Comparative Analysis of IPSS, IPSS-R, and WPSS for Predicting Survival and Leukemic Transformation in Myelodysplastic Neoplasms: A Real-World Single-Center Experience.

<b>Background:</b> Myelodysplastic syndromes are clonal hematopoietic disorders characterized by ineffective hematopoiesis and risk of progression to acute myeloid leukemia. Accurate prognostic stratification is essential to guide treatment, with several scoring systems in clinical use: IPSS, IPSS-R, and WPSS. <b>Objective:</b> We aimed to evaluate the prognostic accuracy of IPSS, IPSS-R, and WPSS in a real-world Romanian MDS cohort by comparing risk classifications with observed overall survival and progression-free survival. <b>Methods:</b> We conducted a retrospective analysis of 117 patients diagnosed with MDS treated in our clinic between 2018 and 2022. All patients had confirmed diagnoses based on bone marrow biopsy and cytogenetic testing. Data were used to assign risk categories based on IPSS, IPSS-R, and WPSS. Survival outcomes were analyzed using Kaplan-Meier curves and log-rank tests. <b>Results:</b> The median age of the cohort was 70 years; gender distribution was balanced. Transfusion dependence was present in 73.5%, and 49.6% had cytogenetic abnormalities. Overall, low-risk classification was assigned in 58.1% (IPSS), 38.5% (IPSS-R), and 38.5% (WPSS) of patients. Median OS was 20 months, and median PFS was 35 months. Although no statistically significant overall survival differences were observed across scoring systems, IPSS-R demonstrated a trend toward stronger prognostic discrimination in multivariable analysis. Reclassification of patients initially categorized as IPSS intermediate-1 revealed a significant survival impact: patients reclassified as lower-risk by IPSS-R and WPSS had a median OS of 67.5 months versus 15 months for those reclassified as higher-risk (IPSS-R: HR = 0.24; <i>p</i> = 0.0017; WPSS: HR = 0.26; <i>p</i> = 0.0031). Similarly, leukemic transformation occurred in 13.6% of reclassified lower-risk patients vs. 52.2% in higher-risk patients (IPSS-R: HR = 0.13; <i>p</i> = 0.0021; WPSS: HR = 0.12; <i>p</i> = 0.002), with a median PFS of 21 months in the higher-risk group. In multivariable Cox regression analysis, IPSS-R stratification remained a strong independent predictor for both OS (HR = 3.22; <i>p</i> = 0.000003) and PFS (HR = 4.77; <i>p</i> < 0.00001), while azacitidine treatment was associated with significantly improved survival (OS: HR = 0.43; <i>p</i> = 0.00002) and reduced risk of progression (PFS: HR = 0.36; <i>p</i> = 0.013).