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Gao Y, Xi Y, Chen W, Meng Y, Su Y. Early predictor for differentiation syndrome in newly diagnosed acute promyelocytic leukaemia patients treated with single-agent arsenic trioxide. Ann Hematol 2024:10.1007/s00277-024-05776-y. [PMID: 38684509 DOI: 10.1007/s00277-024-05776-y] [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: 12/20/2023] [Accepted: 04/23/2024] [Indexed: 05/02/2024]
Abstract
Differentiation syndrome (DS) is the second leading cause of death in acute promyelocytic leukaemia (APL) patients. Few studies have tested predictors of DS events. This study aimed to identify optimized predictors of DS events related to APL. The data of 298 consecutive patients who were newly diagnosed with APL between December 2012 and June 2023 were retrospectively investigated. A systematic review of computer-based patient medical records was conducted to obtain clinical data, including baseline characteristics, routine blood examination findings, biochemical indices and clinical manifestations of DS. Among the 298 patients, 158 were classified into the no-DS group, while 140 had DS. Compared with those of patients without DS, the peripheral blast count, age, and WBC count at each time point were significantly different in patients with DS (P < 0.05 for all time points). Generalized linear mixed models (GLMMs) revealed that WBC Double (Coeff. 0.442, P = 0.000) and WBCPeak (Coeff. 0.879, P = 0.000) were independent risk factors for DS. The frequencies of clinical manifestations of unexplained fever (P = 0.003), dyspnoea (P = 0.002), weight gain of more than 5 kg (P = 0.006), pleural effusion (P = 0.001), pulmonary infiltrates (P < 0.001), pericardial effusion (P = 0.002) and renal failure (P = 0.006) were considerably lower in moderate DS patients than in severe DS patients. The WBCDouble occurs earlier than the WBCpeak occurrence, so WBC Double might be a new indicator of DS.
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Affiliation(s)
- Yujuan Gao
- The First Affiliated Hospital of Harbin Medical University, Long Jiang Road, Harbin, 150007, Heilongjiang Province, China
| | - Yuanyuan Xi
- The First Affiliated Hospital of Harbin Medical University, Long Jiang Road, Harbin, 150007, Heilongjiang Province, China
| | - Wenqi Chen
- The First Affiliated Hospital of Harbin Medical University, Long Jiang Road, Harbin, 150007, Heilongjiang Province, China
| | - Yanfen Meng
- The First Affiliated Hospital of Harbin Medical University, Long Jiang Road, Harbin, 150007, Heilongjiang Province, China
| | - Yanhua Su
- The First Affiliated Hospital of Harbin Medical University, Long Jiang Road, Harbin, 150007, Heilongjiang Province, China.
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2
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Huang DP, Yang LC, Chen YQ, Wan WQ, Zhou DH, Mai HR, Li WL, Yang LH, Lan HK, Chen HQ, Guo BY, Zhen ZJ, Liu RY, Chen GH, Feng XQ, Liang C, Wang LN, Li Y, Luo JS, Fan Z, Luo XQ, Li B, Tang YL, Zhang XL, Huang LB. Long-term outcome of children with acute promyelocytic leukemia: a randomized study of oral versus intravenous arsenic by SCCLG-APL group. Blood Cancer J 2023; 13:178. [PMID: 38052803 PMCID: PMC10698191 DOI: 10.1038/s41408-023-00949-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/08/2023] [Accepted: 11/14/2023] [Indexed: 12/07/2023] Open
Abstract
Realgar-Indigo naturalis formula (RIF), an oral traditional Chinese medicine mainly containing Realgar (As4S4), is highly effective in treating adult acute promyelocytic leukemia (APL). However, the treatment efficacy and safety of RIF have not been verified in pediatric patients. SCCLG-APL group conducted a multicenter randomized non-inferiority trial to determine whether intravenous arsenic trioxide (ATO) can be substituted by oral RIF in treating pediatric APL. Of 176 eligible patients enrolled, 91 and 85 were randomized to ATO and RIF groups, respectively. Patients were treated with the risk-adapted protocol. Induction, consolidation, and 96-week maintenance treatment contained all-trans-retinoic acid and low-intensity chemotherapy, and either ATO or RIF. The primary endpoint was 5-year event-free survival (EFS). The secondary endpoints were adverse events and hospital days. After a median 6-year follow-up, the 5-year EFS was 97.6% in both groups. However, the RIF group had significantly shorter hospital stays and lower incidence of infection and tended to have less cardiac toxicity. All 4 relapses occurred within 1.5 years after completion of maintenance therapy. No long-term arsenic retentions were observed in either group. Substituting oral RIF for ATO maintains treatment efficacy while reducing hospitalization and adverse events in treating pediatric APL patients, which may be a future treatment strategy for APL.
