MRD-guided interventions for patients with AML undergoing allo-HSCT: EBMT recommendations

The European Society for Blood and Marrow Transplantation Practice Harmonization and Guidelines Committee provide best practice recommendations for incorporating measurable residual disease (MRD) assessment into the management of patients with acute myeloid leukemia (AML) undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT), published by Sanz et al. in The Lancet Oncology.

Key data: Molecular MRD assessment by reverse transcription quantitative polymerase chain reaction (RT-qPCR) is recommended for patients with NPM1 mutations or RUNX1::RUNX1T1, CBFB::MYH11, or PML::RARA rearrangements; multiparameter flow cytometry (MFC) is recommended for other molecularly defined subgroups. Pre-transplantation MRD evaluation should be performed within 4 weeks of the start of conditioning. Post-HSCT MRD monitoring is mandatory for all patients, with early evaluation recommended within 60 days post-HSCT and continued for up to 2 years. Immunological interventions such as early immunosuppression tapering or prophylactic donor lymphocyte infusion can be used in patients with detectable MRD, preferentially combined with pharmacological interventions when available. FLT3 inhibitors should be offered as maintenance therapy for 2 years in patients with FLT3-ITD positive AML, with gilteritinib preferred for patients with detectable MRD. Combined immunological and pharmacological strategies should be considered for patients with detectable MRD post-HSCT.

Key learning: MRD monitoring is mandatory for all patients with AML undergoing allo-HSCT. Any level of post-HSCT MRD detection should trigger specific interventions, including immunological strategies and targeted pharmacological agents, to decrease relapse risk and improve transplant outcomes.