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Heparin treatment for the hemorrhagic diathesis of acute promyelocytic leukemia
Heparin Treatment for the Hemorrhagic Diathesis of Acute Promyelocytic Leukemia
HARVEY R. GRALNICK,
M.D.
JOYCE BAGLEY, B.S. ELlsNOR ABRELL, Bethesda,
B.S.
Maryland
From the Hematology Service, Clinical Center, National Institutes of Health, Bethesda, Maryland 20014. Requests for reprints should be addressed to Dr. Harvey R. Gralnick, Hematology Service, Clinical Cent,er, National Institutes of Health, Bethesda, Maryland 20014. Manuscript re-
ceived February
Volume
52,
23, 1971.
February
1972
Four patients with acute promyelocytic leukemia (APL) had clinical, laboratory and postmortem evidence of hemorrhage and thrombosis, Three patients were treated with heparin with prompt improvement of their bleeding and coagulation abnormalities. The fourth patient had a rapidly fatal course with marked coagulation abnormalities and died of hemorrhage. The clinical and coagulation response to heparin suggests that disseminated intravascular coagulation plays a predominant role in the hemorrhagic diathesis of APL. The postmortem findings indicate that disseminated intravascular coagulation (DIC) occurs as a chronic process in APL, with acute exacerbations. Consequently we believe that heparin therapy should be instituted early in the course of the disease and continued until a remission ensues. Fibrinolytic inhibitors should not be primary therapy and should be considered only in conjunction with heparin. Acute promyelocytic leukemia (APL) is characterized as a clinical entity by the presence of many promyelocytes with large azurophilic granules and a clinical course complicated by severe hemorrhage and poor response to chemotherapy. Investigation of the hemorrhagic diathesis of APL has revealed hypofibrinogenemia, factor V deficiency and thrombocytopenia. The pathogenesis of the coagulation deficiencies in APL has been attributed to fibrinolysis, disseminated intravascular coagulation (DIC) or decreased synthesis. Attempts to correct the coagulation abnormalities and bleeding have been either unsuccessful or have resulted in only a partial response. Our purpose is to describe four patients with APL, to present their coagulation abnormalities and to report the effects of heparin therapy on the coagulation abnormalities in three patients. Postmortem findings and their relationship to the hemorrhagic diathesis are presented.
167
HEPARIN
TABLE
TREATMENT
I
Initial
IN ACUTE PROMYELOCYTIC
Coagulation
Studies in Four Patients
Study Prothrombin
time
(set)
10.5-13.5
Plasminogen (casein Factor V (%) Factor VI I-X (%) Factor VI I I (%)
units/ml)
Factor IX (%) Fibrinogen degradation
AND
(set) mm)
30-35 ZOO-450 205-390 >180 2-4 65-140 71-130 62-155 65-135
products
METHODS
Freehold,
N.J.)
as the
substrate
and
measur-
ing nonperchloric acid precipitable peptides at 275 mm. Serum from whole blood clotted at 37°C in the presence of epsilon aminocaproic acid was tested for fibrinogen breakdown products by the agar double diffusion technic [9] and by hemagglutination inhibition [lo] with antifibrinogen antibody prepared in rabbits. Platelet counts were performed using an electronic particle counter [ll]. Whole blood clotting times were measured in glass [12].
168
ET AL.
Case 1
Case 2
Case 3
Case 4
22
13.3
13.0 29.0 16 264 >180 2.4 70
12.0
32 19 196 160 1.7 72
119 187 165 +
110 192 128 -
48 13 94 >180 1.6 50 57
110 ... +
33.2 97 144 >180 1.8 60
101 148 92
CASE REPORTS
Patients. In all four patients the diagnosis of APL was established by bone marrow and periphe’ral blood examination. Two patients were female, aged five and twenty-six years, and two patients were male, aged four and twenty-eight years. Coagulation Studiles. Blood was collected through 19gauge needles into plastic syringes and transferred to nonwettable tubes containing one part 40 per cent sodium citrate to 100 parts blood or one part 20 per cent potassium oxalate to 50 parts blood. After centrifugation at 4°C at a speed of 4,000 rpm for ten minutes, the plasma samples were kept at 4OC and tested immediately or frozen at -20°C and tested within forty-eight hours. Serum was collected from samples clotted in the presence of epsilon aminocaproic acid (final concentration 0.2 M) and thrombin 50 units (Parke-Davis Co., Cincinnati, Ohio), which were allowed to stand at 37°C for four to twenty-four hours, centrifuged, decanted and tested. The following tests were performed on titrated plasma samples: one-stage prothrombin time using rabbit brain thromboplastin (Ortho Diagnostic Division, Ortho Pharmaceutical Co.) [l], partial thromboplastin time with celite as the plasma activator (General Diagnostics Division, Warner-Chilcott Laboratories) [2], factor V assay [3], factor VII-X [4], factor VIII and factor IX [5]. All these tests were performed on a semiautomated coagulation timer (Fibrometer@, BioQuest, Cockeysville, Maryland). The plasminogen assay [6], fibrinogen [7] and euglobulin clot lysis [8] were carried out on oxalate plasma samples. The plasminogen assay was modified by using alpha-casein (Worthington Biochemical,
GRALNICK
with APL
Normal Values
Partial thromboplastin time Platelet count (thousand/cu Fibrinogen (mg %) Euglobulin lysis (min)
MATERIALS
LEUKEMIA-
Case 1. This twenty-six year old white woman (C.S.) was admitted to the National Institutes of Health (NIH) for the third time in January 1967 because of weakness and easy bruisability. She had been admitted to the NIH on two occasions in November 1966, and a diagnosis of Stein-Leventhal syndrome had been made. Two weeks prior to her third admission the patient noticed spontaneous ecchymoses. One week later she noted excessively heavy menstrual bleeding and epistaxis. The patient was found to be anemic and thrombocytopenic, and she was referred to the NIH for evaluation. On admission she was febrile, and numerous large ecchymoses were found over her breasts, arms and legs. The hemoglobin value was 10.5 gm per cent, white blood cell count 25,9OO/cu mm with 88 per cent of the cells promyelocytes containing numerous Auer rods. The platelet count was 13,OOO/cu mm. Bone marrow examination revealed a hypercellular particle composed of promyelocytes. Coagulation studies on admission were abnormal. The patient was treated with antibiotics, combination chemotherapy, platelet transfusions, fresh frozen plasma and 8 gm of fibrinogen. Vaginal bleeding persisted. The fibrinogen level improved, but the other coagulation abnormalities were not affected. The patient required constant transfusions to maintain her hemoglobin level at 8 gm per cent. On the fourth hospital day oliguria and hypofibrinogenemia developed. On the sixth hospital day the coagulation tests were still abnormal, and the patient became confused and dysarthric. The urea nitrogen level had risen to 47 mg per cent. On the seventh hospital day the patient became co.matose; she died later that day. At autopsy leukemic infiltration replaced the bone marrow, spleen and lymph nodes. There were multiple central vein thrombi in the liver. Many of the thrombi were attached to adjacent vessel walls by fibroblasts; others were unattached. Multiple thrombi were found within the myocardial blood vessels. The spleen was and scattered blood vessels contained enlarged, thrombi. The ovaries were consistent with the SteinLeventhal syndrome. The central nervous system was normal.
