Indications

Acute Promyelocytic Leukemia (APML) (see Acute Myeloid Leukemia)

• xxx

Langerhans Cell Histiocytosis (LCH) (see Langerhans Cell Histiocytosis)

• xxxx

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Pharmacology

Binds to Retinoic Acid Receptor-Promyelocytic Leukemia Complex (RAR-PML) Protein

• Promotes differentiation of myeloid precursors and stimulates maturation of leukemic cells
• Decreases disseminated Intravascular coagulation (DIC) and hemorrhagic complications during APML treatment

Toxicity

• Probably due to cytokine release by leukemic cells or enhanced integrin expression on maturing granuloctyes (ATRA causes in vivo maturation of leukemic cells into more normal appearing granulocytes) causing adherence to vascular endothelium and migration into tissues

Metabolism

• xxx

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Administration

Oral (PO)

• Dose: start 50 mg qday, xxx

Dose Adjustment

• Hepatic: xxx
• Renal: xxx

Use in Pregnancy (see Pregnancy)

• xxx

Use During Breast Feeding

• xxx

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Adverse Effects

Cardiovascular Adverse Effects

• Pericardial Effusion (see Pericardial Effusion)
• Episodic Hypotension (see Hypotension)

Pulmonary Adverse Effects

Retinoic Acid Syndrome

• Epidemiology
  • Occurs only following ATRA therapy for APML (but does not occur in patients treated with ATRA for non-hematologic cancers)
  • Occurs in 25% of ATRA-treated APML patients
  • Usually develops between days 2-21 of therapy
• Diagnosis
  • ABG: hypoxemia
  • CBC: leukocytosis may be seen
  • Bronchoscopy with Bronchoalveolar Lavage (BAL): myeloid cells and blasts may be seen
  • Thoracoscopic/Open Lung Biopsy: interstitial infiltration with maturing myeloid cells
• Clinical Patterns
  • Acute Respiratory Distress Syndrome (ARDS) (see Acute Respiratory Distress Syndrome)
  • Interstitial Pneumonitis (see Interstitial Lung Disease)
  • Lung Nodules/Nodular Infiltrates (see Lung Nodule or Mass)
  • Pleural Effusions (see Pleural Effusion-Exudate)
  • Pneumonia/Alveolar Infiltrates (see Pneumonia)
• Treatment
  • Corticosteroids (see Corticosteroids): indicated
    • Dexamethasone 10 mg BID x 10 days -> reverses many cases
• Prognosis
  • Mortality Rate: 9%
  • Need for intubation predicts high mortality
• Prophylaxis
  • Prednisone PO Prophylaxis: when administered during ATRA therapy, decreases the incidence of pulmonary toxicity to 10% of cases

Diffuse Alveolar Hemorrhage (DAH) (see Diffuse Alveolar Hemorrhage)

• Diagnosis
  • Bland alveolar hemorrhage (no capillaritis)
  • Elevated ANCA may be seen

Renal Adverse Effects

• Acute Kidney Injury (AKI) (see Acute Kidney Injury)
• Glomerulonephritis (see Acute Glomerulonephritis)

Other Adverse Effects

• Fever (see Fever)
• Peripheral Edema (see Peripheral Edema)
• Weight Gain (see Weight Gain)
• Sweet’s Syndrome (see Sweet’s Syndrome)

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References

• The retinoic acid syndrome in acute promyelocytic leukemia. Ann Intern Med 1992; 117:292-296
• New chemotherapy-induced pulmonary syndromes. Pulmonary Perspectives. Northbrook, IL: American College of Chest Physicians, 1995; 12(4):4-5
• All-trans retinoic acid in acute promyelocytic leukemia. N Engl J Med 1997; 337:1021-1025