Randomized trials in acute promyelocytic leukemia patients have shown that treatment with a combination of all-trans retinoic acid (ATRA) and arsenic trioxide (ATO) is superior in efficacy to monotherapy, with significantly decreased mortality. So far, there are little data available to explain the success of the ATRA and ATO combination treatment in molecular terms. We showed that ATRA-and ATO-treated cells had the same capacity for superoxide production, which was reduced by two-thirds in the combined treatment. Secreted inflammatory biomarkers (monocyte chemoattractant protein-1 [MCP-1], interleukin-1 beta [IL-1β] and tumor necrosis factor-α [TNF-α]) were significantly decreased and were further reduced in a transglutaminase 2 (TG2) expression-dependent manner. The amount of secreted TNF-α in the supernatant of NB4 TG2 knockout cells was close to 50 times lower than in ATRA-treated differentiated wild-type NB4 cells. The irreversible inhibitor of TG2 NC9 not only decreased reactive oxygen species production 28-fold, but decreased the concentration of MCP-1, IL-1β and TNF-α 8-, 15-and 61-fold, respectively in the combined ATRA + ATO-treated wild-type NB4 cell culture. We propose that atypical expression of TG2 leads to the generation of inflammation, which thereby serves as a potential target for the prevention of differentiation syndrome.(ATRA) both activates the PML-RARα chimera protein and initiates its proteolysis, resulting in the differentiation of APL leukemic cells [1][2][3].In the 2000s, arsenic trioxide (As 2 O 3 /ATO) was approved by the Food and Drug Administration (US FDA) to treat APL. Clinical data have shown that ATO, either as a single agent or combined with ATRA, can improve the outcomes in newly diagnosed and relapsed APL, compared to ATRA treatment alone [4][5][6].When combined with ATRA and chemotherapy, ATO can induce complete remission of APL patients, with a five-year overall survival rate up to 90% [5]. At the molecular level, ATO exhibits cytotoxic effects in a concentration-dependent manner, while at lower concentrations (< 0.5 µM), ATO can induce partial differentiation and at higher concentrations (> 0.5 µM), it initiates apoptosis of APL cells. Some of the signal transduction pathways and transactivations of transcription factors involved are arsenic-induced and redox-sensitive. These include the mitogen-activated protein kinases (MAPKs), extracellular signal-regulated kinases 1/2 (ERK1/2), stress-activated protein kinase/Jun-N terminal protein kinases (SAPK/JNK), the apoptosis signal-regulating kinase 1/thioredoxin (ASK1/TRX) system, the AKT-mTOR pathway, transcription factor AP-1 and the nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) [7]. Although both ATO and ATRA prime the PML-RARα oncoprotein for proteolysis, only ATO is effective as a monotherapy, through the elimination of residual leukemia-initiating cells. The major limitation to ATO treatment is coagulopathy, which is one of the major causes of early death in APL, driven by procoagulant and fibrino...