Patients with myelodysplastic neoplasms (MDS) face the risk of transformation to acute myeloid leukemia (AML). Although prognostic scoring systems exist for risk stratification and treatment decision making in MDS patients (Garcia-Manero G. Am J Hematol. 2023;98(8):1307-1325), disease management remains challenging due to the heterogeneity of clinical courses and long-term outcomes. The natural history of patients with lower-risk MDS (LR-MDS) is very heterogeneous and some LR-MDS patients experience rapid progression despite a generally favorable prognosis.