More than 50% cure can be obtained with allogeneic
bone marrow transplantation (BMT) when patients are transplanted in first remission of AML and ALL or chronic phase of CML. On the other hand, considerable progress has been made recently in treating acute
leukemia with
chemotherapy. Recent studies of intensive
chemotherapy in adults with AML report approximately 40-50% 3-year disease-free survival (DFS). Accordingly, several prospective randomized clinical trials have been conducted on the use of BMT versus intensive
chemotherapy in the treatment of AML. Significant differences in DFS were found only in a few studies though the results of BMT appear to be comparable or superior to
chemotherapy. Therefore, the overall advantage of BMT in first remission AML is smaller than expected. We should know not whether to transplant or to perform
chemotherapy, but rather whether to transplant in first remission or to perform
chemotherapy first and reserve
transplantation as
salvage therapy. Recently
acute promyelocytic leukemia has been successfully treated with differentiation
therapy using
all-trans retinoic acid. Low-dose
aclarubicin has also been reported to be effective as differentiation
therapy in some patients with
myelodysplastic syndrome and atypical AML. With the advance of molecular biology of
cytokines, several of them are now available for clinical use.
G-CSF,
GM-CSF and
M-CSF are potent stimulators for the granulocyte-macrophage production; they are very effective for accelerating hematologic recovery after
chemotherapy-induced myelosuppression or BMT.
Interferon-alpha (IFN-alpha) has been used in the several studies. Furthermore, Ph chromosome positivity can be reduced with long-term administration of IFN-alpha; Ph-positive clone can be undetectable in some patients. Thus, IFN-alpha will be the choice of treatment for CML even if BMT is planned.