procoagulant proteins which, along with the disrupted and activated surface of cell membrane of the cell from which they arise, form a template for coagulation and fibrinolysis.7 The cell-free DNA (cf-DNA)released by the formation of NETs can also activate coagulation via the contact activation system. figure). Through a series of experiments, the authors demonstrate the presence of ETosis in malignant promyelocytes and the effect of ATRA in potentiating and inducing extracellular chromatin release in a timedependent manner. They demonstrate that this effect was prominent in the first 3 days after exposure to ATRA and, beyond that time period, cell death was predominantly due to conventional apoptosis. They further correlated thrombin generation and a strong procoagulant effect to extracellular chromatin and cf-DNA generated by ETosis and the ability of DNAse1 to decrease thrombin generation by degrading cf-DNA. The use of anti-tissue factor antibodies could not reverse this. Additional experiments demonstrated the ability of promyelocytic extracellular chromatin to induce fibrin deposition, plasmin generation, and fibrinolysis. Paradoxically, it impaired clot lysis. Finally, the authors demonstrate the cytotoxic effect of promyelocytic extracellular chromatin on the endothelial cells that they come in contact with. This cytotoxic effect converts these endothelial cells to a procoagulant phenotype, provides additional surface area on which coagulation and fibrin deposition can happen, and may also contribute to loss of integrity of the endothelium. Through the data in their paper, Cao et al demonstrate a novel mechanism of perturbation in coagulation and fibrinolysis in APL that is exacerbated on initiation of treatment with ATRA. The data suggest that targeting this novel mechanism could potentially address the problem of early coagulopathy-related mortality. The cytotoxic effects of promyelocytic extracellular chromatin on endothelial cells could also potentially explain the differentiation syndrome seen after initiation of therapy and apparent susceptibility to bleeding in the presence of what would otherwise be considered adequate hemostatic levels of platelets and coagulation factors.Conflict-of-interest disclosure: The author declares no competing financial interests. n