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Choosing for whom to recommend allogeneic transplantation for acute myeloid leukemia in CR1: a continued, complicated conversation

Kamal N. Menghrajani and Martin S. Tallman

Abstract

The topic today is how we choose which patients with acute myeloid leukemia will benefit from an allogeneic stem cell transplant in their first complete remission (CR1). It’s impressive to us that this is a question that is still being debated. This issue was addressed in a number of studies when M.S.T. was a fellow 3 decades ago. At that time, we looked at clinical factors that might help differentiate which patients would benefit from bone marrow transplantation as opposed to consolidation chemotherapy alone. We found that female sex, a higher number of circulating blasts at presentation, a shorter duration of symptoms, and the absence of hepatitis during induction were predictive of better outcomes with transplant. That study was published in 1989. Now, 3 decades later, progress has been made in that we have multiple sophisticated tools to stratify patients by risk: cytogenetics, fluorescence in situ hybridization, molecular genetics, flow cytometry. Even so, the question of who will benefit from a transplant after the achievement of CR1 remains as important today as it was in 1989. Although molecular genetics and cytogenetics perhaps have the most important influence, the decision to recommend a transplant is also based on the patient’s age and the perceived or calculated risk of transplant-related mortality, as well as on the motivation of the patient. Although the availability of a donor is still a factor, haploidentical grafts are making this less of an issue. Our main considerations in recommending for or against transplantation focus on weighing the benefits of relapse reduction against the expected toxicities, and we work closely with our transplant colleagues to optimize the donor type and conditioning regimen.

Correspondence: Martin S. Tallman, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065; e-mail: tallmanm{at}mskcc.org.

Footnotes

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  • The complete text of this Blood Advances Talk is available as a data supplement.

  • Contribution: K.N.M. and M.S.T. wrote the text.

  • Conflict-of-interest disclosure: M.S.T. received research support from AROG, Cellerant, ADC Therapeutics, and Bioline and served on advisory boards for Orsenix and Daiichi-Sanko. K.N.M. declares no competing financial interests.