IACH 2021 | Transplant indications in AML

I will discuss the indications for transplant in AML. So, AML is the major indication for transplant, allogeneic transplant, both in the Europe and in the States. There is a lot of activities and the news for the last few years is the increasing number of haploidentical transplant. And especially haploidentical transplant with post-transplant cyclophosphamide that will revolutionize the field and change the biology of transplant. And the other issue is the MRD, meaning measurable residual disease. It become a very important factor in the prognostication of AML and in the decision-making to go, or not to go, forward with transplantation. This is especially in intermediate-risk disease.

So, for the haplo, we will show several studies on behalf of the Acute Leukemia Working Party, published in the last two years, in the last year, showing that there is no difference in the haplo transplant compared to, not just the unrelated transplant, but also partially comparing to sibling transportation, both in acute myeloid leukemia, but also in acute lymphatic leukemia, and not just the patient in complete remission, but also in more challenging situation like advanced disease.

And we did this comparison. Also, with post-transplant cyclo both post the haploidentical transplant and post the unrelated transplantation. The number of post-transplant cyclo in sibling transplant, are still lower. And then, therefore, for the MRD in the intermediate-risk disease, where we have to decide according to the leukemia risk and the co-morbidities if the patient will go, or not go, transplantation.

So, the new field of MRD and especially the NPM1 MRD. And so each lab has, should have, the cut-off point for the MRD for NPM1. And then according to the the level of MRD, after the first induction or first course of chemotherapy, we know that patients that don’t clear the NPM1 should go forward on transplantation, while if they have NPM1-positive, FLT3-negative or FLT3-low, and they clear the NPM1, they may escape transplantation. And this is also true partially for co-binding factor, but there we need to wait, not just after the first induction, but after several courses of chemotherapy. And the patients that don’t have full load reduction in the MRD, after the induction and consolidation therapy, they should go for transplantation.