Follicular lymphoma Flashcards
Stage I FL
1 lymph node or nodal group
Stage II FL
Two or more nodal groups on the same side of the diaphragm
Bulky disease in FL defined as
Greater than 10 cm
Characteristic translocation in FL
t(14:18)
FL immunophenotype
B-cell markers (CD 10+,19+,20+,22+)
*BCL2+
often BCL6+
Low KI-67
Indications for treatment
High tumor burden
Tumor >7 cm
3 nodes in 3 distinct areas, each > 3 cm in diameter
Symptomatic splenomegaly
*Ascites or pleural effusion
B symptoms (fevers, night sweats, weight loss)
Cytopenias (leukocytes <1.0 x 10^9/L) due to extensive bone marrow infiltration
Leukemia (>5.0 x 10^9/L)
Grade 3b
___________(below are expert consensus)
Local symptoms due to progressive/bulky nodal disease that are impacting quality of life
Increase in disease tempo (Eg., rapid growth 3 -> 6 cm in several months)
Compromise of organ function due to progressive or bulky disease
Symptomatic extranodal disease (Pleural effusions or peritoneal ascites)
Autoimmune hemolytic anemia (thorough workup to determine separate cause since rarely associated with FL)
Symptomatic splenomegaly
Management of limited stage disease
IF asymptomatic AND no indication for treatment, initial period of observation (Preferred)
Rituxan monotherapy
IF involved sites can be contained within a single radiation field, consult radiation oncology for local radiotherapy
Preferred systemic therapy for advanced stage
BR
IF elderly, rituximab monotherapy
Management of Grade 3B FL
treat as DLBCL w/ RCHOP
1) Role for maintenance therapy in FL 2) clinical benefit
IF high risk disease (elevated LDH OR stage III/IV – See PRIMA inclusion criteria) AND no chronic infections/high infectious risk, maintenance rituximab q56 days for 2 years (PRIMA – 6 year PFS benefit over observation, but no OS benefit
Relapsed refractory management
IF early, CAR-T now preferred
IF late (chemo-sensitive disease), IF R-CHOP frontline, then BR (Preferred - expert consensus)
IF progression after a few years, lenalidomide + rituxan (AUGMENT - R2 – UMass approach)
IF BR frontline AND fit for more chemo AND good response to chemoimmunotherapy, R-CHOP
EZH2 inhibitor approved for FL
tazometastat
Bispecific approved for FL
mosenutuzumab
Firstline for transformed FL
IF no prior chemo, R-CHOP (Pts do well)
IF prior anthracycline, salvage chemo w/ auto-HSCT
IF prior BR, controversial
IF standard DLBCL, R-CHOP
IF HGBL (double or triple hit), intensive chemo
Bispecifics approved for FL + approved line of therapy
- mosunetuzumab
- epcoritamab
*third line
