Patient is a very pleasant 63 year old female with significant past medical hx of triple negative right breast cancer s/p chemo w/ AC-T 2016 - 2017 and radiation who is presenting with neutropenia. WBC 2.58, ANC 0.63, hemoglobin 11.6, MCV 89, platelet count 195k. Bone marrow resulted showing 60-70% blasts, complex cytogenetics, with 2 TP53 mutations, and NF1 mutation. I started patient on Dacogen x 5 days every 28 days, with referral to BMTx evaluation. I want to add venetoclax but can't due to neutropenia. My issue is: how do I give her veneto or even C2 of Dacogen when she's always neutropenic. At baseline she had low wbc, and now sp C1 Dacogen, her platelets and hemoglobin recovered but her ANC is persistently low (since diagnosis). Help would be appreciated! She is ECOG PS 0, she is completely asymptomatic at diagnosis (now mild chemo-fatigue).
This is a tricky case. Typically I would recommend giving venetoclax through the neutropenia. It is assumed her neutropenia is related to the blast burden in her marrow and now drug related so the treatment would actually be to provide optimal treatment for her AML. You can mitigate some toxicity by giving venetoclax for an abbreviated course (14/28 days, for instance). However, with TP53 mutated AML, the benefit of VEN has not been demonstrated (in contrast to other types of AML). If she is planning to proceed with transplant, I would still advocate for adding venetoclax to maximize her chances of proceeding with allogeneic transplant. At this point, my recommendation would be to repeat a bone marrow biopsy to see if her marrow is still packed with AML, in which case I would recommend adding VEN, or if she has cleared her blasts, in which case I would recommend continuing with decitabine even without full ANC recovery. If proceeding with venetoclax, I would recommend doing venetoclax D1-14 with decitabine. Make sure the patient is on prophylactic antimicrobials (you will likely need to dose reduce venetoclax).
