An international expert panel, active within the European Society for Blood and Marrow Transplantation, European LeukemiaNet, Blood and Marrow Transplant Clinical Trial Group, and the International Myelodysplastic Syndromes Foundation developed recommendations for allogeneic hematopoietic stem cell transplantation (HSCT) in myelodysplastic syndromes (MDS) and chronic myelomonocytic leukemia (CMML). Disease risks scored according to the revised International Prognostic Scoring System (IPSS-R) and presence of comorbidity graded according to the HCT Comorbidity Index (HCT-CI) were recognized as relevant clinical variables for HSCT eligibility. Fit patients with higher-risk IPSS-R and those with lower-risk IPSS-R with poor-risk genetic features, profound cytopenias, and high transfusion burden are candidates for HSCT. Patients with a very high MDS transplantation risk score, based on combination of advanced age, high HCT-CI, very poor-risk cytogenetic and molecular features, and high IPSS-R score have a low chance of cure with standard HSCT and consideration should be given to treating these patients in investigational studies. Cytoreductive therapy prior to HSCT is advised for patients with ≥10% bone marrow myeloblasts. Evidence from prospective randomized clinical trials does not provide support for specific recommendations on the optimal high intensity conditioning regimen. For patients with contraindications to high-intensity preparative regimens, reduced intensity conditioning should be considered. Optimal timing of HSCT requires careful evaluation of the available effective nontransplant strategies. Prophylactic donor lymphocyte infusion (DLI) strategies are recommended in patients at high risk of relapse after HSCT. Immune modulation by DLI strategies or second HSCT is advised if relapse occurs beyond 6 months after HSCT.

Allogeneic hematopoietic stem-cell transplantation remains a potential curative therapeutic option for many older patients with MDS. In this analysis, disease stage at time of transplantation, but not recipient age or the intensity of the conditioning regimens, was the most important factor influencing outcomes.

A total of 21 patients with myelofibrosis with myeloid metaplasia (MMM), with a median age of 54 years (range, 27-68 years), were prepared with a reducedintensity conditioning (RIC) regimen. The patients received an allogeneic marrow (n ‫؍‬ 3) or peripheral blood stem-cell (n ‫؍‬ 18) transplant from HLA-matched related (n ‫؍‬ 18) or unrelated (n ‫؍‬ 2), or 1 Ag-mismatched related (n ‫؍‬ 1), donors. RIC regimens included fludarabine/total body irradiation 200 cGy (n ‫؍‬ 5) or 450 cGy (n ‫؍‬ 1), fludarabine/melphalan (n ‫؍‬ 7), thiotepa/cyclophosphamide (n ‫؍‬ 7), and thiotepa/fludarabine (n ‫؍‬ 1). At the time of transplantation, all of the patients were at intermediate (n ‫؍‬ 13) or high (n ‫؍‬ 8) risk, according to the Dupriez classification. Of the patients, 19 had grade III or IV marrow fibrosis. All of the patients achieved full engraftment but one. Posttransplantation chimerism analysis showed more than 95% donor cells in 18 patients, while 2 patients achieved complete donor chimerism after donor leukocyte infusion (DLI). Acute graft-versus-host disease (GVHD) grades II to IV was observed in 7 patients, grades III to IV in 2, and extensive chronic GVHD in 8 of 18 evaluable patients. There were 3 patients who died from acute GVHD, infection, and relapse. There are 18 patients alive 12 to 122 months (median, 31 months) after transplantation, and 17 are in remission (1 after a second transplantation). IntroductionMyelofibrosis with myeloid metaplasia (MMM) is a chronic clonal myeloproliferative disorder characterized by blood cytopenias, megakaryocytic hyperplasia, dysplastic myelopoiesis, reactive marrow fibrosis, and extramedullary hematopoiesis. 1,2 Among the other chronic myeloproliferative diseases, MMM has the worst prognosis, with a median survival of 3.5 to 5.5 years. Many prognostic factors, such as leukocytosis or leukopenia, circulating blast cells and/or immature granulocytic precursors, anemia, thrombocytopenia, and cytogenetic abnormalities, have been previously reported to predict the outcome of this disease. 3-6 A prognostic scoring system was developed by Dupriez et al,5 in which the presence of leukocytosis with more than 30 ϫ 10 9 /L white cells or leukopenia with less than 4 ϫ 10 9 white cells/L, or anemia (hemoglobin [Hgb], Ͻ 100 g/L [10 g/dL]), was used to identify 3 groups of patients with different prognoses, ranging from a median survival of 93 months for score 0, to 26 and 13 months for scores 1 and 2, respectively.Allogeneic hematopoietic stem-cell transplantation is the only curative treatment for MMM, 7 since conventional chemotherapy and/or splenectomy are palliative and do not seem to affect survival. [8][9][10][11][12] Nevertheless, the use of fully myeloablative conditioning regimens has been shown to be associated with a high transplantation-related mortality (TRM) rate, 13-16 especially in advanced and elderly patients. In particular, patients older than 45 years were previously reported to have a significantly worse probability of survival compared with younger patients. 17...