I. Diagnosis of acute promyelocytic leukemia
I Purpose: To establish standard operating procedures for the general diagnosis and treatment of acute promyelocytic leukemia to ensure the correctness and standardization of patient diagnosis and treatment.
Ⅱ Scope: Applicable to the diagnosis and treatment of patients with acute promyelocytic leukemia.
III Diagnostic basis.
According to “World Health Organization Classification of Tumors. Pathology and Genetic of Tumors of Haematopoietic and Lymphoid Tissue.”(2008), “Diagnostic and Efficacy Criteria for Hematologic Diseases ( 3rd edition, Science Press)
IV Diagnostic protocols
1.Take medical history
The history should include the patient’s symptoms (anemia, bleeding, infection and extramedullary infiltration)
The history should include the initial time, severity and treatment, with particular attention to the history of bleeding symptoms.
The personal history should include any history of tumor and family history of tumor; ask about the history of other important organ diseases.
Physical examination should include: anemia, signs related to bleeding, enlargement of liver and spleen lymph nodes, presence of infectious lesions, etc.
2. Admission examination
2.1 At the initial consultation
2.1.1 Routine: routine blood, routine urine, routine stool + occult blood, blood group
2.1.2 Bone marrow
2.1.2.1 Bone marrow classification (should include specific description of the three lines of pathological hematopoiesis)
2.1.2.2 Bone marrow biopsy pathology (paraffin embedded, with immunohistochemical staining for bone marrow pathology;
NPM1 test), suspend the bone marrow biopsy operation if the clinical bleeding tendency is obvious/the coagulation examination shows obvious abnormalities.
2.1.2.3 Full set of histochemistry
2.1.2.4 N-ALP, PAS, iron staining, megakaryocyte enzyme labeling
2.1.2.5 Chromosome karyotype (including PML/RARα fluorescence in situ immunohybridization)
2.1.2.6 Flow cytometry immunophenotyping
2.1.2.7 Molecular biology
Required items.
PML/RARα (quantitative), FLT3/ITD mutation, FLT3/TKD mutation
Required but not yet performed at our institution: PML/RARα (quantitative), FLT3/ITD mutations, FLT3/TKD mutations
RARα-associated fusion gene screening
Optional items that we have performed.
NPM1 mutation, c-Kit mutation, CEBPa mutation
Optional but not yet available: IDH1 mutation, WT1 mutation, CEBPa mutation
IDH1 mutation, WT1 mutation, MLL-PTD, BAALC, EGR, MN1 expression level, MLL, EVI1 and other related gene abnormalities, Micro-RNA screening
2.1.2.8 Electron microscopic morphology and immunohistochemistry (MPO, PPO)
2.1.2.9 P170 protein (drug-resistant immunophenotype)
2.1.2.10 MDR1 (multidrug resistance gene)
2.1.3 Biochemistry
2.1.3.1 Liver and kidney function, fasting glucose
2.1.3.2 Hepatitis B and half, hepatitis C antibody, hepatitis A antibody
2.1.3.3 Electrolyte six items
2.1.3.4 Lactate dehydrogenase and isoenzymes
2.1.3.5 Cardiac enzyme profile
2.1.4 Immunology
2.1.4.1 Immunoglobulin quantification
2.1.4.2 Lymphocyte subsets
2.1.5 Coagulation octet
2.1.6 Other ECG, chest film/lung CT, abdominal ultrasound, cranial CT (suspected intracranial hemorrhage, central nervous system leukemia)
2.1.7 Fundus, oral cavity, ear, nose and throat examination
2.1.8 Bacterial, mycobacterial culture + drug sensitivity
2.1.8.1 Routinely send nasal, oral, pharyngeal, skin, perineum, perianal, sputum culture and culture of secretions from infected sites on admission
2.1.8.2 Send culture of secretion from suspicious site if the body temperature is greater than 38.5℃ for more than 2 days in hospital and the cause of non-infection is difficult to explain
2.1.9 Cerebrospinal fluid examination
Including pressure, routine, biochemical, β2 microglobulin, flow cytometry micro residual disease detection (before achieving complete remission is not considered for cerebrospinal fluid testing)
2.2 Induction treatment period: on day 28-42 of induction treatment, review bone marrow classification, PML-RAR transcript
The complete hematological remission will be entered into post-remission treatment.
