with DIC. The underlying mechanisms involve a complex interplay of procoagulant factors, cytokine release, and endothelial dysfunction. Further studies are needed to develop targeted interventions for prevention and management of these complications.
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Affiliation(s)
- Ghada Araji
- Northwell Health/Staten Island University Hospital, Department of Internal Medicine, Staten Island, NY, USA.
| | - Ahmad Mustafa
- Northwell Health/Staten Island University Hospital, Department of Cardiology, Staten Island, NY, USA
| | - Muhammad Niazi
- Northwell Health/Staten Island University Hospital, Department of Hematology/Oncology, Staten Island, NY, USA
| | - Chapman Wei
- Northwell Health/Staten Island University Hospital, Department of Internal Medicine, Staten Island, NY, USA
| | - Rubal Sharma
- Northwell Health/Staten Island University Hospital, Department of Hematology/Oncology, Staten Island, NY, USA
| | - Saif Abu-Baker
- Northwell Health/Staten Island University Hospital, Department of Internal Medicine, Staten Island, NY, USA
| | - Georges Khattar
- Northwell Health/Staten Island University Hospital, Department of Internal Medicine, Staten Island, NY, USA
| | - Suzanne El-Sayegh
- Northwell Health/Staten Island University Hospital, Department of Internal Medicine, Staten Island, NY, USA
| | - Marcel Odaimi
- Northwell Health/Staten Island University Hospital, Department of Hematology/Oncology, Staten Island, NY, USA
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2
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Hisada Y. Dysregulated hemostasis in acute promyelocytic leukemia. Int J Hematol 2024; 119:526-531. [PMID: 38341391 DOI: 10.1007/s12185-024-03708-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 12/26/2023] [Accepted: 01/04/2024] [Indexed: 02/12/2024]
Abstract
Acute promyelocytic leukemia (APL) is associated with a high incidence of early death, which occurs within 30 days of diagnosis. The major cause of early death in APL is severe bleeding, particularly intracranial bleeding. Although APL is known to be associated with activation of coagulation, hyperfibrinolysis, and thrombocytopenia, the precise mechanisms that cause bleeding have not yet been elucidated. I propose that a combination of four pathways may contribute to bleeding in APL: (1) tissue factor, (2) the urokinase plasminogen activator/urokinase plasminogen activator receptor, (3) the annexin A2/S100A100/tissue plasminogen activator, and (4) the podoplanin/C-type lectin-like receptor 2. A better understanding of these pathways will identify new biomarkers to determine which APL patients are at high risk of bleeding and allow the development of new treatments for APL-associated bleeding.
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Affiliation(s)
- Yohei Hisada
- UNC Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, 116 Manning Drive, 8004 Mary Ellen Jones Bldg, Campus Box #7035, Chapel Hill, NC, 27599, USA.
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3
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Bønløkke ST, Fenger-Eriksen C, Ommen HB, Hvas AM. Impaired fibrinolysis and increased clot strength are potential risk factors for thrombosis in lymphoma. Blood Adv 2023; 7:7056-7066. [PMID: 37756519 PMCID: PMC10694522 DOI: 10.1182/bloodadvances.2023011379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/13/2023] [Accepted: 09/26/2023] [Indexed: 09/29/2023] Open
Abstract
Thrombosis and bleeding are significant contributors to morbidity and mortality in patients with hematological cancer, and the impact of altered fibrinolysis on bleeding and thrombosis risk is poorly understood. In this prospective cohort study, we investigated the dynamics of fibrinolysis in patients with hematological cancer. Fibrinolysis was investigated before treatment and 3 months after treatment initiation. A dynamic clot formation and lysis assay was performed beyond the measurement of plasminogen activator inhibitor 1, tissue- and urokinase-type plasminogen activators (tPA and uPA), plasmin-antiplasmin complexes (PAP), α-2-antiplasmin activity, and plasminogen activity. Clot initiation, clot propagation, and clot strength were assessed using rotational thromboelastometry. A total of 79 patients were enrolled. Patients with lymphoma displayed impaired fibrinolysis with prolonged 50% clot lysis time compared with healthy controls (P = .048). They also displayed decreased clot strength at follow-up compared with at diagnosis (P = .001). A patient with amyloid light-chain amyloidosis having overt bleeding at diagnosis displayed hyperfibrinolysis, indicated by a reduced 50% clot lysis time, α-2-antiplasmin activity, and plasminogen activity, and elevated tPA and uPA. A patient with acute promyelocytic leukemia also displayed marked hyperfibrinolysis with very high PAP, indicating extreme plasmin generation, and clot formation was not measurable, probably because of the extremely fast fibrinolysis. Fibrinolysis returned to normal after treatment in both patients. In conclusion, patients with lymphoma showed signs of impaired fibrinolysis and increased clot strength, whereas hyperfibrinolysis was seen in patients with acute promyelocytic leukemia and light-chain amyloidosis. Thus, investigating fibrinolysis in patients with hematological cancer could have diagnostic value.
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Affiliation(s)
- Søren Thorgaard Bønløkke
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Christian Fenger-Eriksen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark
| | - Hans Beier Ommen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Hematology, Aarhus University Hospital, Aarhus, Denmark
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4
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Hisada Y, Archibald SJ, Bansal K, Chen Y, Dai C, Dwarampudi S, Balas N, Hageman L, Key NS, Bhatia S, Bhatia R, Mackman N, Gangaraju R. Biomarkers of bleeding and venous thromboembolism in patients with acute leukemia. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.10.18.23297216. [PMID: 37905148 PMCID: PMC10615001 DOI: 10.1101/2023.10.18.23297216] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Background Coagulopathy and associated bleeding and venous thromboembolism (VTE) are major causes of morbidity and mortality in patients with acute leukemia. The underlying mechanisms of these complications have not been fully elucidated. Objectives To evaluate the associations between biomarker levels and bleeding and VTE in acute leukemia patients. Patients/Method We examined plasma levels of activators, inhibitors and biomarkers of the coagulation and fibrinolytic pathways in patients ≥18 years with newly diagnosed acute leukemia compared to healthy controls. Multivariable regression models were used to examine the association of biomarkers with bleeding and VTE in acute leukemia patients. The study included 358 patients with acute leukemia (29 acute promyelocytic leukemia [APL], 253 non-APL acute myeloid leukemia [AML] and 76 acute lymphoblastic leukemia [ALL]), and 30 healthy controls. Results Patients with acute leukemia had higher levels of extracellular vesicle (EV) tissue factor (TF) activity, phosphatidylserine-positive EVs, plasminogen activator inhibitor-1 (PAI-1), plasmin-antiplasmin complexes, cell-free DNA and lower levels of citrullinated histone H3-DNA complexes compared to healthy controls. APL patients had the highest levels of EVTF activity and the lowest levels of tissue plasminogen activator among the acute leukemia patients. There were 41 bleeding and 37 VTE events in acute leukemia patients. High EVTF activity was associated with increased risk of bleeding (sHR 2.30, 95%CI 0.99-5.31) whereas high PAI-1 was associated with increased risk of VTE (sHR 3.79, 95%CI 1.40-10.28) in these patients. Conclusions Our study shows alterations in several biomarkers in acute leukemia and identifies biomarkers associated with risk of bleeding and VTE.
