Should autotransplantation in acute myeloid leukemia in first complete remission be revisited?

Despite numerous studies, the best postremission therapy in acute myeloid leukemia (AML) is a subject of intense controversy. Major prognostic factors for disease outcome are the genetic alterations of AML, patient's age, and performance status. AML is more common in older adults, with a median age of 72 years. However, in this age group the unfavorable cytogenetics dominates at a time when biologically it may be most difficult to administer optimal intensive therapy.

Autologous stem cell transplantation (ASCT) enables the administration of high-dose therapy supported by stem cell infusion with a treatment-related toxicity not significantly higher than that associated with chemotherapy and significantly lower than in allogeneic stem cell transplantation. The dilemma of best postremission therapy has not been resolved because of the paucity of randomized controlled studies, especially in various cytogenetic risk and age groups. Instead, the use of genetic randomization by donor availability, analysis of outcome based on intention-to-treat, and mixed populations in the registry data produce variable results.

ASCT has been associated with prolonged disease-free survival as compared to chemotherapy, especially in the favorable and intermediate risk groups. Advances in immunotherapy in AML may propel ASCT as a platform for various immunologic maneuvers.