Coexistent hypercoagulability and acute hypofibrinogenemia in a patient with prostatic carcinoma

Coagulopathy, following medical therapy, for carcinoma of the prostate

Cancer of the prostate can be associated with coagulopathy characterized as primary fibrinolysis or diffuse intravascular coagulopathy (DIC) with secondary fibrinolysis. These complications are usually associated with surgical manipulation of the prostate or with advanced metastatic disease. This report describes a patient with DIC and fibrinolysis following medical management of advanced prostate cancer with gonadotropin-releasing hormone leuprolide, while receiving the androgen receptor blocking agent flutamide. This report suggests that release of procoagulant material from prostatic carcinoma may be so rapid following hormonal management that consumptive coagulopathy with fibrinolysis can follow. Shortened Abstract: Medical management with gonadotropin releasing hormone allowed the expression of consumptive coagulopathy in patients with metastatic prostate cancer.

FIBRINOLYSIS AND CARCINOMA OF THE PROSTATE

In a series of 68 patients suffering from carcinoma of the prostate, plasma fibrinolytic activity has been found to be similar to that in control groups. Some comments have been made on the problem of fibrinolysis and bleeding associated with carcinoma of the prostate, with the suggestion that the part played by fibrinolysis has been over-emphasized.

Thrombosis and hemorrhage in oncology patients

As outlined in this review, patients with cancer may harbor many alterations of hemostasis. These are multifaceted and must be considered when trying to control hemorrhage or thrombosis in cancer patients. Also, hemorrhage or thrombosis is often the final fatal event in many patients with metastatic solid tumor or hematologic malignancies. Patients with malignancy present a major clinical challenge in this new era of oncologic awareness and more aggressive care, which has led to prolonged survival for patients and a longer time frame during which these complications may develop. Therefore, these complications are occurring more commonly. It is important to realize that these alterations of hemostasis exist and must be approached in a sequential and logical manner with respect to diagnosis; only in this way can responsible, efficacious, and rational therapy be delivered to patients. By far the most common alteration of hemostasis in malignancy is that of hemorrhage associated with thrombocytopenia, either drug-induced, or radiation-induced, or from bone marrow invasion. Hemorrhage resulting from DIC, however, is also quite common and may present as hemorrhage, thrombosis, thromboembolus, or any combination thereof. Many antineoplastic drugs and radiation therapy may lead to or significantly enhance hemorrhage in patients with malignancy. Thrombosis, also commonly seen in patients with malignancy, is often a manifestation of low-grade DIC. When approaching the patient with malignancy and either hemorrhage or thrombosis, all the potential defects in hemostasis must be considered, defined from the laboratory standpoint, and treated in as precise and logical manner as possible.

Untreated prostatic carcinoma is not associated with frequent thrombohemorrhagic disorders

We conducted an evaluation of the hemostatic integrity of patients with untreated cancer of the prostate. Of 60 patients analyzed retrospectively, only 1 had a mild case of disseminated intravascular coagulation, possibly associated with concomitant estrogen therapy, and in 1 patient mild deep vein thrombosis developed preoperatively, also possibly associated with multiple medications for concurrent disorders. Of 16 other patients prospectively evaluated on admission, only 1 had frankly abnormal levels of fibrinopeptide A unaccompanied by other coagulation abnormalities. Occasional individuals had minimal, negligible deviations of partial thromboplastin times, thrombin time, or antithrombin III values. In none of these patients did hemostatic complications develop during their hospital stay. These results demonstrate that although an occasional coagulation abnormality may occur in patients with cancer of the prostate (albeit with a lower incidence than in other neoplasms), this malignancy does not require increased precautions with respect to those given to the patient population at large.

Acute gastrointestinal bleeding as the presenting manifestation of prostate cancer

Gastrointestinal bleeding was the presenting manifestation in four patients without readily apparent prostate cancer. Three of these patients had laboratory evidence of acute disseminated intravascular coagulation (DIC) and one patient had a friable rectal mass. The diagnosis of prostate cancer was made in three patients by employing an immunoperoxidase technique for prostatic acid phosphatase in metastatic foci. Dramatic resolution of DIC occurred in two patients following hormone therapy. Radiation therapy was effective in controlling bleeding in another patient. Two patients are alive with no further bleeding episodes at 8 and 18 months follow-up, respectively. In patients who present with a bleeding diathesis and adenocarcinoma of unknown primary, it is important to consider prostate cancer because of its frequent and prolonged responsiveness to hormonal therapy.

