New treatment approaches for myelodysplastic syndrome and secondary leukaemias

Allogeneic BMT is the treatment of choice for patients with MDS or sAML, offering a good chance of long-term disease-free survival if the transplant is performed in an early stage of disease or if the patient receives the transplant in complete remission after polychemotherapy. The transplant is limited to a minority of relatively young patients (aged below 55 years) with an HLA-identical sibling. Allogeneic BMT may also be considered when a closely- or fully-matched unrelated donor has been identified for a young and fit patient. All patients, including those without an excess of blasts, should be conditioned with bone marrow ablative therapy rather than an immune suppressive regime, such as cyclophosphamide alone. For the majority of patients there is no standard therapy other than appropriate supportive care. Relatively young patients below the age of 60 years with poor risk features can be considered for treatment with combination chemotherapy. Maintaining remission after remission-induction chemotherapy is a difficult issue. Patients not eligible for allogeneic BMT could be treated with post-remission chemotherapy or autologous BMT in the framework of prospective studies. Older patients can be considered for treatment with haematopoietic growth factors alone or in combination with differentiating agents such as low-dose Ara-C. This treatment should be delivered within the context of carefully designed and conducted trials.