Background and treatment

Question 1

How is grade I defined under a microscope?

Answer 1

5 or less centroblasts under HPF

Question 2

How is grade II defined under a microscope?

Answer 2

6 to 15 centroblasts under HPF

Question 3

How is grade III defined under a microscope?

Answer 3

More than 15 centroblasts under HPF + centrocytes (IIIa)

More than 15 centroblasts under HPF, solid sheets of centroblasts (IIIb)

Question 4

What markers are follicular lymphoma cells positive for? And negatve for?

Answer 4

Positive for

1. CD19
2. CD20
3. CD21
4. CD10
5. BCL-6

Negative for CD5 and CD43

Question 5

What is the most common genetic marker for follicular lymphoma?

Answer 5

t(14:18) which is a mutation that upregulates bcl-2

Question 6

Most common symptom of disease?

Answer 6

1. Painless, peripheral adenopathy in the cervical, axillary, inguinal and femoral regions

Question 7

How often is the spleen, liver or BM involved with FL at dx?

Answer 7

1. Spleen 40%
2. Liver 50%
3. BM 60-70%

Question 8

FLIPI factors

Answer 8

1. Stage III/IV
2. LDH > normal
3. Age > 60
4. No of nodal sites > 4
5. Hgb < 12

Question 9

What is the 5 year OS for patients with increasing FLIPI scores?

Answer 9

0-1 - 91%

2 - 78%

3 -5 - 52%

Question 10

What dose is recommended for Stage I-II Grade I FL?

Answer 10

24 Gy at 2 Gy per fraction

Question 11

What are NCCN supported indications for treatment of follicular lymphoma patients Staged II (bulky), III-IV?

Answer 11

1. Symptoms
2. Threatened end organ damage
3. Cytopenia secondary to lymphoma
4. Bulky disease
5. Steady progression
6. Patient preference

Question 12

What RT dose should be used palliatively for FL patients with Stage III-IV disease?

Answer 12

2 Gy x 2 fractions

Question 13

When is a BM bx recommended for work up?

Answer 13

All cases

Question 14

What remains the standard treatment for localized low-grade follicular lymphoma?

Answer 14

Locoregional RT to 24 or 30

36 Gy if bulky

Question 15

What labs are needed for FL patients at diagnosis (NCCN)?

Answer 15

1. LDH
2. CBC
3. B2 microglobulin
4. CMP
5. Hepatitis B
6. Pregnancy testing for women of child bearing age

Question 16

What tumor specific genetic mutations are common among FL patients?

Answer 16

t(14:18) - 80-90%

t(2:18) and t(18:22)

Question 17

What imaging is indicated for patients at diagnosis (NCCN)?

Answer 17

1. Diagnostic CT scan of the N/C/A/P
2. PET/CT scan
3. MUGA Scan if doxorubibin is being considered

Question 18

What are NCCN supported first line therapy for patients with Stage III-IV?

Answer 18

1. Bendamustine+rituximab
2. RCHOP
3. RCVP
4. Rituximab

RT 2-30 Gy if needed for bulky or symptomatic disease

Question 19

What are NCCN supported first line therapies for Elderly or Infirm with Stage III-IV disease?

Answer 19

1. Radioimmunotherapy
2. Rituximab
3. Single Alkylators (chlorambucil or cyclophosphamide) +/-rituximab

RT 2-30 Gy if needed for bulky or symptomatic disease

Question 20

Median Age?

Answer 20

60

Question 21

F:M ratio

Answer 21

1.7:1

Question 22

What percentage of patients have B symptoms at diagnosis?

Answer 22

20%

Question 23

What is the definition of bulky disease?

Answer 23

It varies. It can be greater than 5 cm or greater than 10 cm.

Question 24

How often does transformation to DLBCL occur in patients with Stage I disease?

Answer 24

10-15%

Question 25

What is the 10 year DFS for Stage I-II treated with RT?

Answer 25

40-50%

Question 26

What is the median OS for all patients?

Answer 26

1. Median OS: 8-9 years
2. if < 60: 12 years

Question 27

What is the first line chemotherapy for Stage III-IV disease?

Answer 27

1. Rituxan: 375 mg/m2 IV q4 weeks
2. Bendamustine: 90 mg/m2 on day 1 and 2 4 weeks