Acute promyelocytic leukaemia with PML::RARA fusion

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Haematolymphoid Tumours (5th ed.)

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This page was converted to the new template on 2023-12-07. The original page can be found at HAEM4:Acute Promyelocytic Leukemia (APL) with PML-RARA.

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Primary Author(s)*

Yiming Zhong, Ph.D., Megan Piazza, Ph.D., and Shashi Shetty, Ph.D.

Cancer Category / Type

Acute Myeloid Leukaemia

Cancer Sub-Classification / Subtype

Acute Promyelocytic Leukemia (APL) with PML-RARA

Definition / Description of Disease

This is a distinct entity in the World Health Organization (WHO) classification system, and associated French-American-British (FAB) classification is acute promyelocytic leukemia (APL, M3)[1].

Synonyms / Terminology

APL with t(15;17)(q24.1;q21.1)

AML with t(15;17)(q24.1;q21.1)

Epidemiology / Prevalence

Accounts for 5-8% of AML, may occur at any age, but predominantly in adult in mid-life[1].

Clinical Features

Put your text here and fill in the table (Instruction: Can include references in the table)

Signs and Symptoms EXAMPLE Asymptomatic (incidental finding on complete blood counts)

EXAMPLE B-symptoms (weight loss, fever, night sweats)


EXAMPLE Lymphadenopathy (uncommon)

Laboratory Findings EXAMPLE Cytopenias

EXAMPLE Lymphocytosis (low level)

editv4:Clinical Features
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Typical (hypergranular) and microgranular (hypogranular) APL are frequently associated with disseminated intravascular coagulation (DIC). In contrast to typical APL, microgranular APL is associated with increased counts of leukocytes which have rapid doubling time[1].

Sites of Involvement

Bone marrow

Morphologic Features

The abnormal promyelocytes of typical APL have irregular and variable nuclear size and shapes. They are frequently kidney-shaped or bilobed. The cytoplasm is characterized by large granules and stains bright pink, red or purple in Romanowsky staining. In most cases, there are bundles of Auer rods (“faggot cells”) in the cytoplasm. Myeloblasts with single Auer rods may also be present. Auer rods in typical APL are usually larger than those in other types of AML. Microgranular APL is characterized by apparent paucity or absence of granules and predominantly bilobed nuclear shape. The myeloperoxidase (MPO) reaction for both typical and microgranular APL is positive[1].


The immunophenotype has been well characterized[1][2][3].

Finding Marker
Positive (universal) CD13, CD33, CD117, myeloperoxidase (MPO)
Positive (subset) CD2 (microgranular APL), CD34 (microgranular APL), CD56 (20% of APL, associated with a worse outcome)
Negative (universal) HLA-DR, CD15, CD11a, CD11b, CD11c, CD18
Negative (subset) CD2 (typical APL), CD34 (typical APL)

Chromosomal Rearrangements (Gene Fusions)

Put your text here and fill in the table

Chromosomal Rearrangement Genes in Fusion (5’ or 3’ Segments) Pathogenic Derivative Prevalence Diagnostic Significance (Yes, No or Unknown) Prognostic Significance (Yes, No or Unknown) Therapeutic Significance (Yes, No or Unknown) Notes
EXAMPLE t(9;22)(q34;q11.2) EXAMPLE 3'ABL1 / 5'BCR EXAMPLE der(22) EXAMPLE 20% (COSMIC)

EXAMPLE 30% (add reference)


The t(9;22) is diagnostic of CML in the appropriate morphology and clinical context (add reference). This fusion is responsive to targeted therapy such as Imatinib (Gleevec) (add reference).

editv4:Chromosomal Rearrangements (Gene Fusions)
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This AML subtype is classified based on the presence of a PML-RARA fusion, which results from fusion of the 5’ portion of PML at 15q24.1 and the 3’ portion of RARA at 17q21.1[4]. 5'PML-3'RARA transcript is expressed in all cases, and 5'RARA-3'PML transcript is found in 2/3 of cases[5]. Rare cases of APL have cryptic t(15;17)(q24.1;q21.1) such as submicroscopic insertion of RARA into PML leading to the expression of the PML-RARA transcript or three way translocations involving chromosomes 15 and 17 with an additional chromosome[6]. Several variant translocations involving RARA have also been identified, including t(11;17) and t(5;17)[6]. The 4th edition revision to the World Health Organization renamed APL with t(15;17)(q24.1;q21.1) as APL with PML-RARA[1][7].

Chromosomal Rearrangement Genes in Fusion (5’ or 3’ Segments) Pathogenic Derivative Prevalence
t(15;17)(q24.1;q21.1) 5'PML / 3'RARA der(15) 5-8% of AML

editv4:Clinical Significance (Diagnosis, Prognosis and Therapeutic Implications).
Please incorporate this section into the relevant tables found in:
  • Chromosomal Rearrangements (Gene Fusions)
  • Individual Region Genomic Gain/Loss/LOH
  • Characteristic Chromosomal Patterns
  • Gene Mutations (SNV/INDEL)

APL can be differentiated from other types of AML based on microscopic examination of the blood, bone marrow, or biopsy as well as detection of the PML/RARA fusion gene. The prognosis in APL treated with all-trans retinoic acid (ATRA) and arsenic trioxide is favorable, and relapsed or refractory APL cases show a generally good response with arsenic trioxide therapy[8][9]. Expression of CD56 is associated with poor prognosis, while the prognostic significance of FLT3 -ITD mutations remains unclear[10][11].

