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Figure 7.6 Subsequent survival in chemotherapy patients according to initial response (see text for details)

While it is clear that minitransplant produces TRM rates to "only" 20% in patients up to age 75, the potential benefit is less clear. Part of the difficulty in assessing the effectiveness of minitransplant, as well as of various HIs or LIs, is the selection bias that accompanies the initial investigations of these agents. Other avenues of active investigation within transplantation include use of intravenous, rather than oral, busulfan to overcome the erratic pharmacology of the latter,43 anti-CD45 radiolabeled antibodies as a component of the pretransplant "preparative regimen,"44 and use of alternative donors (e.g., unrelated, umbilical cord blood).45 While use of such donors should expand the impact of allo SCT, it is unclear whether donors can be identified within a relevant time frame, particularly if use of donor cells is envisioned during induction. However, it may be possible to wait longer before beginning treatment than is commonly appreciated.46 This may be particularly true in patients with secondary AML/MDS, who usually present with lower circulating blast counts, than in de novo patients.

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