I have a 70 year old man who was diagnosed with high risk AML [JAK2 mutated, complex karyotype with 5 q., 20 q] He was given 7+3 [100 and 60]. He is day 15 today. His day 14 BM shows persistent AML. The biopsy reveals an excellent specimen for interpretation. The overall cellularity appears slightly decreased at 30%. The majority of the cells present consist of blasts. These blasts account for over 90% of the biopsy cellularity. He is clinically doing well. NCCN has listed many options to do reinduction [HiDAC, 7+3, 5+2, MICE, FLAG-IDA]. How would you decide which regimen to offer? Is it standard in your practice to do day 14 bone marrow?
Generally we do a D14 BM BX at our center although as you may know the results don’t hold much in terms of prognostic information. In a patient who has significant blast reduction with 7+3 (eg 90%-> 10%) the giving more cytotoxic chemotherapy makes sense. However, in someone who has 90% at D14, I don’t think additional chemotherapy is likely to induce a remission (although I’m working on an analysis of this now from multiple clinical trials). In this case, the standard has become pivoting to HMA+VEN and I would probably recommend decitabine x 5 days and venetoclax. This allows for a different method of attack against the blasts rather than cytotoxic chemo and has been associated with better response rates. It would also be more tolerable in a 70 year old man.
