Chemotherapy and treatment algorithms for follicular lymphoma: a look at all options

Abstract

The outcome of patients with follicular lymphoma has substantially improved in recent years, mainly due to the widespread use of the monoclonal antibody rituximab and partially due to autologous and allogeneic transplantation, and the introduction of new drugs and to the improvement in diagnostic accuracy. The choice of therapy is still based on patient characteristics, extension of disease and clinical prognostic factors. The majority of patients in need of treatment are still treated with cytotoxic agents in combination with rituximab; nevertheless a number of new agents, which are active in this disease, have recently been developed. It has yet to be determined, whether they will partly or completely replace chemotherapy in the near future. This review focuses on the role and the choice of chemotherapy in different clinical situations of follicular lymphoma, in a time when chemotherapy-free treatment becomes more and more of a topic of discussion.

Keywords:

• alkylating agents
• anthracycline
• bendamustine
• chemotherapy
• follicular lymphoma
• purine analogues
• rituximab
• targeted therapy

Financial & competing interests disclosure

M Ghielmini has potential conflict of interest with Roche, Cellgene, Gilead, Jannsen, Mundipharma. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Key issues

• The treatment of choice of follicular lymphoma (FL) should ideally lead to a long duration of remission, with a minor impact on quality of life.

• Advanced FL remains an incurable disease; allogeneic stem cell transplantation represents the only potentially curative approach in about half of the transplanted patients.

• In limited stage FL, involved field radiotherapy remains the treatment of choice, and may be potentially curative in about 50% of patients.

• Watchful waiting or upfront therapy with rituximab alone can be an acceptable approach in low burden disease advanced stage FL.

• Maintenance therapy with rituximab or INF-α showed a benefit in terms of progression-free survival, but at the moment there is no evidence of improvement in terms of OS.

• The favorable toxicity profile of rituximab–bendamustine compared to rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone has led to a wide use of rituximab–bendamustine in first-line for patients with advanced FL grade 1–2.

• Association of rituximab with the majority of CT regimen conferred a benefit in terms of progression-free survival, overall survival, response rate and duration of response in comparison to CT alone.

• Idelalisib was approved in relapsed FL patients after at least two prior lines of systemic therapies.

• Lenalidomide plus rituximab has been shown to be highly active both in untreated and pre-treated indolent non-Hodgkin lymphomas.

Notes