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9 slides generated from the cancer page, with a quiz from the open benchmark and speaker notes that cite the sources. Arrow keys move between slides; Print gives one slide per page.
Lower-risk myelodysplastic syndromes rarely turn into leukaemia quickly; the problem is anaemia and the transfusions it demands. Erythropoietin, then luspatercept (COMMANDS) and the telomerase blocker imetelstat (IMerge), free many patients from transfusions for months or years, and lenalidomide does the same for the del(5q) subtype.
Risk in myelodysplastic syndromes is scored by IPSS-R (blasts, cytogenetics and depth of cytopenias) and now IPSS-M, which adds mutations such as SF3B1 (favourable) and TP53 (adverse). Very low, low and intermediate IPSS-R groups, or IPSS-M low and moderate-low, are lower risk: median survival is measured in years and leukaemic transformation is uncommon, so treatment aims at the cytopenias and their consequences, chiefly transfusion-dependent anaemia with iron overload, and at quality of life. Watchful waiting is right for patients without symptoms.
Anaemia treatment is stepwise. Erythropoiesis-stimulating agents help around half of patients with a serum erythropoietin below 500 U/L. Lenalidomide gives transfusion independence to most patients with del(5q). Luspatercept, a TGF-beta superfamily ligand trap that releases late-stage red cell maturation, was approved in 2020 after MEDALIST for ring-sideroblast disease after erythropoietin failure, and COMMANDS (2023) moved it to first line: 58.5 percent of transfusion-dependent, erythropoietin-naive patients became transfusion independent for at least 12 weeks with a haemoglobin rise, against 31.2 percent on epoetin alfa. Imetelstat, the first telomerase inhibitor, was approved in 2024 after IMerge: in erythropoietin-refractory patients, 39.8 percent became transfusion independent for eight weeks and 28 percent for 24 weeks, against 15 and 3.3 percent on placebo, at the cost of neutropenia and thrombocytopenia.
| Setting | Approach | Guideline |
|---|---|---|
| Asymptomatic, no transfusions | Observation with blood counts every three to six months; no treatment. | not mapped |
| Anaemia, first line | Luspatercept for ring-sideroblast or SF3B1-mutated disease and for transfusion-dependent patients (COMMANDS); erythropoiesis-stimulating agent where serum erythropoietin is below 500 U/L; lenalidomide for del(5q). | not mapped |
| Anaemia after erythropoietin or luspatercept failure | Imetelstat (IMerge); luspatercept if not yet used; low-dose hypomethylating agent; trials of elritercept and other agents. | not mapped |
| Supportive care | Red cell transfusion to symptoms, iron chelation once ferritin is persistently high, G-CSF for recurrent neutropenic infection, platelet transfusion for bleeding. | not mapped |