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Affiliation(s)
- Yohei Hisada
- UNC Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Sierra J. Archibald
- UNC Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Karan Bansal
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Yanjun Chen
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Chen Dai
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Sindhu Dwarampudi
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Nora Balas
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Lindsey Hageman
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Nigel S. Key
- UNC Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Ravi Bhatia
- Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Nigel Mackman
- UNC Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Radhika Gangaraju
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, USA
- Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, USA
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5
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Hermsen J, Hambley B. The Coagulopathy of Acute Promyelocytic Leukemia: An Updated Review of Pathophysiology, Risk Stratification, and Clinical Management. Cancers (Basel) 2023; 15:3477. [PMID: 37444587 DOI: 10.3390/cancers15133477] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 06/21/2023] [Accepted: 06/28/2023] [Indexed: 07/15/2023] Open
Abstract
Acute promyelocytic leukemia (APL) has a well-established mechanism and a long-term prognosis that exceeds that of any other acute leukemia. These improving outcomes are due, in part, to all-trans retinoic acid (ATRA) and arsenic trioxide (ATO), two targeted and highly active agents in this disease. However, there remains a considerable morbidity and mortality risk in APL secondary to clinically significant hemorrhagic and/or thrombotic events. Prevention and treatment of these coagulopathic complications remain significant impediments to further progress in optimizing outcomes for patients with APL. Moreover, the relative rarity of APL hinders adequately powered randomized controlled trials for evaluating APL coagulopathy management strategies. This review draws from peer-reviewed works falling between initial descriptions of APL in 1957 and work published prior to January 2023 and provides an updated overview of the pathophysiology of hemorrhagic and thrombotic complications in APL, outlines risk stratification parameters, and compiles current clinical best practices. An improved understanding of the pathophysiologic mechanisms driving hemorrhage and thrombosis along with the completion of well-designed trials of management strategies will assist clinicians in developing interventions that mitigate these devastating complications in an otherwise largely curable disease.
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Affiliation(s)
- Jack Hermsen
- University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Bryan Hambley
- Division of Hematology/Oncology, Department of Internal Medicine, University of Cincinnati, 3125 Eden Ave, Cincinnati, OH 45267, USA
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6
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Zhao S, Ge Y, Li Z, Yang T. Influence of cytokines on early death and coagulopathy in newly diagnosed patients with acute promyelocytic leukemia. Front Immunol 2023; 14:1100151. [PMID: 37063881 PMCID: PMC10103902 DOI: 10.3389/fimmu.2023.1100151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 03/06/2023] [Indexed: 04/03/2023] Open
Abstract
IntroductionAcute promyelocytic leukemia (APL) is a subtype of acute myeloid leukemia (AML) with a better prognosis. But early death (ED) rate remains high. APL patients are simultaneously accompanied by coagulopathy and hyperinflammation at the onset. It is not known what effects cytokines have on ED and coagulopathy in these patients. Therefore, the purposes of this study are to explore the clinical differences between APL and other types of AML, the link between cytokines and coagulopathy in newly diagnosed APL, and their roles in the ED for APL.MethodsThis study retrospectively collected the information of 496 adult patients with AML (age ≥14 years at admission) newly diagnosed in the First People's Hospital of Yunnan Province between January 2017 to February 2022, including 115 APL patients. The difference of clinical manifestations between two groups [APL and AML (non-APL)] was statistically analyzed. Then, the factors affecting ED in APL patients were screened, and the possible pathways of their influence on ED were further analyzed.ResultsThe results indicate APL at the onset have a younger age and higher incidence of ED and DIC than other types of AML. Intracranial hemorrhage (ICH), age, and PLT count are found to be independent factors for ED in newly APL, among which ICH is the main cause of ED, accounting for 61.54% (8/13). The levels of cytokines in newly APL are generally higher than that in AML (non-APL), and those in the group of ED for APL were widely more than the control group. IL-17A and TNF-β are directly related to the ED in newly APL, especially IL-17A, which also affects ICH in these patients. Moreover, the increase of IL-17A and TNF-β cause the prolongation of PT in APL patients, which reflected the exogenous coagulation pathway. However, they have no effect on APTT prolongation and FIB reduction. Thus, it is speculated that IL-17A leads to early cerebral hemorrhage death in newly APL by inducing tissue factor (TF) overexpression to initiate exogenous coagulation and further leading to excessive depletion of clotting factors and prolongation of PT.ConclusionsIn conclusion, compared with other types of AML, APL patients have a younger age of onset and high inflammatory state, and are more likely to develop into DIC and die early. Age, and PLT count at diagnosis are independent factors for ED of APL, especially ICH. IL-17A is confirmed to be an independent risk factor for ED and ICH of newly APL. Hence, IL-17A may serve as a predictor of ED in newly diagnosed APL patients, and controlling its expression probably reduce ED in these patients.
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Affiliation(s)
- Shixiang Zhao
- Faculty of Life Science and Technology, Kunming University of Science and Technology, Kunming, China
- Department of Hematology, The First People’s Hospital of Yunnan Province, Kunming, China
- Yunnan Blood Disease Clinical Medical Center, The First People’s Hospital of Yunnan Province, Kunming, China
- Yunnan Blood Disease Hospital, The First People’s Hospital of Yunnan Province, Kunming, China
| | - Yuanyuan Ge
- Department of Cardiology, 920th Hospital of Joint Logistics Support Force, Kunming, China
| | - Zengzheng Li
- Department of Hematology, The First People’s Hospital of Yunnan Province, Kunming, China
- Yunnan Blood Disease Clinical Medical Center, The First People’s Hospital of Yunnan Province, Kunming, China
- Yunnan Blood Disease Hospital, The First People’s Hospital of Yunnan Province, Kunming, China
| | - Tonghua Yang
- Faculty of Life Science and Technology, Kunming University of Science and Technology, Kunming, China
- Department of Hematology, The First People’s Hospital of Yunnan Province, Kunming, China
- Yunnan Blood Disease Clinical Medical Center, The First People’s Hospital of Yunnan Province, Kunming, China
- Yunnan Blood Disease Hospital, The First People’s Hospital of Yunnan Province, Kunming, China
- *Correspondence: Tonghua Yang,
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7
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How to manage coagulopathies in critically ill patients. Intensive Care Med 2023; 49:273-290. [PMID: 36808215 DOI: 10.1007/s00134-023-06980-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 01/06/2023] [Indexed: 02/19/2023]
Abstract
Coagulopathy is a severe and frequent complication in critically ill patients, for which the pathogenesis and presentation may be variable depending on the underlying disease. Based on the dominant clinical phenotype, the current review differentiates between hemorrhagic coagulopathies, characterized by a hypocoagulable and hyperfibrinolysis state, and thrombotic coagulopathies with a systemic prothrombotic and antifibrinolytic phenotype. We discuss the differences in pathogenesis and treatment of the common coagulopathies.
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8
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Hambley BC, Tomuleasa C, Ghiaur G. Coagulopathy in Acute Promyelocytic Leukemia: Can We Go Beyond Supportive Care? Front Med (Lausanne) 2021; 8:722614. [PMID: 34485349 PMCID: PMC8415964 DOI: 10.3389/fmed.2021.722614] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 07/26/2021] [Indexed: 11/24/2022] Open
Abstract
Acute promyelocytic leukemia (APL) is characterized by frequent complications due to a distinct coagulopathy. While advances in treatments have improved long-term survival, hemorrhagic and thrombotic complications remain the most common causes of death and morbidity. Improved understanding of the mechanisms of the coagulopathy associated with APL may lead to therapeutic interventions to mitigate the risk of hemorrhage and thrombosis.
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Affiliation(s)
- Bryan C Hambley
- Division of Hematology/Oncology, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Ciprian Tomuleasa
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania.,Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj Napoca, Romania.,Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Gabriel Ghiaur
- Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania.,Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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9
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Kongstad C, Mikkelsen TS, Hvas AM. Disseminated intravascular coagulation in children with cancer: A systematic review. Pediatr Hematol Oncol 2020; 37:390-411. [PMID: 32202958 DOI: 10.1080/08880018.2020.1733717] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Disseminated intravascular coagulation (DIC) may complicate malignant disease. Numerous studies have investigated this association in adults, however only sparse knowledge exists on DIC in pediatric cancer patients. The objective of this article was to systematically review the literature regarding DIC in pediatric malignancies. PubMed and Embase were searched for relevant articles on January 31, 2020. In total, 6,070 articles were identified out of which 24 articles met inclusion and exclusion criteria. These were included in the qualitative synthesis. The National Institutes of Health's Quality Assessment Tools was used to assess bias in the included articles. The studies were of only moderate quality mainly based on medical charts and demonstrated high heterogeneity, especially as regards to diagnostic criteria. DIC was reported most frequently in patients with acute leukemia, particularly the subtype acute promyelocytic leukemia (APL). Standard coagulation parameters were used as diagnostic laboratory tests supporting the diagnosis of DIC. Hemorrhage was the predominant clinical manifestation, whereas thromboembolic events and organ failure were reported less frequently. Unfractionated heparin, platelet concentrate and fresh frozen plasma were the most frequently used supportive treatment agents. Hemorrhage accounted for the majority of deaths in children with acute leukemia and solid tumors. In conclusion, only a limited number of studies, being heterogenous and of moderate quality, have investigated DIC in pediatric malignancy. Notably, this entity seems to be complicated mainly by hemorrhage. High quality studies are needed to evaluate diagnosis, clinical manifestations and optimal treatment of DIC in childhood cancers.
