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

This is a 71-year-old man who had prostate cancer, staging T3bN1M1b with Gleason score 5+4 and PSA:1889 ng/ml with multiple bony metastases (Fig. 1). Abdominal CT in September 2024 (Fig. 2) ensured no visceral metastasis. However, severe anemia (Hb: 6.1 g/dL) was impressed two months later. Blood transfusion was performed to reach the Hb 9.8 g/dL and he was thereafter treated with Radium-223 without any complication.

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

For severe anemia in patients who have mCRPC with bone metastases and are eligible for Radium 223 treatment, Blood transfusion may potentially increase the risk of metastasis through transfusion-related immunomodulation (TRIM) and should be reserved for symptomatic anemia instead of hemoglobin number.