2.3 Post-remission treatment period
2.3.1 Bone marrow morphology and fusion gene quantification will be performed before each consolidation chemotherapy, and FISH and fusion gene quantification will be performed periodically thereafter.
2.3.2 If there are karyotype abnormalities and other molecular biological markers (e.g. FLT3 abnormalities, etc.) at the initial diagnosis, review to normal.
2.3.3 Immunoglobulin quantification will be rechecked after remission, at 3, 6, 12, 18, 24, and 36 months.
2.3.4 Lymphocyte subsets were rechecked at 3, 6, 12, 18, 24 and 36 months after remission
2.4 After relapse
2.4.1 Bone marrow classification.
2.4.2 Chromosomal karyotype.
2.4.3 Flow cytometry immunophenotyping.
2.4.4 Molecular biology tests see initial examination items.
2.4.5 Multidrug resistance gene (MDR1), multidrug resistance phenotype (P170), leukemia combined drug sensitivity.
2.4.6 Peripheral blood lymphocyte subsets.
2.4.7 Immunoglobulin quantification.
II. Choice of treatment regimen for patients tolerant to anthracycline or hypertrichloremic acid (patients less than 60 years of age)
(cytotoxic drugs such as hydroxyurea and cytarabine can be added in appropriate amounts according to the changes in leukocyte count during treatment; for leukemia higher than 30´109/L during induction therapy, cytarabine 100 mg/day can be added)
(i) Patients with WBC <10´109/L were randomly divided into groups 1, 2 and 3.
1, ATRA + HHT treatment group (study group)
Induction therapy
ATRA 30mg/M2/day, orally for 4-6 weeks
HHT 2.5mg/M2/day (started on day 3-5 of ATRA treatment), intravenous drip for 7 days
Consolidation therapy: (ATRA 30mg/M2/day for 1-2 weeks with each course of chemotherapy)
I HA regimen
HHT 2.5mg/M2/day intravenously for days 1-6
Ara-C 100mg/M2/day IV continuous drip, days 1-6
II HA regimen
HHT 2.5mg/M2/day intravenously for days 1-6
Ara-C 100mg/M2/day, IV continuous drip, days 1-6
III HA regimen
HHT 2.5mg/M2/day intravenously for days 1-6
Ara-C 100mg/M2/day, intravenous continuous drip, day 1-6
2. ATRA+DNR induction therapy group (control group).
Induction therapy
ATRA 30mg/ M2/day, orally for 4-6 weeks
DNR 45mg/M2/day (starting on day 3-5 of ATRA treatment), intravenous drip for 3 days (or total amount divided into 4-5 days of application); or desoxorubicin (IDA) 8mg/M2/day (starting on day 3-5 of ATRA treatment), intravenous drip for 3 days (or total amount divided into 4-5 days of application) (DNR can be replaced by IDA in the following regimen) can be replaced by IDA)
Consolidation therapy: (ATRA 30mg/m2/day for 1-2 weeks for each course of chemotherapy)
I DA regimen
DNR 45mg/M2/day, intravenous drip, days 1-3
Ara-C 100mg/M2/day IV continuous drip, days 1-6
II DA regimen
DNR 45mg/M2/day, intravenous drip, days 1-3
Ara-C 100mg/M2/day, IV continuous drip, days 1-6
III MA regimen
Mitoxantrone (Mito) 6-8mg/M2/day intravenous drip, days 1-3
Ara-C 100mg/M2/day, IV continuous drip, day 1-6
3. ATRA+DNR+HHT induction therapy group (study group)
Induction therapy
ATRA 30mg/M2/day, orally for 4-6 weeks
DNR 45mg/M2/day (start on day 3-5 of ATRA treatment), intravenous drip for 3 days (or total amount split into 4-5 days)
HHT 2.5mg/M2/day (starting from day 3-5 of ATRA treatment), IV drip for 7 days
Consolidation therapy
I HAD regimen
HHT 2.5mg/M2/day intravenously for days 1-6
DNR 45mg/M2/day intravenously for days 1-3
Ara-C 100mg/M2/day, IV continuous drip, day 1-6
II HA regimen
HHT 2.5mg/M2/day intravenously for days 1-6
Ara-C 100mg/M2/day, IV continuous drip, days 1-6
III DA regimen
DNR 45mg/M2/day, intravenous drip, days 1-3
Ara-C 100mg/M2/day, IV continuous drip, day 1-6
(ii) Patients with WBC³10´109/L are group 4.
