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Samer Al Hadidi, MD,MS,FACP Profile picture
@HadidiSamer
Nov 19, 2022 • 22 tweets • 30 min read • Read on X
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Blood smears @ASH_hematology 🧵Heme boards
🩸Malignant Hematopoietic Neoplasms🩸
#mmsm #lymsm #leusm #bmtsm
1⃣ classic Hodgkin's lymphoma
🩸Reed-Sternberg cell👇
🩸Most common: Nodular sclerosis 👇(fibrosis)
🩸Usually:CD30+, CD15+, weak PAX5 +. CD20-, CD45-
🩸9p24.1 alteration
Blood smears @ASH_hematology 🧵Heme boards
🩸Malignant Hematopoietic Neoplasms🩸
#mmsm #lymsm #leusm #bmtsm
2⃣ Nodular lymphocyte-predominant Hodgkin lymphoma
🩸popcorn cell (from germinal center B-cell)👇
🩸CD20+ (different than cHL),Rituxan used in ttt
🩸can transform(DLBCL)
Blood smears @ASH_hematology 🧵Heme boards
🩸Malignant Hematopoietic Neoplasms🩸
#mmsm #lymsm #leusm #bmtsm
3⃣ Follicular lymphoma
🩸Bone marrow with small lymphocytes👇
🩸CD20+,CD10+,BCL6+,BCL2+,CD5-
🩸t(14;18) in up to 90% of cases
Blood smears @ASH_hematology 🧵Heme boards
🩸Malignant Hematopoietic Neoplasms🩸
#mmsm #lymsm #leusm #bmtsm
4⃣ Splenic marginal zone lymphoma
🩸Spindle cell👇
Blood smears @ASH_hematology 🧵Heme boards
🩸Malignant Hematopoietic Neoplasms🩸
#mmsm #lymsm #leusm #bmtsm
5⃣ Burkitt lymphoma
🩸Starry sky appearance👇(can occur in other high grade B-cell lymphoma)
🩸vacuolated cells with deep basophilic cytoplasm👇
🩸t(8;14)(q24;q32):MYC
Blood smears @ASH_hematology 🧵Heme boards
🩸Malignant Hematopoietic Neoplasms🩸
#mmsm #lymsm #leusm #bmtsm
6⃣ MDS
🩸Dysplastic megakaryocytes (widely separated nuclear lobes)👇
🩸Ring sideroblasts, typically SF3B1 mutation👇
🩸Dysplastic neutrophil (hypolobation,hypogranular)👇
Blood smears @ASH_hematology 🧵Heme boards
🩸Malignant Hematopoietic Neoplasms🩸
#mmsm #lymsm #leusm #bmtsm
7⃣ MM-1
🩸plasma cells in BM👇
🩸Rouleaux&circulating plasma cells👇
Blood smears @ASH_hematology 🧵Heme boards
🩸Malignant Hematopoietic Neoplasms🩸
#mmsm #lymsm #leusm #bmtsm
7⃣ MM-2
🩸Russell bodies(intracytoplasmic)/ Mott/Grape cell👇
🩸Dutcher body(intranuclear)👇: can occur in LPL/Waldenstorm's, MYD88+
Blood smears @ASH_hematology 🧵Heme boards
🩸Malignant Hematopoietic Neoplasms🩸
#mmsm #lymsm #leusm #bmtsm
8⃣ Essential thrombocythemia
🩸mutations: JAK2,CALR,MPL
🩸Smear with thrombocytosis👇
Blood smears @ASH_hematology 🧵Heme boards
🩸Malignant Hematopoietic Neoplasms🩸
#mmsm #lymsm #leusm #bmtsm
8⃣ Primary myelofibrosis
🩸Tear drop cells (dacrocytes) 👇 with a blast in the center
Blood smears @ASH_hematology 🧵Heme boards
🩸Malignant Hematopoietic Neoplasms🩸
#mmsm #lymsm #leusm #bmtsm
9⃣ Eosinophils in the setting of FIPL1-PDFGRA rearrangement
🩸Hypereosinophilia
🩸CHIC2 gene (FISH or PCR)- cytogenetics does not pick it
🩸Responds well to imatinib
Blood smears @ASH_hematology 🧵Heme boards
🩸Malignant Hematopoietic Neoplasms🩸
#mmsm #lymsm #leusm #bmtsm
🔟Systemic mastocytosis
🩸Spindly mast cell clusters👇
🩸KIT D816V mutation is most common
⭐️Elevated tryptase levels
Blood smears @ASH_hematology 🧵Heme boards
🩸Malignant Hematopoietic Neoplasms🩸
#mmsm #lymsm #leusm #bmtsm
1⃣1⃣Hairy cell leukemia
🩸hairy cells👇
🩸CD11c+,CD22+,CD25+.CD103+
🩸BRAF V600E mutation
Blood smears @ASH_hematology 🧵Heme boards
🩸Malignant Hematopoietic Neoplasms🩸
#mmsm #lymsm #leusm #bmtsm
1⃣2⃣ CLL
🩸small lymphocytes/soccer ball/cobblestone pattern👇
🩸Smudge/basket cells: cells fragile and get smudged when smear is prepared👇
Blood smears @ASH_hematology 🧵Heme boards
🩸Malignant Hematopoietic Neoplasms🩸
#mmsm #lymsm #leusm #bmtsm
1⃣3⃣CMML
🩸MDS/MPN overlap syndrome
🩸monocytes (needs absolute monocytosis >1000 monocyte per mL)
Blood smears @ASH_hematology 🧵Heme boards
🩸Malignant Hematopoietic Neoplasms🩸
#mmsm #lymsm #leusm #bmtsm
1⃣4⃣Adult T cell leukemia/lymphoma(ATIL)
🩸associated with hypercalcemia and spastic paraparesis
🩸HTLV-1 infection, endemic in the Carribean and Japan
🩸Flower cells 👇
Blood smears @ASH_hematology 🧵Heme boards
🩸Malignant Hematopoietic Neoplasms🩸
#mmsm #lymsm #leusm #bmtsm
1⃣5⃣ Sezary syndrome
🩸Mature T-cell Leukemia
🩸Sezary cell 👇 CD3+/CD4+
🩸erythroderma, generalized lymphadenopathy
Blood smears @ASH_hematology 🧵Heme boards
🩸Malignant Hematopoietic Neoplasms🩸
#mmsm #lymsm #leusm #bmtsm
1⃣6⃣Acute erythroid leukemia
🩸glycophorin A-positive neoplastic cells in BM (Glycophorins=erythroid)
🩸Proerythroblasts: large cells with immature basophilic cytoplasm👇
Blood smears @ASH_hematology 🧵Heme boards
🩸Malignant Hematopoietic Neoplasms🩸
#mmsm #lymsm #leusm #bmtsm
1⃣7⃣ B-ALL
🩸CD10+,CD19+ (B-cell lineage), CD34+ (immature blastic phenotype)
🩸Myeloid associated markers: CD13+,CD33+,MPO-
Blood smears @ASH_hematology 🧵Heme boards
🩸Malignant Hematopoietic Neoplasms🩸
#mmsm #lymsm #leusm #bmtsm
1⃣8⃣ Acute megakaryoblastic leukemia
🩸Megakaryoblasts👇Large,cytoplasmic blebbing,pseudopod formation-granular basophilic cytoplasm
🩸CD41+(glycoprotein IIb/IIIa)&CD61+
Blood smears @ASH_hematology 🧵Heme boards
🩸Malignant Hematopoietic Neoplasms🩸
#mmsm #lymsm #leusm #bmtsm
1⃣9⃣ Acute promyelocytic leukemia
🩸Auer rods👇
🩸Faggot cell (many auer rods together)👇
🩸t(15;17), PML-RARA
End 🧵
Peripheral blood smear is important both for boards and for real life:

