Systemic Front Line Therapy of Follicular Lymphoma: When, to Whom and How

Abstract

The natural history of follicular lymphoma is usually characterized by an indolent course with a high response rate to the first line therapy followed by recurrent relapses, with a time to next treatment becoming shorter after each subsequent treatment line. More than 80% of patients have advanced stage disease at diagnosis. The time of initiation and the nature of the treatment is mainly conditioned by symptoms, tumor burden, lymphoma grading, co-morbidities and patients preference. A number of clinical and biological factors have been determined to be prognostic in this disease, but the majority of them could not show to be predictive of response to treatment, and therefore can’t be used to guide the treatment choice. CD20 expression is the only predictive factor recognized in the treatment of FL and justifies the use of “naked” or “conjugated” anti-CD20 monoclonal antibodies as a single agent or in combination with chemo- or targeted therapy. Nevertheless, as this marker is almost universally found in FL, it has little role in the choice of treatment. The outcome of patients with FL improved significantly in the last years, mainly due to the widespread use of rituximab, autologous and allogeneic transplantation in young and fit relapsed patients, the introduction of new drugs and the improvement in diagnostic accuracy and management of side effects. Agents as new monoclonal antibodies, immuno-modulating drugs, and target therapy have recently been developed and approved for the relapsed setting, while studies to evaluate their role in first line treatment are still ongoing. Here we report our considerations on first line treatment approach and on the potential factors which could help in the choice of therapy.

Estimating the Burden of Illness of Relapsed Follicular Lymphoma and Marginal Zone Lymphoma in Ontario, Canada

“…Most patients received treatment in line with recommendations made by the Lymphoma Canada Scientific Advisory Board guidelines [10]. For patients who relapsed after initial therapy, the duration of response for second-line treatment was shorter, suggesting that the interval of time to relapse decreases with each subsequent relapse event, which is a pattern that was previously noted in the literature [20,21]. Survival after relapse in both cohorts was high, consistent with what is reported in the literature [22] and did not vary significantly for FL patients who received a rituximab-based regimen in the second line of treatment and those who did not.…”

Cutaneous Disease as a Rare Presentation of Follicular Lymphoma Progression

“…Most of the patients have a good response, but recurrence is frequent. 7 Patients who relapse can be treated with the same regimen. Stem cell transplant can be pursued in relapsed and refractory settings but carries high treatment-related mortality.…”

“…Stem cell transplant can be pursued in relapsed and refractory settings but carries high treatment-related mortality. 7 …”

Early Relapse in First-Line Follicular Lymphoma: A Review of the Clinical Implications and Available Mitigation and Management Strategies

“…Current rituximab- and obinutuzumab-based therapies have produced favorable outcomes, with 3-year PFS rates of up to 80% and median PFS of up to 10.5 years [ 11 , 13 , 15 ]. FL is, however, still considered to be incurable and some patients experience unfavorable outcomes [ 16 ], in particular those who relapse or progress early, for whom more effective first-line options are needed [ 13 , 17 , 18 ]. Multiple prognostic systems for identifying patients at risk of early relapse before treatment initiation have been developed, but additional research is needed to guide their real-world utility.…”