Leukemic Involvement Is a Common Feature in Waldenström Macroglobulinemia at Diagnosis

SIMPLE SUMMARY: Waldenström Macroglobulinemia (WM) is a lymphoplasmacytic lymphoma with bone marrow involvement and IgM monoclonal gammopathy. Detection of MYD88 L265P mutation (MYD88mut) has a crucial contribution to the diagnosis, since >90% of WM cases harbor this mutation. No studies have focused specifically on peripheral blood (PB) involvement in this entity. We evaluate the incidence of leukemic involvement in WM by multiparametric flow cytometry (MFC) and molecular techniques (IGH rearrangement and MYD88mut) at diagnosis. Overall, 80/100 (80%) of the patients presented PB involvement by any technique. The presence of PB involvement by MFC in 50% of the patients supports the role of PB immunophenotyping as an objective tool in the evaluation of patients presenting with IgM monoclonal gammopathy and would reinforce the value of this approach in clinical practice, avoiding morbidity especially in cases of indolent clinical behavior and in frail patients. ABSTRACT: Waldenström Macroglobulinemia (WM) is a lymphoplasmacytic lymphoma with bone marrow (BM) involvement and IgM monoclonal gammopathy. To date, no studies have focused specifically on peripheral blood (PB) involvement. In this study, 100 patients diagnosed with WM according to the World Health Organization (WHO) criteria were included based on the demonstration of MYD88mut in BM and the availability of PB multiparametric flow cytometry (MFC) analysis. Leukemic involvement by MFC was detected in 50/100 patients. A low percentage of mature small lymphocytes in PB smears was observed in only 15 cases. MYD88mut by AS-qPCR was detected in PB in 65/100 cases. In cases with leukemic expression by MFC, MYD88mut was detected in all cases, and IGH was rearranged in 44/49 cases. In 21/50 patients without PB involvement by MFC, molecular data were consistent with circulating disease (MYD88mut by AS-qPCR 3/50, IGH rearranged 6/50, both 12/50). Therefore, PB involvement by standard techniques was detected in 71/100 patients. MYD88mut was detected in PB by dPCR in 9/29 triple negative cases. Overall, 80% of the patients presented PB involvement by any technique. Our findings support the role of PB MFC in the evaluation of patients with IgM monoclonal gammopathy and provide reliable information on correlation with molecular features. The development of a feasible MFC assay may stand as an objective tool in the classification of mature B cell neoplasms presenting with IgM monoclonal gammopathy.