hematology.org/education/trai…

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More from @HadidiSamer

Samer Al Hadidi, MD,MS,FACP Profile picture
May 27
My top 7 #ASCO24 abstracts to watch for #mmsm

Will have more details on those once presented/published- those are initial thoughts that may evolve according to more data

There are more interesting data will highlight during the meeting

@ASCO

🧵
#mmsm #ASCO24
1️⃣ IMROZ: Isa-VRd vs VRd i n transplant-ineligible NDMM pts

➡️
✅ follow-up: 5 years

✅Median PFS Isa-VRd(NR, estimated 7.5 years!!) vs VRd(4.5 years)

🛑 Grade 5 TEAE: 2 times higher with Isa-VRd (11% vs 5.5%) meetings.asco.org/abstracts-pres…
Image
#mmsm #ASCO24
Thoughts on IMROZ

Very important data

✅median PFS: 7.5 yrs(estimated)
✅Grade IV AEs: higher though compare to:

MAIA: Dara-Rd: median F/U <5yrs (shorter median follow up),death related to AEs (10%) in Dara-Rd👇 Image
Read 16 tweets
Samer Al Hadidi, MD,MS,FACP Profile picture
Mar 16
#mmsm
How to counsel patients about Cilta Cel using the data from
CARTITUDE-4 and FDA ODAC meeting for earlier use

