In the field of myelofibrosis treatment, allogeneic hematopoietic stem cell transplantation (allo-HSCT) serves as a curative approach, and the optimization of related strategies is particularly crucial. Recently, at the 12th Lu Daopei Hematology Academic Forum, "Hematology Frontier" was honored to invite Dr. Nicolaus Kroger from the University Medical Center Hamburg-Eppendorf in Germany to provide a detailed interpretation of the latest optimization directions and practical experiences in transplant strategies for myelofibrosis treatment. This sharing not only broadened our cognitive horizons but also provided valuable international perspectives and scientific guidance for improving patients' long-term survival rates.Oncology Frontier-Hematology Frontier：In the treatment of myelofibrosis, allogeneic hematopoietic stem cell transplantation (allo-HSCT) is considered the potentially curative therapy. What do you think about optimizing transplant strategies to improve long-term survival rates?
Dr. Nicolaus Kroger：So for myelofibrosis, the disease can be very heterogeneous. So we have patients who can live very long without stem cell transplantation. But if patient has several risk factors and the survival is short, then we would recommend allogeneic hematopoietic stem cell transplantation.
So allogeneic stem cell transplantation is currently the only curative treatment approach for these patients. And the treatment is is many times. It’s not only the chemotherapy and the stem cells. It’s also the post transplant intervention and the pretreatment of the patient to prepare the patient properly for the stem cell transplantation. To reduce, for instance, spleen size, which is one of the options. And the other options is to use more reduced intensity conditioning, which is not so toxic for the patient and can be done also for older patients or elderly patients. And very important what we learned in the last year is the so called post transplant intervention because in the transplant the patients are receiving a new haematopoietic system.
And then in the first years or let’s say the 6 months after transplantation, then the new immune system is working and is trying to kill the myelofibrosis cells, but is also causing graft versus host disease.
Therefore it’s up to the physician to monitor after transplantation very carefully. To harness this graft versus myelofibrosis effect and in order to cure this patient and to avoid relapse, so called non-relapse mortality.
Oncology Frontier-Hematology Frontier：For patients with myelofibrosis, how do you think we can improve conditioning regimens to reduce the risk of relapse after transplantation?
Dr. Nicolaus Kroger：In myelofibrosis, the intensity of the conditioning regimen has no major impact in outcome. That means if you want to reduce the risk of relapse, it’s not the intensity of the conditioning. So we would recommend to go in all these patients with reduced intensity and then regarding reduce the risk of relapse. You should do something post transplantation. If patient has in grafted, you can monitor this patient very closely with molecular markers. And you can check, is there still residual disease? If there still is residual disease, which you can monitor with these markers, then you can, for instance, reduce immunosuppression to increase the t cells, to kill the residual myelofibrosis cells. So for relapse prevention, post transplant is more important than intensity of the conditioning regimen.
Oncology Frontier-Hematology Frontier：what new findings or methods have been identified for assessing the prognosis of myelofibrosis patients after transplantation?
Dr. Nicolaus Kroger：So what we learned in the last years is that the transplant is not only conditioning regimen and then the stem cells infusion. It’s only the preparation to reduce the spleen size, but also to some post transplant. The most important what we learned as to monitor this patient after transplantation, whether there is still residual disease. They can have a normal blood count, they look good, the bone marrow is good. But if you look molecular markers where you can take minimal residual disease, this is important because this can be treated then by increasing the donor t cells, either by reducing immunosuppression, or later by giving donor lymphocyte infusion, to kill also the myelofibrosis cells before they can relapse.
