No donor better

Figure 36.3 Disease-free survival from the MRC AML-10 subgroup analyses not treated on study. The outcome of allogeneic transplantation and autologous transplantation (5 year OS 63% and 71%, respectively) was superior to the result for chemotherapy alone (5 year OS 35%), which is significantly lower than in other reported series of favorable risk AML.74'77'78 The EORTC/GIMEMA trial, which studied 123 patients with favorable risk cytogenetic profiles did not demonstrate a difference in outcomes among patients (68.1 vs 73.9% 4 year DFS)62 although patients with favorable cytogenetic changes benefited most from transplantation.76 Nonetheless, consolida-tive chemotherapy remains the most commonly applied consolidation strategy for favorable-risk patients.

Patients with unfavorable cytogenetics have a very poor prognosis, despite similar rates of remission after induction chemotherapy compared with other AML cytogenetic risk groups. For this reason, transplantation in first remission is widely accepted as standard therapy, wherever a suitable donor is identified. The biologic assignment studies have confirmed that allo-geneic transplantation is a superior therapy in comparison with consolidative chemotherapy or autolo-gous transplantation. The EORTC/GIMEMA trial even suggested that with an increasingly unfavorable prognosis prior to transplantation, the greater the benefits that can be achieved with transplant therapy.62 The prognosis of unfavorable cytogenetic risk AML is poor enough that unrelated allogeneic stem cell transplantation is generally undertaken in first remission, when a suitable HLA-matched sibling donor is unavailable. Since matched, related transplantation is not yet the accepted standard for either intermediate or favorable cytogenetic risk AML in first remission, unrelated donor transplantation cannot be routinely recommended.

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