Therapy-related leukemia and myelodysplasia: evolving concepts of pathogenesis and treatment

Therapy-related leukemia and therapy-related myelodysplasia (t-AML/MDS) are serious and increasingly frequent complications of cytotoxic chemotherapy and/or radiotherapy. Two syndromes can be distinguished, one of which has a long latency (5-7 years or more) and is seen following alkylating agents, frequently with an antecedent dysplastic phase. The other has a short latency period (1-3 years), no antecedent dysplastic phase, and is characteristically seen following topoisomerase II inhibitors. Chromosomal abnormalities can confirm t-leuk/MDS and are predictive of poor prognosis, particularly those involving gains and losses of chromosome 7. There is no standard therapy for t-AML/MDS. This review concentrates on the various treatment approaches for t-AML/MDS. Treatment can be aggressive, with curative intent, particularly for patients who are young with no end-organ damage from the prior malignancy or chemotherapy. Various chemotherapy regimens have been designed to overcome the chemoresistance which is generally characteristic of these syndromes. Bone marrow transplantation offers the best chance for cure, and both myeloablative and nonmyeloablative protocols have been designed. Low dose chemotherapy is an option for patients not able to withstand traditional curative regimens and supportive care is a legitimate option for elderly or infirm patients. Multicenter studies are urgently needed to provide data on which clearcut treatment guidelines can be based, taking into account the patient's age, disease status and risk factors.