Does a patient with stable lymphoplasmacytic lymphoma/Waldenström macroglobulinemia require a restaging CT scan?

Management of Stable Lymphoplasmacytic Lymphoma/Waldenström Macroglobulinemia: Restaging CT Requirements

For a patient with stable lymphoplasmacytic lymphoma/Waldenström macroglobulinemia (WM) without evidence of disease progression, a restaging CT scan is not indicated unless there is clinical evidence of lymphadenopathy, splenomegaly, or new symptoms suggesting disease progression.

Disease Status Assessment

• The patient shows stable disease with:
  • Mildly elevated IgM with stable, small M-spike (0.18)
  • No definitive evidence of progression
  • No B symptoms (fever, night sweats, weight loss) 1
  • No splenomegaly reported
  • Stable hypogammaglobulinemia managed with monthly IVIG
  • Multiple comorbidities under control

Imaging Recommendations for WM

• According to ESMO clinical practice guidelines, imaging studies in WM should be performed selectively:
  • Ultrasound or CT should only be carried out in cases of initial splenomegaly/lymph node enlargements 1
  • PET-CT is not indicated in WM 1
  • Follow-up should include history, physical examination, blood count, routine chemistry, and quantification of IgM every 3 months for 2 years, then every 4-6 months for an additional 3 years 1

Response Criteria and Monitoring

• The patient currently meets criteria for stable disease (SD) in WM:
  • Monoclonal IgM protein is detectable
  • <25% reduction and <25% increase in serum IgM level from baseline
  • No progression in lymphadenopathy/splenomegaly
  • No new signs or symptoms of active disease 1

Risk-Adapted Follow-up Strategy

• For patients with stable WM after treatment:
  • Laboratory monitoring is the primary surveillance method 1
  • Imaging is reserved for patients with:
    • New symptoms
    • Evidence of disease progression on laboratory testing
    • Initial presentation with significant lymphadenopathy or splenomegaly 1

Common Pitfalls in WM Monitoring

• Overuse of imaging in stable WM patients can lead to:

  • Unnecessary radiation exposure
  • Incidental findings requiring further workup
  • Increased patient anxiety
  • Higher healthcare costs without clinical benefit 1

• Important clinical indicators that would warrant restaging CT include:

  • ≥25% increase in serum IgM levels from lowest nadir
  • Development of B symptoms (fever, night sweats, weight loss)
  • New palpable lymphadenopathy or splenomegaly
  • New anemia not explained by other causes 1

Conclusion for This Patient

• Based on the stable clinical and laboratory parameters:
  • Continued laboratory monitoring is appropriate
  • Physical examination to assess for lymphadenopathy or splenomegaly
  • Restaging CT is not indicated at this time given the absence of clinical progression 1
  • Focus should remain on managing the patient's anemia and other comorbidities