4. ATRA+AS2O3+DNR (or IDA) induced remission group
Induction therapy
ATRA 30mg/ M2/day orally for 4-6 weeks
AS2O3 0.15mg/Kg/day (or 10mg/d) intravenously for 4 weeks
DNR 45mg/M2/day (starting on day 3-5 after AS2O3 treatment), IV for 3 days (or total amount divided into 4-5 days); or desoxorubicin (IDA) 8mg/M2/day (starting on day 3-5 after ATRA treatment), IV for 3 days (or total amount divided into 4-5 days) (DNR can be replaced by IDA in the following regimen) can be replaced by IDA)
Consolidation therapy: (1-2 weeks of ATRA at 25mg/M2/d for each course of chemotherapy)
I DA regimen
DNR 45mg/M2/day, IV drip, day 1-3
Ara-C 1.0g/M2/12H, IV continuous drip, days 1-3
II DA regimen
DNR 45mg/M2/day, intravenous drip, days 1-3
Ara-C 1.0g/M2/12H, IV continuous drip, day 1-3
III MA regimen
Mitoxantrone (Mito) 8mg/M2/day, intravenous drip, days 1-3
Ara-C 100mg/M2/day, IV continuous drip, days 1-6
(C) Maintenance therapy: consistent across the four groups.
(1)ATRA 25mg/M2/d, oral, 2 weeks/month, mono-monthly dosing
(2) 6-MP 70 mg/M2/d (100 mg/d) orally for 1 week/month with 2 weeks off
MTX 20 mg/m2 orally on day 8, with a 2-week break
(3)Every 5 months, give one cycle of White Blood Kang (compound Huang Dai tablets): 6 tablets/d, 3 times/day for 1 month. Or AS2O3 0.15mg/Kg/day (or 10mg/d), intravenous drip, for 2 weeks. Take two weeks off and repeat (1) and (2) after checking liver function until the end of two years after reaching complete remission.
Third, intolerant to anthracyclines, high trichostatin, and elderly patients (age > 60 years)
(cytotoxic drugs such as hydroxyurea and cytarabine can be added in appropriate amounts according to the changes in leukocyte count during treatment; for leukemia higher than 30´109/L during induction therapy, 100 mg/day of cytarabine can be added. Some patients may choose to combine mitoxantrone for induction therapy at a dose of 6-8 mg/M-2/day × 3 days depending on cardiac function)
1. Induction therapy: ATRA+ AS2O3
ATRA 25-45mg/M-2/day × 28-40 days
AS2O3 10mg/day × 28-35 days
2. Post-remission consolidation therapy: ATRA+ AS2O3
ATRA 25-45mg/ M-2/day×14days/month, 7 courses of treatment
AS2O3 10mg/d×28days/2months, total 4 courses of treatment, ATRA applied at the same time during the use period
3. Maintenance treatment until 2 years after remission
(1)ATRA 25mg/M-2/day, orally, 2 weeks/month, 2 weeks off
(2) 6-MP 70 mg/M-2/day (100 mg/day) orally for 1 week, with 2 weeks off MTX 20 mg/M-2 orally on day 8, with 2 weeks off
IV. Patients with relapsed APL.
1 , induction therapy.
ATRA+ AS2O3 re-induction: ATRA 25-45 mg/M-2/day x 28-40 days, AS2O3 10 mg/day x 28-35 days.
