May 01, 2025

Episode 209: Blast Crisis

10 minutes

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

Download

2 Comments

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.

...more

View all episodes

By Core EM

4.5

244244 ratings

May 01, 2025

Episode 209: Blast Crisis

10 minutes

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

Download

2 Comments

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.

...more

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More shows like Core EM - Emergency Medicine Podcast

EMCrit FOAM Feed

Emergency Medicine Cases

The Resus Room

EM Clerkship

The Curbsiders Internal Medicine Podcast

Emergency Medical Minute

Core IM | Internal Medicine Podcast

Emergency Medicine Board Bombs

The Internet Book of Critical Care Podcast

The Clinical Problem Solvers

Harrison's PodClass: Internal Medicine Cases and Board Prep

Run the List

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Ninja Nerd

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