AML-156 Early Deaths in Patients With Newly Diagnosed Acute Promyelocytic Leukemia: A Single-Center Retrospective Study From a General Hospital

Context: To evaluate the early death (ED; death within 30 days) rate and its causes in newly diagnosed acute promyelocytic leukemia (APL) patients. Background: APL [t(15;17)] is a highly curable disease. EDs can be as high as 30% in a general hospital. Methods: We retrospectively analyzed new APL patients ≥18 years old treated at MHH between January 2009 and December 2021 using electronic medical records. Data included demographics, WBC, hemoglobin, platelet count on admission, coagulation parameters, presence/absence of disseminated intravascular coagulation, bone marrow or peripheral blood molecular analysis, immunohistochemistry, cytogenetics, Sanz score and risk stratification, timing of initiation of all trans retinoid acid (ATRA), complete response (CR) rate, major adverse events during induction, and ED rate. Results: Twenty-five patients had newly diagnosed APL with flow cytometry, immunohistochemistry, cytogenetics, and molecular testing for t(15;17). Median age was 40 years (20–67 years), and 52% were men. Ten patients were white, 4 were African American, 7 were Hispanic, and 4 were Asian. By Sanz risk stratification, 5 patients had low-risk, 5 had intermediate-risk, and 15 had high-risk disease. Sixteen patients had bleeding diathesis: 8 with intracranial hemorrhage (ICH), 6 with gastrointestinal or genitourinary bleeding, and 1 each with retinal bleed and abdominal wall hematoma. Median time to ATRA initiation was 12 hours. High-risk patients (WBC>10,000) received idarubicin or gemtuzumab ozogomicin. Three patients died before evaluation. Twenty-two patients had a CR with ATRA and arsenic trioxide induction. Induction adverse events were febrile neutropenia (n=6), differentiation syndrome (n=5), and respiratory failure (mechanical ventilation, n=6); 12 required ICU admission, and 4 had acute kidney injury (1 requiring dialysis). Eight patients had ICH with 4 emergent craniotomies and 4 managed conservatively. ED occurred in 3 (12%) patients: 2 within 48 hours of admission and another between days 8 and 15. Two patients died of ICH and one from pseudomonas sepsis and multiorgan failure. Five patients developed thrombotic events: 2 each had pulmonary embolism and stroke and 1 had splenic and renal infarct. Conclusions: In 25 patients, the ED rate was low despite 8 patients presenting with ICH. Early diagnosis, timely administration of ATRA, coagulopathy correction, and critical and neurosurgery care can reduce ED in APL.