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Affiliation(s)
- Christine Kongstad
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Torben Stamm Mikkelsen
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
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10
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Naymagon L, Mascarenhas J. Hemorrhage in acute promyelocytic leukemia: Can it be predicted and prevented? Leuk Res 2020; 94:106356. [PMID: 32445941 DOI: 10.1016/j.leukres.2020.106356] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/11/2020] [Accepted: 04/17/2020] [Indexed: 12/13/2022]
Abstract
Hemorrhagic death is the leading cause of treatment failure in acute promyelocytic leukemia (APL). Our ability to identify patients at greatest risk of hemorrhage, and to actively prevent hemorrhage, remains limited. Nevertheless, some data is available to guide contemporary clinical practice and future investigation. Circulating disease burden, best represented by the peripheral WBC / blast count, is the most consistent predictor of major and fatal bleeding risk. In contrast, laboratory markers of disseminated intravascular coagulation (DIC) appear to be poor predictors. A number of interventions have been posited to reduce bleeding risk. Prompt initiation of all-trans retinoic acid (ATRA), avoidance of invasive procedures, transfusion support, and cytoreduction all have theoretical merit. Though they lack strong evidence to support their benefit with respect to bleeding, they are associated with limited risks, and are therefore advisable. Low-dose therapeutic heparin and antifibrinolytics have not shown the ability to positively modify bleeding risk, and heparin has been associated with harm. Thrombomodulin has shown promise in limited retrospective studies however further prospective data are needed. rFVIIa may have a role in cases of life-threatening bleeding however evidence is largely anecdotal. Additional studies evaluating the above interventions, and investigating other potential interventions are needed.
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Affiliation(s)
- Leonard Naymagon
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States.
| | - John Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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11
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Stahl M, Tallman MS. Acute promyelocytic leukemia (APL): remaining challenges towards a cure for all. Leuk Lymphoma 2019; 60:3107-3115. [PMID: 31842650 PMCID: PMC7479633 DOI: 10.1080/10428194.2019.1613540] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 04/12/2019] [Accepted: 04/24/2019] [Indexed: 12/26/2022]
Abstract
The application of all-trans retinoic acid (ATRA) and arsenic trioxide (ATO) has revolutionized the treatment of acute promyelocytic leukemia (APL). More than 80-90% of patients are expected to be cured with a combination of ATRA, ATO and/or chemotherapy. In this review, we focus on the remaining obstacles to a cure for all patients with APL. We review the issue of early death and coagulopathy and discuss the particular challenges in the care of patients with high-risk APL and patients with relapsed APL. We also give recommendations and highlight ongoing efforts to improve the persistently high early death rate and the outcomes of high risk and relapsed APL patients.
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Affiliation(s)
- Maximilian Stahl
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Martin S Tallman
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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12
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Saes JL, Schols SEM, van Heerde WL, Nijziel MR. Hemorrhagic disorders of fibrinolysis: a clinical review. J Thromb Haemost 2018; 16:S1538-7836(22)02207-3. [PMID: 29847021 DOI: 10.1111/jth.14160] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Indexed: 12/28/2022]
Abstract
Hyperfibrinolytic bleeding can be caused by a deficiency of one of the inhibitors of fibrinolysis (plasminogen activator inhibitor type 1 [PAI-1] or α2-antiplasmin [α2-AP]), or an excess of one of the activators of fibrinolysis: tissue-type plasminogen activator or urokinase-type plasminogen activator. This review focuses on the clinical implications of these disorders. The bleeding phenotype of fibrinolytic disorders is characterized by delayed bleeding after trauma, surgery and dental procedures. Bleeding in areas of high fibrinolytic activity is also common, such as menorrhagia and epistaxis. Patients with α2-AP deficiency present with the most severe bleeding episodes. Recently, it was discovered that hyperfibrinolytic disorders are associated with a high rate of obstetric complications such as miscarriage and preterm birth, especially in PAI-1 deficient patients. Hyperfibrinolytic disorders are probably underdiagnosed because of lack of knowledge and lack of accurate diagnostic tests. A substantial part of the large group of patients diagnosed as 'bleeding of unknown origin' could actually have a hyperfibrinolytic disorder. In the case of a high index of suspicion (i.e. because of a positive family history, recurrent bleeding or uncommon type of bleeding such as an intramedullary hematoma), further testing should not be withheld because of normal results of standard hemostatic screening assays. Timely diagnosis is important because these disorders can generally be treated well with antifibrinolytic agents.
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Affiliation(s)
- J L Saes
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands
- Haemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, the Netherlands
| | - S E M Schols
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands
- Haemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, the Netherlands
| | - W L van Heerde
- Haemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, the Netherlands
| | - M R Nijziel
- Department of Hematology, Catharina Hospital, Eindhoven, the Netherlands
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13
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Wang P, Zhang Y, Yang H, Hou W, Jin B, Hou J, Li H, Zhao H, Zhou J. Characteristics of fibrinolytic disorders in acute promyelocytic leukemia. ACTA ACUST UNITED AC 2018; 23:756-764. [PMID: 29724147 DOI: 10.1080/10245332.2018.1470069] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVES Catastrophic hemorrhage remains the main cause of acute promyelocytic leukemia (APL) treatment failure. This study was aimed to study the pathogenesis of coagulopathy in patients with APL. METHODS Multiple procoagulant and profibrinolytic parameters in plasma and peripheral leukocytes from 24 patients with newly diagnosed APL accompanied by coagulopathy before and after arsenic trioxide (ATO) treatment were evaluated. RESULTS Prior to the treatment, the patients had elevated D-dimer and decreased fibrinogen levels. Plasma urokinase-type plasminogen activator receptor (uPAR) and plasmin-ɑ2 antiplasmin complexes (PAP) levels, plasmin (Pn) activity, and cell surface levels of urokinase-type plasminogen activator (uPA) and tissue-type plasminogen activator (tPA) were significantly higher; plasma plasminogen activator inhibitor-1 (PAI-1) levels and plasminogen (Pg) activity were significantly decreased; plasma plasminogen activator (PA) activity, uPA and tPA levels; and cell surface levels of uPAR and annexin II were not significantly different from levels in the control group. During ATO treatment, both patients' plasma PA activity and uPAR on leukocytes gradually increased, annexin II on leukocytes increased initially and decreased afterwards, and tPA and uPA on leukocytes remained consistently higher in the patients than in the controls. Other parameters gradually tended toward normal values. CONCLUSIONS In APL, activated coagulation system activated fibrinolytic system, and increased uPAR levels could contribute to the hyperfibrinolysis. Annexin II might not be involved in the coagulopathy.
