Disseminated Intravascular Coagulation as an Initial Manifestation of Metastatic Prostate Cancer Emergently Treated with Docetaxel-Based Chemotherapy

Abstract

A 70-year-old male presented with hematuria and bruising of arms and legs for the last three days. He also complained of urinary frequency and hesitancy and weight loss of 40 pounds over a span of four months. Initial blood tests showed prothrombin time (PT) of 25.1 seconds, international normalized ratio (INR) of 2.5, partial thromboplastin time (PTT) of 43.9 seconds, fibrinogen of 60 mg/dl, fibrin degradation products (FDP) of more than 20 μg/ml, and platelets of 88,000/μl. The impression was disseminated intravascular coagulation (DIC). A search was initiated to determine the underlying etiology precipitating DIC. Due to urinary symptoms and weight loss, prostate-specific antigen (PSA) was ordered. PSA was elevated at 942 μg/dl. Computed tomography (CT) of the abdomen and pelvis without contrast showed an enlarged prostate with mass effect on the bladder base, left-sided hydronephrosis, and numerous enlarged pelvic lymph nodes. A bone scan of the whole body showed increased sclerosis of the L3 vertebral body. There was a concern for metastatic prostate cancer precipitating DIC. On first admission, our patient’s DIC was stabilized with FFP and cryoprecipitate transfusions. He refused chemotherapy, and degarelix was not economically feasible. Accordingly, he was started on androgen deprivation therapy (ADT), bicalutamide, and leuprolide as an inpatient, pending the tissue biopsy. The patient refused a prostate biopsy. A bone marrow biopsy was performed which confirmed metastatic prostate adenocarcinoma. The patient was stable for discharge with a plan for outpatient chemotherapy. Subsequently, he was lost to follow-up with the oncology. Six months after the initial presentation, he was readmitted with hematuria. Repeat PSA worsened to 1,970 μg/dl. Blood work was consistent with acute DIC. He refused chemotherapy again. So, he was restarted on ADT. However, his hematuria and DIC panel were worsening. He was emergently started on docetaxel as an inpatient (after patient agreement). Within three days of starting chemotherapy, his hematuria resolved and DIC panel showed consistent improvement.

Disseminated Intravascular Coagulation as the Initial Presentation of Metastatic Prostate Adenocarcinoma

“…The overall incidence of clinically overt DIC in solid tumors is 7%. Possible mechanisms of solid tumor-associated DIC include expression of tumor factor which can then activate coagulation factors, or by the expression of fibrinolytic proteins [ 1 , 4 ]. Further, DIC in cancer is usually less fulminant, more chronic, and subclinical with mostly normal coagulation parameters, until platelets are exhausted and bleeding occurs.…”

“…The estimated incidence of disseminated intravascular coagulation (DIC) in prostate cancer is 13-30%. However, the clinical signs of DIC are only present in 0.4-1.65% of prostate cancer, and therefore, most of them are asymptomatic [ 1 ]. There are few cases of prostate cancer patients presenting initially with bleeding events, who are later found to have DIC secondary to prostate cancer [ 1 - 3 ].…”

“…However, the clinical signs of DIC are only present in 0.4-1.65% of prostate cancer, and therefore, most of them are asymptomatic [ 1 ]. There are few cases of prostate cancer patients presenting initially with bleeding events, who are later found to have DIC secondary to prostate cancer [ 1 - 3 ]. In our case, we highlight a patient who presented with thrombocytopenia and spontaneous bruising, labs indicative of DIC, and found to have metastatic prostate adenocarcinoma.…”

Disseminated intravascular coagulation and subdural hemorrhage in a known case of prostate cancer: a case report

“…Even though complications of DIC could be very serious, DIC is rarely symptomatic in prostate cancer and is present in only 0.4-1.65% of patients and most of the patients remain clinically asymptomatic. [11] chronic DIC is a common presentation in patients with malignancies. It results from a persistent weak or intermittent coagulation activating stimulus.…”

“…Moreover, in patients with DIC secondary to prostate cancer, hormonal therapy, radiopharmaceutical therapy, and chemotherapy are presumed and stated to be effective. [11] [16] while our patient was under supportive care with cryoprecipitate and fresh frozen plasma, his subdural hemorrhage expanded. His cancer was left untreated for 2 years and had progressed and spread to bones.…”