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ISAL 2025 | Guidance for treating APL in the frontline and R/R settings
Maria Teresa Voso, MD, University Tor Vergata, Rome, Italy, gives advice on treating acute promyelocytic leukemia (APL) in the frontline and relapsed/refractory (R/R) settings. She highlights the benefits of a chemotherapy-free combination of arsenic trioxide and all-trans retinoic acid, which is recommended for both standard and high-risk APL, with low rates of relapse and high efficacy in achieving measurable residual disease (MRD) negativity. This interview took place at the 19th International Symposium on Acute Leukemias (ISAL XIX) in Munich, Germany.
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Transcript
Acute promyelocytic leukemia is one of the diseases where we have seen most advances in the last years and there is a targeted treatment which is the combination of arsenic trioxide plus all-trans retinoic acid. And this treatment has been approved for standard-risk APL and induces prolonged survival in over 90% of the patients. And as compared to the chemotherapy, standard chemotherapy, AIDA or AIDA-like regimens, where we see survival rates of about 80% at almost five years...
Acute promyelocytic leukemia is one of the diseases where we have seen most advances in the last years and there is a targeted treatment which is the combination of arsenic trioxide plus all-trans retinoic acid. And this treatment has been approved for standard-risk APL and induces prolonged survival in over 90% of the patients. And as compared to the chemotherapy, standard chemotherapy, AIDA or AIDA-like regimens, where we see survival rates of about 80% at almost five years. And we still see relapses following AIDA chemotherapy, about 13%, again, at four and a half years of follow-up versus three to four percent in patients treated with a chemo-free combination. This is actually the way we should treat patients with APL. In standard-risk APL, the regimen is approved, but also high-risk APL. Both data from our Harmony combined database, including patients treated in the UK AML17 trials with high-risk APL, defined by white blood cell counts over 10,000. And also the recent Apollo trial, which has been presented at the last EHA meeting, showed that also in high-risk APL, the chemo-free combination combined with two doses of idarubicin has high efficacy also in high-risk APL. So also high-risk APL should be treated with a chemo-free combination. And as I mentioned before, the number of relapses following this treatment is very low. And in those cases, if the relapses occur after six months following diagnosis and after treatment, the patient could be re-challenged using the same treatment. And if they are MRD negative, they could be consolidated using autologous stem cell transplant. If they are still MRD positive, then allogeneic stem cell transplant comes into question. And a combination also with Mylotarg can be used to add to the regimen and to improve the rate of MRD negativity. But as I mentioned before, the number of relapses is very low and it’s very difficult to say what to do in patients relapsing after Atra-Ato. Patients who relapsed after the AIDA regimen, and we’ve known this for many years, should be treated with a chemo-free combination. And we can also achieve cure in these patients relapsed after AIDA in about 80% of cases.
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