From the Guidelines
The workup for absolute neutrophil count (ANC) aplasia should begin with a complete blood count with differential to confirm neutropenia (ANC <1500/μL), followed by a bone marrow aspirate and biopsy, as recommended by the European LeukemiaNet 1.
Initial Evaluation
The initial evaluation should include:
- A thorough medication review to identify potential causative agents
- Peripheral blood smear examination
- Testing for underlying conditions, such as viral infections (HIV, hepatitis, CMV, EBV, parvovirus B19) and autoimmune disorders (ANA, rheumatoid factor)
- Essential laboratory tests, including comprehensive metabolic panel, vitamin B12 and folate levels, and immunoglobulin levels
Bone Marrow Evaluation
Bone marrow evaluation is crucial to distinguish ANC aplasia from other causes of neutropenia, typically showing normal erythroid and megakaryocytic lineages but severely reduced or absent myeloid precursors 1.
- Cytogenetic analysis and flow cytometry should be performed to rule out malignancies
- A marrow trephine biopsy should be performed in patients with a dry tap (punctio sicca) 1
Management
Management depends on the underlying cause, with options including:
- G-CSF administration
- Immunosuppressive therapy (cyclosporine, corticosteroids)
- Treatment of any identified underlying conditions
- Prophylactic antibiotics may be necessary for severe neutropenia (ANC <500/μL) to prevent infections, with management guided by the severity of the aplastic anemia, as outlined in the ASCO guideline update 1.
From the Research
ANC Aplastic Anemia Workup
- Aplastic anemia is a serious condition that can be effectively treated with stem cell transplantation or immunosuppression 2, 3.
- The choice of frontline therapy is determined by factors such as disease severity, age of the patient, donor availability, and access to optimal therapies 4.
- For newly diagnosed severe aplastic anemia, bone marrow transplant should be pursued in all pediatric patients and in younger adult patients when a matched sibling donor is available 4.
- Frontline therapy in older adult patients and in all patients lacking a matched sibling donor involves immunosuppressive therapy (IST) with horse antithymocyte globulin and cyclosporine A 4.
- Recent improvements in upfront therapy include encouraging results with closely matched unrelated donor transplants in younger patients and the emerging benefits of eltrombopag combined with initial IST 4.
Treatment Options
- Immunosuppressive therapy using the combination of antithymocyte globulin and cyclosporine A is a common treatment approach for patients without a sibling donor 2.
- HLA identical sibling transplant is a treatment option for patients younger than age 40 with a donor 2.
- The use of rabbit antithymocyte globulin is supported for bone marrow transplant conditioning for severe aplastic anemia due to lower incidence of acute and chronic graft-versus-host disease 5.
Outcomes
- Overall actuarial survival at 7 years was 55% in patients treated with antithymocyte globulin and cyclosporine 3.
- Survival was associated with early satisfaction of response criteria and by blood counts at 3 months 3.
- Approximately half of patients with severe aplastic anemia treated with antithymocyte globulin and cyclosporine have durable recovery and excellent long-term survival 3.
- The long-term outcome of adult patients with severe aplastic anemia treated with bone marrow transplant is superior to those treated with antithymocyte globulin alone 6.