Allogeneic stem cell transplantation for acute myeloid leukemia in first complete remission: are we closer to knowing who needs it?

Acute myeloid leukemia (AML) is a very heterogeneous disease. Prognosis is related not only to intrinsic characteristics such as cytogenetics and molecular markers, but also the patient's ability to tolerate therapy, and treatment response. Allogeneic stem cell transplantation (allo-HCT) has been traditionally indicated for poor-risk disease in first complete remission (CR1) or for treatment of relapsed or refractory AML. 'Poor-risk' disease is now better defined due to genetic subtyping, particularly in chromosomally normal AML. In addition, the presence of comorbid conditions should be included in the decision-making process. Improvements in supportive care and the use of modern conditioning regimens have been associated with improved outcomes, mostly due to a reduction in treatment-related mortality. Therefore, a significant proportion of patients with AML-CR1 can potentially benefit from allo-HCT. We give general guidelines on how to incorporate cytogenetic and molecular risk factors, donor selection, and patient characteristics in order to determine when allo-HCT should be indicated in CR1.