We dive into the recognition and management of blast crisis.
Hosts:
Sadakat Chowdhury, MD
Brian Gilberti, MD



https://media.blubrry.com/coreem/content.blubrry.com/coreem/Blast_Crisis.mp3



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Tags: Hematology, Oncology





Show Notes
Topic Overview

Blast crisis is an oncologic emergency, most commonly seen in chronic myeloid leukemia (CML).
Defined by:

>20% blasts in peripheral blood or bone marrow.
May include extramedullary blast proliferation.


Without treatment, median survival is only 3–6 months.

Pathophysiology & Associated Conditions

Usually occurs in CML, but also in:

Myeloproliferative neoplasms (MPNs)
Myelodysplastic syndromes (MDS)


Transition from chronic to blast phase often reflects disease progression or treatment resistance.

Risk Factors

10% of CML patients progress to blast crisis.
Risk increased in:

Patients refractory to tyrosine kinase inhibitors (e.g., imatinib).
Those with Philadelphia chromosome abnormalities.
WBC >100,000, which increases risk for leukostasis.



Clinical Presentation

Symptoms often stem from pancytopenia and leukostasis:

Anemia: fatigue, malaise.
Functional neutropenia: high WBC count, but increased infection/sepsis risk.
Thrombocytopenia: bleeding, bruising.


Leukostasis/hyperviscosity effects by system:

Neurologic: confusion, visual changes, stroke-like symptoms.
Cardiopulmonary: ARDS, myocardial injury.
Others: priapism, limb ischemia, bowel infarction.


Rapid deterioration is common — early recognition is critical.

Diagnostic Workup

CBC with differential: assess blast % and cytopenias.
Peripheral smear and manual diff: confirm immature blasts.
CMP: screen for tumor lysis syndrome:

Elevated potassium, phosphate, uric acid.
Low calcium.


LDH & uric acid: markers of high cell turnover.
Coagulation studies (PT, PTT): assess for DIC.
Definitive tests (done inpatient): bone marrow biopsy, flow cytometry.

Emergency Department Management

Resuscitation & ABCs: oxygen, IV fluids, vitals monitoring.
Avoid aggressive transfusions:

Risk of hyperviscosity with PRBCs and platelets.


Initiate broad-spectrum antibiotics early:

High suspicion for sepsis in functionally neutropenic patients.


Consider antifungals for prolonged febrile neutropenia.
Cytoreduction strategies:

Hydroxyurea to lower WBCs quickly.
Tyrosine kinase inhibitors (TKIs).
High-dose chemotherapy.


Early consultation with hematology/oncology is essential.
Mutation testing may guide targeted therapy.

Prognosis

Without treatment: median survival ~3 months.
With treatment:

Potential survival >1 year.
Best outcomes in patients who enter a second chronic phase and undergo allogeneic stem cell transplant.



Ethical & Logistical Considerations

Treatment may involve aggressive interventions with serious side effects.
Important to assess:

Patient goals of care.
Capacity for informed consent.


Resource limitations:

Not all hospitals have oncology services.
Patients may require transfer over long distances.


Emphasize early, transparent discussions with patients and families.

Top 3 Take-Home Points

Recognize early: Look for cytopenias, leukostasis, and rapid clinical decline.
Resuscitate appropriately: Start antibiotics; be cautious with transfusions.
Call for help: Early hematology/oncology involvement is essential for definitive care.

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