The American
Journal
of Medicine
HEPARIN
TREATMENT
In this twenty-eight year old white man (C.P.) Case 2. painless hematuria developed in March 1969. At the end of March he had nontraumatic gingival bleeding, and then recurrent hematuria and easy bruisability. He was hospitalized at another hospital where bleeding from venipuncture sites and thrombocytopenia were noted. A bone marrow specimen revealed APL. On admission to tqe NIH the patient had multiple ecchymoses and large purpuric lesions at venipuncture sites. The hemoglobin level was 8.8 gm per cent, white blood cell count 13,3OO/cu mm with 75 per cent of the cells promyelocytes and myeloblasts containing Auer rods. The platelet count was 19,OOO/cu mm. The urine was grossly bloody and contained 3f albumin and red cells; hemoglobinuria was marked. Coagulation studies were normal except for a slightly reduced fibrinogen level (Table I). The patient’s course was complicated by fever, hematuria, granulocytopenia and a poor response to chemotherapy. Three weeks after admission dyspnea and cyanosis
t
t
LEUKEMIA
-
GRALNICK
ET AL.
suddenly developed. The urea nitrogen level rose from 22 to 61 mg per cent. Oozing from a cut down site started, and he began to have brisk hemoptysis. Coagulation studies revealed prolonged prothrombin and partial thromboplastin times with decreased factors V, VII-X and VIII, low fibrinogen and plasminogen, and the presence of fibrinogen degradation products in the serum. Heparin therapy was initiated. with correction of the coagulation abnormalities and cessation of his bleeding (Figure 1). Four days later heparin therapy was discontinued. Scrotal cellulitis developed. Twentyfour hours later the patient complained of blurred vision in his right eye. Funduscopic examination revealed a large retinal hemorrhage, and bleeding from his cut down site started again. Culture from the cellulitis site grew Pseudomonas. Dyspnea and epistaxis recurred. Coagulation studies were again abnormal, and the patient was’ given heparin. The urea nitrogen level rose to 110 mg per cent. One day later the urea nitrogen level rose to 156 mg per cent. The urinary output
+
t
t
FIBRINOGEN
IN ACUTE PROMYELOCYTIC
DEGRADATION PRODUCTS
%
%
I50
‘-+
75
%
____ &_-___~____~
% set
set
250
set
mg,
%
I25 0
35Or-
X103
25
PLATELETS
0 I?+
r
FIBRINOGEN NEG NEG
0
DEGRADATION POS POS
HEPARIN
”
HEPARIN I 7
L_____L I 3
’
25
26
I
27
DAY
of Figure 1. Case 2. Coagulation studies. Administration heparin resulted in elevations of fibrinogen and factor V and Vlll levels.
Volume
52, February
1972
PRODUCTS NEG NEG
I
20
21
22
23
24
DAY Figure 2. Case 3. After heparin administration the fibrinogen and factor Vllf levels rose and fibrinogen degradation products disappeared.
169
HEPARIN
TREATMENT
IN ACUTE PROMYELOCYTIC
LEUKEMIA -
GRALNICK
ET AL.
was adequate, and the epistaxis stopped. Later that day the blood pressure fell abruptly and was unresponsive to pressor therapy.
HEMATURIA OOZING FROM VENA PUNCTURES
I
APL
At autopsy leukemic involvement was found in the pericardium, liver, kidneys, spleen, lymph nodes, bone marrow, skeletal muscle and dura. Acute focal and diffuse hemorrhage were noted in the heart, lungs, stomach, small intestine, kidneys, testes, skin and dura. In addition, the kidneys displayed acute tubular necrosis and regeneration. Case 3. A three year old white girl (M.B.) was admitted to NIH in June 1969 with a diagnosis of APL. Two weeks prior to admission her parents noticed several ecchymoses on her arms, face and legs. A week prior to hospitalization she had spiking fevers. On physical examination the patient was pale and febrile (38.5C). The liver was palpated at the right costal margin, and several large ecchymoses were present on the lower extremities. Laboratory data revealed a hemoglobin level of 5.1 gm per cent, white blood cell count of 16,1OO/cu mm with 74 per cent promyelocytes and myeloblasts containing Auer rods, and a platelet count of 16,OOO/cu mm. Coagulation studies were normal. Whole blood and platelet transfusions were given in addition to antibiotic and antileukemic chemotherapy. During the next five weeks the patient’s course was complicated by fever, infection, leukopenia, anemia, thrombocytopenia and a bone marrow unresponsive to therapy. No evidence of bleeding was noted until the fifth week when hematuria developed suddenly. The patient was afebrile, and no site of infection was apparent. Her hemoglobin level dropped 2.5 gm per cent in eight hours. Coagulation studies revealed prolonged prothrombin and partial thromboplastin times, with marked hypofibrinogenemia and reduced levels of factors V, VII-X and VIII, and the presence of fibrinogen degradation products. intermittent intravenous heparin therapy was instituted. Twenty-four hours later hematuria was detectable only microscopically, and the coagulation studies had reverted to normal except for the platelet count (Figure 2). After four days of heparin therapy extended areas of subcutaneous thrombosis developed over the abdomen. The heparin dosage was increased to 1 mg/kg and then to 1.5 mg/kg even though the coagulation studies had returned to normal. Congestive heart failure with pulmonary edema developed, and the patient was treated with diuretics, digitalization, ‘opiates, phlebotomy and fluid restriction. Terminally the patient was anuric and had right-sided neurologic findings. At autopsy no residual evidence of leukemia was found. Recent and organizing thromboemboli (predominately fibrin and platelets) were found in the lungs, kidneys and heart. In addition an acute massive intracerebral hemorrhage involved the right temporal and
170
30 PROTHROMBIN sac.
20
IOJ
FIBRINDGEN NEG.
KS.
1
6
DEGRADATION
PRODUCTS
PDB
NEG.
NEG.
8
12
HEPARIN
I 7
I
DAY
Case 4. This patient received heparin for Figure 3. forty days. Coagulation factors V, VII-X, VIII and fibrinogen levels rose after heparin therapy and all bleeding ceased.
The
Amerkan
Journal
of
Medkine
HEPARIN TREATMENT
TABLE II
IN ACUTE PROMYELOCYTIC
LEUKEMIA-GRALNICK
ET AL.
Coagulation Studies Before Heparin Therapy in APL Normal Values
S:udy Prothrombln time (set) Partial thromboplastin time (set) Platelet count (thousand/cu mm) Fibrinogen (mg%) Euglobulin lysis(min) Plasminogen (casein units/ml) FactorV(%) Factor VII-X (%)
Factor VIII (%) Factor IX (%> Fibrinogen degradation
products
10.5-13.5 30-35 200-450 205-390 >180 2-4 65-140 71-130 62-155 65-135 -
Casel*
Case2
22
20
18
26.5
48 13 94 >180 1.6 56 57
49 14 190 >180 0.43 5 33 15 99
42 18 55 >180 1.35 24 31 52 102
47 73 34 100 1.97 15 76 61 113
110 ... +
+
Case 3
+
Case4
+
* Did not receive heparin. occipital lobes. Moderate was found bilaterally.
