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It is not an easy case to manage. Considering the pancytopenia of the patient, it would be likely difficult to use CDK inhibitors and maybe everolimus too. Therefore, given the many lines of endocrine and HER-2 directed therapies that the patient has already received, I would probably consider the use of metronomic chemotherapy (for example cyclophosphamide/methotrexate, capecitabine/vinorelbine, capecitabine alone) with trastuzumab
Assuming that she is still ER+, PR+, HER2+++ (there is no information on whether a biopsy of any metastatic lesion was performed) - I would go for metronomic capecitabine (3x500 mg/d) + lapatinib + letrozole. Otherwise, especially if she has sclerotic (not osteolytic or mixed) bone mets and you do not feel like going into lapatinib, I would consider switching to megestrole acetate 160 mg/d combined with metronomic cyclophosphamide 50 mg/d or capecitabine 3x500 mg/d (pretty active regimen in my experience but especially in endocrine-resistant luminal A mBC)
Pending Moderator approval.
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