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alone.79 Patients with favorable prognostic features, including a longer duration of first remission79,80 and favorable cytogenetic features at presentation,81 have more favorable outcomes. The CALGB tested autologous transplantation in a cohort of 50 individuals with AML in second remission. With a short follow-up, 25% of patients remain in remission.82 While other small series exist, because of short follow-up, autologous transplantation cannot be routinely recommended for patients in second or subsequent remission. Allogeneic stem cell transplantation is the recommended therapy for second or subsequent remission AML. The French Bone Marrow Transplant Group (SFGM) retrospectively reviewed the outcomes in 310 patients with relapsed AML who underwent transplantation. The 5-year probability of survival was 35% in patients who underwent transplant in second or subsequent complete remission. This was significantly better than the outcomes for patients transplanted in untreated or refractory relapse (14% and 11%, respectively).83 Overall, patients with sibling donors fared better than patients with unrelated donors (p = 0.001), mainly due to differences in transplant-related mortality. While transplantation in untreated relapse is certainly feasible,84 recent analyses suggest that reinduction chemotherapy may have some value, if only to help determine prognosis with transplantation.

Despite anthracycline-based induction chemotherapy, up to 30% of patients with newly diagnosed AML will not achieve a complete remission. The long-term prognosis for these patients with primary refractory AML is extraordinarily grim, with essentially no long-term survivors in the absence of allogeneic stem cell therapy. Salvage transplantation can result in long-term remissions in approximately 10-30% of individuals when family members or unrelated volunteers are used as donors.83,85-87 In this setting, the use of unrelated donors and adverse cytogenetics negatively impact long-term survival.86 The timing and number of chemotherapy cycles prior to transplantation for refractory AML is likely critical, as patients exposed to multiple rounds of chemotherapy and infectious complications of prolonged neutropenia have a higher incidence of transplant-related morbidity and mortality. Achieving a remission after primary induction failure does not appear to influence long-term outcome86 and so multiple attempts to induce a remission are likely detrimental.

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