Follicular lymphoma medical therapy: Difference between revisions
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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. | 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== | ==Medical Therapy== | ||
* The treatment of follicular lymphoma is based on the stage of the disease. | * The treatment of follicular lymphoma is based on the stage of the disease<ref name="pmid23777769">{{cite journal| author=Tan D, Horning SJ, Hoppe RT, Levy R, Rosenberg SA, Sigal BM et al.| title=Improvements in observed and relative survival in follicular grade 1-2 lymphoma during 4 decades: the Stanford University experience. | journal=Blood | year= 2013 | volume= 122 | issue= 6 | pages= 981-7 | pmid=23777769 | doi=10.1182/blood-2013-03-491514 | pmc=3739040 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23777769 }} </ref><ref name="pmid22211428">{{cite journal| author=McNamara C, Davies J, Dyer M, Hoskin P, Illidge T, Lyttelton M et al.| title=Guidelines on the investigation and management of follicular lymphoma. | journal=Br J Haematol | year= 2012 | volume= 156 | issue= 4 | pages= 446-67 | pmid=22211428 | doi=10.1111/j.1365-2141.2011.08969.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22211428 }} </ref><ref name="pmid24602760">{{cite journal| author=Ardeshna KM, Qian W, Smith P, Braganca N, Lowry L, Patrick P et al.| title=Rituximab versus a watch-and-wait approach in patients with advanced-stage, asymptomatic, non-bulky follicular lymphoma: an open-label randomised phase 3 trial. | journal=Lancet Oncol | year= 2014 | volume= 15 | issue= 4 | pages= 424-35 | pmid=24602760 | doi=10.1016/S1470-2045(14)70027-0 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24602760 }} </ref><ref name="pmid27664263">{{cite journal| author=Dreyling M, Ghielmini M, Rule S, Salles G, Vitolo U, Ladetto M et al.| title=Newly diagnosed and relapsed follicular lymphoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. | journal=Ann Oncol | year= 2016 | volume= 27 | issue= suppl 5 | pages= v83-v90 | pmid=27664263 | doi=10.1093/annonc/mdw400 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27664263 }} </ref> | ||
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* For stage 1 and 2, radiotherapy is done. | * For stage 1 and 2, radiotherapy is done. | ||
* For stages 3 and 4, several chemotherapeutic drugs are used for treatment of follicular lymphoma. | * For stages 3 and 4, several chemotherapeutic drugs are used for treatment of follicular lymphoma. | ||
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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
.
- For stage 1 and 2, radiotherapy is done.
- For stages 3 and 4, several chemotherapeutic drugs are used for treatment of follicular lymphoma.
- Chemotherapy is started when there is high tumor bulk load which includes the following:
- A tumor >7 cm in diameter
- Three nodes in three distinct areas, each >3 cm in diameter
- Symptomatic spleen enlargement
- Organ compression
- Ascites or pleural effusion
Follicular lymphoma
1. Stage 1 and 2:
- Radiation doses of 24-30 Gy have been used .
2. High tumor bulk load
2.1. Adult:
- Preferred regime 1. Bendamustine + rituximab - Day 1: Rituximab 375mg/m2 IV , Days 1 and 2: Bendamustine 90mg/m2 IV over 30–60 minutes. Repeat every 4 weeks for 6 cycles
- Preferred regime 2. Bendamustine + obinutuzumab - Days 1 and 2: Bendamustine 90mg/m2 IV Days 1, 8, 15 of Cycle 1: Obintuzumab 1000mg IV followed by: Days 1 and 2: Bendamustine 90mg/m2 IV Days 1 of Subsequent Cycles: Obintuzumab 1000mg IV. Repeat every 4 weeks for 6 cycles.