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Affiliation(s)
- Ping Wang
- a Center for Hematology and Oncology, The First Affiliated Hospital , Harbin Medical University , Harbin , People's Republic of China.,b Department of Neonatology, The First Affiliated Hospital , Harbin Medical University , Harbin , People's Republic of China
| | - Yingmei Zhang
- a Center for Hematology and Oncology, The First Affiliated Hospital , Harbin Medical University , Harbin , People's Republic of China
| | - Huiyuan Yang
- a Center for Hematology and Oncology, The First Affiliated Hospital , Harbin Medical University , Harbin , People's Republic of China
| | - Wenyi Hou
- a Center for Hematology and Oncology, The First Affiliated Hospital , Harbin Medical University , Harbin , People's Republic of China
| | - Bo Jin
- a Center for Hematology and Oncology, The First Affiliated Hospital , Harbin Medical University , Harbin , People's Republic of China
| | - Jinxiao Hou
- a Center for Hematology and Oncology, The First Affiliated Hospital , Harbin Medical University , Harbin , People's Republic of China
| | - Haitao Li
- a Center for Hematology and Oncology, The First Affiliated Hospital , Harbin Medical University , Harbin , People's Republic of China
| | - Hongli Zhao
- a Center for Hematology and Oncology, The First Affiliated Hospital , Harbin Medical University , Harbin , People's Republic of China.,c Department of Hematology, The Fourth Affiliated Hospital , Harbin Medical University , Harbin , People's Republic of China
| | - Jin Zhou
- a Center for Hematology and Oncology, The First Affiliated Hospital , Harbin Medical University , Harbin , People's Republic of China
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14
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Transcriptomic landscape of acute promyelocytic leukemia reveals aberrant surface expression of the platelet aggregation agonist Podoplanin. Leukemia 2018; 32:1349-1357. [PMID: 29550835 DOI: 10.1038/s41375-018-0069-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Revised: 12/21/2017] [Accepted: 01/25/2018] [Indexed: 12/15/2022]
Abstract
Acute promyelocytic leukemia (APL) is a medical emergency because of associated lethal early bleeding, a condition preventable by prompt diagnosis and therapeutic intervention. The mechanisms underlying the hemostatic anomalies of APL are not completely elucidated. RNA-sequencing-based characterization of APL (n = 30) was performed and compared to that of other acute myeloid leukemia (n = 400) samples and normal promyelocytes. Perturbations in the transcriptome of coagulation and fibrinolysis-related genes in APL extend beyond known culprits and now include Thrombin, Factor X and Urokinase Receptor. Most intriguingly, the Podoplanin (PDPN) gene, involved in platelet aggregation, is aberrantly expressed in APL promyelocytes and is the most distinctive transcript for this disease. Using an antibody panel optimized for AML diagnosis by flow cytometry, we also found that PDPN was the most specific surface marker for APL, and that all-trans retinoic acid therapy rapidly decreases its expression. Functional studies showed that engineered overexpression of this gene in human leukemic cells causes aberrant platelet binding, activation and aggregation. PDPN-expressing primary APL cells, but not PDPN-negative primary leukemias, specifically induce platelet binding, activation and aggregation. Finally, PDPN expression on leukemia cells in a xenograft model was associated with thrombocytopenia and prolonged bleeding time in vivo. Together our results suggest that PDPN may contribute to the hemostatic perturbations found in APL.
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15
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Lad D, Jain A, Varma S. Complications and management of coagulation disorders in leukemia patients. Blood Lymphat Cancer 2017; 7:61-72. [PMID: 31360085 PMCID: PMC6467343 DOI: 10.2147/blctt.s125121] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Patients with leukemia are predisposed to various coagulation abnormalities. Thrombosis and bleeding continue to be a major cause of morbidity and mortality in leukemias. The pathophysiology of these disorders is unique, and not only the disease but also the treatment and other factors play a role. There has been an increase in the understanding of these disorders in leukemias. However, it is still difficult to predict when and which patients will have these complications. The evidence for the management of coagulation abnormalities in leukemias is still evolving and not as established as in solid malignancies. The management of these disorders is complex, and making clinical decisions is often challenging. In the era of specialization, where there are different hematologists looking after benign- and malignant-hematology patients, opinions of thrombosis experts are often sought by leukemia specialists. This review aims to bridge the gap in the knowledge of these disorders between these specialists.
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Affiliation(s)
- Deepesh Lad
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India,
| | - Arihant Jain
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India,
| | - Subhash Varma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India,
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16
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Whatʼs new in the pathogenesis of the coagulopathy in acute promyelocytic leukemia? Curr Opin Hematol 2016; 23:121-6. [DOI: 10.1097/moh.0000000000000221] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Abstract
Thrombocytopenia is a frequent complication of cancer and its treatment. The causes of thrombocytopenia in cancer patients can be diverse and multifactorial. Systemic chemotherapy is the most frequent cause of thrombocytopenia. The degree and duration thrombocytopenia depends upon whether the chemotherapeutic treatment is myeloablative, as used in stem cell transplants, or non-myeloablative, as typically used in solid non-hematologic malignancies. Additional causes of significant thrombocytopenia include tumor involvement of bone marrow and spleen; microangiopathic disorders such as disseminated intravascular coagulation, thrombotic thrombocytopenic purpura or hemolytic uremia syndrome. Lymphoproliferative malignancies can also be associated with secondary immune thrombocytopenia. Due to the broad differential diagnosis associated with cancer related thrombocytopenia, a careful diagnostic evaluation is indicated. The goal of treatment should be to maintain a safe platelet count to allow effective treatment of the underlying malignancy, prevent bleeding complications and to minimize the use of platelet product transfusion.
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18
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Abstract
Acute promyelocytic leukemia (APL) has become the most curable form of acute myeloid leukemia after the advent of all-trans retinoic acid (ATRA). However, early deaths (ED) mostly due to the disease-associated coagulopathy remain the major cause of treatment failure. In particular, hemorrhagic events account for 40-65% of ED and several prognostic factors have been identified for such hemorrhagic deaths, including poor performance status, high white blood cell (WBC) count and coagulopathy. Occurrence of thrombosis during treatment with ATRA may be associated with differentiation syndrome (DS) or represent an isolated event. Some prognostic factors have been reported to be associated with thrombosis, including increased WBC or aberrant immunophenotype of leukemic promyelocytes. Aim of this review is to report the incidence, severity, possible pathogenesis and clinical manifestations of thrombo-haemorrhagic deaths in APL.
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Affiliation(s)
| | - Francesco Lo Coco
- Department of Biomedicine and Prevention, University Tor Vergata, Rome, Italy; Laboratory of Neuro-Oncohematology, Santa Lucia Foundation, Rome, Italy.
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19
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Abstract
D-dimer is the smallest fibrinolysis-specific degradation product found in the circulation. The origins, assays, and clinical use of D-dimer will be addressed. Hemostasis (platelet and vascular function, coagulation, fibrinolysis, hemostasis) is briefly reviewed. D-dimer assays are reviewed. The D-dimer is very sensitive to intravascular thrombus and may be markedly elevated in disseminated intravascular coagulation, acute aortic dissection, and pulmonary embolus. Because of its exquisite sensitivity, negative tests are useful in the exclusion venous thromboembolism. Elevations occur in normal pregnancy, rising two- to fourfold by delivery. D-dimer also rises with age, limiting its use in those >80 years old. There is a variable rise in D-dimer in active malignancy and indicates increased thrombosis risk in active disease. Elevated D-dimer following anticoagulation for a thrombotic event indicates increased risk of recurrent thrombosis. These and other issues are addressed.
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20
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Kwaan HC, Cull EH. The coagulopathy in acute promyelocytic leukaemia – What have we learned in the past twenty years. Best Pract Res Clin Haematol 2014; 27:11-8. [DOI: 10.1016/j.beha.2014.04.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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21
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Methionine-induced hyperhomocysteinemia reverts fibrinolytic pathway activation in a murine model of acute promyelocytic leukemia. Blood 2012; 120:207-13. [DOI: 10.1182/blood-2011-04-347187] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Increased fibrinolysis is an important component of acute promyelocytic leukemia (APL) bleeding diathesis. APL blasts overexpress annexin II (ANXII), a receptor for tissue plasminogen activator (tPA), and plasminogen, thereby increasing plasmin generation. Previous studies suggested that ANXII plays a pivotal role in APL coagulopathy. ANXII binding to tPA can be inhibited by homocysteine and hyperhomocysteinemia can be induced by L-methionine supplementation. In the present study, we used an APL mouse model to study ANXII function and the effects of hyperhomocysteinemia in vivo. Leukemic cells expressed higher ANXII and tPA plasma levels (11.95 ng/mL in leukemic vs 10.74 ng/mL in wild-type; P = .004). In leukemic mice, administration of L-methionine significantly increased homocysteine levels (49.0 μmol/mL and < 6.0 μmol/mL in the treated and nontreated groups, respectively) and reduced tPA levels to baseline concentrations. The latter were also decreased after infusion of the LCKLSL peptide, a competitor for the ANXII tPA–binding site (11.07 ng/mL; P = .001). We also expressed and purified the p36 component of ANXII in Pichia methanolica. The infusion of p36 in wild-type mice increased tPA and thrombin-antithrombin levels, and the latter was reversed by L-methionine administration. The results of the present study demonstrate the relevance of ANXII in vivo and suggest that methionine-induced hyperhomocysteinemia may reverse hyperfibrinolysis in APL.