intra-alveolar
hemorrhage
Case 4. Th’is four year old boy (G.G.) was referred to the NIH in July 1969 with a diagnosis of acute leukemia. The parents had noted multiple petechiae and ecchymoses over his chest, extremities and forehead. On physical examination the child was febrile and covered with large ecchymoses. The liver was palpated 3 cm below the right costal margin: the spleen tip was palpable at the left costal margin. On admission the white blood cell count was 338,OOO/cu mm with over 90 per cent promyelocytes, the platelet count was 31,OOO/cu mm, and the hemoglobin level was 6.2 gm per cent. Prothrombin time and partial thromboplastin times were normal on admission. The patient received hydroxyurea and combination chemotherapy. The white blood cellcount dropped to 132,OOO/cu mm. Five days after admission the white blood cell count had dropped to 32,OOO/cu mm, and the platelet count was 59,OOO/cu mm after several platelet transfusions. The patient was now afebrile. Coagulation studies revealed decreased levels of fibrin-
ogen, plasminogen and factor V (Table I). Five days later repeat studies revealed markedly prolonged prothrombin and partial thromboplastin times with decreased levels of factor V, VII-X and VIII, hypofibrinogenemia, a shortened euglobulin clot lysis and the presence of fibrinogen degradation products (Figure 3). Heparin was administered, with correction of all the coagulation abnormalities. The patient remained on anticoagulant for seven weeks. No bleeding occurred, and the results of all coagulation studies were normal. The leukemia was resistant to various combinations of chemotherapy. At the time heparin therapy was discontinued, a Pseudomonas ulcer developed on the buttock, with pneumonia in the lower lobe of the right lung and congestive heart failure. Seven days later bilateral hydropneumothorax appeared. A few hours later a left hemiparesis was noted. Results of coagulation studies were normal at this time. The patient died seven hours later.
Volume 52, February
1972
At autopsy focal areas of leukemia were found in the lymph nodes, lungs and left adrenal gland. In the bone marrow hematopoiesis appeared to be generally normal but with foci of leukemia. Partially organized thrombi were found in the dural sinuses, kidneys, brain and lungs, without associated parenchymal changes. Aspergillosis involved the spleen, left kidney, left diaphragm and left retroperitoneal space.
RESULTS All four patients presented with varying degrees of bleeding. Hematuria and bleeding from venipuncture and bone marrow sites were the most common finding. The initial coagulation data are presented in Table I, Hypofibrinogenemia was found in three patients. Plasminogen was decreased in three patients, and factor V was minimally decreased in two patients. One of the two patients with low factor V levels had a prolonged prothrombin and partial thromboplastin time, and there were fibrinogen degradation products in her serum. Leukocytosis with large numbers of circulating promyelocytes and thrombocytopenia were present in all four patients. Within one day to five weeks after admission major bleeding occurred in association with major coagulation abnormalities (Table II). At that time all four patients had hypofibrinogenemia, thrombocytopenia, decreased plasminogen levels and decreased levels of factor V and VII-X, with prolonged prothrombin and partial thromboplastin times and fibrinogen degradation products in their serum. One patient had a low factor VIII level; two others had a marked decrease in factor VIII levels compared to initial values. One patient (Case 1) received a fibrinogen infusion in addition to fresh frozen plasma, plate. let and whole blood transfusion without correction of her coagulation abnormalities or her bleed-
HEPARIN TREATMENT IN ACUTE PROMYELOCYTIC LEUKEMIA-
FIBRINOGEN
t FRESH FROZEN FACTOR
%
INFUSION
ficial effect of heparin is balanced against the risk of hemorrhage in a thrombocytopenic, infectionprone patient. After the initiation of heparin therapy, platelet
PIII:
lzp____+-+-+----I
50 set
PLASMA
PARTIAL
THROMBOPLASTIN
TIME
40
+ I I
FIBRINOGEN +
DEGRADATION
PRODUCT
I
I
I
1
I
I
2
3
4
5
6
7
DAY
Figure 4. Case 1. This patient did not receive heparin. The fibrinogen level rose on day 2 after fibrinogen infusion and then fell rapidly to preinfusion levels.
ing. The infusion of 8 gm of fibrinogen resulted in raising the fibrinogen level from 94 to 239 mg per cent (value calculated 254 mg per cent). The fibrinogen half-life, which could only be roughly estimated because of the effects of vaginal bleeding and whole blood transfusions, was found to be shortened to about thirty-six hours (normal halflife is ninety hours) (Figure 4). Three patients were given heparin intravenously every six hours. Because of the profound thrombocytopenia and the possibility of bleeding in these patients heparinization was initiated at a dose of 0.5 mg/kg of body weight. This dose was increased stepwise by 0.1 mg/kg until the LeeWhite clotting time five hours after the previous dose of heparin was one and a half to two times higher than pretreatment values. When the LeeWhite clotting time was twelve to sixteen minutes, heparinization was considered adequate. We believe that “complete” anticoagulation such as is used in deep vein thrombophlebitis or pulmonary embolism is unwarranted in these patients because at that level of anticoagulation the bene-
172
GRALNICK ET AL.
concentrates were administered to each patient because of thrombocytopenia. In two patients the dose of heparin was increased to 1.5 mg/kg of body weight in an attempt to increase the platelet count. The increased dose of heparin by itself did not result in an increment in the platelet count, although in two patients platelet transfusions resulted in a greater increment, and the platelet transfusion requirement was decreased during heparin therapy. In the other heparinized patient, the platelet level and transfusion requirement were not affected. Within twenty-four hours after heparin therapy was initiated bleeding slowed or stopped. At the same time the coagulation abnormalities diminished in all three patients. Within twenty-four hours fibrinogen degradation products disappeared from the serum, and the plasminogen level rose. After forty-eight hours of heparin therapy the fibrinogen level rose dramatically, with an increase in factors V, VII-X and VII’I. One patient (Case 2) received heparin for four days, one (Case 3) for five days and one (Case 4) for forty days. None of these patients had any complications related to their heparin therapy. One patient (Case 4) received heparin intravenously for forty days without any bleeding despite persistent thrombocytopenia. During this period his fibrinogen level rose from 34 to 785 mg per cent, his factor V level from 15 to 200 per cent, and his factor VIII level from 61 to 169 per cent. Postmortem findings revealed widespread thrombosis in three patients. These thromboses were both old and recent. In the one patient (Case 2) without pathologic evidence of thrombosis, widespread acute focal hemorrhage was found at autopsy. The hemorrhages were present in many organs in which no evidence of leukemia was detected. COMMENTS It has been suggested that the coagulation abnormalities in acute promyelocytic leukemia (APL) are due to disseminated intravascular coagulation (DIC), fibrinolysis, or to diminished production of coagulation factors. The studies reported here suggest that the primary coagulation abnormality in APL is DIC, with secondary fibrinolysis. The clini-
The American
Journal
of Medicine
HEPARIN
TREATMENT
response to heparin therapy and the postmortem findings in these four patients support this diagnosis. Coagulation abnormalities in the four patients
cal course,
studied consisted of prolonged prothrombin and partial thromboplastin times, and reduced levels of fibrinogen, factor V and factor VIII (relative to patients with other types of leukemia or to the initial value in the individual patient). This suggested DIC. In addition, reduced levels of factor VII-X were fou,nd. Shortened euglobulin clot lysis, reduced plasminogen and the presence of fibrinogen degradation products in the patients’ serum were suggestive of fibrinolysis. This was probably secondary to DIC since these abnormalities disappeared with heparin therapy. The first patient studied was not treated with heparin. Her coagulation abnormalities diminished slightly with fibrinogen infusions, but bleeding persisted, and she died. In the next three patients heparin was administered during active bleeding. In all three, coagulation abnormalities diminished, and the bleeding stopped. One patient received intravenous heparin for forty days with complete correction of his coagulation abnormalities. The postmortem findings of recent and old thrombi in our cases suggest that intravascular coagulation in APL may be more chronic than had been previously thought. The absence of postmortem thrombi in one of our patients and in other recorded cases is not conclusive evidence against DIC, since thrombus formation may be accompanied by local fibrinolysis. In experimental studies the infusion of thrombin and thromboplastin in animals in amounts which cause DIC does not result in detectable thrombi at autopsy [13,14]. Over seventy cases of APL have been reported. Predominant characteristics have been a poor response to chemotherapy and major bleeding. Hypofibrinogenemia and hemorrhage were first associated with APL by Hillestad [15]. In another report of two patients with APL factor V deficiency and thrombocytopenia were described in addition to hypofibrinogenemia [16]. Other reports have identified increased fibrinolysis, decreased factor II, factor VII, factor VIII, IX and X activity [17-211 in various combinations in APL. When patients respond to chemotherapy, the coagulation abnormalities disappear [16]. When
IN ACUTE PROMYELOCYTIC
LEUKEMIA-GRALNICK
ET AL.
