Use of measurable residual disease to evolve transplant policy in acute myeloid leukemia: A 20‐year monocentric observation

Measurable residual disease (MRD) is increasingly employed as a biomarker of quality of complete remission (CR) in intensively treated acute myeloid leukemia (AML) patients. We evaluated if a MRD‐driven transplant policy improved outcome as compared to a policy solely relying on a familiar donor availability. High‐risk patients (adverse karyotype, FLT3‐ITD) received allogeneic hematopoietic cell transplant (alloHCT) whereas for intermediate and low risk ones (CBF‐AML and NPM1‐mutated), alloHCT or autologous SCT was delivered depending on the postconsolidation measurable residual disease (MRD) status, as assessed by flow cytometry. For comparison, we analyzed a matched historical cohort of patients in whom alloHCT was delivered based on the sole availability of a matched sibling donor. Ten‐years overall and disease‐free survival were longer in the MRD‐driven cohort as compared to the historical cohort (47.7% vs. 28.7%, p = 0.012 and 42.0% vs. 19.5%, p = 0.0003). The favorable impact of this MRD‐driven strategy was evident for the intermediate‐risk category, particularly for MRD positive patients. In the low‐risk category, the significantly lower CIR of the MRD‐driven cohort did not translate into a survival advantage. In conclusion, a MRD‐driven transplant allocation may play a better role than the one based on the simple donor availability. This approach determines a superior outcome of intermediate‐risk patients whereat in low‐risk ones a careful evaluation is needed for transplant allocation.