Radiotherapy with rituximab may be better than radiotherapy alone in first-line treatment of early-stage follicular lymphoma: is it time to change the standard strategy?

Abstract

Early-stage follicular lymphoma (FL) has traditionally been treated with involved-field radiotherapy (RT). Rituximab (R) is a low-toxic, efficient systemic therapy for FL, but there are no data about its clinical impact in early FL. We retrospectively analyzed 93 patients with stage I-II indolent FL treated with RT (n=65) or RT+R (n=14) or R alone (n=14). Median follow-up was 5.0 years for patients with RT, 2.8 years for the RT+R subgroup and 2.5 years for patients treated with R. The complete response rate was 92%, 100% and 86% (not significant) and the median PFS was 3.3 years, not reached and 4.9 years (p=0.035) for the RT, RT+R and R arms, with no impact on overall survival. R combined with RT seems to give better results in terms of global FL control, but longer follow-up and prospective comparison are needed to verify these results.

What is the optimal management of early‐stage low‐grade follicular lymphoma in the modern era?

“…Although the use of chemotherapy decreased from 43% to 36%, use of single‐agent chemotherapy doubled from 5.4% in 1999 to 11.7% in 2006 (Fig. ), which may be related to the promising results noted with single‐agent rituximab . In the late 1990s to early 2000s, several studies demonstrated the benefits of rituximab, predominantly in patients with advanced or recurrent/refractory follicular lymphoma .…”

Clinical management and outcomes of completely resected stage I follicular lymphoma

“…Indeed, some studies have reported that PFS or disease-specific survival improved more after systemic chemotherapy than after irradiation alone or with a WW strategy. 11,31 However, other studies have not found such improvements; 21,24 therefore, the importance of systemic therapy remains debatable. Recently, R has become the preferred candidate for systemic therapy in terms of adverse events such as SPM.…”

“…Recently, R has become the preferred candidate for systemic therapy in terms of adverse events such as SPM. A recent observational study demonstrated excellent survival for patients treated with R with or without irradiation, 11,32,33 although the follow-up period was not long enough to estimate clinical outcome. As most of these studies were retrospective in nature, prospective trials are needed to clarify future directions of treatment for early-stage FL.…”

“…5,6 Moreover, irradiation is the only treatment strategy to demonstrate any advantage in terms of overall survival, although the evidence for this was obtained from retrospective studies. 7,8 However, the reality is that several treatment strategies have been applied for patients with early-stage FL, including combined-modality therapy (CMT), irradiation alone, watch-and-wait (WW), and more recently, rituximab (R)-containing chemotherapy or R monotherapy, [9][10][11] probably because recommendations have been based on relatively small, retrospective studies from a single center. 5,6 Diseasefree survival rates for patients with early-stage disease were Clinical management and outcomes of completely resected stage I follicular lymphoma Norifumi Tsukamoto 9) 44 -54% at 10 years when treated with involved-field irradiation.…”

Radiotherapy for Non-Hodgkin’s lymphoma: still standard practice and not an outdated treatment option

“…The dogma of early-stage, indolent lymphoma as a pure localized disease (amenable to cure with RT) has to be challenged, as nearly half of patients with early-stage FL will relapse within ten years, almost exclusively in distant non-irradiated areas [17]. It should be noted that with the increasing integration of PET-CT into initial management, improved staging accuracy may translate into improved disease control and survival rates for early-stage FL, by excluding patients with occult, distant disease [18].…”