Evaluating the contribution of allogeneic and autologous transplantation to the management of acute myeloid leukemia in adults

It has been widely accepted that patients in first remission of acute myelo id leukemia (AML) with a donor should receive an allograft, and many also b elieve that autologous transplantation is the next best option. Several fac tors cast doubt on these assumptions. For example, it is understood that pa tients who receive transplants are already selected to be at lower risk of relapse, and in addition the risk of relapse varies considerably among pati ents. This can be predicted by several risk factors, the most powerful of w hich is cytogenetics. Major collaborative group trials have attempted to ev aluate the contribution of autograft and allograft to AML treatment in CRL The EORTC-GIEMEMA, GOELAM, UK MRC, and US Intergroup trials randomized appr oximately 1200 patients to autograft versus, or in addition to, chemotherap y. Although relapse risk was reduced in all studies, overall survival was n ot better in three of the trials. Only the MRC trial showed a survival bene fit, but only in patients beyond 2 years of follow-up. Patients in these tr ials for whom donors were available were allocated to allogeneic transplant . This enabled the evaluation of allograft in a donor versus no donor (inte nt-to-treat) analysis. No study showed a survival benefit for the donor arm , although there was a substantial reduction in relapse risk. Analysis with in risk groups suggests that transplantation for good-risk patients is not appropriate and the role of transplantation is uncertain in other groups.