Background/Aim: Prediction of response to azacitidine (AZA) treatment is an important challenge in hematooncology. In addition to protein coding genes (PCGs), AZA efficiency is influenced by various noncoding RNAs (ncRNAs), including long ncRNAs (lncRNAs), circular RNAs (circRNAs), and transposable elements (TEs). Materials and Methods: RNA sequencing was performed in patients with myelodysplastic syndromes or acute myeloid leukemia before AZA treatment to assess contribution of ncRNAs to AZA mechanisms and propose novel disease prediction biomarkers. Results: Our analyses showed that lncRNAs had the strongest predictive potential. The combined set of the best predictors included 14 lncRNAs, and only four PCGs, one circRNA, and no TEs. Epigenetic regulation and recombinational repair were suggested as crucial for AZA response, and network modeling defined three deregulated lncRNAs ) associated with these processes. Conclusion: The expression of various ncRNAs can influence the effect of AZA and new ncRNA-based predictive biomarkers can be defined.Myelodysplastic syndromes (MDS) are a heterogenous group of clonal malignancies characterized by ineffective hematopoiesis resulting in peripheral cytopenia and hypercellular bone marrow dysplasia. MDS patients have an increased tendency to transform to acute myeloid leukemia (AML). When the disease progresses to leukemia, prognosis is clearly unfavorable, with an estimated survival of less than one year (1). The prognosis of MDS patients is assessed based on the Revised International Prognostic Scoring System (IPSS-R) and depends on the number and severity of cytopenia, percentage of bone marrow (BM) blasts and cytogenetics (2).Azacitidine (AZA) is a hypomethylating agent (HMA) that is currently used as a standard care for patients with higher-risk MDS or AML with 20-30% BM blasts when not eligible for intensive chemotherapy and allogeneic transplantation. AZA is a cytidine analogue that, at low doses, inhibits DNA methyltransferases, resulting in DNA hypomethylation. At high doses, AZA is directly cytotoxic to abnormal BM hematopoietic cells because of its incorporation into DNA and RNA (3). Although AZA is extensively used, 30-40% of patients fail to respond or relapse after treatment (4). The International Working Group (IWG) proposed standardized response criteria for evaluating clinically significant responses in MDS (5). Stratification of patients who will benefit from those who will not respond to AZA is essential. In addition to the high costs associated with the treatment, an important issue lies in prolonged exposure to AZA as current recommendations are for a minimum of 6 months of treatment before deeming it a failure. Therefore, proper prediction biomarkers that could potentially prevent prolonged unnecessary adverse effects in AZA-nonresponsive patients are needed.
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