Hypercoagulable state induced by cytostatic drugs in stage II breast cancer patients

An increased incidence of thromboembolic complications occurring in cancer patients during chemotherapy was recently reported. In view of this report, a study in 49 patients receiving adjuvant chemotherapy for Stage II breast cancer was begun in order to determine the effect of antineoplastic drugs on coagulation factors and platelet function. Among the coagulation factors, a significant decrease of thrombin time and partial prothrombin time was observed, whereas platelet function tests were unchanged. This finding suggests a trend towards hypercoagulability induced by chemotherapy. This effect should be considered when chemotherapy is employed in advanced cancer patients at high risk for thrombosis.

Blood loss during and following transurethral resection

Blood loss measurement in transurethral prostatic surgery (TUR) has been studied with the following objectives: (1) to measure the total lost volume (during surgery and 48 hours postoperatively); (2) to compare surgical bleeding and coagulogram alterations in benign prostatic hypertrophy (BPH) and prostatic carcinoma (CaP); (3) to establish the relationship between blood loss, duration of the procedure, and amount of resected tissue. The method of Jansen was used to measure blood loss, and the "coagulogram" included the following parameters: hematrocrit; prothrombin, recalcification, thrombin, and partial thromboplastin times; fibrinogen; platelets and fibrin split products. The study is based on TUR performed on 75 patients from whom a mean weight of 25.68 grams was resected resulting in a mean total bleeding volume of 305 ml. Blood loss over 400 ml was associated with surgical durations of 60 minutes or with resection of over 40 grams of tissue. There was a slight tendency for fibrinolysis in prostatic cancer, which could explain the relatively higher amount of blood loss observed in these cases.

Increased incidence of thromboembolism in stage IV breast cancer patients treated with a five-drug chemotherapy regimen

We report an incidence of thrombosis of 17.6% in 159 patients treated with a five-drug chemotherapy regimen (cyclophosphamide, methotrexate, 5-fluorouracil, vincristine, and prednisone) for Stage IV breast carcinoma. Chi-squared analysis of risk factors for thrombosis (ambulatory status, obesity, family history, smoking, diabetes mellitus, hypertension, liver dysfunction, thrombocytosis, and previous endocrine therapy) showed no difference between the patients who had a thromboembolic event and those who did not. Statistical analysis revealed that a significantly higher incidence of thrombosis occurred during the chemotherapy regimen than when off this regimen (P less than 0.05). Detailed coagulation studies done prospectively on 10 patients receiving the five-drug chemotherapy regimen compared with 10 control patients showed a significantly elevated Factor VIII antigen:activity ratio in the group receiving the chemotherapy regimen compared with the control group and normals. These results implicate the chemotherapeutic regimen in the pathogenesis of the increased incidence of thrombosis. The pathophysiology of thrombosis in settings such as this awaits better in vitro tests defining the "hypercoagulable state."

Effect of transurethral resection on coagulation in carcinoma of prostate

Eleven patients with cancer of the prostate and 10 patients with benign prostatic hypertrophy (BPH) had thirteen parameters of coagulation evaluated before and after transurethral resection (TUR). Changes in fibrinogen and fibrin split products in both groups suggested potential incipient disseminated intravascular coagulation (DIC). It is concluded that prostatic cancer patients are no more susceptible to DIC than patients with BPH.

Fibrinogen kinetics in patients with neoplastic disease

Fibrinogen half-life was determined in 30 patients with active or inactive malignancies by monitoring survival of administered 125I-labeled autologous fibrinogen. Six patients had no evidence of active disease and served as controls having fibrinogen levels and half-lives within the normal range reported in the literature. Twenty-six studies were conducted on 24 patients with various active malignancies. Significantly shorter fibrinogen half-lives were found in patients with active malignancies. The fractional catabolic rates calculated from both the plasma data and the urinary isotope excretion were significantly increased in patients in this group. Although there is some evidence that exposure to intensive chemotherapy may further shorten fibrinogen survival, there is no significant difference between treated and untreated or responding and nonresponding groups. The major determinant of fibrinogen survival appears to be the presence of active malignant disease, in addition to the specific type of malignancy involved.

