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“How I treat” post-transplant relapse of AML
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Allo-HCT is among the principal curative treatment approaches for AML, but the prognosis remains poor for patients who relapse after transplantation.1 Treatment approaches for post-transplantation relapse are highly individualized and are informed by disease genomics and biology, the clinical status of a patient at relapse, and the interval between transplantation and relapse.1 A “how I treat” case series published in Blood by Gooptu et al.1 discussed treatment approaches at early, late, and incipient relapse of AML after allo-HCT. |
| Key learnings |
| Treatment considerations for early relapse include tapering IS, chemotherapy or targeted therapy based on patient fitness and genomic profile, and consolidation with cellular therapy, such as, DLI or a second HCT. |
| Treatment considerations for isolated EM relapse include addressing targetable mutations, assessing disease burden to decide on immediate chemotherapy vs immunotherapies such as checkpoint inhibitors, the need for localized radiation/CNS-directed therapy, and consideration of consolidative DLI/second HCT. |
| In cases of molecular relapse, high-risk patients should be prioritized for clinical trials of conditioning intensification, post-HCT maintenance, peri-transplant adoptive cellular therapies, or novel graft engineering to enhance GVL. Outside of trials, approaches include combining IS tapering, HMAs, and DLI (lower doses in prophylactic/preemptive setting recommended by EBMT). |
| Future directions involve improving relapse prediction and prognostication based on MRD status, exploring novel agents and prioritizing clinical trial enrollment, and discussing comfort-focused care, especially for frail patients. |
Abbreviations: Allo-HCT, allogeneic hematopoietic stem-cell transplantation; AML, acute myeloid leukemia; CNS, central nervous system; DLI, donor lymphocyte infusions; EBMT, European Society for Blood & Marrow Transplantation; EM, extramedullary; GVL, graft vs leukemia; HCT, hematopoietic stem cell transplantation; HMA, hypomethylating agent; IS, immunosuppression; MRD, measurable residual disease.
References
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