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EBMT 2026 | The current role of MRD in allogeneic transplant for AML and unanswered questions that remain
Alexandros Spyridonidis, MD, University of Patras, Patras, Greece, discusses the current role of measurable residual disease (MRD) in allogeneic stem cell transplantation for acute myeloid leukemia (AML), highlighting the need for clearer guidelines on managing MRD-positive patients, including the use of targeted therapies and donor lymphocyte infusions (DLI). Prof. Spyridonidis notes that there are still significant unanswered questions in the field, particularly regarding the measurement and treatment of MRD after transplant, due to the dynamic nature of the graft-versus-leukemia (GVL) effect and confounding factors such as DTA mutations. This interview took place at the 52nd Annual Meeting of the EBMT in Madrid, Spain.
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Transcript
Today in the business meeting and in the Acute Leukemia Working Party, we will discuss the role of MRD during transplant. First, the role of MRD in the post-remission setting, and this is an indication for transplant. We have now very good ELN guidelines on how to handle this, but there are still open questions. For example, if some MRD-negative patients with intermediate disease, if they still have to go to transplant or not...
Today in the business meeting and in the Acute Leukemia Working Party, we will discuss the role of MRD during transplant. First, the role of MRD in the post-remission setting, and this is an indication for transplant. We have now very good ELN guidelines on how to handle this, but there are still open questions. For example, if some MRD-negative patients with intermediate disease, if they still have to go to transplant or not. Maybe we can omit transplant. Also, we know now a lot about how to handle MRD at transplant. We know it’s prognostic. There are still open questions. We don’t know if we have to treat it before, but we know that this has an actionable value. We have to do something after transplant, for example, targeted therapy like FLT3 inhibitors. If we can do pharmacological intervention like AZA maintenance, after what is not clear. And if we should give DLI, it’s also not clear. And so we have open questions on that.
The most chaos and what we don’t know, the most enigmatic, let’s say, is how we handle MRD after transplant. What we don’t know how to handle is how to measure and how to treat MRD after transplant. Because after transplant, the transplant per se is a dynamic process. We have a GVL effect. It might be that it needs some time to clear the MRD. So first, we don’t know the techniques, how to measure it. There are many confounders, like chimerism, like the DTA mutations. We don’t know how to handle if there are host mutations or donor-derived mutations. And also, we don’t know when to measure and if we found MRD positivity, how to treat it. So this is something that we have to work on all together. There is also the Measure consortium that is trying to answer these questions and I’m sure that next year in EBMT we’ll have some answers to these questions.
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