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Diagnosis and Treatment of Myelodysplastic SyndromesA Review

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Abstract

Importance  Myelodysplastic neoplasms (MDS), formerly known as myelodysplastic syndromes, are clonal hematopoietic malignancies that cause morphologic bone marrow dysplasia along with anemia, neutropenia, or thrombocytopenia. MDS are associated with an increased risk of acute myeloid leukemia (AML). The yearly incidence of MDS is approximately 4 per 100 000 people in the United States and is higher among patients with advanced age.

Observations  MDS are characterized by reduced numbers of peripheral blood cells, an increased risk of acute myeloid leukemia transformation, and reduced survival. The median age at diagnosis is approximately 70 years, and the yearly incidence rate increases to 25 per 100 000 in people aged 65 years and older. Risk factors associated with MDS include older age and prior exposures to toxins such as chemotherapy or radiation therapy. MDS are more common in men compared with women (with yearly incidence rates of approximately 5.4 vs 2.9 per 100 000). MDS typically has an insidious presentation, consisting of signs and symptoms associated with anemia, thrombocytopenia, and neutropenia. MDS can be categorized into subtypes that are associated with lower or higher risk for acute myeloid leukemia transformation and that help with therapy selection. Patients with lower-risk MDS have a median survival of approximately 3 to 10 years, whereas patients with higher-risk disease have a median survival of less than 3 years. Therapy for lower-risk MDS is selected based on whether the primary clinical characteristic is anemia, thrombocytopenia, or neutropenia. Management focuses on treating symptoms and reducing the number of required transfusions in patients with low-risk disease. For patients with lower-risk MDS, erythropoiesis stimulating agents, such as recombinant humanized erythropoietin or the longer-acting erythropoietin, darbepoetin alfa, can improve anemia in 15% to 40% of patients for a median of 8 to 23 months. For those with higher-risk MDS, hypomethylating agents such as azacitidine, decitabine, or decitabine/cedazuridine are first-line therapy. Hematopoietic cell transplantation is considered for higher-risk patients and represents the only potential cure.

Conclusions and Relevance  MDS are diagnosed in approximately 4 per 100 000 people in the United States and are associated with a 5-year survival rate of approximately 37%. Treatments are tailored to the patient’s disease characteristics and comorbidities and range from supportive care with or without erythropoiesis-stimulating agents for patients with low-risk MDS to hypomethylating agents, such as azacitidine or decitabine, for patients with higher-risk MDS. Hematopoietic cell transplantation is potentially curative and should be considered for patients with higher-risk MDS at the time of diagnosis.

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Article Information

Accepted for Publication: August 3, 2022.

Corresponding Author: Mikkael A. Sekeres, MD, MS, Division of Hematology, Department of Medicine, Sylvester Comprehensive Cancer Center, University of Miami, 1120 NW 14th St, Ste 610M, Miami, FL 33156 (msekeres@med.miami.edu).

Author Contributions: Dr Sekeres had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: Sekeres.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: Sekeres.

Administrative, technical, or material support: Sekeres.

Supervision: Sekeres.

Conflict of Interest Disclosures: Dr Sekeres reported personal fees from BMS, Novartis, and Pfizer (serving on advisory boards) outside the submitted work. Dr Taylor reported honorarium from Karyopharm Therapeutics; and grants from the National Cancer Institute/National Institutes of Health, the Doris Duke Charitable Foundation, and the Edward P. Evans Foundation outside the submitted work.

Additional Contributions: The authors would like to thank John Reynolds, MLIS, AHIP, from the University of Miami Miller School of Medicine Calder Library, Miami, Florida, for his assistance with the literature review. Mr Reynolds did not receive any compensation.

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