Prostate cancer with disseminated intravascular coagulation and excessive fibrinolysis (DIC XFL).

Abstract

e15063 Background: DIC XFL is a potentially life threatening complication of prostate cancer. Most reports are anecdotal involving only a handful of patients. This report describes the clinical findings in 42 patients seen over a 6 year period at Memorial Sloan-Kettering Cancer Center (MSKCC). Methods: Patients with prostate cancer seen at MSKCC between 2000 and 2006 were included if they had a single fibrinogen level < 150 mg/dL and two of the following: a platelet count of less than 150 x 109/L, D-dimer levels of > 0.5 mcg/mL and prolonged PT or aPTT. Patients with comorbid conditions causing coagulopathy were excluded. Results: 42 patients were identified. All had adenocarcinoma of the prostate, including one with neuro-endocrine features. Patients tended to have high-grade disease as defined by Gleason score: 6 (15%), 7 (31%) and 8-10 (54%). One patient developed DIC XFL immediately following prostatectomy. The remainder had advanced metastatic disease: bone (93%), nodes (55%) and viscera (36%). The median platelet count was 45 x 109/L and the median fibrinogen level was 45 mg/dL. These patients were heavily pretreated: 93% were castrate resistant and 50% of the patients had chemotherapy. The following sites of bleeding were observed: skin and soft tissue (26%), hematuria (21%), intracranial (21%), gastrointestinal (17%) and none (21%). Deep vein thromboses were not documented. Management included blood product transfusion, heparin, hormonal and chemotherapy. Overall, patients had a median survival of 4 weeks with a range of 3-14 weeks (25th and 75th percentiles). Hematologic improvement, defined as normalization of fibrinogen, was seen in 20% of the patients. 88% of responders received further hormonal or chemotherapy and all had improvement in PSA with a mean decrease of 65%. Median survival in this group was better at 26 weeks. Conclusions: DIC XFL is a rare complication of advanced stage prostate cancer. Measurement of fibrinogen is essential for diagnosis. Untreated, the risk of hemorrhage is high and the prognosis is poor. Prompt recognition and initiation of active prostate cancer therapy is therefore important. Hematologic responses appear to correlate with PSA decreases. No significant financial relationships to disclose.