Myelodysplastic syndrome (MDS) is a clonal disorder characterized by ineffective hematopoiesis, which can lead to either fatal cytopenias or acute myelogenous leukemias (AML). During the last 15 years, important progress has been made in the understanding of the biology and prognosis of MDS. Risk-adapted treatment strategies were established due to the high median age (60-75 years) of MDS patients and the individual history of the disease (number of cytopenias, cytogenetic changes, transfusion requirements). The use of allogeneic bone marrow transplantation for MDS patients currently offers the only potentially curative treatment, but this form of therapy is not available for the 'typical' MDS patient who is >60 years of age. The development of small molecules directed against specific molecular targets with minimal adverse effects is the hope for the future. Innovative uses of immunomodulatory agents and the optimizing of cytotoxic treatment should continue to help in the treatment of MDS.