the disease relapses, the coagulation abnormalities have recurred. This suggests a prominent role for the promyelocyte in the coagulation disorder. Treatment of the hemorrhagic diathesis of APL has included fibrinolytic inhibitors (epsilon aminocaproic acid), fibrinogen infusion, fresh frozen plasma, platelet concentrates and heparin. Two reports have suggested that heparin therapy is beneficial, and in one report epsilon aminocaproic acid therapy stopped bleeding. Verstraete et al. [22] reported a rise in fibrinogen levels with heparin therapy in one patient, and Rand et al. [21] gave heparin to two patients with partial amelioration of bleeding and a slight diminution in coagulation abnormalities in one of them. Nilsson et al. [18] administered very large amounts of epsilon aminocaproic acid (24 to 36 gm a day) to a patient with APL. The bleeding ceased, and the hyperfibrinolysis subsided. Other workers have reported less success with epsilon aminocaproic acid [19,20]. Fibrinogen infusions alone have usually not been beneficial. The possibility that the promyelocytes in APL produce a thromboplastic-like substance or hberate enzymes which initiate clotting has been suggested by others [23,24]. We have demonstrated a marked increase in tissue factor activity in promyelocytes over the amount found in normal leukocytes and in myeloblasts from patients with acute myeloblastic leukemia [25]. It is likely that the release of this procoagulant and the initiation of DIC are related to the turnover and destruction of promyelocytes. Since we believe that DIC is responsible for the coagulation abnormalities noted in APL a potential hazard of chemotherapy is the destruction of large numbers of promyelocytes with liberation of their procoagulant activity. This sudden release of procoagulant may initiate or exacerbate clinically inapparent DIC. It would seem advisable to institute heparin therapy together with chemotherapy. Platelet transfusions or plasma component therapy can be instituted as necessary after heparinization. In our experience larger and longer platelet increments were seen after heparinization, suggesting decreased consumption in the presence of heparin. Heparin therapy should be continued if possible until the tumor mass is markedly reduced or until a hematologic remission ensues.
HEPARINTREATMENTIN ACUTE PROMYELOCMICLEUKEMIA-GRALNICK ET AL.
REFERENCES 1. 2.
3.
4.
5.
6.
7.
8.
9. 10.
11.
12. 13,
Quick A: Dn the quantitative estimation of prothrombin. Amer J Cfin Path 15: 560, 1945. Langdell R, Wagner R, Brinkhous K: Effects of antihemophiliac factor on one-stage clotting tests. J Lab Clin Med 41: 637, 1953. Stefanini M: New one-stage procedures for the quantitative determination of prothrombin and labile factor. Amer J Clin Path 20: 233, 1950. Owren P, Aas K: The control of dicumarol therapy and the quantitative determination of prothrombin and proconvertin. Stand J Clin Lab Invest 3: 201, 1951. Simone J, Vanderheiden J, Abildgaard C: A semiautomatic one-stage factor VIII assay with a commercially prepared standard. J Lab Clin Med 69: 706, 1967. Alkjaersig N, Fletcher A, Shxerry S: The mechanism of clot dissolution by plasmi’n. J Clin Invest 38: 1086, 1959. Ratnoff 0, Menzie C: A new method for the determination of fibrinogen in small samples of plasma. J Lab Clin Med 37: 316, 1951. Milstone H: A factor in normal human blood which participates in streptococcal fibrinolysis. J lmmun 42: 109.1941. Ouchterlony 0: Progress in Allergy (Kados, Waks. man. eds). Basal and New York. 1962. Israels’E, Rayner ll, lsraels H, Zipursky A: A microhemagglutination inhibition assay for the quantitation of fibrinogen breakdown products. J Lab Clin Med 71: 333, 1968 Bull B, Schneiderman M, Brecher G: Platelet counts with the Coulter counter. Amer J Clin Path 44: 678,1965. Lee R,, White P: A clinical study of the coagulation time of blood. Amer J Med Sci 145: 495, 1913. Lee L: Reticuloendothelial clearance of circulating fibrin in the pathogenesis of the generalized
14.
15. 16.
17.
18.
19. 20.
21.
22.
23. 24.
25.
Schwartsman reaction. J Exp Med 115: 1065, 1962. Lewis JH, Szeto I: Effects of intravenous tissue thromboplastin in dogs: development of an anti. coagulant. J Lab Clin Med 60: 261, 1962. Hillestad LK: Acute promyelocytic leukemia. Acta Med Stand 159: 189, 1957. Didisheim P, Trombold TS, Vandervoart R, Mibashan R: Acute promyelocytic leukemia with fibrinogen and factor V deficiencies. Blood 23: 717, 1964, Bernard J, Lasneret J, Chome J, Levy P, Boiron M: A cytological and histological study of acute promvelocvtic leukemia. J Clin Path 16: 319. 1963. Nil&on IM, Sjoerdsma A, Waldenstrom J: Antifibrulolytic activity and metabolism of epsilon aminocaproic acid in man. Lancet 1: 1322, 1960. Ryder RJW: Promyelocytic leukemia and hypofibrinogenaemia. Acta Haemat 35: 181, 1966. Rosenthal RL: Acute promyelocytic leukemia associated with hypofibrinogen’emia. Blood 21: 495, 1963. Rand JJ, Maloney WC, Sise HS: Coagulation defects in acute promyelocytic leukemia. Arch Intern Med (Chicago) 123: 39, 1969. Verstraete M, Vermylen C, Vermylen J, Vanderbraucke J: Excessive consumption of blood coagulation components as cause of hemorrhagic diathesis. Amer J Med 38: 899, 1965. Quigley H: Peripheral leukocyte thromboplastin in promyelocytic leukemia. Fed Proc 26: 648, 1967. Baker W, Bang NU, Nachman RL, Raafat F, Horowitz HI: Hypofibrinogenemic hemorrhage in acute myelogenous I,eukemia treated with heparin. Ann Intern Med 861: 116, 1964. Gralnick HR, Bagley J, Abrell E: The hemorrhagic diathesis of acute promyelocytic leukemia: pathogenesis and treatment, Program XIII International Congress of Hematology, 1970, p 52.