With data of Cilta cel and Ide cel, assuming having access to both for a given patient, I will personally chose Cilta cel (I explained this before)

🧵
In the first ~6 months after we plan to give you Cilta-cel, you have one out of 12 (8%) chances of dying either of progressive disease or adverse event to Cilta cel, this will depend on the bridging therapy we will use and your response to it (planning is important to ⬇️risk)

/1 Image
If you are able to get your Cilta cel, the risk of death in the first 3 months is 5% , most of those deaths (4%) were related to adverse events. Given the study was done in COVID era, some of the deaths were related to that infection so the risk maybe lower nowadays-esp USA

/2 Image
Read 16 tweets
Samer Al Hadidi, MD,MS,FACP Profile picture
Sep 14, 2023
GRIFFIN trial @TheLancetHaem #mmsm

➡️

✅Phase II trial of Dara-RVd vs. RVd
✅Final analysis after all pts had completed at least 1 year of follow-up after end of study ttt, had died, or withdrew from study participation.

Some learning points

🧵 thelancet.com/journals/lanha…
Image
Primary endpoint of the study

➡️stringent complete response rate by end of post-HSCT consolidation
➡️Very important portion of the study 👇
➡️Assumption is 15% difference between Dara-RVd vs. RVd.

Note that statistical significance can be ascertained for 1ry endpoint Image
Did the study meet the 1ry endpoint?
sCR post transplant
Dara-RVd: 42%
RVd: 32%

Difference of 10% only

This means study didn't meet 1ry endpoint

Now the assumption for power calculation was 35% sCR in RVd group which was actually less in the study so this is not the reason. Image
Read 10 tweets
Samer Al Hadidi, MD,MS,FACP Profile picture
Aug 30, 2023
Mezigdomide plus Dexamethasone in Relapsed and Refractory Multiple Myeloma | @NEJM #mmsm

➡️

Quick initial look

🧵 www-nejm-org.libproxy.uams.edu/doi/full/10.10…
Image
Mezigdomide was previously known as CC-92480

✅ modulator of E3 ubiquitin ligase complex containing cereblon
✅ binds to cereblon and subsequently induces proteasome-mediated degradation of certain transcription factors➡️ activation of T-cells Image
✅Pts on expansion cohort were triple class refractory👇

🛑Plasmacytoma was 40% (extramedullary soft-tissue only and bone-based plasmacytomas with a measurable soft-tissue component)

✅weekly Dex 40 mg (for pts >=75 yrs 20 mg)
✅phase II dose is 1 mg daily for D1-21/28 days
Image
Image
Read 7 tweets
Samer Al Hadidi, MD,MS,FACP Profile picture
Aug 11, 2023
#mmsm
Given the approval of talquetamab and AEs specific for this agent, here I provide some counseling tips and maneuvers to help lessen special AEs

✅Dose: 0.8 mg/kg SC every 2 wks: my preferred dosing

✅About 3 out 4 pts had a response per FDA package insert (n=87 pts)

🧵 Image
#mmsm
🛑dysgeusia: unpleasant or altered taste sensation
🛑No Grade III/IV for this condition

G I: Altered taste but no change in diet
G II: Altered taste with change in diet (e.g., oral supplements); noxious or unpleasant taste; loss of taste

Absence of GIII/IV≠don't exist Image
#mmsm

Ageusia means complete loss of taste (18% per package insert)

How to treat?

Nothing definite, some things may help

✅Check zinc deficiency, can replace/supplement
✅Low dose clonazepam (0.5 mg), may help
✅Oral rinse, pilocarpine oral rinse 1 or 2%-esp with dry mouth
Read 11 tweets
Samer Al Hadidi, MD,MS,FACP Profile picture
May 27, 2023
Check out our correspondence for the real world data on the use of ide cel #mmsm @JCO_ASCO @ASCO @UAMSMyeloma @uamscancer

Intent Matters: Real-World Applicability of ide-cel Usage in the United States

➡️ascopubs.org/doi/10.1200/JC…

Led by @rajshekharucms @columbiacancer

🧵
✅Violation of intent to treat principle

🛑17 of 196 (~9%) of patients who did not proceed to CAR T-cell infusion because of either disease progression/death (n = 12) or manufacturing failure (n = 5) were excluded from the final efficacy analysis👇 Image
➡️ It is important to note that excluding pts who progress while waiting for CAR-T will not reflect the actual real world efficacy of CAR-T therapy
🛑We are adding layers of selection bias:
✅intent to manufacture
✅intent to treat
Notice the PFS/OS curves👇 ImageImage
Read 16 tweets

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