Cancer Treatment Today

Allogeneic stem cell transplantation replaces the recipients cells with donor cells and provides a graft versus host reaction that helps to control leukaemia. Autologous transplantation, on the other hand, enables intensification of therapy without a lasting anti leukaemia effect. The ASBMT Position Statement for treatment of adult AML states, “There is no significant advantage of autologous SCT over chemotherapy.” The ASBMT Position Statement for treatment of children with AML states: “Autologous SCT and chemotherapy in the first complete remission are equivalent in outcomes. Allogeneic SCT shows superior overall survival (OS) and leukemia-free survival when compared to chemotherapy for patients in the first complete remission (CR1). Thus, allogeneic SCT is recommended in the first complete remission.

The Center for International Blood and Marrow Transplantation Research ([CIBMTR], Keating, 2012) analyzed data for autologous HSCT compared to HLA-identical sibling allogeneic HSCT for treatment of AML in CR1. Although autologous HSCTs have been used when there have been no suitable allogeneic donors, higher rates of relapsed disease have resulted after autologous HSCT. Based on the CIBMTR data, the authors concluded “Treatment failure (death or relapse) after autologous peripheral blood was significantly more likely [relative risk 1.32 (1.06-1.64); P=0.011].” The NCCN lists autologous HSCT as a treatment option for AML, but the recommendation is 2B, which is based on a lower level of evidence and consensus that is not uniform.
Wang and colleagues (2010) reported data from a meta-analysis of randomized trials of autologous HSCT treatment of AML in CR1. The authors noted the use of autologous HSCT in the management of AML remains “contentious.” Data from 13 studies involving 12 randomized controlled trials, which included both pediatric and adult populations, were included in the meta-analysis. For adults, autologous HSCT had higher transplant-related mortality (TRM) and lower relapse rate compared to non-transplant therapy. Participants randomized to autologous HSCT had a significantly higher risk of death in CR1 compared to those assigned to receive chemotherapy or no further therapy (RR = 1.90, 95% CI = 1.34–2.70). There was a significant DFS with autologous HSCT compared to chemotherapy alone (HR = 0.89, 95% CI = 0.80–0.98). When the studies were pooled by age, DFS was not significantly different in children, and the significant difference remained for adults who had HSCT. However, the DFS did not translate to a difference in OS (HR = 1.05, 95% CI = 0.91–1.21). The authors concluded that “Autologous SCT should not be considered as the first-line post-remission therapy for AML in patients in CR1.”

In fact, NCCN removed this treatment option for Post-remission Therapy for patients in 2014.

Wang J, Ouyang J, Zhou R, et al. Autologous hematopoietic stem cell transplantation for acute myeloid leukemia in first complete remission: a meta-analysis of randomized trials. Act Haematol. 2010; 124:61-71.

American Society for Blood and Bone Marrow Transplantation. Policy Statements, Guidelines and Reviews. Available at: http://www.asbmt.org/. Accessed on February 25, 2014

A. Keating, http://www.haematologica.org/content/early/2012/08/28/haematol.2012.062059.full.pdf