Follicular lymphoma medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sowminya Arikapudi, M.B,B.S. [2]
Overview
The optimal therapy for follicular lymphoma depends on the stage at diagnosis, age and prognostic scores. The predominant therapy for follicular lymphoma is chemotherapy. Adjunctive hematopoietic stem cell transplantation, and radioimmunotherapy may be required.
Medical Therapy
There is no consensus regarding the best treatment protocol. Several considerations should be taken into account including age, stage, and prognostic scores.
- Patients with advanced disease who are asymptomatic might benefit from a watch and wait approach as early treatment does not provide survival benefit.[1][2]
- When patients are symptomatic, specific treatment is required, which might include various combinations of
- alkylators,
- nucleoside analogues,
- anthracycline-containing regimens (e.g., CHOP),
- monoclonal antibodies rituximab,
- radioimmunotherapy,
- autologous, and allogeneic hematopoietic stem cell transplantation.
- The disease is regarded as incurable (although allogeneic stem cell transplantation may be curative, the mortality from the procedure is too high to be a first line option.
- The exception is localized disease, which can be cured by local irradiation.
Drug Regimen
- First-line therapy[3]
- Regimen: Bendamustine PLUS Rituximab
- Regimen: RCHOP (Rituximab AND Cyclophosphamide AND Doxorubicin ANDVincristine AND Prednisone)
- Regimen: RCHOP (Rituximab AND Cyclophosphamide AND Vincristine AND Prednisone)
- Regimen: Rituximab (375 mg/m2 weekly for 4 doses)
- First-line therapy for Elderly
- Regimen: Radioimmunotherapy
- Regimen: Rituximab (375 mg/m2 weekly for 4 doses)
- Regimen: Single-agent alkylators (e.g., Chlorambucil OR Cyclophosphamide) ± Rituximab
- First-line consolidation or extended dosing (optional)
- Regimen: Radioimmunotherapy (after induction with chemotherapy or chemoimmunotherapy)
- Regimen: Rituximab (maintenance 375 mg/m2 one dose every 8 weeks for 12 doses for patients initially presenting with high tumor burden)
- Regimen: Rituximab (maintenance 375 mg/m2 one dose every 8 weeks for 4 doses for patients initially treated with single agent rituximab)
- Second-line and subsequent therapy
- Regimen: Chemoimmunotherapy (as listed under first-line therapy)
- Regimen: FCMR (Fludarabine AND Cyclophosphamide AND Mitoxantrone AND Rituximab)
- Regimen: Fludarabine PLUS Rituximab
- Regimen: Idelalisib
- Regimen: Lenalidomide ± Rituximab
- Regimen: Radioimmunotherapy
- Regimen: Rituximab
- Regimen: RFND (Rituximab AND Fludarabine AND Mitoxantrone AND Dexamethasone
- Second-line Consolidation or Extended Dosing
- High-dose therapy with autologous stem cell rescue
- Allogenic stem cell transplant for highly selected patients
- Rituximab maintenance 375 mg/m2 one dose every 12 weeks for 2 years
- For patients with locally bulky or locally symptomatic disease, consider ISRT 4-30 Gy ± additional systemic therapy.
- Consider prophylaxis for tumor lysis syndrome.
References
- ↑ Follicular Lymphoma: Perspective, Treatment Options, and Strategy by T. Andrew Lister, MD, FRCP, http://www.medscape.org/viewarticle/709528_transcript
- ↑ Watchful Waiting in Low–Tumor Burden Follicular Lymphoma in the Rituximab Era: Results of an F2-Study Database http://jco.ascopubs.org/content/30/31/3848.abstract?sid=40023c4f-fb96-484b-a302-1ade09cc741e
- ↑ "Non-Hodgkin's Lymphomas (NCCN.org)" (PDF).