Hematology

	Answer 1 Close serial monitoring. This patient almost certainly has IgM monoclonal gammopathy of uncertain significance (MGUS), defined as the presence of monoclonal IgM (< 3 g/dL); bone marrow with less than 10% involvement by CD10-, CD20+, CD23-, CD138- lymphoplasmacytic lymphocytes; and no evidence of end-organ damage (eg, anemia, hepatosplenomegaly, serum hyperviscosity, B symptoms [fever, weight loss, night sweats], adenopathy). Patients with IgM MGUS have an approximate 46-fold increased risk of developing WM compared with the general population.1 Although a bone marrow biopsy or CT scan may reveal greater than 10% marrow infiltration or modest enlargement of lymph nodes or the spleen, this would not change management if symptoms are absent. Patients with asymptomatic (“smoldering”) WM may be followed for years in some cases without intervention. In patients with significant symptoms, systemic chemotherapy would not be started until the diagnosis was confirmed by immunohistologic testing or flow cytometry. REFERENCES 1.  Fonseca R, Hayman S. Waldenström macroglobulinaemia. Br J Haematol 2007;138:700-20. Click here to return to the questions
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