Restricted Anthracycline Strategy in Pediatric Acute Promyelocytic Leukemia - A Single Centre Experience

Acute promyelocytic leukemia (APML) is a highly curable leukemia of childhood. In low- and middle-income countries, anthracycline toxicity, such as infections and cytopenias, can lead to mortality. In this study, we describe the outcomes of Pediatric APML treated on a protocol that restricts anthracycline use. A retrospective chart review of children with APML treated between January 2015 and December 2023 was conducted. An ATO-ATRA (Arsenic trioxide-All trans retinoic acid) based treatment protocol was employed, but with a unique strategy that restricts anthracycline use to progressive leucocytosis, irrespective of risk stratification. Out of 16 children, 10 (62.5%) were high-risk APML and 6 (37.5%) were standard-risk APML. Of these, 3 children died of hemorrhage very early during therapy, and one abandoned therapy. Of the 12 (75%) children who completed induction therapy, all received hydroxyurea, and only 3 (25%) received anthracycline for cytoreduction. All achieved hematological remission post-induction. While three were lost to follow-up thereafter, the remaining 9 (75%) completed consolidation and are in long-term molecular remission. Hydroxyurea as a cytoreductive agent in APML allows for restricting anthracycline use to progressive leucocytosis without compromising outcomes.