Individual Region Genomic Gain / Loss / LOH

Put your text here and fill in the table (Instructions: Includes aberrations not involving gene fusions. Can include references in the table. Can refer to CGC workgroup tables as linked on the homepage if applicable.)

Chr # Gain / Loss / Amp / LOH Minimal Region Genomic Coordinates [Genome Build] Minimal Region Cytoband Diagnostic Significance (Yes, No or Unknown) Prognostic Significance (Yes, No or Unknown) Therapeutic Significance (Yes, No or Unknown) Notes



chr7:1- 159,335,973 [hg38]




Presence of monosomy 7 (or 7q deletion) is sufficient for a diagnosis of AML with MDS-related changes when there is ≥20% blasts and no prior therapy (add reference).  Monosomy 7/7q deletion is associated with a poor prognosis in AML (add reference).




chr8:1-145,138,636 [hg38]




Common recurrent secondary finding for t(8;21) (add reference).

editv4:Genomic Gain/Loss/LOH
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Not applicable

Characteristic Chromosomal Patterns

Put your text here (EXAMPLE PATTERNS: hyperdiploid; gain of odd number chromosomes including typically chromosome 1, 3, 5, 7, 11, and 17; co-deletion of 1p and 19q; complex karyotypes without characteristic genetic findings; chromothripsis)

Chromosomal Pattern Diagnostic Significance (Yes, No or Unknown) Prognostic Significance (Yes, No or Unknown) Therapeutic Significance (Yes, No or Unknown) Notes

Co-deletion of 1p and 18q


See chromosomal rearrangements table as this pattern is due to an unbalanced derivative translocation associated with oligodendroglioma (add reference).

editv4:Characteristic Chromosomal Aberrations / Patterns
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Not applicable

Gene Mutations (SNV / INDEL)

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Gene; Genetic Alteration Presumed Mechanism (Tumor Suppressor Gene [TSG] / Oncogene / Other) Prevalence (COSMIC / TCGA / Other) Concomitant Mutations Mutually Exclusive Mutations Diagnostic Significance (Yes, No or Unknown) Prognostic Significance (Yes, No or Unknown) Therapeutic Significance (Yes, No or Unknown) Notes
EXAMPLE: TP53; Variable LOF mutations


EGFR; Exon 20 mutations

EXAMPLE: BRAF; Activating mutations


EXAMPLE: 30% (add Reference)

EXAMPLE: IDH1 R123H EXAMPLE: EGFR amplification EXAMPLE:  Excludes hairy cell leukemia (HCL) (add reference).

Note: A more extensive list of mutations can be found in cBioportal (, COSMIC (, ICGC ( and/or other databases. When applicable, gene-specific pages within the CCGA site directly link to pertinent external content.

editv4:Gene Mutations (SNV/INDEL)
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There is not specific information on mutations related to this subtype of AML at this time.

Other Mutations

Type Gene/Region/Other
Concomitant Mutations 34-45% of APL have FLT3 mutations[1].
Secondary Mutations About 40% of APL cases have secondary cytogenetic abnormalities with trisomy 8 being the most frequent (10-15%)[1].
Mutually Exclusive Not applicable

Epigenomic Alterations

Not applicable

Genes and Main Pathways Involved

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Gene; Genetic Alteration Pathway Pathophysiologic Outcome
EXAMPLE: BRAF and MAP2K1; Activating mutations EXAMPLE: MAPK signaling EXAMPLE: Increased cell growth and proliferation
EXAMPLE: CDKN2A; Inactivating mutations EXAMPLE: Cell cycle regulation EXAMPLE: Unregulated cell division
EXAMPLE:  KMT2C and ARID1A; Inactivating mutations EXAMPLE:  Histone modification, chromatin remodeling EXAMPLE:  Abnormal gene expression program
editv4:Genes and Main Pathways Involved
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The protein encoded by the PML (promyelocytic leukemia) gene is a member of the tripartite motif (TRIM) family and it functions as a transcription factor and tumor suppressor. PML is the core component of subnuclear structures called PML nuclear bodies (PML-NBs) and it interacts with a large number of proteins including p53 and has been implicated in several cellular functions such as cellular senescence, apoptosis, and hematopoietic stem cell maintenance[12][13]. The gene RARA (Retinoic acid receptor, alpha) encodes a nuclear retinoic acid receptor which regulates transcription in a ligand-dependent manner[14]. The fusion of PML and RARA results in expression of a hybrid protein with altered functions. This fusion protein deregulates transcriptional control such as RAR targets and disrupts PML nuclear bodies[15].

