# Myelofibrosis and allogeneic transplantation: critical points and challenges

## TL;DR

This review discusses the challenges and key considerations in using allogeneic stem cell transplantation as a potential cure for myelofibrosis.

## Contribution

The paper identifies critical areas for improvement in patient selection and outcome prediction for myelofibrosis transplants.

## Key findings

- Current drugs manage symptoms but do not alter the progression of myelofibrosis.
- HSCT remains the only curative option but is complicated by multiple patient and disease factors.
- Prospective trials are scarce, making evidence-based decisions difficult in this field.

## Abstract

New available drugs allow better control of systemic symptoms associated with myelofibrosis (MF) and splenomegaly but they do not modify the natural history of progressive and poor prognosis disease. Thus, hematopoietic stem cell transplantation (HSCT) is still considered the only available curative treatment for patients with MF. Despite the increasing number of procedures worldwide in recent years, HSCT for MF patients remains challenging. An increasingly complex network of the patient, disease, and transplant-related factors should be considered to understand the need for and the benefits of the procedure. Unfortunately, prospective trials are often lacking in this setting, making an evidence-based decision process particularly arduous. In the present review, we will analyze the main controversial points of allogeneic transplantation in MF, that is, the development of more sophisticated models for the identification of eligible patients; the need for tools offering a more precise definition of expected outcomes combining comorbidity assessment and factors related to the procedure; the decision-making process about the best transplantation time; the evaluation of the most appropriate platform for curative treatment; the impact of splenomegaly; and splenectomy on outcomes.