Busulfan, Fludarabine Phosphate, and Anti-Thymocyte Globulin Followed By Donor Stem Cell Transplant and Azacitidine in Treating Patients With High-Risk Myelodysplastic Syndrome and Older Patients With Acute Myeloid Leukemia

Inclusion Criteria:

Meets one of the following sets of criteria:

Myelodysplastic syndromes (MDS):

Disease with high-risk features (found either at diagnosis or before initiation of cytotoxic therapy), defined as one of the following:

International prognostic scoring system (IPSS) risk >= intermediate-2
Refractory anemia with excess blasts by French-American-British (FAB) classification
High-risk cytogenetics (either complex or -7)
Less than 10% bone marrow blasts as determined by bone marrow biopsy within the past 4 weeks (reduction in marrow blast percentage may be achieved with chemotherapy or other therapy)
Less than 75 years old

Acute myeloid leukemia (AML):

No FAB M3
No acute leukemia following blast transformation of prior chronic myelogenous leukemia or other myeloproliferative disease
Patients with preceding MDS or treatment-related AML are eligible
Prior central nervous system (CNS) involvement is allowed provided the disease is in remission at transplantation

Morphologic complete remission (leukemia-free state) is defined as meeting all of the following criteria:

Bone marrow blasts < 5% (as determined by bone marrow within the past 4 weeks), but without requirement for normal peripheral blood counts
No extramedullary leukemia
No blasts in peripheral blood

Achieved complete remission (CR) after no more than 2 courses of induction chemotherapy

Patients treated with azacitidine or decitabine who achieve a leukemia-free state are eligible (may have required up to 4 courses of therapy to reach this status)
Age 60 to 74 years

Donors must meet the following criteria:

One of the following:

HLA-identical sibling (6/6) by serologic typing for class (A, B) and low-resolution molecular typing for class II (DRB1)
Matched unrelated donor (8/8) by high-resolution molecular typing at HLA-A, -B, -C, and DRB1
No syngeneic donors
Eastern Cooperative Oncology Group (ECOG) performance status 0-2
Calculated creatinine clearance ≥ 40 mL/min
Bilirubin < 2 mg/dL OR bilirubin 2-3 mg/dL provided direct bilirubin is normal
Aspartate aminotransferase (AST) < 3 times upper limit of normal
Diffusing capacity of the lung for carbon monoxide (DLCO) > 40% with no symptomatic pulmonary disease
Left ventricle ejection fraction (LVEF) >= 30% by echocardiogram (ECHO) or multigated acquisition (MUGA)
Not pregnant or nursing
Negative pregnancy test
Fertile patients must use effective contraception
No uncontrolled diabetes mellitus or active serious infections
No known hypersensitivity to E. coli-derived products, azacitidine, or mannitol
No human immunodeficiency virus (HIV) infection or active hepatitis B or C

Prior azacitidine or decitabine allowed

No patients who progressed from MDS to AML during treatment with azacitidine or decitabine
At least 4 weeks since prior deoxyribonucleic acid (DNA)-hypomethylating chemotherapy, radiotherapy, and/or surgery

No more than 2 courses of consolidation therapy before transplantation (for patients with AML)

Any consolidation regimen that does not require transplantation can be used
No more than 6 months from documentation of morphologic CR to transplantation