Workup steps (19)

• 1lab Complete Blood Count with Differential
  Baseline cytopenia assessment and ongoing monitoring of myelosuppression.
• 2lab Peripheral Blood Smear (manual review)
  Морфологія еритроцитів, лейкоцитів, тромбоцитів — детекція бластів, dysplasia, schistocytes, abnormal lymphoid forms; обов'язково при будь-якій незрозумілій цитопенії або leukocytosis.
• 3lab Comprehensive Metabolic Panel
  Електроліти (Na, K, Cl, HCO3), креатинін + BUN (renal function), глюкоза, кальцій, альбумін, total protein. Базова метаболічна оцінка перед будь-якою терапією + основа TLS risk + dosing adjustments.
• 4lab Liver Function Tests
  Assess hepatic function — baseline + during BR cycles + DAA therapy + HBV reactivation monitoring.
• 5lab Lactate Dehydrogenase
  Tumor burden surrogate; rising LDH suggests transformation or progression in indolent lymphoma.
• 6lab ESR + C-Reactive Protein
  Markers of systemic inflammation. У гематологічному workup: differential diagnosis запальних vs neoplastic причин лімфаденопатії; ESR > 100 mm/h при myeloma / advanced lymphoma.
• 7lab Serum + Urine Protein Electrophoresis with Immunofixation
  Detect monoclonal protein (M-spike). Mandatory: будь-який unexplained anemia + hypercalcemia + bone pain + renal failure + neuropathy. Diagnostic core MM/MGUS/Waldenström.
• 8lab Quantitative Immunoglobulins (IgG, IgA, IgM)
  Hypogammaglobulinemia (CLL, MM, post-rituximab) → infection risk; hypergammaglobulinemia (chronic infections, autoimmune); monoclonal spike screening parallel до SPEP.
• 9lab Serum Free Light Chains (Kappa, Lambda, Ratio)
  Detect light chain only myeloma + AL amyloidosis (where SPEP/UPEP normal). Mandatory у MM workup; abnormal FLC ratio (<0.26 or >1.65) is myeloma-defining criterion (per IMWG).
• 10lab Beta-2 Microglobulin
  Prognostic marker для MM (component of R-ISS staging) + lymphomas (FLIPI for follicular). Reflects tumor burden + renal function.
• 11lab Serum Uric Acid
  Baseline перед cytoreductive therapy + TLS (tumor lysis syndrome) risk assessment. Elevated uric acid + high tumor burden → TLS prophylaxis (allopurinol / rasburicase).
• 12lab Beta-HCG (Pregnancy Test)
  Mandatory screen у childbearing-age жінок перед cytotoxic / teratogenic therapy + перед PET-CT, certain imaging. Більшість chemotherapy схем teratogenic.
• 13imaging Whole-Body MRI (or low-dose whole-body CT)
  Skeletal survey для multiple myeloma — replaces traditional radiographic survey. Detects ≥1 focal lytic lesion (myeloma-defining event per IMWG). Per IMWG 2014/2024 — WB-MRI / WB-CT / PET-CT preferred over plain X-ray.
• 14imaging Contrast-Enhanced CT Chest/Abdomen/Pelvis
  Initial staging imaging для більшості hematologic malignancies — лімфаденопатія mapping, organomegaly, extranodal involvement. Часто replaced by PET-CT для definitive lymphoma staging, але CECT доступніша для початкового workup.
• 15histology Bone Marrow Aspirate (cytology + flow + cytogenetics + molecular)
  Cytologic + immunophenotypic + cytogenetic + molecular characterization. Mandatory у acute leukemia, MDS, MM, MPN. Often combined з trephine (BMAT). Provides material для multiple downstream tests.
• 16histology Bone Marrow Trephine Biopsy (Core)
  Architecture + cellularity + fibrosis grade (важливо у MPN/PMF) + IHC for staging lymphomas (15-20% NHL з marrow involvement). Component of bone marrow study (зазвичай combined з aspirate).
• 17histology Flow Cytometry (Immunophenotyping)
  Immunophenotypic characterization of leukocytes — discriminates lymphoid vs myeloid lineage, B vs T vs NK, mature vs immature, monoclonal vs reactive. Mandatory у acute leukemia + lymphoma + MDS + MPN workup.
• 18other FISH Panel (disease-specific)
  Targeted detection of recurring translocations / deletions. Disease-specific panels: MM (del 17p, t(4;14), t(14;16), 1q gain, del 1p); AML (PML-RARα, RUNX1-RUNX1T1, CBFB-MYH11, MLL); CLL (del 11q, del 13q, del 17p, trisomy 12); MPN (BCR-ABL); lymphoma (MYC, BCL2, BCL6 break-apart).
• 19histology Tissue biopsy + IHC panel + ancillary molecular
  Mayo / IMWG MGUS risk stratification: 0 risk factors → 5% 20-year progression; 3 risk factors → 58%. BM justified в inermediate/high risk OR будь-яких CRAB features.
  Biopsy preferred: Bone marrow aspirate + trephine — required if intermediate/high risk MGUS, smoldering MM, or any CRAB feature

Питання що мають бути закриті (7)

• MGUS / smoldering MM / active MM (per IMWG criteria)?
• CRAB features присутні? (Ca, Renal, Anemia, Bone lesions)
• SLiM-CRAB extension features (BM PC ≥60%, FLC ratio ≥100, MRI > 1 focal lesion)?
• Mayo risk stratification (M-spike size + isotype + FLC ratio)?
• AL amyloidosis exclusion (organ-specific features — neuropathy, cardiomyopathy, nephrotic syndrome)?
• Якщо MGUS — annual surveillance frequency?
• Якщо active MM → escalate до WORKUP-SUSPECTED-MULTIPLE-MYELOMA + treatment planning

MDT brief