2. Treatment after bone marrow remission.
①Fusion gene conversion is feasible for autologous stem cell transplantation
②Fusion gene conversion but no transplantation conditions can be applied to AT0 10mg/d×28 days, a total of 6 courses of consolidation
(3) Allogeneic stem cell transplantation for HLA-compatible sibling/unrelated/haploid donors with positive fusion gene
④For fusion gene positive but no transplantation condition.
A: Clinical trial
B: GO monoclonal antibody combined with chemotherapy
C: Combination chemotherapy
3 . Failure of re-induction therapy (bone marrow not in remission)
① Clinical trial
② GO monoclonal antibody combined with chemotherapy
③ Combination chemotherapy
④ Allogeneic hematopoietic stem cell transplantation
V. Prevention and treatment of central nervous system leukemia (CNSL).
Prevention of CNSL leukemia (i.e., intrathecal injection) should be started after reaching complete remission for a total of
4-6 times, to be completed during the consolidation treatment.
The sheath injection regimen is as follows.
Methotrexate (MTX) 10mg,
Ara-C 50mg.
Dexamethasone (DXM) 10mg.
Sixth, the induction and consolidation of treatment after the end of follow-up monitoring treatment: APL patients still need to follow up and monitor 3-5 years after the completion of all treatment, the conditions should be performed immune function monitoring (including immunoglobulin quantification, immune cell subpopulation analysis)
①Monthly peripheral blood counts up to 3 years, every 3-6 months up to 5 years.
(ii) Bone marrow cell morphology was tested every 3 months until 3 years, and then every 6 months until 5 years.
③Fusion gene quantification every 3 months until 3 years, then every 6 months until 5 years; if fusion gene negative, continue maintenance treatment until 2 years after remission; if fusion gene positive, review in 4 weeks, negative continue maintenance treatment, if positive, treat as relapse.
④If the fusion gene is negative and the patient develops hematocrit without a cause, the bone marrow and karyotype should be retested to exclude secondary myelodysplastic syndrome and AML.
VII. Pre-chemotherapy preparation.
1. Pre-chemotherapy preparation for febrile patients.
Immediate pathogenic microbial culture and antibiotics are recommended for febrile patients. Patients with definite organ infections should choose the appropriate antibiotics according to the site of infection and the results of pathogenic microbial culture, while the selection of therapeutic drugs should be formulated by integrating the patient’s condition and the characteristics of antibacterial drugs. For more details, please refer to the principles of antibiotic use for hematology patients.
2.Component blood transfusion.
If Hb80g/L, PLT20×109/L or there is active bleeding, transfuse concentrated red blood cells and single platelets respectively. If there is a tendency of Disseminated Intravascular Coagulation (DIC) or obvious abnormalities of clotting test index, then single platelets with PLT50×109/L should be transfused to enhance coagulation factor supplementation. The indication for transfusion can be relaxed for those with cardiac insufficiency.
3.The use of heparin and antifibrinolytic drugs.
Small doses of heparin and antifibrinolytic drugs can be used with reference to the coagulation test results and clinical bleeding symptoms.
4.Patients and family members sign the following consent forms.
Notification of serious or critical illness, informed consent for chemotherapy, informed consent for blood transfusion, consent for bone puncture, consent for lumbar puncture, consent for intravenous cannulation (when available)
VIII. Treatment during and after chemotherapy.
1.Infection prevention and control: see the use of antibiotics in hematology
2. Corresponding prevention and control of organ function damage: antiemetic, hepatoprotection, hydration, alkalinization, prevention and control of uric acid nephropathy (allopurinol), acid suppressants, etc.
3.Component transfusion: Hb80g/L, PLT20×109/L or with active bleeding, transfusion of concentrated red blood cells and single platelets, respectively. The indication for transfusion can be relaxed for those with cardiac insufficiency.
4. Hematopoietic growth factor: If the absolute neutrophil value (ANC) is ≤0.5×109/L after chemotherapy, granulocyte colony-stimulating factor (G-CSF) 5μg- Kg-1 – d-1 can be used.
5. Prevention and treatment of differentiation syndrome: If differentiation syndrome occurs in about patients in induction therapy, adequate amount of glucocorticoids should be applied promptly.