Conclusion
For children with relapsed MDS with a good performance status and absence of uncontrolled infections, GvHD, and other treatment related toxicities, a second HCT should be considered if disease control can be achieved and if aligned with the family’s goals. Acknowledging that early second HCT is associated with increased TRM16,18,21, temporizing disease control with less myelosuppressive agents, like hypomethylating agents in tandem with DLI, may be beneficial. Individualized treatment approaches that utilize targeted therapies with less risk for TRM like Bcl-2 inhibition (e.g.venetoclax)38 or immunotherapy (e.g. magrolimab) should be further studied in pediatric MDS. Consolidation strategies in the event of relapse after second HCT are not standardized; selected novel treatments might provide therapeutic benefit with minimal toxicity and therefore warrant consideration.