HARVEY R. GRALNICK,
M.D.
JOYCE BAGLEY, B.S. ELlsNOR ABRELL, Bethesda,
B.S.
Maryland
From the Hematology Service, Clinical Center, National Institutes of Health, Bethesda, Maryland 20014. Requests for reprints should be addressed to Dr. Harvey R. Gralnick, Hematology Service, Clinical Cent,er, National Institutes of Health, Bethesda, Maryland 20014. Manuscript re-
ceived February
Volume
52,
23, 1971.
February
1972
Four patients with acute promyelocytic leukemia (APL) had clinical, laboratory and postmortem evidence of hemorrhage and thrombosis, Three patients were treated with heparin with prompt improvement of their bleeding and coagulation abnormalities. The fourth patient had a rapidly fatal course with marked coagulation abnormalities and died of hemorrhage. The clinical and coagulation response to heparin suggests that disseminated intravascular coagulation plays a predominant role in the hemorrhagic diathesis of APL. The postmortem findings indicate that disseminated intravascular coagulation (DIC) occurs as a chronic process in APL, with acute exacerbations. Consequently we believe that heparin therapy should be instituted early in the course of the disease and continued until a remission ensues. Fibrinolytic inhibitors should not be primary therapy and should be considered only in conjunction with heparin. Acute promyelocytic leukemia (APL) is characterized as a clinical entity by the presence of many promyelocytes with large azurophilic granules and a clinical course complicated by severe hemorrhage and poor response to chemotherapy. Investigation of the hemorrhagic diathesis of APL has revealed hypofibrinogenemia, factor V deficiency and thrombocytopenia. The pathogenesis of the coagulation deficiencies in APL has been attributed to fibrinolysis, disseminated intravascular coagulation (DIC) or decreased synthesis. Attempts to correct the coagulation abnormalities and bleeding have been either unsuccessful or have resulted in only a partial response. Our purpose is to describe four patients with APL, to present their coagulation abnormalities and to report the effects of heparin therapy on the coagulation abnormalities in three patients. Postmortem findings and their relationship to the hemorrhagic diathesis are presented.
167
HEPARIN
TABLE
TREATMENT
I
Initial
IN ACUTE PROMYELOCYTIC
Coagulation
Studies in Four Patients
Study Prothrombin
time
(set)
10.5-13.5
Plasminogen (casein Factor V (%) Factor VI I-X (%) Factor VI I I (%)
units/ml)
Factor IX (%) Fibrinogen degradation
AND
(set) mm)
30-35 ZOO-450 205-390 >180 2-4 65-140 71-130 62-155 65-135
products
METHODS
Freehold,
N.J.)
as the
substrate
and
measur-
ing nonperchloric acid precipitable peptides at 275 mm. Serum from whole blood clotted at 37°C in the presence of epsilon aminocaproic acid was tested for fibrinogen breakdown products by the agar double diffusion technic [9] and by hemagglutination inhibition [lo] with antifibrinogen antibody prepared in rabbits. Platelet counts were performed using an electronic particle counter [ll]. Whole blood clotting times were measured in glass [12].
168
ET AL.
Case 1
Case 2
Case 3
Case 4
22
13.3
13.0 29.0 16 264 >180 2.4 70
12.0
32 19 196 160 1.7 72
119 187 165 +
110 192 128 -
48 13 94 >180 1.6 50 57
110 ... +
33.2 97 144 >180 1.8 60
101 148 92
CASE REPORTS
Patients. In all four patients the diagnosis of APL was established by bone marrow and periphe’ral blood examination. Two patients were female, aged five and twenty-six years, and two patients were male, aged four and twenty-eight years. Coagulation Studiles. Blood was collected through 19gauge needles into plastic syringes and transferred to nonwettable tubes containing one part 40 per cent sodium citrate to 100 parts blood or one part 20 per cent potassium oxalate to 50 parts blood. After centrifugation at 4°C at a speed of 4,000 rpm for ten minutes, the plasma samples were kept at 4OC and tested immediately or frozen at -20°C and tested within forty-eight hours. Serum was collected from samples clotted in the presence of epsilon aminocaproic acid (final concentration 0.2 M) and thrombin 50 units (Parke-Davis Co., Cincinnati, Ohio), which were allowed to stand at 37°C for four to twenty-four hours, centrifuged, decanted and tested. The following tests were performed on titrated plasma samples: one-stage prothrombin time using rabbit brain thromboplastin (Ortho Diagnostic Division, Ortho Pharmaceutical Co.) [l], partial thromboplastin time with celite as the plasma activator (General Diagnostics Division, Warner-Chilcott Laboratories) [2], factor V assay [3], factor VII-X [4], factor VIII and factor IX [5]. All these tests were performed on a semiautomated coagulation timer (Fibrometer@, BioQuest, Cockeysville, Maryland). The plasminogen assay [6], fibrinogen [7] and euglobulin clot lysis [8] were carried out on oxalate plasma samples. The plasminogen assay was modified by using alpha-casein (Worthington Biochemical,
GRALNICK
with APL
Normal Values
Partial thromboplastin time Platelet count (thousand/cu Fibrinogen (mg %) Euglobulin lysis (min)
MATERIALS
LEUKEMIA-
Case 1. This twenty-six year old white woman (C.S.) was admitted to the National Institutes of Health (NIH) for the third time in January 1967 because of weakness and easy bruisability. She had been admitted to the NIH on two occasions in November 1966, and a diagnosis of Stein-Leventhal syndrome had been made. Two weeks prior to her third admission the patient noticed spontaneous ecchymoses. One week later she noted excessively heavy menstrual bleeding and epistaxis. The patient was found to be anemic and thrombocytopenic, and she was referred to the NIH for evaluation. On admission she was febrile, and numerous large ecchymoses were found over her breasts, arms and legs. The hemoglobin value was 10.5 gm per cent, white blood cell count 25,9OO/cu mm with 88 per cent of the cells promyelocytes containing numerous Auer rods. The platelet count was 13,OOO/cu mm. Bone marrow examination revealed a hypercellular particle composed of promyelocytes. Coagulation studies on admission were abnormal. The patient was treated with antibiotics, combination chemotherapy, platelet transfusions, fresh frozen plasma and 8 gm of fibrinogen. Vaginal bleeding persisted. The fibrinogen level improved, but the other coagulation abnormalities were not affected. The patient required constant transfusions to maintain her hemoglobin level at 8 gm per cent. On the fourth hospital day oliguria and hypofibrinogenemia developed. On the sixth hospital day the coagulation tests were still abnormal, and the patient became confused and dysarthric. The urea nitrogen level had risen to 47 mg per cent. On the seventh hospital day the patient became co.matose; she died later that day. At autopsy leukemic infiltration replaced the bone marrow, spleen and lymph nodes. There were multiple central vein thrombi in the liver. Many of the thrombi were attached to adjacent vessel walls by fibroblasts; others were unattached. Multiple thrombi were found within the myocardial blood vessels. The spleen was and scattered blood vessels contained enlarged, thrombi. The ovaries were consistent with the SteinLeventhal syndrome. The central nervous system was normal.