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22
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Choudhry A, DeLoughery TG. Bleeding and thrombosis in acute promyelocytic leukemia. Am J Hematol 2012; 87:596-603. [PMID: 22549696 DOI: 10.1002/ajh.23158] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Revised: 01/31/2012] [Accepted: 02/04/2012] [Indexed: 11/11/2022]
Abstract
Acute promyelocytic leukemia (APL) has evolved from being a deadly to a highly curable disease, due to targeted molecular therapy with all-trans retinoic acid (ATRA). As a result, the incidence of early hemorrhagic deaths for which APL is notorious has reduced to 5-10% as reported in clinical trials. These results are not replicated outside of clinical trials as is evident from recent population-based registries. High incidence of early hemorrhagic deaths remains the greatest contributor to treatment failure in this otherwise curable leukemia. Additionally, thrombosis is now being increasingly recognized in APL patients and may be associated with ATRA usage.
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Affiliation(s)
- Aditi Choudhry
- Legacy Emanuel and Legacy Good Samaritan Hospitals Internal Medicine Residency Training Program, 3181 SW Sam Jackson Park Road, Portland, OR 97201-3098, USA
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23
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Pathogenesis and treatment of thrombohemorrhagic diathesis in acute promyelocytic leukemia. Mediterr J Hematol Infect Dis 2011; 3:e2011068. [PMID: 22220265 PMCID: PMC3248345 DOI: 10.4084/mjhid.2011.068] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Accepted: 12/10/2011] [Indexed: 12/21/2022] Open
Abstract
Acute promyelocytic leukemia (APL) is a distinct subtype of myeloid leukemia characterized by t(15;17) chromosomal translocation, which involves the retinoic acid receptor-alpha (RAR-alpha). APL typically presents with a life-threatening hemorrhagic diathesis. Before the introduction of all-trans retinoic acid (ATRA) for the cure of APL, fatal hemorrhages due, at least in part, to the APL-associated coagulopathy, were a major cause of induction remission failure. The laboratory abnormalities of blood coagulation found in these patients indicate the occurrence of a hypercoagulable state. Major determinants of the coagulopathy of APL are endogenous factors expressed by the leukemic cells, including procoagulant factors, fibrinolytic proteins, and non-specific proteolytic enzymes. In addition, these cells have an increased capacity to adhere to the vascular endothelium, and to secrete inflammatory cytokines [i.e. interleukin-1beta (IL-1beta) and tumor necrosis factor (TNF-alpha)], which in turn stimulate the expression of prothrombotic activities by endothelial cells and leukocytes. ATRA can interfere with each of the principal hemostatic properties of the leukemic cell, thus reducing the APL cell procoagulant potential, in parallel to the induction of cellular differentiation. This effect occurs in vivo, in the bone marrow of APL patients receiving ATRA, and is associated with the improvement of the bleeding symptoms. Therapy with arsenic trioxide (ATO) also beneficially affects coagulation in APL. However, early deaths from bleeding still remain a major problem in APL and further research is required in this field. In this review, we will summarize our current knowledge of the pathogenesis of the APL-associated coagulopathy and will overview the therapeutic approaches for the management of this complication.
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24
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Breen KA, Grimwade D, Hunt BJ. The pathogenesis and management of the coagulopathy of acute promyelocytic leukaemia. Br J Haematol 2011; 156:24-36. [DOI: 10.1111/j.1365-2141.2011.08922.x] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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25
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Kwaan HC, Huyck T. Thromboembolic and bleeding complications in acute leukemia. Expert Rev Hematol 2011; 3:719-30. [PMID: 21091148 DOI: 10.1586/ehm.10.71] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The risk of both thromboembolic and bleeding complications is high in acute leukemia. This double hazard has a significant negative impact on the morbidity and mortality of patients with this disease. The clinical manifestations of both complications show special features specific to the form of acute leukemia. Recognition of these characteristics is important in the diagnosis and management of acute leukemia. In this article, several additional issues are addressed, including the features of bleeding and thrombosis in acute promyelocytic leukemia, the current understanding of the leukostasis syndrome and the iatrogenic complications including catheter-associated thrombosis, and the adverse effects of therapeutic agents used in acute leukemia. As regards the bleeding complications, thrombocytopenia is a major cause. Corrective measures, including recent guidelines on platelet transfusions, are provided.
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Affiliation(s)
- Hau C Kwaan
- Division of Hematology/Oncology, Northwestern University Feinberg School of Medicine, 710 Fairbanks Court, Chicago, IL 60611, USA.
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26
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27
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Richards EM, Marcus RE, Harper P, Flanagan DW, Baglin TP. Intra-ocular haemorrhage, a frequent complication of acute promyelocytic leukaemia. CLINICAL AND LABORATORY HAEMATOLOGY 2008; 14:169-78. [PMID: 1451396 DOI: 10.1111/j.1365-2257.1992.tb00362.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
We have found a high incidence of ocular haemorrhage in patients with acute promyelocytic leukaemia (APL). We describe a series of seven consecutive cases of APL, five of which developed ocular haemorrhage. There were no consistent detectable abnormalities in coagulation predictive of ocular damage. Ocular haemorrhage occurred despite the use of aggressive blood product support and its incidence was not altered by the use of the anti fibrinolytic agent tranexamic acid or by the use of heparin. Complete spontaneous resolution of the ocular pathology occurred in three of the five cases of ocular haemorrhage and partial recovery occurred in one. The fifth patient required surgical intervention. The mechanisms underlying the coagulopathy associated with APL are poorly understood. We discuss the evidence in support of primary disseminated intravascular coagulation and primary fibrinolysis. A logical approach to the management of the bleeding complications in APL can only follow greater understanding of the underlying pathophysiology.
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Affiliation(s)
- E M Richards
- Department of Haematology, Addenbrooke's Hospital, Cambridge, UK
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28
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Culligan DJ, Merriman L, Kell J, Parker J, Jovanovic JV, Smith N, Grimwade D. The Management of Acute Promyelocytic Leukemia Presenting During Pregnancy. ACTA ACUST UNITED AC 2007. [DOI: 10.3816/clk.2007.n.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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29
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Abstract
Despite the development of highly effective treatment strategies for acute promyelocytic leukaemia around 10% of patients die in the presentation period as a consequence of the associated bleeding diathesis. The cause of the coagulopathy is complex resulting from a combination of tissue factor (TF) and cancer procoagulant (CP) induced disseminated intravascular coagulation, exaggerated fibrinolysis due predominantly to enhanced expression of annexin II on APL blast cell membranes and blast cell production of cytokines. All-trans retinoic acid (ATRA) has revolutionised the treatment of APL. When combined with chemotherapy long term survival rates of up to 80% can be achieved. Commencement of ATRA induces APL blast cell differentiation and is associated with a rapid resolution of the bleeding tendency through a combination of effects which include up regulation of thrombomodulin and down regulation of TF and CP production and cell surface expression of annexin II.
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Affiliation(s)
- Carolina Arbuthnot
- Department of Haematology, University Hospital Birmingham NHS Foundation Trust, Edgbaston, Birmingham, UK.
