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.