Allogeneic hematopoietic stem cell transplantation (HSCT) is one of the principal curative approaches in the treatment of acute myeloid leukemia (AML); however, relapse after transplantation remains a catastrophic event with poor prognosis. The incidence of relapse has remained unchanged over the last 3 decades despite an evolving understanding of the immunobiology of the graft-versus-leukemia effect and the immune escape mechanisms that lead to post-HSCT relapse. The approach to posttransplant relapse is highly individualized and is dictated both by disease biology and genomics as well as the patient's clinical status at the time of relapse and the interval between relapse and transplantation. With the help of 3 illustrative cases, we discuss our approach to early, late, and incipient relapse. Current therapeutic strategies incorporate immunosuppression taper when feasible, a variety of targeted and nontargeted chemotherapeutic agents, and consolidative cellular therapies including donor lymphocyte infusions or a second allogeneic transplant. We then summarize evolving frontiers in the treatment and prognostication of relapse, including the critical role of measurable residual disease. Finally, we emphasize enrollment on clinical trials and thoughtful discussions regarding goals of care and supporting frail patients as universal principles that should be incorporated in approaches to treatment of AML relapse after transplantation.
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HOW I TREAT|
May 8, 2025
How I treat AML relapse after allogeneic HSCT Available to Purchase
Mahasweta Gooptu,
Mahasweta Gooptu
Department of Hematology/Oncology, Dana-Farber Cancer Institute, Boston, MA
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H. Moses Murdock,
H. Moses Murdock
Department of Hematology/Oncology, Dana-Farber Cancer Institute, Boston, MA
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Robert J. Soiffer
Robert J. Soiffer
Department of Hematology/Oncology, Dana-Farber Cancer Institute, Boston, MA
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Blood (2025) 145 (19): 2128–2137.
Article history
Submitted:
October 10, 2024
Accepted:
December 16, 2024
First Edition:
December 24, 2024
Citation
Mahasweta Gooptu, H. Moses Murdock, Robert J. Soiffer; How I treat AML relapse after allogeneic HSCT. Blood 2025; 145 (19): 2128–2137. doi: https://doi.org/10.1182/blood.2024025705
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May 8 2025
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Integrating Palliative Care into the Treatment Landscape of Post-HSCT AML Relapse
Despite the availability of new targeted therapies, prognosis remains very poor(2). Still, we often propose, as default, toxic, burdensome, and costly interventions—such as a second transplant or DLI—based on limited evidence and a remote chance of cure, often without fully addressing trade-offs with patients(3).
The goal of oncologic treatment is to help patients live longer and better(4). Sometimes, living better means being at home, using one’s own bathroom, and sleeping beside a loved one. Yet patients often overestimate small chances of cure, believing aggressive therapy will restore these experiences—when it may instead prevent them or even shorten life.
This binary framing—curative vs. non-curative—can lead patients with near-certain poor outcomes to undergo treatments unlikely to extend life meaningfully and almost certain to impair quality of life. Transparent conversations about prognosis and uncertainty must be central to compassionate care. We advocate that palliative care be included not as a sentence in the conclusion, but as a legitimate option in the treatment algorithm—and implemented early, alongside any therapeutic path.
The authors have no conflicts of interests to declare
Author contact: ygonzaga@inca.gov.br
References
1. Gooptu M, Murdock HM, Soiffer RJ. How I treat AML relapse after allogeneic HSCT. Blood;145(19):2128–37.
2. Bejanyan N, Weisdorf DJ, Logan BR, Wang HL, Devine SM, De Lima M, et al. Survival of Patients with Acute Myeloid Leukemia Relapsing after Allogeneic Hematopoietic Cell Transplantation: A Center for International Blood and Marrow Transplant Research Study. Biology of Blood and Marrow Transplantation;21(3):454–9.
3. Hui D, Bansal S, Park M, Reddy A, Cortes J, Fossella F, et al. Differences in attitudes and beliefs toward end-of-life care between hematologic and solid tumor oncology specialists. Annals of Oncology;26(7):1440–6.
4. Bommier C, Maurer MJ, Lambert J. What clinicians should know about surrogate end points in hematologic malignancies. Blood;144(1):11–20.