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Follicular Lymphoma: Up-Front Therapy

Panelists: Ian W. Flinn, MD, PhD, Sarah Cannon Research Institute; Matthew Lunning, DO, University of Nebraska Medical Center; John M. Pagel, MD, PhD, Swedish Cancer Institute; Pier Luigi Zinzani, MD, PhD, University of Bologna
Published: Wednesday, Aug 07, 2019



Transcript: 

Ian W. Flinn, MD, PhD: Pier Luigi, most patients, when they’re first diagnosed with follicular lymphoma, we’re not necessarily treating them, right? They get watched and waited until a certain time. What drives you to want to start therapy on someone with follicular lymphoma? And then maybe just a couple of words on how you perhaps pick an initial treatment for patients.

Pier Luigi Zinzani, MD, PhD: This is a very important issue. We are using the GELF [Groupe d’Etude des Lymphomes Folliculaires] criteria, from the French group, published several years ago, and I think is very important to evaluate this issue. Because at the end of the day, at least 30%, 40% of the patients are diagnosed with follicular lymphoma. I think it’s sufficient to watch and wait this patient because it’s an indolent disease with very low tumor burden and good performance status, and we have time to treat these patients. As my colleague said before, it’s an indolent disease, and in several cases, we don’t use treatment for 5, 7, 8, 10 years. I have some patients with a diagnosis of follicular lymphoma done 10 years ago who, in all this period, only watch and wait without any kind of treatment.

It could be important in terms of treatment when we have early stage [follicular lymphoma]. You can use rituximab as single agent. For example, there was a very important trial published several years ago by UK colleagues concerning the comparison between watch and wait versus rituximab versus rituximab induction plus maintenance treatment with rituximab. And at the end of the day, probably in this setting of patients, rituximab plus maintenance treatment with rituximab for at least 2 years could be the best choice in this trial.

In our hands in the clinic, in real life every day, we are using sometimes 4-week administration of rituximab. Then we stop and we see if there is some reduction of the lymph nodes, of the tumor burden. Then we can decide to re-treat the patient with conventional chemoimmunotherapy the second time. Anyway, as I said before, it’s very important to evaluate the patient with GELF criteria because at least the patient doesn’t need any kind of treatment at the beginning of this long story with indolent lymphoma.

Ian W. Flinn, MD, PhD: And the GELF criteria are basically in people who have big, bulky lymph nodes, pleural effusions, organ compromise, maybe cytopenias, those types of things; they’re very symptomatic. So we heard from colleagues here in Italy. In Nebraska, are you doing similar things?

Matthew Lunning, DO: I think when you meet GELF criteria you have to be careful, because over time, GELF criteria have changed, depending upon studies. I think the original BNLI [British National Lymphoma Investigation] and GELF came out around the same period of time, and in some instances, in some review, in some clinical trials, there may be additions beyond GELF criteria. I think when you find a patient who has follicular lymphoma who has GELF criteria, that opens the door for a discussion about therapy. It’s not necessarily a mandate for therapy, but at least it’s a discussion in trying to plant the seed that your lymphoma is likely going to need treatment in the near future. And whether or not it’s going to be rituximab monotherapy, rituximab plus chemotherapy, or a clinical trial, I think that’s the door to start the conversation.

John M. Pagel, MD, PhD: Yeah, I would just say I think most commonly in the United States and in my practice, bendamustine/rituximab would be my go-to regimen. I would say that caveat of the more aggressive patient I might be thinking of R-CHOP [rituximab, cyclophosphamide, doxorubicin, prednisone, vincristine]. And then that older patient, I’m going to be thinking about single-agent rituximab, and that might be enough therapy in and of itself. I think those tenets that we’ve had for many, many years of how we approach patients with chemoimmunotherapy or just antibody alone in the frontline setting really haven’t changed significantly, despite the increased information and data that we continue to accumulate.

Ian W. Flinn, MD, PhD: I’m impressed by the variability in how long people are watching and waiting. I remember when the RESORT trial was being designed, 1 of the biggest issues about it was that no one could agree when it was appropriate to start therapy versus watch and wait. And this was presumably among people who were lymphoma experts. And so there’s a huge variability, I think, in practices about when to start treatment and when not.

