
    slow recruitment rate
  
['myelodysplastic syndromes']
['nivolumab', 'azacitidine', 'fludarabine', 'cyclophosphamide', 'cytarabine', 'all trans retinoic acid', 'sildenafil', 'melphalan']

        Inclusion Criteria:

          -  Patients with myelodysplastic syndrome (MDS) (up to 20% blasts) of any risk. Patients
             with lower risk MDS (low and int-1 by IPSS) should have failed prior
             non-hypomethylating agent therapy (ie growth factors or lenalidomide). Patients with
             higher risk MDS (int-2 or high by IPSS) should have failed prior at least one therapy
             with a hypomethylating agent or Ara-C.

          -  Age 18 years or older.

          -  No severe organ dysfunction: creatinine <=2.5 x ULN; serum bilirubin <=2.5 x ULN; AST
             and ALT <=5 x ULN.

          -  Karnofsky index >=70%

          -  Females of childbearing potential must have a negative serum or urine beta human
             chorionic gonadotrophin (beta-hCG) pregnancy test result within 24 hours prior to the
             first dose of treatment and must agree to use an effective contraception to avoid
             pregnancy for 24 weeks

          -  Males who have partners of childbearing potential must agree to use an effective
             contraceptive method during the study and for 24 weeks after the last dose of
             nivolumab.

        Exclusion Criteria:

          -  Another malignancy requiring treatment at the time of inclusion

          -  History of interstitial lung disease or pneumonitis

          -  Patients with any other known concurrent severe and/or uncontrolled medical condition
             (e.g. uncontrolled diabetes; cardiovascular disease including congestive heart failure
             NYHA Class III or IV, myocardial infarction within 6 months, and poorly controlled
             hypertension; chronic renal failure; or active uncontrolled infection) which, in the
             opinion of the investigator could compromise participation in the study

          -  Active, known or suspected autoimmune disease requiring treatment at the time of
             inclusion

          -  Pregnancy or breastfeeding

          -  Patients unwilling or unable to comply with the protocol

          -  Somatic or psychiatric disorder making the patient unable to sign informed consent

          -  Prior treatment with anti-PD-1, anti-PD-L1, or anti-CTLA4 therapy
      