The Annual Scientific Replace in Hematological Malignancies, showing on-line in early June and now publishing within the August concern of the American Journal of Hematology (AJH), consists of an replace on myelodysplastic syndromes by Guillermo Garcia-Manero, MD, who leads the MDS Part within the Division of Leukemia at The College of Texas MD Anderson Most cancers Middle in Houston.

“Higher understanding of the pathobiology of MDS is leading to newer approaches for sufferers,” Garcia-Manero states. “As a consequence, the therapy panorama for sufferers with MDS is beginning to change.”

The replace notes that sufferers’ prognosis is assessed with completely different scoring strategies, which all embody an analysis of the proportion of blasts within the bone marrow, peripheral cytopenias, cytogenic characeterics. A more moderen methodology additionally incorporates genomic information, which might additionally support in prognosis.

The article presents a therapy algorithm based mostly on lower-risk or higher-risk classification, however it does name for next-generation sequencing at baseline “and every time a therapeutic determination goes to be made,” as a result of there isn’t a different option to determine small subsets of sufferers who usually tend to have a response to particular therapies, reminiscent of allogeneic stem cell transplant (alloSCT), based mostly on their genomic profile.

Garcia-Manero cited a report on a small group of sufferers at MD Anderson with very excessive response charges based mostly on this strategy.

Early-stage circumstances. The article distinguishes betweenclonal cytopenia of undetermined significance (CCUS), clonal hematopoiesis of indeterminate potential (CHIP), and idiopathic cytopenia of undetermined significance (ICUS), during which dysplasia shouldn’t be seen however the potential for development to MDS exists. At this stage, Garcia-Manero writes, “Sufferers with ICUS/CHIP/CCUS shouldn’t be handled however adopted preferentially in a devoted ‘CHIP’ clinic.

Consideration ought to be paid to the care of comorbidities. Scientific trials may very well be thought-about if out there.”

Decrease-risk MDS. Garcia-Manero hedges his suggestions on this part by noting that issues may change with outcomes from the COMMANDS trial, which he offered on the American Society of Scientific Oncology (ASCO) simply as his replace went to press. COMMANDS discovered that luspatercept, accepted for different populations in 2020, allowed 58.5% of the lower-risk sufferers handled first-line to keep away from transfusions for not less than 12 weeks whereas rising hemoglobin, in contrast with 31.2% of sufferers receiving epoetin alfa, an erythropoiesis-stimulating agent (ESA).

The article’s part on decrease threat MDS additionally discusses use of lenalidomide and azanucleosides, together with oral decitabine/cedazuridine (oral dec/ced), accepted in 2020. Garcia-Mareno stated use of those brokers within the US is principally in second-line therapy and completely different from use in Europe. He discusses at size the significance of correct dosing; at MD Anderson, investigators designed a sequence of medical trials investigating attenuated doses and schedules of each azacytidine and decitabine. When these trial designs had been criticized for not together with comparisons of hypomethylating brokers (HMAs), a 3rd research was designed and is accruing sufferers.

Garcia-Mareno notes that use of HMAs in lower-risk MDS is best facilitated with the provision of oral brokers; the advice sees extra use of oral brokers sooner or later. Up to now, information on oral dac/ced and oral azacytidine have been printed, though the latter shouldn’t be accepted in MDS. He notes that the section 3 trial for oral dec/ced straight in contrast sufferers to intravenous decitabine, and “This allowed for intrapatient PK comparability. Outcomes offered at [American Society of Hematology] 2019 demonstrated nearly an identical pharmacokinetic (PK) profile between each IV decitabine and the oral model.” The article outlines ongoing research in each brokers.

He talked about the section 2/3 iMerge trial (NCT02498661), additionally offered at ASCO, during which imetelstat, a telomerase inhibitor, produced a considerably larger charge of 8-week transfusion independence than placebo. Since then, FDA has granted a brand new drug utility for imetelstat for use for sufferers with transfusion-dependent anemia in sufferers with low- to intermediate–threat MDS.

One other part of the paper addresses therapy of sufferers with lower-risk MDS and thrombocytopenia.

Larger-risk sufferers. Garcia-Mareno writes that choices for sufferers identified with higher-risk MDS “haven’t advanced considerably” for the reason that final AJH replace, and that “azanucleosides stay the usual of care of a majority of sufferers.” He wrote that remaining outcomes for the research (NCT03306264) on oral dec/ced will come this 12 months; the final replace was reported on clinicaltrials.gov. on Might 31, 2023. Garcia-Mareno stated the report could reply questions on interim information that recommend higher responses for sufferers with sure p53 mutations.

Though the paper notes that “no research has in contrast 5-azacitidine vs decitabine” and response charges seem related, “solely 5-azacitidine has been related to enchancment of survival in a randomized trial. Based mostly on this, we contemplate 5-azacitidine commonplace remedy for front-line therapy in larger threat MDS.”

Garcia-Mareno goes on to stipulate when sufferers ought to be thought-about for remedy much like that used to deal with sufferers with acute myeloid leukemia, reminiscent of an allogeneic stem cell transplant (alloSCT); for lower-risk MDS, usually youthful, fitter sufferers can be thought-about. The algorithm for higher-risk sufferers distinguishes between these older and youthful than aged 70 to 75, when a person’s skill to tolerate varied therapy approaches should be weighed towards potential advantages. Suggestions concerning alloSCT are very particular within the higher-risk inhabitants: “Though alloSCT ought to be thought-about for sufferers with higher-risk MDS this is probably not the case in sufferers with excessive threat mutations reminiscent of TP53, in whom, in our opinion, transplant could must be thought-about provided that an optimum donor is obtainable.”

Nonetheless, the problem of what to do for sufferers who fail HMAs is a frightening one, and Garcia-Mareno concludes with a dialogue of the “complete remedy” strategy alongside alloSCT, together with the talk over bridging remedy. “The arrival of highly effective new mixtures with magrolimab or venetoclax argue for complete remedy that might render sufferers [minimal residual disease]-negative pre transplant adopted with post-transplant upkeep remedy, both with focused approaches of HMAs. Additional research are wanted on this space.”

Reference

Garcia-Manero G. Myelodysplastic syndromes: 2023 replace on prognosis, risk-stratification, and administration. Am J Hematol. 2023;98(8):1307‐1325. doi:10. 1002/ajh.26984