What is the role of consolidation therapy in the treatment of acute promyelocytic leukemia (APL)?

Updated: May 03, 2019
  • Author: Sandy D Kotiah, MD; Chief Editor: Emmanuel C Besa, MD  more...
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For consolidation therapy in acute promyelocytic leukemia (APL), the National Comprehensive Cancer Network (NCCN) recommends basing the choice of regimen on the agents used for induction therapy. For example, patients who received all-trans-retinoic acid (ATRA) plus arsenic trioxide (ATO) would continue to receive ATRA/ATO, while those treated with ATRA plus chemotherapy would for the most part continue to receive those agents. In some cases, mitoxantrone may be added. [14] Another consolidation regimen consists of 2 years of 6-mercaptopurine (6-MP), methotrexate, and ATRA.

Retrospective studies by the independent groups GINEMA and PETHEMA showed statistically improved outcomes when ATRA was added to chemotherapy for 15 days. The PETHEMA group used three cycles of consolidation with idarubicin to mitoxantrone to idarubicin, but with higher doses of idarubicin for intermediate- to high-risk patients. The APL 2000 group used daunorubicin and cytarabine in differing doses for two cycles of consolidation.

Montesinos et al reported that of 918 patients who achieved complete remission with induction and consolidation therapy with ATRA and anthracycline-based chemotherapy, 17 patients developed therapy-related myeloid neoplasms (t-MN) or secondary acute myelogenous leukemia. [29]

The 6-year cumulative incidence of these complications overall was 2.2%. In subgroups of APL in low-, intermediate-, and high-risk patients, the 6-year incidence was 5.2%, 2.1%, and 0%, respectively. The study shows that t-MN is a relatively infrequent, long-term, and severe complication after first-line treatment of APL with ATRA and anthracycline-based regimens. [29]

Powell et al investigated the role of ATO in consolidation therapy. [30] In their study, 481 patients all underwent the same induction regimen with daunorubicin, cytarabine, and ATRA. They were then randomized to consolidation treatment with either two cycles of daunorubicin and ATRA or two 25-day courses of ATO. At 3 years, event-free survival and disease-free survival were significantly better for the ATO consolidation arm (P< 0.0001), but the difference in overall survival was not statistically significant (P = 0.59).

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