Tuning the Rigging before Sailing off into the Stormy Sea of Stem Cell Transplants for Patients with Myelodysplastic Syndromes

The role of hypomethylating agents in myelodysplastic syndrome: changing the management paradigm

Modern treatment of myelodysplastic syndromes (MDS) with hypomethylating agents (HMAs) such as azacitidine (Vidaza) and decitabine (Dacogen) has changed the clinical landscape of these disorders. Novel drug combinations of HMAs with histone deacetylase inhibitor therapy may synergistically target different dysregulated molecular mechanisms within MDS clones. This article reviews current trial data concerning the use of the main HMAs in MDS patients where intensive chemotherapy and allogeneic stem cell transplantation is generally not an option. Collated data are presented of the clinical response outcomes, toxicity profiles and prognostic response criteria. Vidaza use in low-risk MDS cases, the selected place of allogeneic stem cell transplantation in older patients with significant comorbidity and the novel drug combination strategies for the future are discussed.

Can hypomethylating agents provide a platform for curative therapy in myelodysplastic syndromes?

The hypomethylating agents (HMAs) azacitidine and decitabine have changed the treatment landscape of myelodysplastic syndromes (MDS) since their approval by the United States Food and Drug Administration (US FDA) in 2004 and 2006, respectively. However, neither agent is able to cure patients with MDS, and when patients fail to respond to treatment with these agents, their prognosis is poor. For this reason, investigators are currently testing combination regimens with an HMA as a backbone and altering the dose, schedule, and method of delivery of HMAs. Additionally, more than 30 new molecules are currently being tested in interventional studies for which patients with MDS are eligible to enroll. These efforts may further improve outcomes for patients with MDS. For the time being, allogeneic stem cell transplantation (ASCT) remains patients' only real opportunity for cure and should be performed whenever possible in patients with higher-risk disease.