Genetic Diagnostic Testing Methods

Karyotype, FISH, RT-PCR

Familial Forms

Not applicable

Additional Information

Not applicable





(use the "Cite" icon at the top of the page) (Instructions: Add each reference into the text above by clicking on where you want to insert the reference, selecting the “Cite” icon at the top of the page, and using the “Automatic” tab option to search such as by PMID to select the reference to insert. The reference list in this section will be automatically generated and sorted. If a PMID is not available, such as for a book, please use the “Cite” icon, select “Manual” and then “Basic Form”, and include the entire reference.)

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Arber DA, et al., (2017). Acute myeloid leukaemia with recurrent genetic abnormalities, in World Health Organization Classification of Tumours of Haematopoietic and Lymphoid Tissues, Revised 4th edition. Swerdlow SH, Campo E, Harris NL, Jaffe ES, Pileri SA, Stein H, Thiele J, Arber DA, Hasserjian RP, Le Beau MM, Orazi A, and Siebert R, Editors. Revised 4th Edition. IARC Press: Lyon, France, p134-136.
  2. Dong, Henry Y.; et al. (2011). "Flow cytometry rapidly identifies all acute promyelocytic leukemias with high specificity independent of underlying cytogenetic abnormalities". American Journal of Clinical Pathology. 135 (1): 76–84. doi:10.1309/AJCPW9TSLQNCZAVT. ISSN 1943-7722. PMID 21173127.
  3. Gorczyca, Wojciech (2012). "Acute promyelocytic leukemia: four distinct patterns by flow cytometry immunophenotyping". Polish Journal of Pathology: Official Journal of the Polish Society of Pathologists. 63 (1): 8–17. ISSN 1233-9687. PMID 22535601.
  4. de Thé, H.; et al. (1990). "The t(15;17) translocation of acute promyelocytic leukaemia fuses the retinoic acid receptor alpha gene to a novel transcribed locus". Nature. 347 (6293): 558–561. doi:10.1038/347558a0. ISSN 0028-0836. PMID 2170850.
  5. Warrell, R. P.; et al. (1993). "Acute promyelocytic leukemia". The New England Journal of Medicine. 329 (3): 177–189. doi:10.1056/NEJM199307153290307. ISSN 0028-4793. PMID 8515790.
  6. 6.0 6.1 Grimwade, D.; et al. (1997). "Characterization of cryptic rearrangements and variant translocations in acute promyelocytic leukemia". Blood. 90 (12): 4876–4885. ISSN 0006-4971. PMID 9389704.
  7. Arber, Daniel A.; et al. (2016). "The 2016 revision to the World Health Organization classification of myeloid neoplasms and acute leukemia". Blood. 127 (20): 2391–2405. doi:10.1182/blood-2016-03-643544. ISSN 1528-0020. PMID 27069254.
  8. "Huang ME, Ye YC, Chen SR, et al. Use of all-trans retinoic acid in the treatment of acute promyelocytic leukemia. Blood. 1988;72(2):567-572". Blood. 128 (26): 3017. 2016. doi:10.1182/blood-2016-11-750182. ISSN 1528-0020. PMID 28034863.
  9. de Thé, Hugues; et al. (2017). "Acute Promyelocytic Leukemia: A Paradigm for Oncoprotein-Targeted Cure". Cancer Cell. 32 (5): 552–560. doi:10.1016/j.ccell.2017.10.002. ISSN 1878-3686. PMID 29136503.
  10. Ferrara, F.; et al. (2000). "CD56 expression is an indicator of poor clinical outcome in patients with acute promyelocytic leukemia treated with simultaneous all-trans-retinoic acid and chemotherapy". Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology. 18 (6): 1295–1300. doi:10.1200/JCO.2000.18.6.1295. ISSN 0732-183X. PMID 10715300.
  11. Schnittger, Susanne; et al. (2011). "Clinical impact of FLT3 mutation load in acute promyelocytic leukemia with t(15;17)/PML-RARA". Haematologica. 96 (12): 1799–1807. doi:10.3324/haematol.2011.049007. ISSN 1592-8721. PMC 3232262. PMID 21859732.
  12. Pearson, M.; et al. (2000). "PML regulates p53 acetylation and premature senescence induced by oncogenic Ras". Nature. 406 (6792): 207–210. doi:10.1038/35018127. ISSN 0028-0836. PMID 10910364.
  13. Bernardi, Rosa; et al. (2007). "Structure, dynamics and functions of promyelocytic leukaemia nuclear bodies". Nature Reviews. Molecular Cell Biology. 8 (12): 1006–1016. doi:10.1038/nrm2277. ISSN 1471-0080. PMID 17928811.
  14. Melnick, A.; et al. (1999). "Deconstructing a disease: RARalpha, its fusion partners, and their roles in the pathogenesis of acute promyelocytic leukemia". Blood. 93 (10): 3167–3215. ISSN 0006-4971. PMID 10233871.
  15. de Thé, Hugues; et al. (2010). "Acute promyelocytic leukaemia: novel insights into the mechanisms of cure". Nature Reviews. Cancer. 10 (11): 775–783. doi:10.1038/nrc2943. ISSN 1474-1768. PMID 20966922.


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