Prognostic impact of bone marrow iron and serum ferritin in patients with myelodysplastic syndromes.

We analysed 3,748 patients with myelodysplastic syndromes (MDS) to evaluate the prevalence and prognostic relevance of bone marrow (BM) iron accumulation at the time of initial diagnosis, its relationship with serum ferritin (SF), and its impact on overall survival (OS). Cytomorphological and/or histopathological BM iron assessment revealed that approximately 50% of patients already had increased iron stores at diagnosis. Elevated BM iron was significantly associated with more severe anaemia, higher SF levels, and lower transferrin levels. BM iron accumulation likely reflects prolonged ineffective erythropoiesis with increased intestinal iron absorption prior to transfusion dependency. Survival analyses demonstrated that increased BM iron adversely affected OS particularly in patients with MDS with increased blasts (MDS IB), whereas no significant effect was observed in lower-blast MDS. Multivariate Cox regression identified age and WHO subtype as the strongest prognostic factors overall, with SF as an independent predictor of OS; notably, in MDS IB, cytomorphological BM iron content emerged as the strongest independent prognostic parameter. These findings support a role for iron-induced oxidative stress in promoting genomic instability and disease progression in higher-risk MDS. We conclude that assessment of BM iron content and serum ferritin at diagnosis provides important prognostic information and should be incorporated into the initial evaluation of MDS patients.