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30
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Kopf E, Miskin R. A RUNX/AML-binding motif residing in a novel 13-bp DNA palindrome may determine the expression of the proximal promoter of the human uPA gene. J Thromb Haemost 2005; 3:2057-64. [PMID: 16102112 DOI: 10.1111/j.1538-7836.2005.01510.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Urokinase-type plasminogen activator (uPA) is a multifunctional extracellular serine protease implicated in different events including fibrinolysis, tissue remodeling, and hematopoiesis. The human uPA gene contains a major promoter region at around 2000 bp upstream from the transcription start site (+1), and a second regulatory region spanning nucleotides -90/+32 within the proximal promoter. Here, an inspection of this region revealed a novel 13-bp palindrome residing at position +8/+20. Interestingly, the palindrome contains the DNA consensus-binding hexamer for the RUNX/AML family of transcription factors that play a role in hematopoiesis, leukemia, and several developmental processes. Measuring the expression for promoter-reporter constructs after transfection revealed that deletion of the palindrome abrogated most of the proximal promoter activity in 293A cell. Additionally, electrophoretic mobility shift assays have shown that the palindrome could bind the RUNX1 component in nuclear extracts of myeloid cell lines exclusively through its RUNX motif. The palindrome was found in five additional human genes, two of which (MYH11 and MLLT1) have been linked to chromosomal rearrangements leading to leukemia. The data presented here have implicated, for the first time, RUNX/AML in the regulation of the uPA gene. The significance of the novel palindrome regarding gene regulation through the RUNX motif deserves further investigation.
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Affiliation(s)
- E Kopf
- Department of Biological Chemistry, The Weizmann Institute of Science, Rehovot, Israel
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31
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Tallman MS, Lefèbvre P, Baine RM, Shoji M, Cohen I, Green D, Kwaan HC, Paietta E, Rickles FR. Effects of all-trans retinoic acid or chemotherapy on the molecular regulation of systemic blood coagulation and fibrinolysis in patients with acute promyelocytic leukemia. J Thromb Haemost 2004; 2:1341-50. [PMID: 15304040 DOI: 10.1111/j.1538-7836.2004.00787.x] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We studied the pathogenesis of the bleeding disorder in acute promyelocytic leukemia by measuring procoagulant, profibrinolytic, and proinflammatory mediators in peripheral blood and bone marrow cells from 25 previously untreated patients. Patients were induced with either all-trans retinoic acid (ATRA) or chemotherapy. Plasma levels of fibrinopeptide A (FPA), fibrin d-dimer, thrombin antithrombin (TAT) complex, prothrombin fragment 1.2 (F1.2), urokinase-type plasminogen activator (uPA), tissue-type plasminogen activator (t-PA) and plasminogen activator-inhibitor 1 (PAI-1) were measured before and after therapy, as was the cellular expression of the genes for tissue factor (TF) and interleukin-1 beta (IL-1 beta). The mean plasma levels of fibrin d-dimer, F1.2, TAT and FPA were markedly elevated prior to therapy and declined during the first 30 days of treatment with either ATRA or chemotherapy, but more rapidly and to a greater extent in patients treated with ATRA. ATRA treatment was associated with a significant decrease in TF gene expression in bone marrow cells during the first 30 days of treatment, whereas IL-1 beta gene expression, which decreased in the cells of six patients treated with either chemotherapy or ATRA, actually increased in the remaining six patients treated with either chemotherapy or ATRA. In patients with APL, treatment with either chemotherapy or ATRA rapidly ameliorates the coagulopathy, as indicated by an abrupt decline in markers of clotting activation. An increase in cytokine gene expression (e.g. IL-1 beta) may provide an explanation for the persistent hypercoagulability observed in some patients with APL, regardless of therapeutic approach. Our data confirms and extends earlier observations by others that ATRA is more effective than chemotherapy alone in rapidly reducing the procoagulant burden of APL tumor cells. However, our data also suggests that cytokine expression in some patients may be accelerated by either chemotherapy or ATRA. The implications of this observation for understanding the retinoic acid syndrome will require further studies.
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Affiliation(s)
- M S Tallman
- Department of Medicine, Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois, USA.
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32
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Falanga A, Rickles FR. Pathogenesis and management of the bleeding diathesis in acute promyelocytic leukaemia. Best Pract Res Clin Haematol 2003; 16:463-82. [PMID: 12935963 DOI: 10.1016/s1521-6926(03)00059-8] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Life-threatening bleeding, which remains a challenging complication of acute leukaemia, is particularly characteristic of the subtype, acute promyelocytic leukaemia (APL). The clinical picture and laboratory abnormalities are most compatible with the diagnosis of disseminated intravascular coagulation (DIC). Evidence for diffuse activation of the coagulation system, hyperfibrinolysis and systemic elaboration of non-specific protease activity can usually be demonstrated and occurs most commonly during induction chemotherapy. While both host- and tumour-associated mechanisms can be implicated in the pathogenesis of the coagulopathy, leukaemic cell properties appear to be the proximate cause of activation of the haemostatic mechanisms. In this chapter we summarize the current state of knowledge of the pathogenesis of the coagulopathy of APL and the therapeutic approaches that have proved most useful for the management of this complication. Special attention is devoted to the use of all-trans-retinoic acid (ATRA), which has revolutionized the treatment of APL and markedly ameliorated the APL-related coagulopathy.
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Affiliation(s)
- Anna Falanga
- Hematology-Oncology Department, Ospedali Riuniti di Bergamo, Largo Barozzi 1, 24128, Bergamo, Italy.
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33
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Kwaan HC, Wang J, Boggio LN. Abnormalities in hemostasis in acute promyelocytic leukemia. Hematol Oncol 2002; 20:33-41. [PMID: 11921015 DOI: 10.1002/hon.687] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Our understanding of the hemostatic abnormalities in acute promyelocytic leukemia (APL) has undergone remarkable changes over the past three decades. Hemorrhagic complications lead to significant morbidity and mortality in patients with APL. Up to 30% of early deaths are due to hemorrhagic complications. Our concept of the coagulation changes in APL have evolved from a simple belief that the bleeding was due to disseminated intravascular coagulation (DIC) from underlying infection, to a knowledge that the APL cells themselves are responsible for the bleeding. We have observed that apoptotic APL cells have increased generation of thrombin and therefore contribute to the hypercoagulability and DIC. In addition, excessive fibrinolysis has been recognized to play an important role. The advent of a new therapeutic approach with all-trans-retinoic acid has improved overall survival and has greatly shortened the hemorrhagic phase of the disease, but only to produce a new complication, the retinoic acid syndrome. Its pathogenesis and management still remain to be the challenge for the present.
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Affiliation(s)
- Hau C Kwaan
- Division of Hematology/Oncology, Department of Medicine, Northwestern University Medical School, the Robert H.Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, USA
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34
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Watson HG, Chee YL, Greaves M. Rare acquired bleeding disorders. REVIEWS IN CLINICAL AND EXPERIMENTAL HEMATOLOGY 2001; 5:405-29; quiz following 431. [PMID: 11844136 DOI: 10.1046/j.1468-0734.2001.00050.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Accurate diagnosis of the cause of bleeding is a prerequisite for determination of the optimal therapeutic response. Clinicians are generally aware of the more prevalent hemorrhagic syndromes but some rare acquired conditions are also of importance. In many of these, inhibitors of coagulation factors or of platelet adhesion/aggregation cause bleeding. These inhibitors are generally, but not always, immunoglobulins. In this review, the less common inhibitors of coagulation and hemostasis, as well as some important but rare nutritional, iatrogenic and disease associated hemorrhagic disorders, are described.
