Autologous stem cell transplantation for acute myeloid leukemia

Abstract

Summary:Autologous bone marrow transplant (ABMT) and stem cell transplantation (ASCT) are important treatment modalities for acute myeloid leukemia (AML). The role of ASCT in first remission patients remains controversial. Phase II and phase III studies demonstrate that patients with favorable-risk cytogenetics benefit from ASCT, with reduction in relapse and improvement in leukemia-free survival (LFS). Patients with poor-risk cytogenetics do not appear to benefit significantly from ASCT and should preferentially be treated with allogeneic transplant. The role of ASCT for patients with intermediate risk disease is uncertain. It appears that ASCT in first remission will improve disease-free survival compared to standard chemotherapy. Sufficient patients who relapse after chemotherapy treatment can be salvaged with ASCT in second remission such that the beneficial effect on overall survival is blunted. ASCT produces equivalent results to ABMT but with reduced morbidity. The collection of stem cells during recovery from intensive dose consolidation therapy appears to be an attractive strategy that can increase the percentage of patients who are able to receive their intended transplant. Consolidation therapy prior to stem cell collection and transplant has been shown to decrease the relapse rate and improve outcomes, but the optimal nature of this consolidation therapy is unknown. For patients with AML in second remission, ABMT/ ASCT offers a substantial salvage rate, and is particularly effective for patients with acute promyelocytic leukemia. Bone Marrow Transplantation (2003) 31, 731-738. doi:10.1038/sj.bmt.1704020 Keywords: autologous stem cell transplantation; acute myeloid leukemia During the last 5 years, autologous transplantation has emerged as another promising approach to improve postremission therapy of AML.1 Autologous transplant offers a way to use the antileukemia effectiveness of ablative therapy without the morbidity and mortality of graft-versus-host disease that complicates allogeneic transplant. In addition to improved safety, autologous transplant is also more broadly applicable, potentially allowing the treatment of all patients who achieve remission and extending the age of transplant to 60 or even 70 years.Despite a wealth of phase II studies as well as some large phase III studies, the role of autologous transplant in the treatment of patients with AML in first remission remains unsettled. A number of phase II studies have produced outcomes that appear superior to those achievable with standard chemotherapy, including high dose ara-C (HDAC). However, the results of phase III studies have been interpreted by some to minimize the role of upfront autologous transplant in first remission. These phase III studies were designed and implemented before the importance of prognostic features, especially cytogenetics, were fully appreciated. Based on our current understanding of heterogeneity of AML and the need to approach treatment with a risk-adapted method, the question no longer appears to be 'Wh...

Is there still a role for autologous stem cell transplantation in acute myeloid leukemia?

“…The role of ASCT in AML remains controversial. Phase II and III trials showed that ASCT provides lower relapse rates than conventional CHT and improves DFS in some but not in all studies [3,[7][8][9]. Our retrospective study analyzed the role of ASCT in patients with AML, with good, intermediate and poor prognostic features.…”

“…However, despite subsequent treatments intended to maintain such remission, most patients relapse within 2 to 3 years of initial presentation [1]. In the last two decades, ASCT has been used to consolidate a substantial number of patients with AML who do not have an HLA-matched related or unrelated donor [1, [3][4][5][6]. The role of ASCT in AML remains controversial.…”

“…Despite a wealth of phase II studies as well as some large phase III studies, the role of autologous transplant in the treatment of patients with AML in first remission remains unsettled. A number of phase II studies have produced outcomes that appear superior to those achievable with standard chemotherapy, including high dose Ara-C [3]. However, the results of phase III studies have been interpreted by some to minimize the role of upfront autologous transplant in first remission.…”

“…Post-remission treatment remains a critical issue in this disease [1,2]. During the last years, autologous transplantation has emerged as another promising approach to improve post-remission therapy of AML [3]. Autologous transplant offers a way to use the antileukemia effectiveness of ablative therapy without the morbidity and mortality of graft-versus-host disease that complicates allogeneic transplant.…”

Continuous infusion idarubicin and oral busulfan as conditioning for patients with acute myeloid leukemia aged over 60 years undergoing autologous stem cell transplantation

“…10,11 Different approaches including in vivo or ex vivo purging, immunotherapy post-ASCT and intensification of the conditioning regimen have been investigated in an attempt to achieve more durable disease control. [23][24][25] Although the adoption of alternative regimens such as BAVC result in lower TRM as compared to BuCy2, the relapse rate is higher. 13 More recently, promising results have been reported with reduced intensity allogeneic SCT, but toxicity is still relevant and a compatible donor is needed.…”