AUTOLOGOUS OR ALLOGENEIC BONE-MARROW TRANSPLANTATION COMPARED WITH INTENSIVE CHEMOTHERAPY IN ACUTE MYELOGENOUS LEUKEMIA

Background. Allogeneic or autologous bone marrow transplantation and i ntensive consolidation chemotherapy are used to treat acute myelogenou s leukemia in a first complete remission. Methods. After induction tre atment with daunorubicin and cytarabine, patients who had a complete r emission received a first course of intensive consolidation chemothera py, combining intermediate-dose cytarabine and amsacrine. Patients wit h an HLA-identical sibling were assigned to undergo allogeneic bone ma rrow transplantation; the others were randomly assigned to undergo aut ologous bone marrow transplantation (with unpurged bone marrow) or a s econd course of intensive chemotherapy, combining high-dose cytarabine and daunorubicin. Comparisons were made on the basis of the intention to treat. Results. A total of 623 patients had a complete remission; 168 were assigned to undergo allogeneic bone marrow transplantation, a nd 254 were randomly assigned to one of the other two groups. Of these patients, 343 completed the treatment assignment: 144 in the allogene ic-transplantation group, 95 in the autologous-transplantation group, and 104 in the intensive-chemotherapy group. The relapse rate was high est in the intensive-chemotherapy group and lowest in the allogeneic-t ransplantation group, whereas the mortality rate was highest after all ogeneic transplantation and lowest after intensive chemotherapy. The p rojected rate of disease-free survival at four years was 55 percent fo r allogeneic transplantation, 48 percent for autologous transplantatio n, and 30 percent for intensive chemotherapy. However, the overall sur vival after complete remission was similar in the three groups, since more patients who relapsed after a second course of intensive chemothe rapy had a response to subsequent autologous bone marrow transplantati on. Other differences were also observed, especially with regard to he matopoietic recovery (it occurred later after autologous transplantati on) and the duration of hospitalization (it was longer with bone marro w transplantation). Conclusions. During first complete remission in ac ute myelogenous leukemia, autologous as well as allogeneic bone marrow transplantation results in better disease free survival than intensiv e consolidation chemotherapy with high-dose cytarabine and daunorubici n. Transplantation soon after a relapse or during a second complete re mission might also be appropriate.