The American
Journal
of Medicine
HEPARIN
TREATMENT
In this twenty-eight year old white man (C.P.) Case 2. painless hematuria developed in March 1969. At the end of March he had nontraumatic gingival bleeding, and then recurrent hematuria and easy bruisability. He was hospitalized at another hospital where bleeding from venipuncture sites and thrombocytopenia were noted. A bone marrow specimen revealed APL. On admission to tqe NIH the patient had multiple ecchymoses and large purpuric lesions at venipuncture sites. The hemoglobin level was 8.8 gm per cent, white blood cell count 13,3OO/cu mm with 75 per cent of the cells promyelocytes and myeloblasts containing Auer rods. The platelet count was 19,OOO/cu mm. The urine was grossly bloody and contained 3f albumin and red cells; hemoglobinuria was marked. Coagulation studies were normal except for a slightly reduced fibrinogen level (Table I). The patient’s course was complicated by fever, hematuria, granulocytopenia and a poor response to chemotherapy. Three weeks after admission dyspnea and cyanosis
t
t
LEUKEMIA
-
GRALNICK
ET AL.
suddenly developed. The urea nitrogen level rose from 22 to 61 mg per cent. Oozing from a cut down site started, and he began to have brisk hemoptysis. Coagulation studies revealed prolonged prothrombin and partial thromboplastin times with decreased factors V, VII-X and VIII, low fibrinogen and plasminogen, and the presence of fibrinogen degradation products in the serum. Heparin therapy was initiated. with correction of the coagulation abnormalities and cessation of his bleeding (Figure 1). Four days later heparin therapy was discontinued. Scrotal cellulitis developed. Twentyfour hours later the patient complained of blurred vision in his right eye. Funduscopic examination revealed a large retinal hemorrhage, and bleeding from his cut down site started again. Culture from the cellulitis site grew Pseudomonas. Dyspnea and epistaxis recurred. Coagulation studies were again abnormal, and the patient was’ given heparin. The urea nitrogen level rose to 110 mg per cent. One day later the urea nitrogen level rose to 156 mg per cent. The urinary output
+
t
t
FIBRINOGEN
IN ACUTE PROMYELOCYTIC
DEGRADATION PRODUCTS
%
%
I50
‘-+
75
%
____ &_-___~____~
% set
set
250
set
mg,
%
I25 0
35Or-
X103
25
PLATELETS
0 I?+
r
FIBRINOGEN NEG NEG
0
DEGRADATION POS POS
HEPARIN
”
HEPARIN I 7
L_____L I 3
’
25
26
I
27
DAY
of Figure 1. Case 2. Coagulation studies. Administration heparin resulted in elevations of fibrinogen and factor V and Vlll levels.
Volume
52, February
1972
PRODUCTS NEG NEG
I
20
21
22
23
24
DAY Figure 2. Case 3. After heparin administration the fibrinogen and factor Vllf levels rose and fibrinogen degradation products disappeared.
169
HEPARIN
TREATMENT
IN ACUTE PROMYELOCYTIC
LEUKEMIA -
GRALNICK
ET AL.
was adequate, and the epistaxis stopped. Later that day the blood pressure fell abruptly and was unresponsive to pressor therapy.
HEMATURIA OOZING FROM VENA PUNCTURES
I
APL
At autopsy leukemic involvement was found in the pericardium, liver, kidneys, spleen, lymph nodes, bone marrow, skeletal muscle and dura. Acute focal and diffuse hemorrhage were noted in the heart, lungs, stomach, small intestine, kidneys, testes, skin and dura. In addition, the kidneys displayed acute tubular necrosis and regeneration. Case 3. A three year old white girl (M.B.) was admitted to NIH in June 1969 with a diagnosis of APL. Two weeks prior to admission her parents noticed several ecchymoses on her arms, face and legs. A week prior to hospitalization she had spiking fevers. On physical examination the patient was pale and febrile (38.5C). The liver was palpated at the right costal margin, and several large ecchymoses were present on the lower extremities. Laboratory data revealed a hemoglobin level of 5.1 gm per cent, white blood cell count of 16,1OO/cu mm with 74 per cent promyelocytes and myeloblasts containing Auer rods, and a platelet count of 16,OOO/cu mm. Coagulation studies were normal. Whole blood and platelet transfusions were given in addition to antibiotic and antileukemic chemotherapy. During the next five weeks the patient’s course was complicated by fever, infection, leukopenia, anemia, thrombocytopenia and a bone marrow unresponsive to therapy. No evidence of bleeding was noted until the fifth week when hematuria developed suddenly. The patient was afebrile, and no site of infection was apparent. Her hemoglobin level dropped 2.5 gm per cent in eight hours. Coagulation studies revealed prolonged prothrombin and partial thromboplastin times, with marked hypofibrinogenemia and reduced levels of factors V, VII-X and VIII, and the presence of fibrinogen degradation products. intermittent intravenous heparin therapy was instituted. Twenty-four hours later hematuria was detectable only microscopically, and the coagulation studies had reverted to normal except for the platelet count (Figure 2). After four days of heparin therapy extended areas of subcutaneous thrombosis developed over the abdomen. The heparin dosage was increased to 1 mg/kg and then to 1.5 mg/kg even though the coagulation studies had returned to normal. Congestive heart failure with pulmonary edema developed, and the patient was treated with diuretics, digitalization, ‘opiates, phlebotomy and fluid restriction. Terminally the patient was anuric and had right-sided neurologic findings. At autopsy no residual evidence of leukemia was found. Recent and organizing thromboemboli (predominately fibrin and platelets) were found in the lungs, kidneys and heart. In addition an acute massive intracerebral hemorrhage involved the right temporal and
170
30 PROTHROMBIN sac.
20
IOJ
FIBRINDGEN NEG.
KS.
1
6
DEGRADATION
PRODUCTS
PDB
NEG.
NEG.
8
12
HEPARIN
I 7
I
DAY
Case 4. This patient received heparin for Figure 3. forty days. Coagulation factors V, VII-X, VIII and fibrinogen levels rose after heparin therapy and all bleeding ceased.
The
Amerkan
Journal
of
Medkine
HEPARIN TREATMENT
TABLE II
IN ACUTE PROMYELOCYTIC
LEUKEMIA-GRALNICK
ET AL.
Coagulation Studies Before Heparin Therapy in APL Normal Values
S:udy Prothrombln time (set) Partial thromboplastin time (set) Platelet count (thousand/cu mm) Fibrinogen (mg%) Euglobulin lysis(min) Plasminogen (casein units/ml) FactorV(%) Factor VII-X (%)
Factor VIII (%) Factor IX (%> Fibrinogen degradation
products
10.5-13.5 30-35 200-450 205-390 >180 2-4 65-140 71-130 62-155 65-135 -
Casel*
Case2
22
20
18
26.5
48 13 94 >180 1.6 56 57
49 14 190 >180 0.43 5 33 15 99
42 18 55 >180 1.35 24 31 52 102
47 73 34 100 1.97 15 76 61 113
110 ... +
+
Case 3
+
Case4
+
* Did not receive heparin. occipital lobes. Moderate was found bilaterally.
