The Time to Treatment: A Retrospective Analysis of the Time to All-trans Retinoic Acid (ATRA) in Patients with Suspected Acute Promyelocytic Leukemia (APL)

PURPOSE: Acute promyelocytic leukemia (APL) is a subtype of acute myeloid leukemia (AML) defined by the chromosomal translocation t(15;17), which creates fusion of the promyelocyte gene and the retinoic acid receptor alpha gene. Dysplastic promyelocytes induce aberrations in coagulation leading to hemorrhage and disseminated intravascular coagulation (DIC), which often devolves into a rapidly fatal course. Prompt administration of all-trans retinoic acid (ATRA) reverses the coagulopathy in patients with suspected APL, which ultimately decreases morbidity and mortality. PATIENTS AND METHODS: This retrospective study examines 91 patients over a 5-year period who received ATRA for a suspected or confirmed diagnosis of APL at a tertiary care hospital. We quantified the time for ATRA to be ordered and administered in addition and analyzed variables that potentially influenced time to treatment. RESULTS: The mean time from hospital admission to administration of ATRA was 6 hours and 28 minutes. The clinical variable that improved the time to administration was signs or symptoms of bleeding upon admission. Notably, 89% of the patients in this study were accepted as a transfer from an outside hospital. CONCLUSIONS: Even in tertiary care centers with substantial resources, the time to ATRA remains too long. The need to rapidly recognize, triage, and treat patients with suspected APL is further heightened by the fact that the majority of patients initially present to community hospitals where there is a dearth of ATRA available and transfer times to tertiary hospitals can sometimes be days.