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Affiliation(s)
- H G Watson
- Department of Medicine and Therapeutics, University of Aberdeen, Polworth Building, Foresterhill, Aberdeen AB25 2ZD, Scotland, UK
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35
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Abstract
As the biochemical mechanisms of hypercoagulable states are revealed, the syndromes of venous thromboembolism have been increasingly associated with specific aberrations. Most of these changes involve an increase in procoagulant potential, for example, by activation of the coagulation cascade, or by a defect or decrease in natural inhibitors of clotting. Similar abnormalities of the fibrinolytic pathways may contribute, as can loss of inhibitory mechanisms of endothelial cells, as well as changes in vascular anatomy and rheologic patterns of blood flow. All of these factors can directly influence thrombus formation and/or the physiologic response to the thrombus.(1)
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Affiliation(s)
- D Matei
- Vascular Medicine Program, Los Angeles Orthopaedic Hospital/University of California at Los Angeles, Los Angeles, CA 90007, USA
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36
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Abstract
Alterations of hemostasis commonly accompany the progression of malignant disease and every known component of the hemostatic mechanism may be affected by this disease process. Nearly all patients with an active neoplasm will exhibit at least subtle biochemical changes in hemostasis, and a minority of these patients will also develop clinical thrombosis or hemorrhage. In this paper, we will review intravascular coagulation and fibrinolysis, thrombocytopenia, and thrombocytosis, as well as more rare thrombotic and hemorrhagic events resulting from the direct interactions of neoplasms, or of their products, with the individual elements of hemostatic mechanisms. Thrombotic and hemorrhagic events resulting from the induction of autoimmune or thrombotic microangiopathic syndromes are also discussed. This review focuses on the clinical thrombotic and bleeding syndromes that may occur as a result of this interaction between neoplasia and hemostasis.
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Affiliation(s)
- G H Goldsmith
- James Graham Brown Cancer Center, University of Louisville, Kentucky, USA
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37
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Robbie L, Berry S, Moir E, Booth NA, Culligan D, Tighe J, Watson H, King D, Bennett B. Myeloid leukaemic cells can lyse fibrin directly. Br J Haematol 2000; 111:524-9. [PMID: 11122094 DOI: 10.1046/j.1365-2141.2000.02381.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Purified preparations of circulating leukaemic blast cells from patients with acute myeloid (M1-7) or acute lymphoblastic leukaemia, and the myeloid or lymphoid cells from patients with chronic myeloid or lymphocytic forms of leukaemia, were incorporated into clots prepared from fibrinogen and plasminogen. Patterns of lysis were followed and measured by light transmission in a microtitre plate reader. Mature polymorphonuclear and mononuclear cell fractions from normal individuals were studied concurrently for comparison. Blast cells from the myeloid forms of acute leukaemia (M2-4) and 'myeloid' cell fractions from patients with chronic myeloid leukaemia were capable of lysing plasminogen-containing clots; this activity was neutralized by addition of immunoglobulin against urokinase plasminogen activator (u-PA), but not by anti-tissue plasmogen activator (t-PA). Mature polymorphonuclear and mononuclear cells from normal individuals lacked lytic activity, as did the leukaemic cells from patients with acute lymphoblastic or chronic lymphocytic leukaemia. Lysed blast cells showed the presence of free plasminogen activator on sodium dodecyl sulphate polyacrylamide gel electrophoresis (SDS-PAGE) with overlay zymography, also neutralized by anti-u-PA, whereas normal polymorphonuclear and mononuclear cells did not. These observations suggest that mechanisms underlying some forms of severe bleeding in acute myeloid leukaemias have a critical fibrinolytic component generated by the blast cells themselves.
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Affiliation(s)
- L Robbie
- Department of Medicine and Therapeutics, University of Aberdeen, UK
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Robbie L, Berry S, Moir E, Booth NA, Culligan D, Tighe J, Watson H, King D, Bennett B. Myeloid leukaemic cells can lyse fibrin directly. Br J Haematol 2000. [DOI: 10.1111/j.1365-2141.2000.02381.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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39
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Vickers M, Jackson G, Taylor P. The incidence of acute promyelocytic leukemia appears constant over most of a human lifespan, implying only one rate limiting mutation. Leukemia 2000; 14:722-6. [PMID: 10764161 DOI: 10.1038/sj.leu.2401722] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
It is believed that most malignancies become more common with increasing age due to the requirement for several mutations to accumulate and subsequently interact. The age specific incidence of acute promyelocytic leukemia (APL) was investigated using population-based data from 77 million subject years of observation, yielding 149 consecutive cases. The incidence appears approximately constant with respect to age, an observation not previously reported with any other malignancy. These findings are most easily explained by there being only one rate limiting genetic event required to initiate the disease, although other, non-rate limiting mutations may also be necessary for disease development. It is also argued that this mutation is probably restricted to cells committed to differentiation, which may explain why APL is curable by chemotherapy.
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Affiliation(s)
- M Vickers
- Department of Haematology, Medicine and Therapeutics, Aberdeen, Foresterhill, UK
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40
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Meijers JC, Oudijk EJ, Mosnier LO, Bos R, Bouma BN, Nieuwenhuis HK, Fijnheer R. Reduced activity of TAFI (thrombin-activatable fibrinolysis inhibitor) in acute promyelocytic leukaemia. Br J Haematol 2000; 108:518-23. [PMID: 10759708 DOI: 10.1046/j.1365-2141.2000.01890.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Acute promyelocytic leukaemia (APL) is a disease that is distinguished from other leukaemias by the high potential for early haemorrhagic death. Several processes are involved, such as disseminated intravascular coagulation and hyperfibrinolysis. Recently, TAFI (thrombin-activatable fibrinolysis inhibitor) was identified as a link between coagulation and fibrinolysis. TAFI can be activated by thrombin, and in its activated form potently attenuates fibrinolysis by removing C-terminal lysine and arginine residues that are important for the binding and activation of plasminogen. Activation of TAFI by the coagulation system results in a down-regulation of fibrinolytic activity and, thereby, prevents a rapid dissolution of the fibrin clot. To establish whether TAFI was involved in the severity of the bleeding complications in APL, the TAFI antigen and activity levels were determined in a group of 15 patients. The TAFI antigen concentration was normal, but the activity of TAFI was severely reduced in APL by approximately 60%. The reduction of TAFI activity was most probably caused by the action of plasmin on TAFI because in vitro experiments revealed that plasmin slightly reduced antigen levels but severely reduced TAFI activity. The acquired functional TAFI deficiency in APL may contribute to the severity of the haemorrhagic diathesis because of the impaired capacity of the coagulation system to protect the fibrin clot from fibrinolysis.
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Affiliation(s)
- J C Meijers
- The Department of Haematology, University Medical Centre, Utrecht, The Netherlands.
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42
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Scherrer A, Wohlwend A, Kruithof EK, Vassalli JD, Sappino AP. Plasminogen activation in human acute leukaemias. Br J Haematol 1999; 105:920-7. [PMID: 10554801 DOI: 10.1046/j.1365-2141.1999.01432.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Plasminogen activation is implicated in solid tumour growth, invasion and metatastic spread. However, little is known about its role in leukaemia. We investigated the production by leukaemic cells of plasminogen activators [urokinase (uPA) and tissue-type PA (tPA)], cell surface receptor for uPA (uPAR) and PA inhibitors (PAI-1 and PAI-2). Leukaemic cells from 37 patients [26 with acute myeloid leukaemia (AML) and 11 with acute lymphoid leukaemia (ALL)] were analysed for mRNA content and enzymatic activities. High levels of uPA mRNA were found in M1, M2, M3 and M4-M5 AMLs, whereas tPA mRNA was not detected in any of the analysed cases. uPAR mRNA was confined to subtypes M4-M5. PAI-1 mRNA was detected in M3 and M4-M5. PAI-2 mRNA was found predominantly in M2 and M4-M5. SDS-PAGE/zymography analyses of cell extracts and supernatants after 24 and 48 h of culture confirmed the production of active uPA by AML cells (mainly M4-M5). but not by ALL. The finding of uPA, uPAR, PAI-1 and PAI-2 synthesized by leukaemic cells suggests that plasminogen activation may contribute to the invasive behaviour of these cells, the fibrinolytic imbalance observed in leukaemic patients and the differentiation and proliferation of M4-M5 by interaction of uPA with uPAR.
