Authors
Shabrina A. L. Jarrell, Molly John, MD
Introduction
As the second leading cause of cancer death in American men, prostate cancer can progress to many disabling symptoms associated with disease progression. Unfortunately, it is estimated that there will be 268,490 new cases and 34,500 people will die of prostate cancer in 2022. Disseminated Intravascular Coagulation (DIC), an acquired and potentially fatal coagulation disorder that has long been associated with cancer, can arise with metastatic prostate cancer. The pathophysiology underlying the association of cancer and DIC is partially understood.
Case Presentation
An 89-years-old male with metastatic adenocarcinoma of the prostate presented to the emergency department (ED) due to intermittent spontaneous bleeding from the right anterior lower extremity (RLE) and right posterior forearm (RUE) that started as a contusion 1 week prior. Despite suture placement at the urgent care, he continued to bleed. Six weeks prior to the presentation, he experienced a fall without any bleeding event. Physical exam revealed multiple ecchymoses on bilateral upper extremities, and upper quadrant regions secondary to the fall, and a bleeding wound on the RLE. The patient denied any epistaxis, hematuria, hematochezia, chest pain, shortness of breath, rash, or petechiae. Labs revealed WBC 7.6, hemoglobin 11.0, hematocrit 32.8, platelet 156, aPTT 38.5, PT 16.7, INR 1.45, D-Dimer 47.07, and fibrinogen 86. He was started on 2 units of cryoprecipitate and a q8h DIC panel. During the hospital stay, multiple bleeding events from RLE and epistaxis were noted, and labs revealed worsening DIC panel, aPTT 37.5, PT 16.8, INR 1.46, D-Dimer 89.53, and fibrinogen 99. His PSA increased from 25.0 to 47.6 ng/mL in 2 weeks. Subsequently, he received 1 dose of docetaxel 100 mg. On day 6 of admission, his coagulopathy improved obviating the need for transfusion. Throughout his stay of 8 days, he received a total of 14 units of cryoprecipitate and 3 units of fresh frozen plasma (FFP). Day 4 post-discharge, labs revealed aPTT 26.9, PT 13.3, INR 1.15, D-Dimer 11.28, and fibrinogen 220.
Discussion
This case illustrates treating the causative factor of DIC, prostate cancer in this case, is the best treatment. With median survival rate of 2-4 weeks for patients with prostate cancer complicated by DIC without treatment, early recognition and treatment are crucial and can be lifesaving for acute severe bleeding secondary to cancer. Supportive treatment should be promptly started and can be given to manage coagulopathy. However, it should not be used as the primary means of treatment. The promising outcome of this treatment—docetaxel 100 mg q3w, and prednisone 5 mg BID—highlight the importance of chemotherapy to improve survival.
References
- U.S. Cancer Statistics Working Group. U.S. Cancer Statistics Data Visualizations Tool, based on 2021 submission data (1999-2019). U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; November 2022. Accessed at on 1 November 2022.
- National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) Program. SEER Cancer Stat Facts: Prostate Cancer. Accessed at on 1 November 2022.
- Hyman DM, Soff GA, et al. Disseminated intravascular coagulation with excessive fibrinolysis in prostate cancer: a case series and review of the literature. Oncology. 2011;81:119-125. [PMID: 21986538] doi:10.1159/000331705
- Ni B, Wang J. Disseminated intravascular coagulation secondary to advanced prostate cancer: clinical characteristics, management, and prognosis [Abstract]. J Clin Oncol. 2018;36. Abstract 355. doi:10.1200/JCO.2018.36.6_suppl.355
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