Non-bacterial thrombotic endocarditis: clinicopathologic correlations

Sixty-five cases of nonbacterial thrombotic endocarditis (NBTE) were discovered at autopsy during a 10 year period--an incidence of 1.6 per cent in the adult autopsy population. In 51 cases, one or more malignant neoplasms were associated; adenocarcinoma represented the most frequent histologic type of related neoplasm. Coagulation abnormalities suggestive of disseminated intravascular coagulation (DIC) were present in 18.5 per cent of the cases. It is possible that both the valvular and peripheral intravascular thromboses in at least some cases of NBTE represent the abnormal coagulation of DIC. Arterial thrombosis with infarction occurred in many peripheral organs. Splenic and renal were most frequent, but cerebral and cardiac consequences were the most significant.

Thrombophlebitis and cancer. A review

Thrombophlebitis has been associated with virtually all cancers, especially gastrointestinal, urogenital, and lung neoplasms. Although occurring infrequently in cancer patients, thrombophlebitis may appear before the cancer has become symptomatic and may lead to an earlier diagnosis of cancer. The phlebitic syndrome associated with cancer, although not unique, is distinctive. It is often recurrent and migratory, often involves unusual locations, and is often resistant to anticoagulation therapy. Pulmonary emboli are frequent complications. The pathogenesis of phlebitis in cancer patients is not well understood. Evidence suggests that many cancer patients are hypercoagulable, with abnormalities in platelets, coagulation factors, and the fibrinolytic system. These changes may results from the elaboration of thromboplastin-like substances from the cancer tissue.

Disseminated intravascular coagulation in the urologic patient

Gram-negative septicemia and metastatic prostatic cancer are frequent causes of disseminated intravascular coagulation. The clinical manifestations of this condition as well as the laboratory data vary considerably, depending on the patient's compensatory mechanisms in relation to the magnitude and duration of the thromboplastin or endotoxin release. Treatment centers primarily on correcting the underlying disorder. Secondly, deficient clotting factors and platelets should be replaced in the appropriate patient. Heparinization is often unnecessary. The use of drugs that inhibit the protective fibrinolytic mechanism is contraindicated in disseminated intravascular coagulation.

Thrombosis and intracranial tumors

334 necropsy reports of intracranial neoplasm from an autopsy material over 13 years were reviewed to study the relationship of intracranial tumors to vascular thrombosis. The incidence of venous thrombosis in intracranial tumors was found to be 27.5% while that of a control group without malignancies taken at random from the autopsy material was 17%. The difference gives a statistical significance of P less than or equal to 0.05. The parameters of sex, surgical intervention, the malignancy and the histological type of the tumor apparently dod not affect thrombus formation to a statistically significant degree. There is increased thrombosis frequency with increasing age. The presence of hemiparesis or hemiparalysis does not affect the incidence of thrombosis. However, it determines to a great degree the lateralization of the thrombus.

Plasminogen activator in the human prostate

The distribution of plasminogen activator in fresh human prostatic tissue has been studied, using a histological technique. The vascular endothelium consistently showed fibrinolytic activity while inconstant and lesser activity arose from the epithelial cells of glands and ducts. Increased epithelial activity was often accompanied by evidence of trauma. Activity of the secretions was insignificant. The source of the fibrinolytic activity of blood in prostatic disease and of the seminal fluid remains uncertain, and cannot yet be ascribed to the prostatic epithelium.

Hypofibrinogenaemia in metastatic carcinoma of the prostate: suppression of systemic fibrinolysis by haparin

In a patient with generalized prostatic carcinoma and hypofibrinogenaemia heparin infusion on four occasions abolished systemic fibrinolysis as determined by euglobulin clot lysis time, bovine fibrin plate assay, thromboelastography, and immunoelectrophoretic demonstration of fibrinogen split products. The pathogenesis of hypofibrinogenaemia in cases of prostatic carcinoma and the possibility of a direct heparin effect on fibrinolysis are discussed. Despite the lack of histological evidence for intravascular coagulation, the findings are considered additional evidence for the view that fibrinolysis in this syndrome may be secondary to intravascular coagulation.

Defibrination syndrome with defective thrombinfibrinogen reaction reversible by protamine

A patient with the obstetric defibrination syndrome successfully treated with human fibrinogen is described. The blood not only contained low levels of fibrinogen capable of clotting but also contained an inhibitor of the thrombin-fibrinogen reaction. This was neutralized in vitro with protamine but it was not heparin. Neither abnormality was detected by a latex agglutination test for plasma fibrinogen. The use of this test does not therefore exclude the diagnosis of the defibrination syndrome.