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Page de couverture de Episode 209: Blast Crisis

Episode 209: Blast Crisis

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 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. Read More
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