Incidence of thrombocytopenia and serious hemorrhage among patients with solid tumors

Abstract

To evaluate the incidence of thrombocytopenia and bleeding among patients with solid tumors treated intensively with chemotherapy, the records of 1274 patients treated between 1972 and 1980 on protocols known to produce significant myelosuppression were reviewed. Three hundred one patients with solid tumors (breast, lung, melanoma, sarcoma, primary brain, testicular, hypernephroma and others) experienced 5063 days of thrombocytopenia (platelet count < 50,000/ μl) and 670 days of severe thrombocytopenia (platelet count < 20,000/μl). The median number of days thrombocytopenia was 6 (range, 1 ‐250). There were only 44 episodes of clinically detectable serious bleeding, primarily gastrointestinal (26/44), during thrombocytopenia and all but seven episodes first occurred at platelet counts between 20,000‐50,000/ μl. Fifteen of the 44 bleeding episodes were associated with coagulation abnormalities, 24 occurred during serious infection, and 12 occurred at sites of tumors. One hundred forty‐seven of the 301 patients (49%) received platelet transfusions. In 86 thrombocytopenic patients with central nervous system (CNS) tumors, there was no evidence of CNS bleeding during thrombocytopenia. Hemorrhagic deaths were uncommon, and of the 12 patients who died of bleeding, 7 had normal counts. There is a very low incidence of significant thrombocytopenia or bleeding among patients with solid tumors treated with combination chemotherapy or experimental agents escalated to maximally tolerated doses. These data suggest that with respect to thrombocytopenic bleeding intensive treatment of patients with solid tumors can be pursued with relative safety utilizing the standard transfusion supportive measures now widely available.

Thrombocytopenia and craniotomy for tumor: A National Surgical Quality Improvement Program analysis

“…Comorbidities collected by the NSQIP and present in at least 20 patients were evaluated: smoking (within the past year); alcohol abuse (at least 2 drinks/day); hypertension requiring medication; prior cardiac surgery or percutaneous coronary intervention; congestive heart failure; chronic obstructive pulmonary disease; dyspnea; diabetes mellitus; preoperative dialysis; and weight loss of >10% within 6 months. Obesity was defined as a body mass index >30 to 40 kg/m and morbid obesity as a body mass index >40 kg/m. Preoperative laboratory values were used to determine baseline renal insufficiency (creatinine > 1.4 mg/dL) and anemia (hematocrit < 30%).…”

“…However, intraoperative hemostasis may be difficult to achieve in patients with hypothrombotic conditions. Thrombocytopenia is common in oncology patients and may be attributable to several different etiologies, including myelosuppression, disseminated intravascular coagulation, liver failure, heparin‐induced thrombocytopenia, idiopathic thrombocytopenia purpura, and thrombotic thrombocytopenia purpura …”

The bleeding risk index

“…Most prominent among these were correlates of the depth and duration of thrombocytopenia, which have been known as predictive of bleeding in patients with leukemia since 1962 1. The predictive value of these factors was confirmed subsequently in patients with lymphomas and solid tumors 2, 3. To support decisions to prescribe platelet transfusions, the BRI uses correlates of prolonged and profound thrombocytopenia that are available on Day 1 of a chemotherapy cycle, including platelet count, bone marrow metastases, and therapy with agents highly toxic to the bone marrow.…”

“…To support decisions to prescribe platelet transfusions, the BRI uses correlates of prolonged and profound thrombocytopenia that are available on Day 1 of a chemotherapy cycle, including platelet count, bone marrow metastases, and therapy with agents highly toxic to the bone marrow. However, unlike their leukemic counterparts, who often bleed spontaneously, patients with lymphomas or solid tumors often bleed from tumor sites 2–5. The impact of genitourinary or gynecologic primary tumors on the risk of bleeding in the BRI underscores this well‐known clinical fact.…”

“…Although no threshold was identified that separated patients who definitely required prophylactic platelet transfusion from those who did not, a standard of care evolved: Prophylactic platelet transfusions were given below a threshold of 20,000 platelets per μL. Despite widespread use of this strategy, its applicability to patients with solid tumors or lymphoma has been questioned widely based on the observation that many patients tolerate platelet counts < 20,000 per μL, whereas others develop bleeding at higher platelet counts 2–7. A number of investigators have suggested that a threshold of 10,000 platelets per μL should be used 6–11.…”