Acute Promyelocytic Leukemia Follow-up

Updated: May 07, 2015
  • Author: Sandy D Kotiah, MD; Chief Editor: Emmanuel C Besa, MD  more...
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Follow-up

Further Outpatient Care

Outpatient care should include transfusion support and frequent blood monitoring during the consolidation and maintenance phases of acute promyelocytic leukemia (APL) therapy.

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Further Inpatient Care

Inpatient care for patients with acute promyelocytic leukemia (APL) should be focused on transfusion support for anemia, coagulopathy, and thrombocytopenia; treatment of infections; and monitoring for retinoic acid syndrome. Patients should also be monitored for tumor lysis syndrome when appropriate during the induction phase of treatment.

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Inpatient & Outpatient Medications

ATRA should be prescribed on both an inpatient and outpatient basis. Patients should also be on prophylactic antifungal and antiviral medications during treatment, as these individuals have altered lymphocyte function. This is caused by the underlying leukemia and by cytotoxic therapy.

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Deterrence/Prevention

No risk factor has been identified for primary acute promyelocytic leukemia (APL). It is still unclear whether there are certain forms of environmental or occupational exposure that predispose susceptible individuals to APL.

Secondary APL may follow treatment with cytotoxic agents, especially mitoxantrone, or radiotherapy. Secondary APL accounts for 10-20% of cases. The evolution of treatment strategies for primary cancers has reduced the incidence of secondary APL in breast cancer patients but increased it in prostate cancer patients. Characteristics and outcomes of secondary APL are similar to those of primary APL. [33]

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Complications

The most important complications of acute promyelocytic leukemia (APL) are bleeding diathesis secondary to underlying coagulopathy (5%), infection (2.3%), and differentiation syndrome (1.4%). [18] The coagulopathy should be monitored closely to prevent early mortality. Infection can occur at any time and should be treated promptly with antibiotics. Patients with differentiation syndrome should be treated with IV steroids to prevent treatment-related mortality.

A long-term observational study of 1025 patients with APL in first complete remission found that therapy-related myeloid neoplasms (t-MNs) are a rare but severe complication. Therapy for APL in these patients consisted of all-trans-retinoic acid (ATRA) plus anthracycline chemotherapy. Further research is needed to determine how to decrease the frequency of t-MN following ATRA plus anthracycline-based therapy. [34]

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Prognosis

Unlike most leukemias, acute promyelocytic leukemia (APL) has a very good prognosis, with an overall 70% cure rate. However, since the early 1990s, there have been reports of extramedullary relapse to the skin and CNS with APL that are associated with a poor prognosis.

A retrospective review showed that expression of CD56 (in >20% of promyelocytes) correlates with a higher risk of extramedullary relapse and high WBC counts. [35]

An additional retrospective analysis examined the outcome of 155 patients with the microgranular variant who were treated with all-trans-retinoic acid (ATRA) – based therapy in three clinical trials. The analysis revealed no difference in incidence of complications, survival, and response compared with patients who had classical M3 morphology. [36]

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Patient Education

For patient education information, see the Cancer Center, as well as Leukemia. In addition, patients should visit the Leukemia and Lymphoma Society Web page for further information at The Leukemia & Lymphoma Society (www.leukemia-lymphoma.org).

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