intra-alveolar
hemorrhage
Case 4. Th’is four year old boy (G.G.) was referred to the NIH in July 1969 with a diagnosis of acute leukemia. The parents had noted multiple petechiae and ecchymoses over his chest, extremities and forehead. On physical examination the child was febrile and covered with large ecchymoses. The liver was palpated 3 cm below the right costal margin: the spleen tip was palpable at the left costal margin. On admission the white blood cell count was 338,OOO/cu mm with over 90 per cent promyelocytes, the platelet count was 31,OOO/cu mm, and the hemoglobin level was 6.2 gm per cent. Prothrombin time and partial thromboplastin times were normal on admission. The patient received hydroxyurea and combination chemotherapy. The white blood cellcount dropped to 132,OOO/cu mm. Five days after admission the white blood cell count had dropped to 32,OOO/cu mm, and the platelet count was 59,OOO/cu mm after several platelet transfusions. The patient was now afebrile. Coagulation studies revealed decreased levels of fibrin-
ogen, plasminogen and factor V (Table I). Five days later repeat studies revealed markedly prolonged prothrombin and partial thromboplastin times with decreased levels of factor V, VII-X and VIII, hypofibrinogenemia, a shortened euglobulin clot lysis and the presence of fibrinogen degradation products (Figure 3). Heparin was administered, with correction of all the coagulation abnormalities. The patient remained on anticoagulant for seven weeks. No bleeding occurred, and the results of all coagulation studies were normal. The leukemia was resistant to various combinations of chemotherapy. At the time heparin therapy was discontinued, a Pseudomonas ulcer developed on the buttock, with pneumonia in the lower lobe of the right lung and congestive heart failure. Seven days later bilateral hydropneumothorax appeared. A few hours later a left hemiparesis was noted. Results of coagulation studies were normal at this time. The patient died seven hours later.
Volume 52, February
1972
At autopsy focal areas of leukemia were found in the lymph nodes, lungs and left adrenal gland. In the bone marrow hematopoiesis appeared to be generally normal but with foci of leukemia. Partially organized thrombi were found in the dural sinuses, kidneys, brain and lungs, without associated parenchymal changes. Aspergillosis involved the spleen, left kidney, left diaphragm and left retroperitoneal space.
RESULTS All four patients presented with varying degrees of bleeding. Hematuria and bleeding from venipuncture and bone marrow sites were the most common finding. The initial coagulation data are presented in Table I, Hypofibrinogenemia was found in three patients. Plasminogen was decreased in three patients, and factor V was minimally decreased in two patients. One of the two patients with low factor V levels had a prolonged prothrombin and partial thromboplastin time, and there were fibrinogen degradation products in her serum. Leukocytosis with large numbers of circulating promyelocytes and thrombocytopenia were present in all four patients. Within one day to five weeks after admission major bleeding occurred in association with major coagulation abnormalities (Table II). At that time all four patients had hypofibrinogenemia, thrombocytopenia, decreased plasminogen levels and decreased levels of factor V and VII-X, with prolonged prothrombin and partial thromboplastin times and fibrinogen degradation products in their serum. One patient had a low factor VIII level; two others had a marked decrease in factor VIII levels compared to initial values. One patient (Case 1) received a fibrinogen infusion in addition to fresh frozen plasma, plate. let and whole blood transfusion without correction of her coagulation abnormalities or her bleed-
HEPARIN TREATMENT IN ACUTE PROMYELOCYTIC LEUKEMIA-
FIBRINOGEN
t FRESH FROZEN FACTOR
%
INFUSION
ficial effect of heparin is balanced against the risk of hemorrhage in a thrombocytopenic, infectionprone patient. After the initiation of heparin therapy, platelet
PIII:
lzp____+-+-+----I
50 set
PLASMA
PARTIAL
THROMBOPLASTIN
TIME
40
+ I I
FIBRINOGEN +
DEGRADATION
PRODUCT
I
I
I
1
I
I
2
3
4
5
6
7
DAY
Figure 4. Case 1. This patient did not receive heparin. The fibrinogen level rose on day 2 after fibrinogen infusion and then fell rapidly to preinfusion levels.
ing. The infusion of 8 gm of fibrinogen resulted in raising the fibrinogen level from 94 to 239 mg per cent (value calculated 254 mg per cent). The fibrinogen half-life, which could only be roughly estimated because of the effects of vaginal bleeding and whole blood transfusions, was found to be shortened to about thirty-six hours (normal halflife is ninety hours) (Figure 4). Three patients were given heparin intravenously every six hours. Because of the profound thrombocytopenia and the possibility of bleeding in these patients heparinization was initiated at a dose of 0.5 mg/kg of body weight. This dose was increased stepwise by 0.1 mg/kg until the LeeWhite clotting time five hours after the previous dose of heparin was one and a half to two times higher than pretreatment values. When the LeeWhite clotting time was twelve to sixteen minutes, heparinization was considered adequate. We believe that “complete” anticoagulation such as is used in deep vein thrombophlebitis or pulmonary embolism is unwarranted in these patients because at that level of anticoagulation the bene-
172
GRALNICK ET AL.
concentrates were administered to each patient because of thrombocytopenia. In two patients the dose of heparin was increased to 1.5 mg/kg of body weight in an attempt to increase the platelet count. The increased dose of heparin by itself did not result in an increment in the platelet count, although in two patients platelet transfusions resulted in a greater increment, and the platelet transfusion requirement was decreased during heparin therapy. In the other heparinized patient, the platelet level and transfusion requirement were not affected. Within twenty-four hours after heparin therapy was initiated bleeding slowed or stopped. At the same time the coagulation abnormalities diminished in all three patients. Within twenty-four hours fibrinogen degradation products disappeared from the serum, and the plasminogen level rose. After forty-eight hours of heparin therapy the fibrinogen level rose dramatically, with an increase in factors V, VII-X and VII’I. One patient (Case 2) received heparin for four days, one (Case 3) for five days and one (Case 4) for forty days. None of these patients had any complications related to their heparin therapy. One patient (Case 4) received heparin intravenously for forty days without any bleeding despite persistent thrombocytopenia. During this period his fibrinogen level rose from 34 to 785 mg per cent, his factor V level from 15 to 200 per cent, and his factor VIII level from 61 to 169 per cent. Postmortem findings revealed widespread thrombosis in three patients. These thromboses were both old and recent. In the one patient (Case 2) without pathologic evidence of thrombosis, widespread acute focal hemorrhage was found at autopsy. The hemorrhages were present in many organs in which no evidence of leukemia was detected. COMMENTS It has been suggested that the coagulation abnormalities in acute promyelocytic leukemia (APL) are due to disseminated intravascular coagulation (DIC), fibrinolysis, or to diminished production of coagulation factors. The studies reported here suggest that the primary coagulation abnormality in APL is DIC, with secondary fibrinolysis. The clini-
The American
Journal
of Medicine
HEPARIN
TREATMENT
response to heparin therapy and the postmortem findings in these four patients support this diagnosis. Coagulation abnormalities in the four patients
cal course,
studied consisted of prolonged prothrombin and partial thromboplastin times, and reduced levels of fibrinogen, factor V and factor VIII (relative to patients with other types of leukemia or to the initial value in the individual patient). This suggested DIC. In addition, reduced levels of factor VII-X were fou,nd. Shortened euglobulin clot lysis, reduced plasminogen and the presence of fibrinogen degradation products in the patients’ serum were suggestive of fibrinolysis. This was probably secondary to DIC since these abnormalities disappeared with heparin therapy. The first patient studied was not treated with heparin. Her coagulation abnormalities diminished slightly with fibrinogen infusions, but bleeding persisted, and she died. In the next three patients heparin was administered during active bleeding. In all three, coagulation abnormalities diminished, and the bleeding stopped. One patient received intravenous heparin for forty days with complete correction of his coagulation abnormalities. The postmortem findings of recent and old thrombi in our cases suggest that intravascular coagulation in APL may be more chronic than had been previously thought. The absence of postmortem thrombi in one of our patients and in other recorded cases is not conclusive evidence against DIC, since thrombus formation may be accompanied by local fibrinolysis. In experimental studies the infusion of thrombin and thromboplastin in animals in amounts which cause DIC does not result in detectable thrombi at autopsy [13,14]. Over seventy cases of APL have been reported. Predominant characteristics have been a poor response to chemotherapy and major bleeding. Hypofibrinogenemia and hemorrhage were first associated with APL by Hillestad [15]. In another report of two patients with APL factor V deficiency and thrombocytopenia were described in addition to hypofibrinogenemia [16]. Other reports have identified increased fibrinolysis, decreased factor II, factor VII, factor VIII, IX and X activity [17-211 in various combinations in APL. When patients respond to chemotherapy, the coagulation abnormalities disappear [16]. When
IN ACUTE PROMYELOCYTIC
LEUKEMIA-GRALNICK
ET AL.