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Affiliation(s)
- Dan-Ping Huang
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Liang-Chun Yang
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yi-Qiao Chen
- Department of Pediatric Hematology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Wu-Qing Wan
- Department of Pediatrics, Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Dun-Hua Zhou
- Department of Pediatrics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Hui-Rong Mai
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Shenzhen, Guangdong, China
| | - Wan-Li Li
- Department of Hematology, Hunan Children's Hospital, Changsha, Hunan, China
| | - Li-Hua Yang
- Department of Pediatrics, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - He-Kui Lan
- Department of Pediatrics, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Hui-Qin Chen
- Department of Pediatrics, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Bi-Yun Guo
- Department of Pediatrics, First Affiliated Hospital of Xiamen University, Xiamen, Fujian, China
| | - Zi-Jun Zhen
- Department of Pediatrics, Sun Yat-sen University Cancer Center, Guanzhou, Guangdong, China
| | - Ri-Yang Liu
- Department of Pediatrics, Huizhou Central People's Hospital, Huizhou, Guangdong, China
| | - Guo-Hua Chen
- Department of Pediatrics, First People's Hospital of Huizhou, Huizhou, Guangdong, China
| | - Xiao-Qin Feng
- Department of Pediatrics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Cong Liang
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Li-Na Wang
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yu Li
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Jie-Si Luo
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Zhong Fan
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xue-Qun Luo
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Bin Li
- Biostatistics Team, Clinical Trials Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guandong, China
| | - Yan-Lai Tang
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.
| | - Xiao-Li Zhang
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.
| | - Li-Bin Huang
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.
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Luo JS, Zhang XL, Huang DP, Chen YQ, Wan WQ, Mai HR, Chen HQ, Wen H, Liu RY, Chen GH, Li Y, Luo XQ, Tang YL, Huang LB. Differentiation syndrome and coagulation disorder - comparison between treatment with oral and intravenous arsenics in pediatric acute promyelocytic leukemia. Ann Hematol 2023:10.1007/s00277-023-05270-x. [PMID: 37199788 DOI: 10.1007/s00277-023-05270-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 05/08/2023] [Indexed: 05/19/2023]
Abstract
Realgar-Indigo naturalis formula (RIF), with A4S4 as a major ingredient, is an oral arsenic used in China to treat pediatric acute promyelocytic leukemia (APL). The efficacy of RIF is similar to that of arsenic trioxide (ATO). However, the effects of these two arsenicals on differentiation syndrome (DS) and coagulation disorders, the two main life-threatening events in children with APL, remain unclear. We retrospectively analyzed 68 consecutive children with APL from South China Children Leukemia Group-APL (SCCLG-APL) study. Patients received all-trans retinoic acid (ATRA) on day 1 of induction therapy. ATO 0.16 mg/kg day or RIF 135 mg/kg·day was administrated on day 5, while mitoxantrone was administered on day 3 (non-high-risk) or days 2-4 (high-risk). The incidences of DS were 3.0% and 5.7% in ATO (n = 33) and RIF (n = 35) arms (p = 0.590), and 10.3% and 0% in patients with and without differentiation-related hyperleukocytosis (p = 0.04), respectively. Moreover, in patients with differentiation-related hyperleukocytosis, the incidence of DS was not significantly different between ATO and RIF arms. The dynamic changes of leukocyte count between arms were not statistically different. However, patients with leukocyte count > 2.61 × 109/L or percentage of promyelocytes in peripheral blood > 26.5% tended to develop hyperleukocytosis. The improvement of coagulation indexes in ATO and RIF arms was similar, with fibrinogen and prothrombin time having the quickest recovery rate. This study showed that the incidence of DS and recovery of coagulopathy are similar when treating pediatric APL with RIF or ATO.
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Affiliation(s)
- Jie-Si Luo
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xiao-Li Zhang
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Dan-Ping Huang
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yi-Qiao Chen
- Department of Pediatric Hematology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Wu-Qing Wan
- Department of Pediatrics, Second Xiangya Hospital, Changsha, Hunan, China
| | - Hui-Rong Mai
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Shenzhen, China
| | - Hui-Qin Chen
- Department of Pediatrics, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Hong Wen
- Department of Pediatrics, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian, China
| | - Ri-Yang Liu
- Department of Pediatrics, Huizhou Central People's Hospital, Huizhou, Guangdong, China
| | - Guo-Hua Chen
- Department of Pediatrics, First People's Hospital of Huizhou, Huizhou, Guangdong, China
| | - Yu Li
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xue-Qun Luo
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yan-Lai Tang
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.
| | - Li-Bin Huang
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.
