Ann Hematol DOI 10.1007/s00277-013-2000-1

ORIGINAL ARTICLE

Outcomes and prognostic factors of first relapsed acute promyelocytic leukemia patients undergoing salvage therapy with intravenous arsenic trioxide and chemotherapy Yinjun Lou & Shanshan Suo & Yin Tong & Hongyan Tong & Wenbin Qian & Haitao Meng & Wenyuan Mai & Jian Huang & Wenjuan Yu & Jie Jin

Received: 23 August 2013 / Accepted: 23 December 2013 # Springer-Verlag Berlin Heidelberg 2014

Abstract Arsenic trioxide (ATO) is an effective therapy for relapsed acute promyelocytic leukemia (APL) patients; however, the optimal treatment strategy remains unclear, and knowledge of the prognostic factors is still limited. We retrospectively analyzed the outcomes of 64 consecutive first relapsed APL patients (12 with molecular relapse and 52 with hematologic relapse). Patients received re-induction with intravenous ATO-based regimens. Patients who achieved a CR2 were offered further courses of alternating ATO/conventional chemotherapy with or without stem cell transplantation (SCT). With a median follow-up of 27 months (range, 6–57) in the molecular relapsed subgroup, the 3-year relapse-free survival (RFS) and overall survival (OS) rates were 81.5 % and 100 %, respectively. With a median follow-up of 38 months (range, 0–129) in the hematologic relapse group, the 3-year RFS and OS rates were 57.1 % and 72.1 %, respectively. Furthermore, in the hematologic relapse group, we compared the outcome between relapsed patients after previous ATO therapy (n=20) with those who did not receive prior ATO therapy (n=32). The CR2 rate was 80 % (16/20) vs. 93.8 % (30/32), (p=0.189). However, the relapse rate was 68.8 % (11/16) vs. 33.3 % (10/30), (p=0.03). The 4-year OS rate was 62.4 % vs. 71.2 %, (p=0.816), and the 4-year RFS rate was 29.8 % vs. 66.2 % (p=0.023). The results indicate that, irrespective of frontline therapy with ATO, salvage therapy with an ATO-based regimen remains effective. However, the long-term survival for those patients who received previous ATO-based treatment was inferior compared to those who Y. Lou : S. Suo : Y. Tong : H. Tong : W. Qian : H. Meng : W. Mai : J. Huang : W. Yu : J. Jin (*) Department of Hematology, Institute of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University, 79# Qingchun Road, Hangzhou 310003, China e-mail: [email protected]

did not receive prior ATO. In addition, the alternating ATO/ chemotherapy strategy can be a post-remission treatment option in a subset of patients. Keywords Acute promyelocytic leukemia . Relapse . Arsenic trioxide . Prognostic factors . Stem cell transplantation

Introduction The incorporation of all-trans retinoic acid (ATRA) and arsenic trioxide (ATO) into the frontline treatment regimens of acute promyelocytic leukemia (APL) has led to markedly improved cure rates that exceed 85 % in clinical trials [1–5]. Despite these advances, early death and disease relapse remain the two major causes of treatment failure [6–8]. Currently, a common salvage strategy for relapsed APL includes the administration of ATO-based re-induction, followed by ATO and/or stem cell transplantation (SCT) [9–11]. Several studies demonstrated that approximately 80–85 % of relapsed patients following initial ATRA and chemotherapy treatment can achieve a second complete remission (CR2) [12–14]. However, limited data are available on the efficacy of ATO treatment in relapsed patients who had prior ATO-containing therapy. In addition, the optimal strategy for post-remission therapy after ATO induced CR2 remains controversial. The role of repeated courses of ATO and chemotherapy is unclear, particularly on those only molecular relapsed patients. To address this issue and define the prognostic factors for relapsed APL, we performed a retrospective analysis over a 10-year period in first relapsed APL patients in our institution.

