Who should be transplanted in first remission of acute myeloid leukaemia?

Patients under 40 years with other than high risk disease do not benefit from an allograft in CR1, particularly if they have received gemtuzumab ozogamicin in induction. High risk can be defined by cytogenetics (Complex; abnormalities of chromosome 5 and 7; 3q-; Ph(1)) in addition, adverse features could include presentation with high white cell count or secondary disease, or a failure to have a satisfactory blast cell reduction to induction course 1 (to <15% marrow blasts), an EVI-1 mutation, although the risk with that mutation is frequently primary resistance. While there is an increasing list of molecular characteristics that could indicate a higher risk, there is in general an absence of clear evidence that they are predictive of a benefit from transplant. This does not mean that they should not be transplanted, just that it is uncertain. Some of the newer markers like minimal residual disease fall into the same category. The decision to allograft is also influenced by the estimated transplant risk. This can be minimised by high quality molecular matching techniques, the availability of a non-parous donor who is CMV seronegative and a patient with a favourable co-morbidity score. Patients who do fail first-line chemotherapy require an allograft unless the duration of first remission, which is a major determinant of outcome, is long e.g. >2 years. The possible exception to this could be core binding factor leukaemias who may have durable survival after relapse with transplant alone.