Considerations for choosing the optimal treatment before allogeneic HCT in patients with MDS. In general, there are 3 potential treatment options for transplantation-eligible patients before allogeneic HCT. The figure provides some rationale for choosing the optimal therapy before a planned transplantation. PD indicates progressive disease. 1Donor already identified. 2In general, IC can achieve higher complete response rates than AZA irrespective of karyotype abnormalities. The recommendation above is based on the fact that patients with a poor-risk karyotype have a lower chance to respond to IC than patients with normal cytogenetics (∼ 40% vs 70%). In patients with poor-risk karyotype and no identified donor, a soft “bridging” (although with a lower chance of response than with IC) that avoids the immediate toxicities of IC might be a reasonable alternative. Alternatively, patients with a good-risk karyotype have a good chance of responding to IC, which might therefore be considered as an option even in the immediate absence of a compatible donor.
