Treatment for relapsed acute promyelocytic leukemia: what is the best post-remission treatment?
Gi-June Min1, Byung-Sik Cho1, Sung-Soo Park1, Silvia Park1, Young-Woo Jeon2, Seung-Ah Yahng3, Seung-Hawn Shin4, Jae-Ho Yoon1, Sung-Eun Lee1, Ki-Seong Eom1, Yoo-Jin Kim1, Seok Lee1, Chang-Ki Min1, Seok-Goo Cho1, Jong Wook Lee1, Hee-Je Kim1
Department of Hematology, 1Seoul St. Mary's Hematology Hospital, College of Medicine, The Catholic University of Korea, 2Yeouido St. Mary's Hematology Hospital, College of Medicine, The Catholic University of Korea, Seoul, 3Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, 4Eunpyeong St. Mary's Hematology Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
Correspondence to: Byung-Sik Cho, M.D., Ph.D.
Department of Hematology, Leukemia Research Institute, Seoul St. Mary's Hematology Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea
E-mail: cbscho@catholic.ac.kr
Published online: July 27, 2022.
© The Korean Journal of Hematology. All rights reserved.

Abstract
Background: Arsenic trioxide (ATO) is the standard treatment for relapsed acute promyelocytic leukemia (APL). However, consensus on post-remission therapies is still lacking.
Method : We evaluated 52 patients who experienced relapse following initial treatment of APL between 2000 and 2019 at Catholic Hematology Hospital. Among them, 41, 30, and 11 patients received reinduction, ATO, and 11 conventional intensive chemotherapy (IC).
Results : The ATO reinduction group showed a significantly higher second complete molecular remission (mCR2) rate, superior neutrophil and platelet recovery, and a lower infection rate than the IC reinduction group. No significant differences were observed in survival outcomes after postremission treatment among the ATO-based (N=19), autologous (N=12), and allogeneic (N=6) hematopoietic stem cell transplantation (HSCT) groups. In the ATO-based and autologous HSCT groups, among patients with mCR2 after ATO reinduction, nine and five patients experienced a second relapse, respectively (50.7% vs. 41.7%, P=0.878). Among these patients, seven received salvage allogeneic HSCT; six remained alive. The other seven patients received ATO without HSCT. Five died from disease progression, and two survived and have been in mCR2 since.
Conclusion : Post-remission treatment outcomes of patients with relapsed APL were not significantly different, regardless of the treatment option, suggesting the feasibility of ATO-based treatment without HSCT in mCR2. Allogeneic HSCT may be an effective salvage treatment modality for patients with a second relapse. Owing to a few cases of relapsed APL, multicenter prospective studies may help elucidate the efficacy of each post-remission treatment.
Keywords: Acute promyelocytic leukemia, Relapse, Arsenic trioxide, Stem cell transplantation, Post-remission therapy


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