Risks and benefits in a personalized application of allogeneic transplantation in patients with AML in first CR

Allogeneic hematopoietic stem cell transplantation (alloHSCT) strongly reduces relapse in patients with acute myeloid leukemia (AML) in first complete remission (CR). Estimated as relative risk, the graft-vs-leukemia effect of alloHSCT is associated with a hazard ratio of approximately 0.35 with endpoint relapse compared with autologous HSCT or postremission chemotherapy in comparative studies. Strikingly, that hazard ratio is similarly operational in favorable and adverse-risk AML. It suggests that only in case of excessive nonrelapse mortality (NRM) alloHSCT should be withheld as postremission treatment. Therefore, the application of alloHSCT in patients with AML in first CR should be personalized and based on both risks and benefits of alloHSCT, which are on the one hand the risk for NRM and on the other hand the risk of relapse. The risk of NRM can be estimated by a dedicated score for patients with AML in first CR, whereas the latest European LeukemiaNET risk classification may be applied for estimating the risk of relapse. In addition, the assessment of measurable residual disease further discriminates patients with a low vs high risk of relapse and may be incorporated in decision making.