Acute promyelocytic leukemia (APL) is characterized M3 in the French-American and British (FAB) classification and represents approximately 5-10% of all leukemia in adults. 1) In about 95-98% of the cases, APL is associated with the reciprocal translocation, t(15; 17)(q22; q21) 2,3) and the reciprocal fusion of the retinoic acid receptor (RAR)a gene on chromosome 17 with the promyelocytic leukemia (PML) gene on chromosome 15. The resulting PML-RARa fusion gene encodes a chimeric protein 4,5) that causes the pathogenesis of APL. 2,6) Huang et al. reported that all-trans retinoic acid (ATRA)-a vitamin A derivative-yielded a high rate of complete remission for APL patients.7) Several clinical studies have shown that ATRA treatment in combination with chemotherapy induced survival rate of 67-84% at 2-4-years. [8][9][10][11] Currently, ATRA has become a first-line treatment of newly diagnosed APL. [8][9][10][11] The combination of ATRA with chemotherapy can obtain long-term survival in 70% of newly diagnosed APL. Nevertheless, the remaining 30% of patients relapse and are often resistant to further treatment with ATRA and chemotherapy. 12) In 1996, the Chinese Shanghai II Medical University Group reported that arsenic trioxide induced apoptosis of APL cells, 13) and 14 of 15 patients who relapsed after ATRA therapy achieved complete remission (CR) with no serious adverse events.14) Several studies reported that intravenous infusion of arsenic trioxide was effective in approximately 90% of relapsed APL patients who are resistant to ATRA and chemotherapy.14-16) However these studies have not accurately investigated the metabolism of arsenic trioxide after the intravenous infusion.In this study, arsenic trioxide was administered intravenously to ATRA-resistant APL patient, and we determined the efficacy of arsenic trioxide in APL as well as the serum or urine concentrations of inorganic arsenic and the methylated metabolites.
MATERIALS AND METHODS
PatientThe patient was a 72-year-old male patient weighing 57.5 kg. In September 1999, he was diagnosed with APL. The marrow smears showed increased promyelocytes (80%). Chromosome analysis revealed 47; ϩ8, t(15; 17)(q22; q11-21). He achieved first CR with ATRA and chemotherapy. Subsequently the consolidation therapy was started on Day 56, which led to PML-RARa negative, followed by one-year maintenance therapy with ATRA. In January 2001, He relapsed and achieved second CR with ATRA. However, in July 2001, the bone marrow smear obtained during the maintenance therapy revealed an increase of promyelocytes, and the patient was diagnosed as relapsed and ATRA resistant APL. Because the cumulative dose of anthracyclines had reached a limiting dose, and the patient was elderly, the induction therapy with further chemotherapy seemed to be highly risky. Before arsenic trioxide treatment, the protocol was reviewed and approved by the institutional ethical committee of our hospital, and written informed consent was obtained from the patient and his family (based on the ethical principle...