NK cell alloreactivity in acute myeloid leukemia in the post-transplant cyclophosphamide era

Allogeneic hematopoietic stem cell transplantation (alloSCT) for myeloid leukemia remains one of the most effective anti-tumor treatments available, capable of curing an increasingly higher proportion of patients. Alloreactivity generated by T cells has limited efficacy in the early post-transplant period while most patients will relapse within 6 months after transplantation. Prior studies in T cell depleted grafts showed that, with the elimination of T cells, natural killer (NK) cells provide most of the anti-tumor effect in the early post-transplant period. Administration of unmodified T cells to mitigate infections and relapse will expose the patient to a high risk of graft-vs-host disease (GvHD). Post-transplant cyclophosphamide (PTCy), initially used for haploidentical (haplo) donor transplants, is now also increasingly utilized in HLA matched donor transplants to prevent GvHD. In most patients, PTCy eliminates, at least in part, alloreactive T and NK cells early post-transplant. Administration of modified NK cells in the early post-transplant period makes intuitive sense to enhance the anti-tumor effect of the graft and thereby prevent relapse. Effective application of cellular therapy early after transplant has opened a new direction and could revolutionize the field of hematopoietic stem cell transplantation.