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Liao LH, Chen YQ, Huang DP, Wang LN, Ye ZL, Yang LH, Mai HR, Li Y, Liang C, Luo JS, Wang LN, Luo XQ, Tang YL, Zhang XL, Huang LB. The comparison of plasma arsenic concentration and urinary arsenic excretion during treatment with Realgar-Indigo naturalis formula and arsenic trioxide in children with acute promyelocytic leukemia. Cancer Chemother Pharmacol 2022; 90:45-52. [DOI: 10.1007/s00280-022-04449-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 06/04/2022] [Indexed: 11/28/2022]
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Sasijareonrat N, Jahn N, Ungprasert P, Owattanapanich W. Efficacy and the Adverse Effects of Oral Versus Intravenous Arsenic for Acute Promyelocytic Leukemia: A Meta-Analysis of Randomized-Controlled Studies. Technol Cancer Res Treat 2021; 19:1533033820937008. [PMID: 32583728 PMCID: PMC7318817 DOI: 10.1177/1533033820937008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Acute promyelocytic leukemia, a subtype of acute myeloid leukemia, is highly curable. In subgroup of patients with non-high-risk acute promyelocytic leukemia, intravenous arsenic trioxide plus all-trans-retinoic acid is considered the preferred regimen for acute promyelocytic leukemia. Recently, there are interests in the use of the oral form of arsenic, named the Realgar-Indigo naturalis formula, but the data on its efficacy and safety are still relatively limited. The current study was conducted with the aims to identify and summarize the results of all available randomized-controlled studies. A systematic review was conducted in the 2 major databases, utilizing the terms for arsenic and acute promyelocytic leukemia. Eligible studies had to be randomized-controlled studies that compared efficacy and/or adverse effects of oral arsenic versus intravenous arsenic for treatment of patients with acute promyelocytic leukemia. The Mantel-Haenszel method was used to pool the effect estimates and 95% confidence intervals of the included studies together. A total of 4 randomized controlled studies with 482 patients with acute promyelocytic leukemia (258 in Realgar-Indigo naturalis formula group and 224 in intravenous arsenic trioxide group) were included in the meta-analysis. The chances of achieving complete remission were numerically higher in the Realgar-Indigo naturalis formula group but the difference was not statistically significant (pooled odds ratio: 4.59, 95% CI: 0.74-28.57, I2 = 0%). Similarly, other efficacy outcomes, including 30-day mortality rate, overall survival, and event-free survival, also tended to favor the Realgar-Indigo naturalis formula group but the difference was not statistically significant. There was no significant difference in the chance of developing differentiation syndrome, cardiac complications, grades 3 to 4 liver toxicity, grades 3 to 4 renal toxicity, and infection between the 2 groups. The results may suggest that all-trans-retinoic acid plus oral Realgar-Indigo naturalis formula regimen is, at minimum, not a worse alternative to the standard all-trans-retinoic acid plus intravenous intravenous arsenic trioxide regimen for treatment of acute promyelocytic leukemia, especially for patients with low-to-intermediate risk.
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Affiliation(s)
| | - Nikolaus Jahn
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| | - Patompong Ungprasert
- Clinical Epidemiology Unit, Department of Research and Development, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Weerapat Owattanapanich
- Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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6
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Xu ZL, Huang XJ. Therapeutic Approaches for Acute Promyelocytic Leukaemia: Moving Towards an Orally Chemotherapy-Free Era. Front Oncol 2020; 10:586004. [PMID: 33194735 PMCID: PMC7606937 DOI: 10.3389/fonc.2020.586004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 09/30/2020] [Indexed: 12/18/2022] Open
Abstract
The treatment of acute promyelocytic leukaemia (APL) has evolved dramatically over the past several decades, making the disease a highly curable form of acute leukaemia. The discoveries of all-trans retinoic acid (ATRA) and arsenic trioxide (ATO) were landmark events, leading to historic revolutions in the treatment of APL. One major change was from chemotherapy-based to chemotherapy-free treatment regimens, and the combination of ATRA plus ATO without chemotherapy has been recommended as the standard therapy for non-high-risk APL. The other major change was from the intravenous administration of medicine in the hospital to a largely home-based oral approach, which is a more cost-effective and convenient treatment model. In this review, we focus on the evolution of therapeutic approaches for APL, as well as the challenges that remain with the current approaches.
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Affiliation(s)
- Zheng-Li Xu
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Xiao-Jun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
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7
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The simpler, the better: oral arsenic for acute promyelocytic leukemia. Blood 2019; 134:597-605. [PMID: 31113776 DOI: 10.1182/blood.2019000760] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 04/29/2019] [Indexed: 12/24/2022] Open
Abstract
Arsenic trioxide and all-trans retinoic acid have become the frontline treatments for patients with acute promyelocytic leukemia (APL). Despite the long wait for an oral arsenic drug, a commercially available agent, realgar-indigo naturalis formula (RIF), was not launched in China until 2009. Since then, over 5000 APL patients have been treated with oral RIF in China. Oral arsenic not only shows a clinical efficacy comparable to that of IV formulations but also displays a better safety profile, improved quality of life, and lower medical costs for patients. The promising results promote incorporating an outpatient postremission therapy model into clinical practice for both low-risk and high-risk APL patients in China. In this review, we discuss the evolution of oral arsenic RIF in the treatment of APL, with a special focus on how to address the related complications during induction therapy.
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