A 35-year-old man with AML (de novo, normal cytogenetics) achieves CR1 after 7+3 induction. Molecular testing reveals NPM1 mutation with FLT3-ITD low allele burden. He has a matched sibling donor available. According to ELN 2022 risk stratification, what is his risk category and recommended post-remission strategy?
- A Favorable risk — consolidation with high-dose cytarabine (HiDAC) × 4 cycles
- B Intermediate risk — allogeneic stem cell transplant in CR1
- C Favorable risk — MRD-guided consolidation; transplant only if MRD positive post-induction ✓
- D Adverse risk — allogeneic transplant in CR1 mandatory
Correct answer: C. Favorable risk — MRD-guided consolidation; transplant only if MRD positive post-induction
Explanation
Per ELN 2022 AML classification, NPM1 mutation without FLT3-ITD (or with low FLT3-ITD allele ratio <0.5) is ELN favorable risk. Favorable-risk AML has excellent outcomes with HiDAC consolidation; allogeneic SCT in CR1 does not improve overall survival and exposes patients to transplant-related mortality. MRD assessment after consolidation guides further decisions — MRD persistence or conversion to positive post-consolidation identifies patients who benefit from SCT. This is a paradigm shift from earlier algorithms that recommended SCT for all intermediate and above.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.