Ann Hematol

Patients and methods Patients We collected the data of all patients with first relapsed APL who registered in the database of our hospital from January 2002 to December 2012. We also included a few patients who were initially diagnosed and treated at other institutions but were then transferred to our hospital after relapse. We reviewed the medical records including clinical and laboratory information both at diagnosis and after relapse. Isolated extramedullary relapse was not included. The study was approved by the Institutional Review Board and in accordance with the Declaration of Helsinki. Treatment strategies of newly diagnosed APL All newly diagnosed APL patients were initially administered according to two protocols: ATRA plus ATO combination regimen for remission induction [15, 16], or ATRA-based regimen for induction [17]. In brief, the ATRA plus ATO protocol combines ATRA with ATO for remission induction followed by three courses of chemotherapy consolidation and ATRA/ATO maintenance. In the ATRA-based induction group, patients received ATRA (25 mg/m2/day) orally until CR. After CR achievement, patients were further divided into two subgroups according to the different regimens for postremission therapy: ATRA/chemotherapy; or ATO/ATRA/chemotherapy. Details of the protocols have been described previously [16, 17]. Treatment strategies of relapsed APL patients Re-induction and post-remission regimens were modified from the Shanghai protocol [14]. For remission re-induction, ATO was administered intravenously at a dose of 10 mg/day until bone marrow remission was observed or up to a cumulative maximum of 60 doses (for the molecular relapse subgroup, ATO was administered for 28 days). At the discretion of the treating physician, ATRA was administered at a dose of 20– 25 mg/m2/day orally during ATO administration. Patient’s complete blood count, coagulation, renal/liver function and electrocardiography were routinely monitored. Patients received mini-dose chemotherapy (idarubicin 6 mg/m2/day for 2–5 days, or daunorubicin 40 mg/m2/day for 2–5 days, or mitoxantrone 2 mg/day for 7–10 days) once the white blood cell (WBC) count exceeded 10.0×109/L. After CR2 achievement, autologous (auto) or allogeneic (allo) SCT was generally recommended for patients younger than 60 years. AutoSCT was restricted to individuals who achieved a molecular remission. Patients who did not receive the SCT

procedure were offered consolidation with alternating courses of ATO (10 mg/day for 28 days) and conventional chemotherapy (daunorubicin 40–45 mg/m2/day on days 1 to 3, idarubicin 8–10 mg/m2/day on days 1 to 3, or homoharrgtonine 4 mg/m2/day, days 1 to 3; with cytarabine 100 mg/m2/day on days 1 to 7). The sequential therapy was administrated for a total of 6–8 courses with an interval of 4–5 weeks for each course. Central nervous system (CNS) prophylaxis was attained by means of intrathecal injection of methotrexate, cytarabine, and corticosteroids. Patients with cytological evidence of CNS leukemia received intrathecal injections twice a week and/or cranial irradiation, until complete clearance of leukemic cells in the cerebrospinal fluid (CSF). The PML-RARA transcripts were detected by a nested qualitative or real-time quantitative reverse transcription polymerase chain reaction (RT-PCR) analysis with a sensitivity of 10−4 [18]. Molecular monitoring was carried out after each treatment course. Patients who had a relapse again were further treated with ATO, ATRA and chemotherapy with or without SCT. Definitions and statistical analysis Hematologic relapse was confirmed morphologically (>5 % blasts or abnormal promyelocytes in the bone marrow) as well as molecularly (PML-RARA positive). Molecular relapse was defined as PML-RARA positivity in two subsequent consecutive tests and in the absence of overt hematologic relapse [19]. A hematologic CR was defined using conventional criteria, including bone marrow blasts and abnormal promyelocytes ≤5 %; with an absolute neutrophil count ≥1.0×109/l and a platelet count ≥100×109/l. A molecular CR was defined as a negative RT-PCR result from bone marrow cells [20]. Overall survival (OS) was defined as the time from first relapse to death or last follow-up. Relapse-free survival (RFS) was defined as the time from second remission to last follow-up or an event (relapse). The follow-up data were updated in May 2013. Baseline parameters between groups were compared using chi-square test or the Fisher’s exact test for categorical variables and the Mann–Whitney test for continuous variables. A Kaplan–Meier survival analysis was performed to estimate the probabilities of OS and RFS, and differences between the curves were analyzed by the log-rank test. Factors associated with a p24 Salvage induction, ATO vs. ATO plus ATRA

0.955 0.083 0.219 0.585 0.381 0.139 0.982 0.218

Relapse-free survival

Multivariate HR (95 % CI)

p value

2.96 (1.09–8.05)

0.033

2.56 (1.01–6.52)

0.048

Univariate p value 0.419 0.614 0.232 0.157 0.212 0.000 0.504 0.121

HR (95% CI) hazard ratio (95 % confidence interval), ATO arsenic trioxide, ATRA all-trans retinoic acid

Multivariate HR (95%CI)

p value

0.96 (0.37–2.47)

0.931

4.74 (1.99–11.22)

Outcomes and prognostic factors of first relapsed acute promyelocytic leukemia patients undergoing salvage therapy with intravenous arsenic trioxide and chemotherapy.

Arsenic trioxide (ATO) is an effective therapy for relapsed acute promyelocytic leukemia (APL) patients; however, the optimal treatment strategy remai...
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