Therapy of high-risk myelodysplastic syndromes

Higher-risk myelodysplastic syndrome (HR-MDS) is a heterogeneous group of hematopoietic malignancies primarily affecting the elderly, characterized by ineffective hematopoiesis, cytopenias, and a risk of transformation to acute myeloblastic leukemia. This review outlines the current landscape of HR-MDS management, focusing on risk stratification, treatment options, and challenges. The International Prognostic Scoring Systems (IPSS-R and IPSS-M) classify patients into risk categories, integrating cytogenetics and molecular data to guide therapy. Hypomethylating agents remain the standard of care for non-transplant-eligible patients, though their efficacy varies, with median overall survival ranging from 13-19 months. Promising novel agents include anti-apoptotic drugs (e.g., venetoclax), mutation-targeted drugs (e.g., TP53, IDH1/2), signal transduction inhibitors, inflammation pathway inhibitors and immune checkpoint inhibitors. Combinations of hypomethylating agents and these novel agents have shown promise in early trials as initial or salvage therapy but have failed to improve survival in phase III studies. Allogeneic hematopoietic stem cell transplantation is the only potentially curative option, yet its applicability is limited by patient age, comorbidities, and donor availability. Post-transplant relapse monitoring via chimerism and measurable residual disease is critical, with preemptive donor lymphocyte infusion recommended for relapse prevention. Future research should focus on mutation-driven therapies and inclusive trial designs to optimize HR-MDS management.