We asked, and you answered! Here are the responses from this month’s “You Make the Call” question on how you would treat a patient with acute promyelocytic leukemia and CNS disease.
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I would consider using the APML4 protocol but would introduce IT methotrexate during the consolidation phase. I would also consider the European APL protocol with high-dose cytarabine during consolidation.
Hasmukh Jain, MD, DM
Mumbai, India
One option is additional triple induction therapy, like in acute lymphoblastic leukemia induction.
Another possibility to consider is baseline flow cytometry on the cerebrospinal fluid sample.
Ambar Garg, MD
Raipur, India
I would continue with systemic ATO plus IT chemotherapy until negative for CNS involvement and then follow with MRI. I would also consider the use of radiotherapy. I think the soft tissue expansion of the sacrum into the spinal canal is the cause of the red blood cells in the LP sample.
Yaquelin Garcia, MD
Lima, Peru
I would treat the patient with IT methotrexate.
Timoleon Anguita, MD
Santiago, Chile
This is a very challenging case. I would manage the CNS disease with craniospinal irradiation and IT chemotherapy; this would provide good CNS disease control without interfering with the consolidation therapy.
If she had been treated earlier for Ewing sarcoma, I would have considered a secondary APL. Another possibility would be Li-Fraumeni syndrome.
Zubair Syed, MD, MBBS, MRCP
Corpus Christi, Texas