NCCN Guidelines® Updates

NCCN Guidelines® Updates

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Myelodysplastic Syndromes, published in this issue (page 838), include the latest updates. To assist readers interested in noting how the guidelines were updated, highlights of major changes pertaining to the abbreviated version published in this issue are printed below. To view the complete list of updates and full versions of these guidelines, visit the NCCN Web site at

Myelodysplastic Syndromes

Updates in Version 2.2014 of the NCCN Guidelines for Myelodysplastic Syndromes from Version 2.2013 include:


  • Footnote “b” was modified: Confirm diagnosis of MDS according to FAB or WHO criteria for classification with application of IPSS. See Classification Systems (MDS-3 and MDS-5). The percentage of marrow myeloblasts based on morphologic assessment (aspirate smears preferred) should be reported. Flow cytometric estimation of blast percentage should not be used as a substitute for morphology in this context. In expert hands, expanded flow cytometry may be a useful adjunct for diagnosis in difficult cases.


  • French-American-British (FAB) Classification of MDS tables was removed.
  • “Refractory anemia with excess blasts in transformation (RAEB-T)” was added to the table with footnote “l.”
  • Footnote “I” was added.


  • Footnote “p” was modified: “Examples include thrombocytosis, leukocytosis, and splenomegaly. In addition, RARS-T has been suggested as a provisional MDS/MPN entity for individuals with RARS and platelet counts ≥450,000 ×109/L.” [Chapter 4, in Swerdlow S, Campo E, Harris NL, et al (Eds.). World Health Organization Classification of Tumours of Haematopoietic and Lymphoid Tissues, 4th edition. IARC Press, 2008, pp 85-86.]


  • Revised International Prognostic Scoring System (IPSS-R) was included.
  • Footnotes “x” and “y” were added.
  • The following websites were added for accessing the IPSS-R calculator tool: or A mobile App for the calculator tool is also available for smartphones at MDS IPSS-R.


  • “IPSS-R: Very Low, Low, Intermediate” was added to the heading.
  • Following “Clinically significant cytopenia(s),” “or increased marrow blasts” was added.
  • Following “Clinically relevant thrombocytopenia or neutropenia,” “or increased marrow blasts” was added.
  • “No response” was changed to “Disease progression/no response.”
  • Footnote “bb” was added: “IPSS-R Intermediate patients may be managed as very low/low risk or high/very high risk depending upon additional prognostic factors such as age, performance status, serum ferritin levels, and serum LDH levels. If patients initially are managed as lower risk but fail to respond, move to higher risk management strategies.”
  • “Immunosuppressive therapy (IST)” was moved to earlier under Azacytidine/decitabine under treatment. The section now reads: “Azacytidine/decitabine or ISTee or Clinical trial.”
  • Footnote “ee” was modified: “Patients generally ≤60 y, and ≤5% marrow blasts or those with hypocellular marrows, HLA-DR15 positivity, or PNH clone positivity.”


  • “IPSS-R: Very Low, Low, Intermediate” was added to the heading.
  • Under treatment, “No response” was changed to “No response or intolerance.”
  • Footnote “gg” was modified: “Except for patients with low neutrophil counts or low platelet counts. Recommended initial dose is: 10 mg/d for 21 out of 28 days monthly for 2-4 months to assess response (See Discussion). Alternative option to lenalidomide may include an initial trial of ESAs in patients with serum EPO ≤ 500 mU/mL.”


  • “IPSS-R: Intermediate, High, Very High” was added to the heading.
  • Footnote ll was modified: “Based on age, performance status, major comorbid conditions, psychosocial status, patient preference, and availability of caregiver. Patients may be taken immediately to transplant or bridging therapy should be used to decrease marrow blasts to an acceptable level prior to transplant.”


  • Footnote “gg” was added to lenalidomide.

The goal of the NCCN Guidelines® Updates is to provide readers with important changes that the NCCN Guidelines Panels have incorporated into an algorithm since it was last published. For a more complete detailing of the updated guideline’s modifications, please access the NCCN Guidelines® in this issue or, for the complete and most up-to-date version, at

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