Radium-223 is the first bone-targeting agent which improved overall survival in patients with castration resistant prostate cancer and bone metastases but is associated with deterioration, bone pain, and hematologic toxicities. Whether blood transfusion may potentially increase the risk of metastasis in prostate cancer patients remains uncertain.

Here we present a 71-year-old male who had advanced prostate cancer with multiple bone lesions diagnosed via MRI in February 2024 (Fig. 1). An abdominal CT performed in September 2024 (Fig. 2) didn’t show any evidence of significant progression. However, severe anemia (Hb: 6.1 g/dL) was impressed in November 2024 and blood transfusion was performed at admission. He was also treated with radium-223 during the admission and was discharged smoothly.

This time he experienced epigastric discomfort for one week and presented to our emergency department. Laboratory data showed anemia, thrombocytopenia, elevated AST and ALT, elevated bilirubin, elevated alkaline phosphatase, and hypoalbuminemia. CT scan of the abdomen in December 2024 (Fig. 3) revealed numerous metastatic liver nodules, and likely metastatic lymphadenopathy. After shared decision-making regarding the treatment plan, the patient opted for palliative care over chemotherapy.

In patients with advanced prostate cancer under radium-223 treatment, blood transfusion is necessary but may potentially increase the risk of metastasis in patients with prostate cancer.