Optimizing treatment for elderly patients with acute promyelocytic leukemia: is it time to replace chemotherapy with all-trans retinoic acid and arsenic trioxide?

This review focuses on the treatment of acute promyelocytic leukemia (APL) in elderly patients and offers recommendations for improving outcomes. Nineteen percent of patients with APL are > or =60 years. Rates of response and survival are lower in elderly compared with younger patients, owing to a higher incidence of early deaths or deaths in remission. However, relapse-free survival rates are similar in both groups. Ongoing trials assess the role of reduced-intensity regimens. All-trans retinoic acid (ATRA) and concurrent arsenic trioxide is associated with high rates of response and molecular remission and low rates of induction deaths. We propose this combination as the treatment of choice in patients with APL, including the elderly. Patients with elevated leukocyte counts may also benefit from gemtuzumab ozogamicin therapy, with or without leukapheresis. Monitoring major organ function and toxicity is essential. Patients should be assessed for minimal residual disease using polymerase chain reaction testing for promyelocytic leukemia-retinoic acid receptor alpha. If molecular relapse is evident, treatment with ATRA and idarubicin, with or without gemtuzumab ozogamicin, is recommended.