Occurrence Of Deep Vein Thrombosis and Pulmonary Embolism In Acute Promyelocytic Leukemia (APL) Patients
Authors: Lamneck Jennifer A. , Wells Jeremy C. , Mangaonkar Abhishek , Jillella Anand , Kota Vamsi 
Published: October 2019

Abstract
APL is a highly curable malignancy with cure rates in excess of 90% in most co-operative group trials. Population-based studies show that the survival is approximately 65-70% with up to 30% early deaths. The most common reasons of early deaths are bleeding, differentiation syndrome (DS) and infection. The bleeding seen in APL is due to disseminated intravascular coagulation (DIC) and is very unique to this disease. It can be very severe in some patients leading to fatal bleeding resulting in early deaths. APL can also induce a pro-coagulant state although much more rare than the bleeding condition. There have been reports of deep vein thrombosis in patients being treated for APL however most of the literature is in the form of case reports and there is very limited data on the incidence of thrombosis in APL. Here we report the incidence of DVT/PE in patients undergoing induction for APL at our institution.

Methods
We performed a retrospective chart review on patients diagnosed with APL who received induction between December 1, 2004 and July 30, 2013 at Georgia Regents University and also patients who were referred to us from surrounding treatment centers with whom we co-manage APL patients. Radiological evidence of deep vein thrombosis or pulmonary embolism by either ultrasound or CT scans was reviewed.

Results
Forty-one patients with APL treated by our facility were reviewed. Seven patients died during induction and 1 patient refused treatment. Age range of the patients treated was 21-75 years. In the surviving 33 patients either treated or co-managed at our institution, 6 patients (18.2%) had thrombosis (DVT/PE). Age range of the patients with DVT was 30-70 years. 4 out of 6 patients that developed DVT were female. In three patients it was associated with a catheter in the same arm. 5 out of 6 patients had the thrombosis around the time of hematological recovery with one patient developing DVT early in the hospitalization. All patients were treated with anticoagulation and there were no deaths from DVT/PE.

Conclusions
Acute deep vein thrombosis is felt to be a relatively uncommon presentation in APL. At our institution we found an increased incidence of DVT/PE mostly occurring around the time of hematological recovery. APL can also induce a pro-coagulant state and it is unclear as to why most of the patients had thrombotic episodes around the time of hematological recovery. There is also an increase in differentiation syndrome in the late stages of induction which might be cytokine mediated inflammation. This same process may also play a role in increased incidence of thrombotic episodes seen in this group of patients. We present this data to increase physician awareness regarding the possibility of DVT/PE in APL patients especially around the time of count recovery. We now routinely advocate the use of Venodynes in APL patients and are more rigorous with the implementation especially given our observation of increased incidence of DVT/PE.

Disclosures:
No relevant conflicts of interest to declare.