- Preferred regime 3. RCHOP (Category 1) - Day 0: Rituximab 375mg/m2 IV Day 1: Cyclophosphamide 750mg/m2 IV + doxorubicin 50mg/m2 IV + vincristine 1.4mg/m2 IV (max 2mg) Days 1–5: Prednisone 100mg/m2 orally. Repeat every 3 weeks for 6 to 8 cycles
- Preferred regime 4. CHOP + obinutuzumab - Day 1: Cyclophosphamide 750mg/m2 IV + doxorubicin 50mg/m2 IV + vincristine 1.4mg/m2 IV (max 2mg) Days 1–5: Prednisone 100mg/m2 orally Days 1, 8, 15 of Cycle 1: Obintuzumab 1000mg IV followed by: Day 1: Cyclophosphamide 750mg/m2 IV + doxorubicin 50mg/m2 IV + vincristine 1.4mg/m2 IV (max 2mg) Days 1–5: Prednisone 100mg/m2 orally Days 1 of Subsequent Cycles: Obintuzumab 1000mg IV. Repeat every 3 weeks for 6 to 8 cycles.
- Alternate regime 1. CVP + obinutuzumab - Day 1: Cyclophosphamide 750mg/v IV + vincristine 1.4mg/v IV (max 2mg) Days 1–5: Prednisone 40mg/v orally Days 1, 8, 15 of Cycle 1: Obintuzumab 1000mg IV followed by: Day 1: Cyclophosphamide 750mg/v IV + vincristine 1.4mg/v IV (max 2mg) Days 1–5: Prednisone 40mg/m2 orally Days 1 of Subsequent Cycles: Obintuzumab 1000mg IV. Repeat every 3 weeks for 6 to 8 cycles
- Alternate regime 2. Rituximab, Day 1: Rituximab 375mg/m2 IV. Repeat every 7 days for 4 cycles
2.2. Elderly
- Preferred regime 1. Rituximab 375mg/m2 IV. Repeat every 7 days for 4 cycles
- Preferred regime 2. Single agent alkylator ± rituximab - Chlorambucil 0.1mg/kg/day for 45 days then on days 1–15, monthly for 4 months • Rituximab 375mg/m2 weekly for 4 doses, then monthly for 4 infusions
3. Consolidation and extended dosing
- Rituximab maintenance - Day 1: Rituximab 375mg/m2 IV. Repeat every 8 weeks for 12 cycles for patients initially presenting with high tumor burden.
- Obinutuzumab maintenance - Day 1: Obinutuzumab 1000 mg IV. Repeat every 8 weeks for 12 cycles.
- Radioimmunotherapy - 90Yttrium-ibritumomab-tiuxetan 15 MBq/kg (0.4 mCi/kg) single dose after induction with chemotherapy.
High-dose therapy with autologous stem cell rescue and Allogeneic stem cell transplant for highly selected patients.
References
- ↑ Tan D, Horning SJ, Hoppe RT, Levy R, Rosenberg SA, Sigal BM; et al. (2013). "Improvements in observed and relative survival in follicular grade 1-2 lymphoma during 4 decades: the Stanford University experience". Blood. 122 (6): 981–7. doi:10.1182/blood-2013-03-491514. PMC 3739040. PMID 23777769.
- ↑ McNamara C, Davies J, Dyer M, Hoskin P, Illidge T, Lyttelton M; et al. (2012). "Guidelines on the investigation and management of follicular lymphoma". Br J Haematol. 156 (4): 446–67. doi:10.1111/j.1365-2141.2011.08969.x. PMID 22211428.
- ↑ Ardeshna KM, Qian W, Smith P, Braganca N, Lowry L, Patrick P; et al. (2014). "Rituximab versus a watch-and-wait approach in patients with advanced-stage, asymptomatic, non-bulky follicular lymphoma: an open-label randomised phase 3 trial". Lancet Oncol. 15 (4): 424–35. doi:10.1016/S1470-2045(14)70027-0. PMID 24602760.
- ↑ Dreyling M, Ghielmini M, Rule S, Salles G, Vitolo U, Ladetto M; et al. (2016). "Newly diagnosed and relapsed follicular lymphoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up". Ann Oncol. 27 (suppl 5): v83–v90. doi:10.1093/annonc/mdw400. PMID 27664263.