Prophylactic heparin in APL.

In a recent article, Goldberg and presented the Brigham and Women’s Hospital and Dana Farber Cancer Institute’s experience in managing acute pnomyelocytic leukemia (APL) without hepanin. They also analyzed historical data and concluded “that the coagulopathy associated with APL can be successfully managed with intensive chemotherapy and blood product support” and that “the necessity for the inclusion of prophylactic hepanin therapy into the remission induction regimens of all patients with APL has not been proven.” Although the benefit of prophylactic hepanin in APL is unproven, the thrust of the article made a case against the use of hepanin and by its title (“Is hepanin administration necessary during induction hemothenapy for patients with acute promyelocytic leukemia?”) suggested the exclusion of hepanin in the management of these patients. Because of flaws in this study and in the authors’ analysis of previous studies, however, one can make no conclusion about the use of hepanin in patients with APL based on this article. In presenting their own data, the authors demonstrate a complete remission rate comparable to that of series that have included hepanin in conjunction with anthracycline-based chemotherapy. ” Because the data presented did not include coagulation parameters at the time of entry non an indication of bleeding status, however, the results may reflect a population of patients with a lesser bleeding diathesis. The paucity of data makes a meaningful conclusion about the comparability of this series to other series in the literature impossible. Also of concern is the authors’ use of historical studies to analyze the cumulative experience with and without hepanin and their application of a statistical method to validate their conclusions. Based on their own experience combined with eight series of patients treated during different decades with different protocols and vanable ancillary support, the authors concluded that no statistically proven benefit for hepanin was evident. No statistical test could accurately be applied to such divergent studies. Furthermore, the authors’ extraction of data from the eight references was flawed (Table 1 ). They stated that their comparison was limited to anthracycline-based protocols, yet 1 3 of 60 patients treated by Kantanjian and colleagues4 did not receive anthracyclines. Four additional hemorrhagic deaths among patients treated without hepanin were not included in the analysis when that stipulation was applied to another study.’ Furthermore, nine deaths included among the hemorrhagic deaths of patients treated with hepanin occurred during aplasia, by which time the hepanin should have been discontinued. The data from Cunningham and co-workers’ were incorrectly reported. Correcting