T he article by Ferrara et al. 1 in this issue of Cancer describes the treatment of patients with poor prognosis myelodysplastic syndromes (MDS) using intensive remission induction chemotherapy followed by peripheral blood stem cell transplantation for patients age Ο½ 60 years. Thirty-two patients with refractory anemia with excess of blasts in transformation (RAEBt) and 10 patients with refractory anemia with excess of blasts (RAEB) were treated, with an overall complete remission rate of 74% (90% for patients age Ο½ 60 years and 56% for patients ages 60 -75 years). The median survival for all patients was 13 months with a median disease free survival (DFS) of 18 months. Because the usual median survivals for patients with these types of MDS are 6 months and 2 years, respectively, these results suggest that treatment led to improved survival. Similarly, other investigators have reported complete remission rates in this subset of patients ranging from 45-70% with remission rates being higher in patients age Ο½ 40 years than in patients age ΟΎ 40 years and responses, both in terms of remission induction outcome and duration, which were substantially worse in MDS characterized by cytogenetic abnormalities usually associated with a poor prognosis. [2][3][4][5][6][7][8][9][10][11][12][13][14] Before concluding that intensive remission induction therapy results in improved survival, it should be recognized that the treated patients were a select group. In the study by Ferrara et al., patients age ΟΎ 75 years were excluded from treatment and of 74 consecutive patients with high risk MDS, 41% were excluded from treatment for a variety of reasons.
Although no direct comment can be made regarding the possible role of transplantation in the study by Ferrara et al., other reports are available that can help put the role of transplantation into perspective. Among 93 MDS patients who received an allograft, the 5-year actuarial DFS was 41%, with recurrences occurring in 28% of patients and a nonrecurrence mortality rate of 43%. 15 Only patients whose bone marrow contained Υ 5% blasts recurred (51%). Patients age Ο½ 40 years and who had Ο½ 5% blasts in their bone marrow had a DFS of 62% at 4 years. A more recent assessment by the same group of 251 MDS patients who were underwent bone marrow transplantation found an overall DFS rate of 40% with a recurrence rate of 18%.
Assessment of transplantation outcome on the basis of the Inter-