Venetoclax and Azacitidine in Treating Patients with Recurrent, Refractory, or Treatment-Naive Blastic Plasmacytoid Dendritic Cell Neoplasm

Inclusion Criteria

• Histologically confirmed diagnosis of blastic plasmacytoid dendritic cell neoplasm (BPDCN) per 2016 World Health Organization (WHO) criteria
• In Cohort A, Safety Lead-In (single agent venetoclax): BPDCN relapsed after or refractory to at least one prior treatment regimen (hydroxyurea is not considered a prior treatment regimen)
• In Cohort B, combination venetoclax plus azacitidine: * BPDCN relapsed after or refractory to at least one prior treatment regimen (hydroxyurea is not considered a prior treatment regimen) OR * Treatment-naive BPDCN, and who decline tagraxofusp or intensive induction chemotherapy or who are unable to receive tagraxofusp or intensive induction chemotherapy due to unfitness, co-morbidity or other factors
• Eastern Cooperative Oncology Group (ECOG) performance status 0, 1, or 2
• Serum creatinine =< 1.5 x upper limit of normal (ULN)
• Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) < 2.5 x ULN
• Total bilirubin < 1.5 x ULN (if total bilirubin is > 1.5 x but < 3 x ULN, and thought to be elevated due to Gilbert’s disease or the patient’s BPDCN, the subject may be eligible but must discuss with the principal investigator [PI])
• White blood cell (WBC) < 10,000/uL on day of first therapy, cytoreduction may be achieved using hydroxyurea
• Ability to understand and the willingness to sign a written informed consent document
• Able to adhere to study visit schedule and other protocol requirements including follow-up for survival assessment
• Women of child-bearing potential and men enrolled on this protocol must agree to use adequate contraception for the duration of study participation and for 2 months after completion venetoclax administration

Exclusion Criteria

• Prior treatment with venetoclax
• Received treatment with chemotherapy, radiation, or biologic cancer therapy within 14 days of first protocol treatment. Prior and concurrent hydroxyurea is permitted during the first cycle
• Hematopoietic stem cell transplantation (HSCT) within 60 days of first protocol treatment, or active graft-versus-host-disease
• Known active central nervous system (CNS) involvement by BPDCN
• Known positive status for human immunodeficiency virus (HIV) infection; known active hepatitis B or hepatitis C infection
• Clinically significant cardiopulmonary disease including uncontrolled or New York Heart Association (NYHA) class 3 or 4 congestive heart failure, uncontrolled angina, uncontrolled hypertension, uncontrolled arrhythmia, myocardial infarction or stroke within 6 months of first protocol treatment
• Patients with known active advanced malignant solid tumors are excluded (except for basal or squamous skin cancers, or carcinomas in situ). Patients with additional hematologic malignancies that require treatment are excluded
• Patients with gastrointestinal (GI) tract disease causing the inability to take oral medication, malabsorption syndrome, a requirement for intravenous (IV) alimentation, prior surgical procedures affecting absorption, uncontrolled inflammatory GI disease (e.g., Crohn’s disease, ulcerative colitis)
• Pregnant women are excluded from this study because there is an unknown but potential risk for adverse events in the developing fetus with venetoclax (negative urine or serum pregnancy test required within 14 days of Cycle 1, Day 1). Because nursing infants have unknown potential for adverse events secondary to treatment of the mother, breastfeeding should be discontinued if the mother is treated with venetoclax
• Infection is a common feature of BPDCN and acute leukemias. Patients with active infection are permitted to enroll provided that the infection is controlled (patients on IV or PO antibiotics are allowed). Patients with uncontrolled infection shall not be enrolled until infection is treated and brought under control
• Subject has received the following within 7 days prior to the initiation of study treatment: * Strong and moderate CYP3A inducers * Strong and moderate CYP3A inhibitors
• Subject has consumed grapefruit, grapefruit products, Seville oranges (including marmalade containing Seville oranges), or Star fruit within 3 days prior to the initiation of study treatment