Latest Cancer TreatmentsDr. Mohammadreza Dabiri
Dr. Mohammadreza Dabiriفارسی

Treating acute promyelocytic leukaemia (APL): a cancer treated without chemotherapy

Why APL is now one of the most curable leukaemias, why every hour counts, and what treatment with tretinoin and arsenic is like

Updated: 28 October 20262 min read5 references
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Key points

  • APL is now one of the most curable blood cancers; with tretinoin and arsenic, and no chemotherapy, 97 in 100 patients were alive and free of relapse after 2 years [2].
  • The main danger is the first few days: the disease starts with bleeding, and about 17 in 100 patients still die in those first days [4].
  • Tretinoin should be started the moment APL is suspected, even before the genetic test result [5].

The story of APL: from the deadliest to the most curable

Acute promyelocytic leukaemia (APL) is a type of acute leukaemia in which immature blood cells "get stuck" at a particular stage. These cells release clotting substances, and the patient may come in with bruising, bleeding from the gums and nose, or bleeding in the brain; this bleeding is the biggest danger of the first days [5]. For years the only treatment was chemotherapy.

In 1988 doctors at the Shanghai Institute of Haematology tried something new: they gave 24 patients tretinoin, a drug from the vitamin A family. It forced the stuck cells to mature, and all the patients went into remission without their bone marrow being wiped out [1]. Later arsenic trioxide was added to this treatment.

Finally, a large Italian-German study showed that tretinoin with arsenic, without any chemotherapy, is better than the old treatment (tretinoin with chemotherapy): two years later almost all patients were alive and free of relapse [2], and it stayed that way years later [3].

24 of 24
Patients in the first Shanghai report who went into remission with tretinoin
1988 [1]
97 vs 86
In every 100 patients, alive and free of relapse after 2 years
Tretinoin + arsenic versus tretinoin + chemotherapy [2]
17 in 100
Patients who died in the first days
US population data [4]

Why every hour counts

Treatment today is so good that most APL deaths happen in the first days, before the drugs have fully taken effect. In the United States, one in 6 patients was found to die in the first days, and more among older people. The researchers said doctors who see the patient first need to recognise this disease better [4].

That is why the European guideline says tretinoin should start the moment the doctor suspects APL, before the genetic test result arrives, while low clotting factors and platelets are replaced at the same time [5].

What is treatment like?

  1. 1

    Starting tretinoin straight away in hospital

    Tretinoin tablets are started on the first day, and platelet and clotting factor transfusions are given to prevent bleeding [5].

  2. 2

    Arsenic trioxide

    In low-‎ to intermediate-risk patients, arsenic injections with tretinoin take the place of chemotherapy [2, 5]. In high-risk patients (very high white cell count) another drug is sometimes needed as well [5].

  3. 3

    Consolidation cycles

    After remission, several more cycles of the same two drugs are given; the whole treatment takes a few months [2].

  4. 4

    Follow-up

    Regular tests to make sure the disease has not come back [5].

When should you see a doctor straight away?

Unexplained bruises, bleeding from the gums or nose that will not stop, or tiny red spots on the skin, together with tiredness or fever, should be checked the same day; a simple blood count is the first step (symptoms of blood cancer). During treatment, report a severe headache, breathlessness, rapid weight gain or swelling straight away; it may be a sign of a complication that needs early treatment [5].

Frequently asked questions

Isn't arsenic poisonous?

Arsenic trioxide at an exact dose and under medical supervision is a standard APL drug, and in studies it caused less infection and fewer low blood counts than chemotherapy [2]. The ECG and blood salts are checked regularly during treatment [5].

Does APL come back?

With today's treatment, relapse is uncommon [2, 3]; regular follow-up is needed to make sure.

Is APL the same as ordinary acute leukaemia?

No. APL is a special type of acute myeloid leukaemia with a completely different treatment; that is why diagnosing it quickly matters [5].

For physicians

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For physicians

With a suspicious peripheral blood or bone marrow smear (especially with DIC), start ATRA before PML::RARA confirmation; fibrinogen above 100 to 150 mg/dL, platelets above 30 to 50 thousand and INR below 1.5; avoid central catheters and lumbar puncture before and during induction [5]. APL0406 (low to intermediate risk): 2-year EFS 97% with ATRA + ATO versus 86% with ATRA + idarubicin [2]; confirmed at final follow-up [3]. SEER: early death 17.3%, and 24.2% at age 55 and over [4]. Doses: ATRA + arsenic trioxide · 10 cheap steps that save patients' lives.

Scientific evidence

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Scientific evidence

1 item
Clinical trial · Phase 3

Retinoic acid and arsenic trioxide for acute promyelocytic leukemia

N Engl J Med · 2013
97% vs 86%2-year event-free survival
Summary

Read more

Related cancer types

Blood cancers (leukaemia, lymphoma and myeloma)Leukaemia

Treatment guides

Chemotherapy or targeted therapy? Ask this before treatment startsComplete, on-time, uninterrupted treatment: a simple way to live longerNew treatments for multiple myeloma: from melphalan to four-drug combinations and cell therapyTreating acute myeloid leukaemia (AML) in older adults: when intensive chemotherapy is not possibleTreating CML (chronic myeloid leukaemia): a near-normal life with one tabletChemotherapy or targeted tablets in CLL? The story of a treatment that was replacedThe best treatment for CLL (chronic lymphocytic leukaemia) in 2026

References

5 references
Show all references, 1 with a study cardClose the reference list

Numbers in the text, such as [1], refer to these sources. Sources with a “Study card” button are summarised in the site’s evidence library.

  1. 1
    Use of all-trans retinoic acid in the treatment of acute promyelocytic leukemiaHuang ME, Ye YC, Chen SR, et al · Blood · 1988;72:567-572
    PubMed Back to text: 1 2
  2. 2
    Retinoic acid and arsenic trioxide for acute promyelocytic leukemiaLo-Coco F, Avvisati G, Vignetti M, Thiede C, Orlando SM, Iacobelli S, et al · N Engl J Med · 2013;369:111-121
    Study cardDOIPubMed Back to text: 1 2 3 4 5 6 7 8
  3. 3
    Improved Outcomes With Retinoic Acid and Arsenic Trioxide Compared With Retinoic Acid and Chemotherapy in Non-High-Risk Acute Promyelocytic Leukemia: Final Results of the Randomized Italian-German APL0406 TrialPlatzbecker U, Avvisati G, Cicconi L, Thiede C, Paoloni F, Vignetti M, et al · J Clin Oncol · 2017;35:605-612
    DOIPubMed Back to text: 1 2 3
  4. 4
    Early death rate in acute promyelocytic leukemia remains high despite all-trans retinoic acidPark JH, Qiao B, Panageas KS, et al · Blood · 2011;118:1248-1254
    DOIPubMed Back to text: 1 2 3 4
  5. 5
    Management of acute promyelocytic leukemia: updated recommendations from an expert panel of the European LeukemiaNetSanz MA, Fenaux P, Tallman MS, et al · Blood · 2019;133:1630-1643
    DOIPubMed Back to text: 1 2 3 4 5 6 7 8 9 10 11

This page is based on reputable scientific sources and was last updated on 28 October 2026. The content of this website is for educational and informational purposes only and does not replace consultation, diagnosis or treatment by a specialist physician. Consult your treating physician about any treatment decision.

Printed from the website; the full and up-to-date version: https://drdabiri.com/en/articles/apl-treatment-without-chemotherapy/

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