Hemorrhagic disseminated intravascular coagulation after (177)Lu-Dotatate in metastatic midgut neuroendocrine tumor: A case report

RATIONALE: Peptide receptor radionuclide therapy with (177)Lu-Dotatate represents a major breakthrough in the treatment of metastatic well differentiated neuroendocrine tumors. This treatment is generally well tolerated. Reported severe long-term hematological side effects are rare and include hematopoietic neoplasms and bone marrow failure. PATIENTS CONCERNS: We describe the case of a patient presenting spontaneous bleeding and bruising occurring 6 weeks after the first administration of (177)Lu-Dotatate. Blood tests showed anemia, thrombocytopenia, prolonged clotting times, profound fibrinolysis and low levels of coagulation factors II and V. There were no signs of tumor lysis syndrome. DIAGNOSES: We made the diagnosis of acute disseminated intravascular coagulation. INTERVENTION: Treatment consisted of multiple transfusions of fresh frozen plasma, fibrinogen and platelets, and corticosteroids. Acute disseminated intravascular coagulation (DIC) persisted for 10 days and then resolved. OUTCOMES: Metabolic imaging 5 months after the (177)Lu-Dotatate administration showed disease progression. Treatment with 177Lu-Dotatate was not rechallenged due to the occurrence of DIC. LESSONS: Our case suggests that acute hemorrhagic disseminated intravascular coagulation can be a rare and life-threatening subacute side effect of (177)Lu-Dotatate peptide receptor radionuclide therapy.