I have MDS patient with EB-2, 15% by IHC (CD34 and CD117) and 7% by flow, normal cytogenetics, NGS does not have TP53, IPSS-R, and IPSS-M are high. Would you go blasts by flow or by IHC? Would you give HMA alone or HMA with Ven or take the patient directly to transplant? Do you prefer Aza or Decitabine in this setting? Would you give Aza five days or seven days? If you would add Ven, is it for 14 days or 21 days? At what blast % do you add Ven to HMA in MDS patients? Is there any time you would recommend 7+3 to the MDS patients? And after how many cycles do you take patients to transplant? I thought I would marrow after one cycle; if blasts are less than 5%, send the patient to transplant (donor is available), but Uptodate is saying to give four cycles of HMA, but I doubt four cycles are universal.

MDS Specialist

I would favor HMA+ven with plan to go to transplant if able to reduce blasts to < 5%. To answer some of your specific questions: 1. If flow and IHC both show increased blasts, I tend to favor the one that is higher as I don't want to underestimate the disease. I like HMA with Ven better than HMA alone given higher CR rates and faster responses, especially if the goal is transplant. I don't have a preference between Aza and Decitabine in this setting. I would give Aza for 7 days. I would add Ven for 21 days and consider dose-modifying for future cycles if recovery is delayed. That being said, 14 days of ven is probably fine as well and I would favor that if there is any fibrosis in the marrow as this may predict for delayed count recovery. I tend to favor adding Ven to HMA at 10% blasts. Typically, we check a bone marrow biopsy at 21 days. If blasts are down to <5% and transplant is feasible, we'll give one more cycle and proceed w transplant. You could also send after the first cycle if transplant is ready. I do not think you need to give 4 cycles of HMA, but I certainly wouldn't discontinue HMA if you don't see a response until after 4 cycles as it can take that long to work.