Community Oncologist

Myelodysplastic syndrome with excess blasts - 1 - IPSS-M score Moderate High. IPSS-R score: Intermediate. - Bone marrow 2022 with 5-9% blasts, 40-50% cellularity, dyspoietic erythropoiesis and megakaryocyte - NGS with ASXL mutation, normal cytogentics - Hg 8.9, WBC, Plt WNL. A/w fatigue and increased SOB This gentleman is 88 years old. We discussed chemo vs EPO and opted for EPO. Hg minimally responsive to increasing doses of EPO (9.4 with minimal but some improvement in SOB). Would you add Revlimid or consider HMA next?

MDS Specialist

Great question. In pursuing the EPO route I would make sure I’ve maximized ESA. Can do up to 80K retacrit or 500ucg aranesp weekly. Assuming no response to ESA I would not add in GCSF due to presence of 5-9% blasts. Depending on how fit he is and knowing his age I might pursue an HMA over revlimid. I’ve given HMA to folks over 90 and they’ve tolerated it pretty well, though they were fit. He’ll likely require transfusions after starting in case that might be an issue in coming in frequently. Inqovi (oral decitabine) might be an option just to save trips to infusion center if he’s unable to make it, otherwise would do azacitidine if he’s not compliant with oral meds or insurance issues. If unfit for HMA, I would try off-label luspatercept before Revlimid, as it has a better toxicity profile and likely to be similarly efficacious.