How do you work up patients with low level monoclonal lymphocytosis and adenopathy?

Asymptomatic patients who have MBL (<5 x 10⁹/L malignant B-cells in blood) and associated lymph node disease that is palpable have the diagnosis of CLL/SLL. If they are asymptomatic, I do not scan these individuals or biopsy the palpable lymph node.

My approach here would be to:

1. Initiate prognostic testing (if patient desires) to determine their IPS score for progression risk;
2. Assess infection risk/history and ensure vaccines are up to date;
3. Counsel about secondary risks of cancer and ensure all screening tests are up to date.

If they are symptomatic with a rapidly growing large node with elevated LDH, etc., and I suspect another diagnosis (large cell lymphoma or de novo Richter's), I do proceed with a PET scan and biopsy. This is extreme...

In the setting where the blood has a CLL-like clone but does not meet criteria for CLL, I would obtain a lymph node biopsy to confirm the diagnosis of SLL. Although this is most likely to be the case, MBL clones can be seen in the blood concomitantly with other cancers as well.

Depends on the clinical context, whether the patient is symptomatic or not, and the size and distribution of lymph nodes. Patients with MBL can have other concomitant malignancies.

Interesting question. I can only see one benefit of a biopsy at that stage, and it would be to r/o a concurrent process, as finalizing a diagnosis of CLL or SLL wouldn’t change the management strategy in what one can assume is an asymptomatic patient.

I would consider a biopsy of an enlarged node, depending on the characteristics of the node, independent of the monoclonal B-cell lymphocytosis.