Autologous hematopoietic cell transplantation for AML in first remission – An abandoned practice or promising approach?

Patients with acute myeloid leukemia (AML) who achieve complete remission after induction therapy require post remission therapy (PRT) in order to remain disease free. The role of autologous hematopoietic cell transplantation (autoHCT) in the PRT setting is controversial and is largely based on older trials that were hampered by low transplant realization rates and relatively high nonrelapse mortality rates as compared to chemotherapy-based approaches. In this review we summarize current data regarding autoHCT in the PRT setting. Most current studies demonstrate that autoHCT is better than chemotherapy-based PRT in terms of leukemia free survival. In most recent studies, autoHCT results in comparable outcomes to allogeneic hematopoietic cell transplantation (alloHCT) from matched sibling or matched unrelated donors in patients with intermediate-risk AML in first complete remission and can be considered as a valid alternative. Adverse-risk AML patients do not benefit from autoHCT and should be referred to alloHCT. Minimal residual disease (MRD) is a powerful prognostic factor and may identify patients that could benefit from an autoHCT PRT. As with other PRT approaches, MRD negativity at the time of autoHCT is associated with the best outcomes. Prospective risk-adapted approaches that assign patients to autoHCT based on disease-risk and MRD status are ongoing and may pave the way for revisiting autoHCT in specific subpopulations of AML patients in first remission.