What is the treatment algorithm for follicular lymphoma (FL)?

Updated: Jan 16, 2019
  • Author: Francisco J Hernandez-Ilizaliturri, MD; Chief Editor: Koyamangalath Krishnan, MD, FRCP, FACP  more...
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Answer

Answer

Diagnosis of FL involves the following:

  • Perform staging studies and determine FLIPI (Follicular Lymphoma International Prognostic Index) score [3]
  • Assess therapeutic risk-to-benefit ratio for each patient
  • Establish therapy end points (ie, palliation, best response, durable remission, or molecular remission)

Stage I/II

Treatment options are as follows:

  • Involved-field radiotherapy (IFRT)
  • Clinical trials
  • Watch and wait

Advanced-stage (stages III-IV or bulky stage II) – asymptomatic

Treatment options are as follows:

  • Clinical trial with correlative science studies (ie, rituximab plus other biologic agents or small molecules, and/or other monoclonal antibodies [mAbs] or immunotoxins)
  • Rituximab chemotherapy
  • Watch and wait

Advanced-stage (stages III-IV or bulky stage II) – any GELF or BNLI risk factors or high-risk FLIPI score

Treatment options are as follows::

  • Clinical trial evaluating novel upfront immunochemotherapy approaches with or without postinduction therapy (rituximab maintenance, radioimmunotherapy [RIT], or bone marrow transplantation [BMT]), with correlative science studies

  • If not on clinical trial: Rituximab plus cyclophosphamide, vincristine, doxorubicin, and prednisone (R-CHOP) or other anthracycline-containing regimens (preferred for FL grade 3) or rituximab plus bendamustine (FL grades 1-2)

  • Rituximab plus fludarabine or rituximab plus cyclophosphamide, vincristine, and prednisone (CVP); if not eligible for anthracyclines

Relapse

In all cases of relapse, check the following:

  • Lymphoid tissue for gene profiling and proteomic analysis
  • Biomarkers of disease
  • Availability of preclinical studies with novel agents

For relapse where the duration of remission is at least 1 y, therapeutic options include the following:

  • Clinical trial with correlative science studies
  • Rituximab chemotherapy with or without rituximab maintenance
  • Rituximab re-treatment (if used initially)
  • RIT
  • High-dose chemotherapy and autologous stem cell transplantation (SCT) if two relapses have occurred

For relapse where the duration of remission is < 1 y, therapeutic options include the following:

  • Clinical trial with correlative science studies
  • Salvage therapy followed by autologous SCT or allogeneic SCT, if eligible
  • Rituximab chemotherapy with or without rituximab maintenance
  • RIT

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