Case Presentation: An 84 year old male with past medical history of prostate cancer with metastasis to bone presented with thrombocytopenia. His original diagnosis of prostate cancer was made with a PSA and a transrectal ultrasound-guided needle biopsy of the prostate. The biopsy showed extensive adenocarcinoma in all core samples taken. Bone scan at that time showed metastatic disease. Patient was treated surgically and maintained on Lupron injections every 3-6 months; PSA was 0.16. On follow-up 3 months later, PSA was 9.5 despite recent Lupron. PSA rose to 25.5 on recheck 1 month later. Repeat bone scan raised concern for further metastatic disease. Patient developed severe thrombocytopenia that led to admission. Peripheral blood smear demonstrated schistocytes; lab work revealed elevated d-dimer, LDH, PT, PTT, and low fibrinogen. Complete infectious workup was negative. CT chest/abd/pelvis done during admission showed severe prostate enlargement invading into the base of the urinary bladder; subsequently was started on Abiraterone and Prednisone. Bone marrow biopsy revealed metastatic invasion. He received multiple transfusions of cryoprecipitate to maintain fibrinogen level >100. He was discharged with scheduled cryoprecipitate transfusions. He was quickly readmitted for continued complications of DIC, treated with multiple units of cryoprecipitate. Patient was admitted a third time and required cryoprecipitate and PRBCs almost every day and was started on Degarilix. However, he developed acute respiratory distress possibly from alveolar hemorrhage and passed away from complications secondary to respiratory failure. Patient did not undergo CPR or intubation after the family met together decided this would be against his wishes given his poor prognosis.

Discussion: Disseminated intravascular coagulation (DIC) is a rare occurrence in metastatic prostate cancer, but is still the most common coagulopathy. DIC is far more common with other solid tumor cancers. Most estimations put the prevalence of subclinical DIC at 13-30%; however estimates of clinical expression of DIC are reportedly seen in only 0.4–1.65% and only in advance stages of prostate cancer. Clinically significant DIC is regarded as a poor prognostic factor for survival. Survival as reported by Memorial Sloan-Kettering Cancer Centre with DIC averages only 4-14 weeks with median survival period of only 4 weeks. The mechanism for worse prognosis is thought to be due to a correlation between fibrinolysis with tumor invasion, that increased fibrinolysis promotes metastasis and therefore relates with poor prognosis.

Conclusions: There are significant difficulties for hormone resistant metastatic prostate cancer as seen in this case. Rapid elevation in PSA and declining platelets heralded patient’s relapse. This suggests the importance of aggressively working up patients with possible advanced metastatic disease and earlier intervention in those with declining platelet counts as survival with DIC in metastatic disease is very poor. It also highlights the importance of discussing expectations and goals of care with patients early on. This patient’s clinical presentation with advanced metastatic prostate cancer and DIC was very predictive of a poor clinical outcome and delaying these conversations can have negative outcomes on patients, family members, and caregivers in the hospital. While this can occur outside the hospital setting, it is imperative to share this information once the diagnosis of DIC has been made within the hospital.