Core EM - Emergency Medicine Podcast

Episode 209: Blast Crisis

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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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