Transcript Edited for Clarity

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Transcript: 

Ian W. Flinn, MD, PhD: Pier Luigi, most patients, when they’re first diagnosed with follicular lymphoma, we’re not necessarily treating them, right? They get watched and waited until a certain time. What drives you to want to start therapy on someone with follicular lymphoma? And then maybe just a couple of words on how you perhaps pick an initial treatment for patients.

Pier Luigi Zinzani, MD, PhD: This is a very important issue. We are using the GELF [Groupe d’Etude des Lymphomes Folliculaires] criteria, from the French group, published several years ago, and I think is very important to evaluate this issue. Because at the end of the day, at least 30%, 40% of the patients are diagnosed with follicular lymphoma. I think it’s sufficient to watch and wait this patient because it’s an indolent disease with very low tumor burden and good performance status, and we have time to treat these patients. As my colleague said before, it’s an indolent disease, and in several cases, we don’t use treatment for 5, 7, 8, 10 years. I have some patients with a diagnosis of follicular lymphoma done 10 years ago who, in all this period, only watch and wait without any kind of treatment.

It could be important in terms of treatment when we have early stage [follicular lymphoma]. You can use rituximab as single agent. For example, there was a very important trial published several years ago by UK colleagues concerning the comparison between watch and wait versus rituximab versus rituximab induction plus maintenance treatment with rituximab. And at the end of the day, probably in this setting of patients, rituximab plus maintenance treatment with rituximab for at least 2 years could be the best choice in this trial.

In our hands in the clinic, in real life every day, we are using sometimes 4-week administration of rituximab. Then we stop and we see if there is some reduction of the lymph nodes, of the tumor burden. Then we can decide to re-treat the patient with conventional chemoimmunotherapy the second time. Anyway, as I said before, it’s very important to evaluate the patient with GELF criteria because at least the patient doesn’t need any kind of treatment at the beginning of this long story with indolent lymphoma.

Ian W. Flinn, MD, PhD: And the GELF criteria are basically in people who have big, bulky lymph nodes, pleural effusions, organ compromise, maybe cytopenias, those types of things; they’re very symptomatic. So we heard from colleagues here in Italy. In Nebraska, are you doing similar things?

Matthew Lunning, DO: I think when you meet GELF criteria you have to be careful, because over time, GELF criteria have changed, depending upon studies. I think the original BNLI [British National Lymphoma Investigation] and GELF came out around the same period of time, and in some instances, in some review, in some clinical trials, there may be additions beyond GELF criteria. I think when you find a patient who has follicular lymphoma who has GELF criteria, that opens the door for a discussion about therapy. It’s not necessarily a mandate for therapy, but at least it’s a discussion in trying to plant the seed that your lymphoma is likely going to need treatment in the near future. And whether or not it’s going to be rituximab monotherapy, rituximab plus chemotherapy, or a clinical trial, I think that’s the door to start the conversation.

John M. Pagel, MD, PhD: Yeah, I would just say I think most commonly in the United States and in my practice, bendamustine/rituximab would be my go-to regimen. I would say that caveat of the more aggressive patient I might be thinking of R-CHOP [rituximab, cyclophosphamide, doxorubicin, prednisone, vincristine]. And then that older patient, I’m going to be thinking about single-agent rituximab, and that might be enough therapy in and of itself. I think those tenets that we’ve had for many, many years of how we approach patients with chemoimmunotherapy or just antibody alone in the frontline setting really haven’t changed significantly, despite the increased information and data that we continue to accumulate.

Ian W. Flinn, MD, PhD: I’m impressed by the variability in how long people are watching and waiting. I remember when the RESORT trial was being designed, 1 of the biggest issues about it was that no one could agree when it was appropriate to start therapy versus watch and wait. And this was presumably among people who were lymphoma experts. And so there’s a huge variability, I think, in practices about when to start treatment and when not.

Transcript Edited for Clarity
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