Clinical Pearls in the Management of Follicular Lymphoma

Clinical pearls for community physicians regarding the optimal management of patients with follicular lymphoma.


Bijal D. Shah, MD, MS: I will now turn to the group and say follicular lymphoma is something that most folks are going to be seeing in their practice. Are there pearls that we can leave them with to help guide the care of their patients?

Ian W. Flinn, MD, PhD: I guess it’s the long-term game that you’re trying to play here, right? For most people they’re not those POD24 [progression of disease within 2 years] patients, so most people are going to have a pretty close to near normal life expectancy. Thus, trying to think about not just what the frontline therapy is going to be today, but how you’re going to manage patients over time I think is important. I’m also seeing a number of patients that I feel like maybe we start therapy too early. I’m not 100% sure why that it is, but just like chronic lymphocytic leukemia, I think we need to wait till the patients progress and have real reasons to treat rather than diving right in.

Caron A. Jacobson, MD, MPH: I think a lot of patients can stay in the community for quite a long time with follicular lymphoma and there’s much less loss, I think, by referral to a tertiary center later, but I think for the high-risk patients like POD24 and primary refractory patients, they should be referred in. I think patients who are relapsing after their second therapy should be referred in, and I think it’s really important to biopsy everybody at relapse because missing transformation has implications for responsiveness to therapy.

Bijal D. Shah, MD, MS: Michael?

Michael Wang, MD: I have no more to add. I agree with it all.

Bijal D. Shah, MD, MS: That’s great. Brian, anything else?

Brian T. Hill, MD, PhD: I think the point of transformation is important. At the time of initial presentation, so many times we’re getting core needle biopsies, small biopsies and under the microscope it looks like a grade 1/2. We’re really excited about bendamustine, and it’s less toxic, and there’s no alopecia, and people aren’t losing their hair. I think that’s great, but there are cases where we need to be on the lookout for, maybe, you’re missing a transformation at time of presentation. Thus, if the PET [positron emission tomography] scan shows really high SUVs [standardized uptake values], if the LDH [lactate dehydrogenase] is very elevated, those are the patients who you give them bendamustine-Rituxan, or I’ve seen them given bendamustine-Rituxan and then 6 months later they actually have diffuse large B-cell lymphoma. In those cases, I think just be on the lookout for missing what the patient is telling you and just not focusing too much on the pathology in that case.

Bijal D. Shah, MD, MS: Great advice. Thank you.

Transcript edited for clarity.

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