MRD-guided transplant decisions in intermediate-risk AML

The idea is to use ultra-sensitive residual disease tests, NPM1 qPCR or error-corrected NGS, after two cycles of induction to decide which intermediate-risk acute myeloid leukaemia patients really need an allogeneic transplant. MRD status is the strongest predictor of relapse, transplant carries substantial risk, and its benefit concentrates in MRD-positive patients; ELN 2022 already recommends transplant for them, but randomised confirmation is lacking. The hypothesis is that MRD-negative patients can receive chemotherapy consolidation instead with equal overall survival and less toxicity. The test randomises MRD-negative patients to transplant or consolidation with MRD surveillance; myeloMATCH, HOVON and AMLSG trials already stratify by MRD, so it is being tested at scale.