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Affiliation(s)
- A Scherrer
- Division of Haematology, University Hospital of Geneva and University of Geneva Medical School, Switzerland
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43
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Menell JS, Cesarman GM, Jacovina AT, McLaughlin MA, Lev EA, Hajjar KA. Annexin II and bleeding in acute promyelocytic leukemia. N Engl J Med 1999; 340:994-1004. [PMID: 10099141 DOI: 10.1056/nejm199904013401303] [Citation(s) in RCA: 268] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Acute promyelocytic leukemia (APL) is associated with a hemorrhagic disorder of unknown cause that responds to treatment with all-trans-retinoic acid. METHODS We studied a newly described receptor for fibrinolytic proteins, annexin II, in cells from patients with APL or other leukemias. We examined initial rates of in vitro generation of plasmin by tissue plasminogen activator (t-PA) in the presence of APL cells that did or did not have the characteristic translocation of APL, t(15;17). We also determined the effect of all-trans-retinoic acid on the expression of annexin II and the generation of cell-surface plasmin. RESULTS The expression of annexin II, as detected by a fluorescein-tagged antibody, was greater on leukemic cells from patients with APL than on other types of leukemic cells (mean fluorescence intensity, 6.9 and 2.9, respectively; P<0.01). The t(15;17)-positive APL cells stimulated the generation of cell-surface, t-PA-dependent plasmin twice as efficiently as the t(15;17)-negative cells. This increase in plasmin was blocked by an anti-annexin II antibody and was induced by transfection of t(15;17)-negative cells with annexin II complementary DNA. The t(15;17)-positive APL cells contained abundant messenger RNA for annexin II, which disappeared through a transcriptional mechanism after treatment with all-trans-retinoic acid. CONCLUSIONS Abnormally high levels of expression of annexin II on APL cells increase the production of plasmin, a fibrinolytic protein. Overexpression of annexin II may be a mechanism for the hemorrhagic complications of APL.
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MESH Headings
- Adolescent
- Adult
- Annexin A2/drug effects
- Annexin A2/genetics
- Annexin A2/immunology
- Annexin A2/metabolism
- Antibodies/physiology
- Child
- Child, Preschool
- Female
- Fibrinolysin/biosynthesis
- Fibrinolysis/drug effects
- Fibrinolysis/immunology
- Hemorrhagic Disorders/etiology
- Humans
- Leukemia/metabolism
- Leukemia, Promyelocytic, Acute/complications
- Leukemia, Promyelocytic, Acute/genetics
- Leukemia, Promyelocytic, Acute/metabolism
- Leukemia, Promyelocytic, Acute/physiopathology
- Male
- Middle Aged
- RNA, Messenger/genetics
- Transcription, Genetic/drug effects
- Transfection
- Translocation, Genetic
- Tretinoin/pharmacology
- Tumor Cells, Cultured
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Affiliation(s)
- J S Menell
- Department of Pediatrics, Weill Medical College of Cornell University, New York, NY, USA.
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Federici AB, D'Amico EA. The role of von Willebrand factor in the hemostatic defect of acute promyelocytic leukemia. Leuk Lymphoma 1998; 31:491-9. [PMID: 9922039 DOI: 10.3109/10428199809057608] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Bleeding complications are often associated with acute promyelocytic leukemia (APL) they occur frequently at the onset of APL and become more serious during chemotherapy. The increased bleeding tendency of APL is caused by a massive proteolytic state, triggered by procoagulant substances, plasminogen activators and proteinases released into the circulation from leukemic cells. The introduction of all-trans-retinoic acid (ATRA) into the treatment of APL has reduced bleeding complications. However the mechanisms of the hemostatic defects in patients with APL and their modifications during ATRA with or without chemotherapy are still incompletely understood. Attempts at characterizing and monitoring these hemostatic abnormalities have been made by using several laboratory parameters. Among them we have studied the structural modifications of von Willebrand Factor (vWF). In APL, plasma vWF is massively degraded, with specific fragments produced by the action of plasmin and elastase. After ATRA therapy, proteolysis diminishes progressively in parallel with the improvement of other hemostatic measurements. We conclude that abnormalities of vWF structure and function might adversely affect hemostasis in APL and that their improvement after ATRA administration might explain in part the effectiveness of this drug in reducing hemorrhagic complications.
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Affiliation(s)
- A B Federici
- The Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, I.R.C.C.S. Maggiore Hospital and Institute of Internal Medicine, University of Milano, Italy
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McWilliam N, Robbie L, Booth N, Bennett B. Plasminogen activator in acute myeloid leukaemic marrows: u-PA in contrast to t-PA in normal marrow. Br J Haematol 1998; 101:626-31. [PMID: 9674732 DOI: 10.1046/j.1365-2141.1998.00762.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Leukaemic and normal bone marrow samples were compared in terms of their content of the fibrinolytic agents, tissue plasminogen activator (t-PA) and urokinase-type plasminogen activator (u-PA) and their inhibitors. plasminogen activator inhibitors 1 and 2 (PAI-1 and PAI-2). Normal marrow contained t-PA as the principal plasminogen activator, whereas in leukaemic marrow samples u-PA was the predominant activator. Both normal and leukaemic marrows contained PAI-1 in similar amounts, but whereas normal marrow contained significant amounts of PAI-2 the leukaemic marrows contained very little. Plasminogen activators were present in uncomplexed, active forms and plasmin-alpha2-antiplasmin complexes were generated locally more prominently in leukaemic marrows. u-PA associated with blast cells may contribute to the severe forms of haemorrhage sometimes occurring in myeloid types of leukaemia.
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Affiliation(s)
- N McWilliam
- Department of Medicine and Therapeutics, University of Aberdeen, Institute of Medical Sciences, Foresterhill
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46
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47
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48
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Higuchi T, Shimizu T, Mori H, Niikura H, Omine M. Coagulation patterns of disseminated intravascular coagulation in acute promyelocytic leukemia. Hematol Oncol 1997; 15:209-17. [PMID: 9722892 DOI: 10.1002/(sici)1099-1069(199711)15:4<209::aid-hon615>3.0.co;2-s] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Coagulation patterns of 19 newly-diagnosed acute promyelocytic leukemia (APL) patients with disseminated intravascular coagulation (DIC) at presentation were studied. Seventeen patients had hemorrhagic complications, of which four were fatal. Fatal hemorrhages were related with lower fibrinogen level and lower platelet count. DIC of the APL patients without infection was characterized by low fibrinogen and normal antithrombin III (ATIII) level. Thrombin-ATIII complex level was elevated in all patients examined. Patients with infection had higher fibrinogen levels than those without infection and some patients had reduced ATIII level. Ten remission inductions were tried with multidrug chemotherapy and seven with all-trans retinoic acid (ATRA). Complete remission was achieved in seven of ten inductions with chemotherapy and in all seven inductions with ATRA. Two patients treated with chemotherapy had fatal hemorrhage after starting therapy but none treated with ATRA.
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Affiliation(s)
- T Higuchi
- Division of Hematology, Internal Medicine, Showa University Fujigaoka Hospital, Yokohama, Japan
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49
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Affiliation(s)
- S J Kempin
- Desert Hospital Comprehensive Cancer Center, Palm Springs, California 92262, USA
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50
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DeLoughery TG, Goodnight SH. Acute promyelocytic leukaemia in the all trans retinoic acid era. Med Oncol 1996; 13:233-40. [PMID: 9152974 DOI: 10.1007/bf02990936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Bleeding diathesis is a common complication of acute promyelocyctic leukaemia (APL). Multiple haemostatic defects are found in most patients with APL, which often worsen following cytoreductive chemotherapy. Besides thrombocytopenia, most patients develop disseminated intravascular coagulation, systemic fibrinolysis or both. A major aim in treating haemostatic defects of APL is to prevent death or disability from bleeding until chemotherapy clears the malignant promyelocytes from the blood and bone marrow. The therapeutic options are discussed in this review and practical guidelines for treatment are outlined.
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