SOHO State of the Art Updates and Next Questions | The Optimal Management of Waldenström Macroglobulinemia.

Abstract

Waldenström macroglobulinemia (WM) is a rare IgM-secreting lymphoplasmacytic lymphoma with recurrent somatic mutations in MYD88 and CXCR4 observed in the malignant cells of >90% and 30% to 40% of the patients. Given its rarity, WM poses specific diagnostic and management challenges. The diagnosis of WM is clinicopathological and no pathognomonic findings exist. The combination of a monoclonal IgM paraproteinemia, lymphoplasmacytic lymphoma in the bone marrow or other organs, and the MYD88 L265P mutation makes a diagnosis of WM with a high specificity. Approximately, a third of the patients will be asymptomatic at diagnosis and the best approach is to observe, as these patients have similar survival rates than age, sex and year of diagnosis-matched individuals of the general population. Eighty percent of patients diagnosed with asymptomatic WM will need treatment within 10 years. Treatment is indicated in symptomatic patients in whom the symptoms affect the patients' activities and are likely to be caused by the disease process. Multiple standard treatment options are safe and effective in symptomatic patients, including rituximab in combination with alkylating agents or proteasome inhibitors, covalent BTK inhibitors, and BCL2 antagonists. Noncovalent BTK inhibitors have emerged as a novel treatment option. Second-generation BCL2 antagonists, BTK degraders, antibody-drug conjugates and bispecific T-cell engagers are being evaluated in clinical trials. Multinational collaborative consortia to accelerate clinical trial design and execution in WM have emerged in Europe and the United States.