Who Should Receive an Allogeneic Transplant in First Complete Remission?

The decision to incorporate allogeneic hematopoietic stem cell transplant (allo-HSCT) into front-line therapy in adult acute lymphoblastic leukemia (ALL) should be primarily guided by measurable residual disease (MRD) status and the ALL regimen utilized. While there is no doubt that allo-HSCT benefits patients with poor MRD response after induction or consolidation, the indication of allo-HSCT in cases of good MRD clearance is not clear. As targeted immunotherapies result in high MRD-negative CR rates, early incorporation of these therapies may also prove valuable in reducing the need for HCT in the front-line setting. This review discusses the data and controversies related to allo-HSCT in the front-line therapy of Philadelphia chromosome-negative and -positive ALL.