M alignant disorders are poorly understood at the biological level in general, and myelodysplastic syndromes (MDS), a heterogeneous clonal stem cell disorder, in particular, are further confounded by representing a group of diseases rather than a single entity with clinical and biological heterogeneity within each subtype. The basis for grouping these assorted diseases under one MDS umbrella is the clinical presentation of variable cytopenias despite a generally cellular and dysplastic marrow. Diagnosis is based on bone marrow morphology, percentage of blasts, unexplained cytopenias and cytogenetics. These components have been used to classify the disease (French-American British 1 or FAB and World Health Organization 2 or WHO classifications) and to predict prognosis (International Prognostic Scoring System 3 or IPSS). The typical patient is elderly; thus with the increase in our aging population, the incidence of MDS has now surpassed that of acute myeloid leukemia (AML). Approximately 30% of MDS patients will progress to AML, but the majority die from infection or bleeding due to an increasing profundity of the cytopenias. The paradox of MDS is that despite peripheral cytopenia, the marrow is most often hypercellular. The initial breakthrough in understanding the biological basis of this paradox came with the demonstration that, in MDS, bone marrow cells were not only rapidly proliferating, but also undergoing excessive apoptosis. [4][5][6][7] As a result, the maturing hematopoietic cells are eliminated in the marrow and do not reach the peripheral blood, accounting for the cytopenias in the presence of a cellular marrow composed of mostly apoptotic cells. Furthermore, it was demonstrated that multiple cytokines involved in mediating apoptosis and proliferation are deregulated in MDS marrows. [7][8][9] While the MDS cell itself probably contributes, recent insights suggest that it is the bone marrow microenvironment that is also responsible for potentiating disease pathology and progression through cytokine imbalance. In summary then, MDS appears to be a disease of both the seed and the soil (the cell and its microenvironment) where peripheral cytopenias appear to be the result of an increased proliferation-increased apoptosis in the clonal cells and deregulated proapoptotic and trophic cytokines in the marrow.Approximately half the patients with MDS present with recurring cytogenetic abnormalities most commonly affecting chromosomes 5, 7, 8, and 20. These have been shown to greatly affect prognosis and survival. 3 Despite the presence of these well recognized karyotypic aberrations, genetic mutations that accompany them have not been well understood and, in fact, mutation in a specific biological pathway that is common to multiple MDS subtypes has not been identified. In short, apoptosis has remained the sole unifying biological characteristic of the disease.Recently, however, a possible cohesive genetic explanation for this increased apoptosis has been taking shape. Initial hints began with the study of pat...