Exploring the Optimal Role of Transplant for Patients with Acute Lymphoblastic Leukemia
At the 2025 Lymphoma, Leukemia & Myeloma (LL&M) Congress in New York, New York, Alexandra Gomez Arteaga, MD, Weill Cornell Medicine, New York, New York, discusses the role of transplant for patients with acute lymphoblastic leukemia (ALL), including those who fail to demonstrate MRD negativity after initial treatment and those with higher genomic risk.
Transcript:
Hello, I'm Dr. Alexandra Gomez Arteaga. I'm an assistant professor at Weill Cornell Medicine and I'm the director of allogeneic stem cell transplant there.
Today we gave a talk about when we transplant in ALL in 2025. I think that a lot of the doctors in the community say never. But the truth is that we have a couple of patients that we have to consider for transplant upfront, or if they do not achieve the complete remission that we hoped for.
We talked about 3 different scenarios. The first one was for Philadelphia-negative ALL. We really want to make sure that we look into the MRD dynamics and their genomic risk. The genomic risk, there's the new NCCN guidelines were updated in 2025, and they tell us who are the patients that we have to be more concerned for. For patients who have high-risk genomics, such as TP53 or complex cytogenetics, or low hypodiploid, these are the patients that we want to transplant upfront as part of the upfront therapy without thinking if they got into remission with a CR or MRD negativity, because unfortunately at this time in 2025, these patients still have a high risk of relapse.
On the other hand, for patients who have a low genomic risk, but they did not achieve MRD negativity within the first 3 months of treatment, and for working definitions that includes blinatumomab, we should consider a stem cell transplant after 3 months if they're still MRD positive. Some people will ask, will these patients go to a CAR-T instead? And the answer is, we still don't know.
We know that we still have a way to salvage these patients if they achieved MRD negativity and they go to transplant even though they were MRD positive right before. And some patients who go to transplant with low-level MRD. At the same time, things are changing fast, so we need to make sure that we follow closely the literature for how we are able to redefine each genomic risk differently based on concurrent mutations and things like that.
For Philadelphia-positive ALL, we think about high white blood cell count at diagnosis as a risk. Also if they don't go into a complete molecular response within 3 months, complete molecular response within 3 months, biclonal, not [caused] by BCR-ABL, it's going to be a very important market to take these patients to transplant.
Finally, for T-ALL, we have these new ways of redefining the risk, which is MRD and also genomic risk. If the patients are high genomic risk, JAK mutations or complex cytogenetics, TP53, or if they don't achieve an MRD in negativity upfront, these are the patients that we should take to transplant.
The field is moving fast, so we have to balance high relapse risk versus transplant related mortality. Transplant in 2025 is also getting better. There's less risk associated to it. We're getting better with the conditioning. We have donor referral.
The most important point to highlight is that, regardless of what our patients have, we should type them early and make an early referral for BMT [bone marrow transplant] because we never know what their response is going to be in 3 months. If they need a transplant and we don't have a donor ready, we'll be in trouble.
Source:
Gomez Arteaga A. When do we Transplant in ALL? Presented at Lymphoma, Leukemia & Myeloma Congress; October 14-17, 2025. New York, NY.