the disease relapses, the coagulation abnormalities have recurred. This suggests a prominent role for the promyelocyte in the coagulation disorder. Treatment of the hemorrhagic diathesis of APL has included fibrinolytic inhibitors (epsilon aminocaproic acid), fibrinogen infusion, fresh frozen plasma, platelet concentrates and heparin. Two reports have suggested that heparin therapy is beneficial, and in one report epsilon aminocaproic acid therapy stopped bleeding. Verstraete et al. [22] reported a rise in fibrinogen levels with heparin therapy in one patient, and Rand et al. [21] gave heparin to two patients with partial amelioration of bleeding and a slight diminution in coagulation abnormalities in one of them. Nilsson et al. [18] administered very large amounts of epsilon aminocaproic acid (24 to 36 gm a day) to a patient with APL. The bleeding ceased, and the hyperfibrinolysis subsided. Other workers have reported less success with epsilon aminocaproic acid [19,20]. Fibrinogen infusions alone have usually not been beneficial. The possibility that the promyelocytes in APL produce a thromboplastic-like substance or hberate enzymes which initiate clotting has been suggested by others [23,24]. We have demonstrated a marked increase in tissue factor activity in promyelocytes over the amount found in normal leukocytes and in myeloblasts from patients with acute myeloblastic leukemia [25]. It is likely that the release of this procoagulant and the initiation of DIC are related to the turnover and destruction of promyelocytes. Since we believe that DIC is responsible for the coagulation abnormalities noted in APL a potential hazard of chemotherapy is the destruction of large numbers of promyelocytes with liberation of their procoagulant activity. This sudden release of procoagulant may initiate or exacerbate clinically inapparent DIC. It would seem advisable to institute heparin therapy together with chemotherapy. Platelet transfusions or plasma component therapy can be instituted as necessary after heparinization. In our experience larger and longer platelet increments were seen after heparinization, suggesting decreased consumption in the presence of heparin. Heparin therapy should be continued if possible until the tumor mass is markedly reduced or until a hematologic remission ensues.
HEPARINTREATMENTIN ACUTE PROMYELOCMICLEUKEMIA-GRALNICK ET AL.
REFERENCES 1. 2.
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4.
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7.
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9. 10.
11.
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Quick A: Dn the quantitative estimation of prothrombin. Amer J Cfin Path 15: 560, 1945. Langdell R, Wagner R, Brinkhous K: Effects of antihemophiliac factor on one-stage clotting tests. J Lab Clin Med 41: 637, 1953. Stefanini M: New one-stage procedures for the quantitative determination of prothrombin and labile factor. Amer J Clin Path 20: 233, 1950. Owren P, Aas K: The control of dicumarol therapy and the quantitative determination of prothrombin and proconvertin. Stand J Clin Lab Invest 3: 201, 1951. Simone J, Vanderheiden J, Abildgaard C: A semiautomatic one-stage factor VIII assay with a commercially prepared standard. J Lab Clin Med 69: 706, 1967. Alkjaersig N, Fletcher A, Shxerry S: The mechanism of clot dissolution by plasmi’n. J Clin Invest 38: 1086, 1959. Ratnoff 0, Menzie C: A new method for the determination of fibrinogen in small samples of plasma. J Lab Clin Med 37: 316, 1951. Milstone H: A factor in normal human blood which participates in streptococcal fibrinolysis. J lmmun 42: 109.1941. Ouchterlony 0: Progress in Allergy (Kados, Waks. man. eds). Basal and New York. 1962. Israels’E, Rayner ll, lsraels H, Zipursky A: A microhemagglutination inhibition assay for the quantitation of fibrinogen breakdown products. J Lab Clin Med 71: 333, 1968 Bull B, Schneiderman M, Brecher G: Platelet counts with the Coulter counter. Amer J Clin Path 44: 678,1965. Lee R,, White P: A clinical study of the coagulation time of blood. Amer J Med Sci 145: 495, 1913. Lee L: Reticuloendothelial clearance of circulating fibrin in the pathogenesis of the generalized
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Schwartsman reaction. J Exp Med 115: 1065, 1962. Lewis JH, Szeto I: Effects of intravenous tissue thromboplastin in dogs: development of an anti. coagulant. J Lab Clin Med 60: 261, 1962. Hillestad LK: Acute promyelocytic leukemia. Acta Med Stand 159: 189, 1957. Didisheim P, Trombold TS, Vandervoart R, Mibashan R: Acute promyelocytic leukemia with fibrinogen and factor V deficiencies. Blood 23: 717, 1964, Bernard J, Lasneret J, Chome J, Levy P, Boiron M: A cytological and histological study of acute promvelocvtic leukemia. J Clin Path 16: 319. 1963. Nil&on IM, Sjoerdsma A, Waldenstrom J: Antifibrulolytic activity and metabolism of epsilon aminocaproic acid in man. Lancet 1: 1322, 1960. Ryder RJW: Promyelocytic leukemia and hypofibrinogenaemia. Acta Haemat 35: 181, 1966. Rosenthal RL: Acute promyelocytic leukemia associated with hypofibrinogen’emia. Blood 21: 495, 1963. Rand JJ, Maloney WC, Sise HS: Coagulation defects in acute promyelocytic leukemia. Arch Intern Med (Chicago) 123: 39, 1969. Verstraete M, Vermylen C, Vermylen J, Vanderbraucke J: Excessive consumption of blood coagulation components as cause of hemorrhagic diathesis. Amer J Med 38: 899, 1965. Quigley H: Peripheral leukocyte thromboplastin in promyelocytic leukemia. Fed Proc 26: 648, 1967. Baker W, Bang NU, Nachman RL, Raafat F, Horowitz HI: Hypofibrinogenemic hemorrhage in acute myelogenous I,eukemia treated with heparin. Ann Intern Med 861: 116, 1964. Gralnick HR, Bagley J, Abrell E: The hemorrhagic diathesis of acute promyelocytic leukemia: pathogenesis and treatment, Program XIII International Congress of Hematology, 1970, p 52.