Acute myeloid leukemia (AML) is characterized by a block of terminal differentiation of hematopoietic precursors and the repression of normal hematopoiesis by expanding immature blasts. AMLs are frequently associated with specific chromosomal translocations, resulting in the generation of chimeric genes. These genes encode chimeric transcription factors, which possess chromatin-modeling activity and deregulate the transcription of specific target genes [1].The use of all-trans retinoic acid (ATRA) has significantly improved the treatment results in acute promyelocytic leukemia (APL). The great majority of patients treated with ATRA as a single agent will experience a relapse within a few months. Nevertheless, when used in combination with conventional chemotherapy, the efficacy of ATRA increases dramatically, improving the long-term survival of APL patients to 75% [2]. In non-APL AML, the effects of ATRA are less clear. The majority of non-APL AML blast cells are sensitive to ATRA in vitro, but a considerable proportion of the cells are resistant [3]. This stresses the need for more knowledge about the molecular mechanisms of ARTA and the demand for tools to predict ARTA sensitivity. A distinct subset of AML, making up *10% of all AML cases, is characterized by a t(8;21)(q22;q22) translocation and, morphologically, by the presence of myeloblasts, showing maturation in the neutrophil lineage. The t(8;21) juxtaposes the RUNX1 gene on chromosome 21 with the CBFT1 gene on chromosome 8, generating the AML1-ETO fusion transcription factor. We now present four patients with AML treated with ATRA alone, who were initially misdiagnosed as APL according to the FrenchAmerican-British (FAB) classification.Case 1: In July 2007, a 25-year-old man with a fever and cough was admitted to other hospital. Peripheral blood counts showed hemoglobin (Hb) 65 g/L, white blood cells (WBC) 23.3610 9 /L, blood platelet cells (plts) 69610 9 /L. Bone marrow examination revealed a hypercellularity with 16% myeloblasts and 52% abnormal promyelocytes in the existence of Auer rods, large granules packed in cytoplasm and nuclei irregular in size and shape. Diagnosis was made as APL based on FAB classification. The patient received arsenic trioxide (10 mg/day) for 30 days, WBC was 15.8610 9 /L with normal platelet count, and the level of promyelocytes in bone marrow was reduced to 18.4%. Then, he was admitted to our hospital and continued to receive arsenic trioxide. At this point, the diagnosis was changed from APL to t(8;21) AML according to karyotype analysis, flow cytometric immunophenotyping of bone marrow cells and reverse transcription polymerase chain reaction (RT-PCR) ( Table I). Interphase fluorescence in situ hybridization (FISH) showed 96.7% of AML1-ETO fusion gene in bone marrow cells but failed to demonstrate the presence of PML-RARa fusion gene. Myeloblasts in peripheral blood disappeared, and promyelocytes decreased from 18.4% to 9.16% by the 50th day after arsenic trioxide treatment was initiated. However, FISH analysis for AML1-E...