How I treat transplant-eligible patients with myelofibrosis.

Despite approval of JAK inhibitors and novel agents for patients with myelofibrosis (MF), disease-modifying responses remain limited and hematopoietic stem cell transplantation (HSCT) remains the only potentially curative treatment option. Numbers of HSCT continue to increase worldwide for MF, but its inherent therapy-related morbidity and mortality limit its use for many patients. Furthermore, MF patients often present at older age, with cytopenia, splenomegaly, and severe bone marrow fibrosis, posing challenges in managing these patients throughout the whole HSCT procedure. Although implementation of molecular analyses enabled improved understanding of disease mechanisms and subsequently sparked development of novel drugs with promising activity, prospective trials in the HSCT setting are often lacking, making an evidence-based decision process particularly difficult. To illustrate how we approach MF patients with respect to HSCT, we present 3 different clinical scenarios to capture relevant aspects that influence our decision-making regarding indication for or against HSCT. We will describe how we perform HSCT according to different risk and furthermore discuss our up-to-date approach to reduce transplant-related complications. Last, we will show how to harness graft-versus-MF effects particularly in the post-transplant period to achieve the best possible outcomes for patients.