A patient of metastatic breast cancer on exemestane and everolimus gets prolonged thrombocytopenia (30,000) that responds only partially to platelet infusion, even after everolimus has been stopped. Can everolimus be tried again if the platelets recover, say after a month of stopping everolimus or should it be abandoned? Neutropenia as well as anemia accompanied the picture, though not as severe as the thrombocytopenia. Could the bone marrow suppression be attributed totally to the drug or could it mean disease burden on the bone marrow? Is there any way of knowing this?
I think you have two different problems with this patient:
1. the first is the refractory to platelet transfusion which should be evaluated according to the international standards with the evaluation of Plt recovery and eventually with searching for alloantubodies
2. the reason why of thrombocytopenia. In this setting the only way to be sure about the nature of thrombocytopenia is a bone marrow examination, which will help in differentiating between a primitive marrow involvement and a drug induced hypoplasia. Moreover a peripheral blood smear will also help you in ruling out the presence of a compensated DIC (together with a full coagulation).
The last possible diagnosis is a Immune thrombocytopenia concurring with the breast cancer and so you would see a rise in PMN after everolimus withdrawal and a still low platelet count.
There was a presentation during 2009 ASH meeting about drug induced thrombocytopenia, you can refer to.
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