Synopsis
Recognise evolving systemic coagulation activation in cancer, distinguish bleeding- and thrombosis-dominant phenotypes, treat the malignant or infective trigger and use components and anticoagulation according to clinical need.
- DIC is an acquired systemic process of excessive coagulation activation with factor and platelet consumption, secondary fibrinolysis and variable bleeding, thrombosis and organ failure.
- Cancer causes acute haemorrhagic DIC in APL, chronic thrombotic DIC in metastatic adenocarcinoma and mixed phenotypes intensified by sepsis, surgery or treatment.
- First-line tests are serial platelet count, PT, APTT, fibrinogen and D-dimer with blood film, haemoglobin, renal, liver and haemolysis assessment; no single normal result excludes early DIC.
- A falling platelet or fibrinogen trend and rising PT and fibrin markers are more useful than one static value; an ISTH score supports but does not replace clinical diagnosis.
- Treat the cause first: give ATRA immediately when APL is suspected, treat sepsis and start tumour-directed therapy through haematology or oncology.
- Do not transfuse solely to normalise laboratory values in a stable non-bleeding patient; use platelets, plasma and fibrinogen support for active bleeding or a high-risk invasive procedure.
- BSH supports platelet transfusion when DIC with bleeding or high procedural risk has platelets below 50 × 10^9/L; plasma is guided by bleeding with prolonged coagulation, not PT alone.
- When thrombosis clearly predominates, therapeutic heparin can be considered with haematology despite abnormal tests, using unfractionated heparin when rapid reversibility is important.
Key red flags
Headache, focal neurology, reduced consciousness or severe hypertension with coagulopathy requires urgent intracranial bleeding assessment.
Persistent venepuncture oozing, mucosal bleeding, haematuria, gastrointestinal bleeding or rapidly expanding bruising indicates clinically active consumption.
Cold painful cyanotic digits, skin necrosis, renal failure, respiratory deterioration or confusion may reflect microvascular thrombosis despite simultaneous bleeding.
Suspected APL with bleeding or abnormal coagulation requires immediate ATRA before genetic confirmation because early haemorrhagic death is preventable.
Sepsis, shock, transfusion reaction and tumour lysis can accelerate a compensated cancer DIC into fulminant organ failure.
Bruising, mucosal bleeding and abnormal coagulation with abnormal promyelocytes or pancytopenia requires immediate ATRA and haematology support.
Oliguria, hypoxaemia, confusion, jaundice or skin mottling can reflect widespread fibrin deposition and endothelial injury.
Investigation priorities
Detect consumption and fibrin turnover and measure its direction over hours.
Management branches
Cancer coexists with bleeding, thrombosis, falling platelets or abnormal coagulation.
- Assess ABCDE, bleeding sites, skin and limb perfusion, neurological state and infection and obtain serial DIC panel, film, haemolysis and organ tests.
- Identify the likely trigger and use the ISTH score as supporting structure while acting immediately on major bleeding, shock or limb and brain threat.
- Call haematology and the tumour team early and communicate whether bleeding, thrombosis or organ failure currently dominates.