We evaluated the prognostic significance of vascular endothelial growth factor (VEGF) protein expression in 79 bone marrow biopsy specimens of patients with myelodysplastic syndromes (MDS). VEGF levels normalized for bone marrow cellularity (VEGF index [VEGFi]) were higher in the World Health Organization (WHO) classification-based prognostic scoring system (WPSS) "very high risk" than in the "very low risk" group (P = .009) and in patients with MDS with a poor karyotype than in the other cytogenetic risk groups (P = .015). High VEGFi (>75(th) percentile) predicted transfusion dependence (adjusted odds ratio, 10.38; 95% confidence interval, 1.02-106), and were correlated with leukemia-free survival and overall survival. The inclusion of VEGFi in the International Prognostic Scoring System and WPSS maintained its significant prognostic role in predicting leukemia-free and overall survival; it also seemed to improve the discrimination of the different prognostic classes, especially WPSS low-risk classes. Our findings support the clinical relevance of VEGFi expression in the bone marrow biopsy specimens of patients with MDS.