Table 5.

Workup for diagnosis and complete evaluation of systemic mastocytosis; modified from Gotlib et al 2018.

Careful medical history, including allergic reactions, presence of mediator-induced symptoms and related triggers, previous and current drug treatment, previous fractures	Mandatory
Physical examination to evaluate the presence and distribution of typical skin lesions, hepatosplenomegaly and/or lymphadenomegaly	Mandatory
Laboratory tests:
Basal serum tryptase level	Mandatory
Complete blood count, alkaline phosphatase, lactate dehydrogenase, liver function tests, beta2microglobulin	Mandatory
25-OH-vitamin D, serum CTX (C-terminal telopeptide of type I collagen), parathormon, serum calcium and phosphorus, 24h calciuria and phosphaturia, serum Vitamin B12, folate, iron, albumin, cholesterol	Recommended to evaluate bone turnover Recommended to evaluate malabsorption
Histological examination of the BM biopsy with evaluation of the MC infiltrate, BM cellularity, dysmyelopoiesis, reticulin fibrosis and collagen and immunohistochemical examination for the al least the following markers: CD117, CD25, tryptase (optional CD30)	Mandatory
BM smear stained with May-Grunwald Giemsa (MGG) with evaluation of MC count and morphology, blast count, dysmyelopoiesis. Additional stain with Toluidine Blue strongly suggested for MC count and morphology	Mandatory
Detection of KIT mutation in BM with:*	Mandatory
- ASO-qPCR, ddPCR	Strongly recommended
- PNA-mediated PCR technique	If D816V KIT negative
- Next generation sequencing.	If D816V KIT negative also with PNA mediated PCR
Detection ofKIT D816V mutation on PB with ASO-qPCR, ddPCR	Useful as screening. The BM study is necessary in any case
Detection of V617F of JAK2 mutation (or MPL, CARL mutations), FIP1L1-PDGFRalfa rearrangement.	If suggestion of associated MPN or marked eosinophilia
NGS for other myeloid mutations	Suggested in advanced SM (prognostic value)
Multi-parameter flow cytometry on BM samples using a panel including at least CD45, CD34, CD117, CD25, CD2 (optional CD30)	Strongly recommended, mandatory in cases with normal or slightly raised tryptase levels
PB smears (for evaluation monocytosis, eosinophilia, dysplasia, circulating MC)	Mandatory
BM Cytogenetic study	Mandatory in advanced variants or suspicion of myeloid neoplasia
Radiological investigations:
Evaluation of abdomen by US scan or RMN or CT	Mandatory
Bone densitometry	Mandatory
Study of the whole skeleton or limited to x-ray of the whole column and pelvis	Mandatory
Bone scan, PET-CT	Only in selected cases
Esophagogastroduodenoscopy and colonscopy with immunohistochemistry with CD117, tryptase, CD25	Only in selected cases, if significant and/or unresponsive symptoms to the anti-mediator therapy
Organ-directed biopsy (eg. liver) with immunohistochemistry with CD117, tryptase, CD25	If needed
Allergologic evaluation including delivery and instruction on the use of self-injecting adrenaline (2 autoinjectors/year)	Mandatory
Tests for hymenoptera allergy, drugs or food	If needed
Venom immunotherapy	If needed
Osteometabolic evaluation: for diagnosis and treatment of any bone involvement	Mandatory
Dermatological evaluation for presence and extension of skin lesions, skin biopsy if needed, management of skin symptoms	Mandatory

Abbreviation: MC: mast cells, BM: bone marrow; PB: peripheral blood; SM systemic mastocytosis, ASO-qPCR: allele specific oligonucleotide quantitative polymerase chain reaction (PCR); ddPCR: digital droplet PCR; PNA: peptide nucleic acid; MPN: myeloproliferative neoplasia.*⁴⁰