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Ninan MJ, Morrison VA. Therapeutic approaches to non-Hodgkin’s lymphoma in the elderly patient. Expert Rev Hematol 2014; 2:173-82. [DOI: 10.1586/ehm.09.7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Michallet ASAS, Lebras LL, Bauwens DD, Bouafia-Sauvy FF, Berger FF, Tychyj-Pinel CC, D'Hombres AA, Salles GG, Coiffier BB. Early stage follicular lymphoma: what is the clinical impact of the first-line treatment strategy? J Hematol Oncol 2013; 6:45. [PMID: 23816219 PMCID: PMC3723590 DOI: 10.1186/1756-8722-6-45] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2013] [Accepted: 06/26/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Less than 20% of patients with follicular lymphoma (FL) present with Ann Arbor Stage I or II disease at diagnosis. Numerous therapeutic options exist, however radiation therapy is considered the standard of care for early-stage disease based on single-institution or retrospective series. Our aim was to revisit the outcome of patients with localized FL in the rituximab era. PATIENTS AND METHODS We analyzed the characteristics and outcomes of 145 early-stage FL patients, who were retrospectively divided into six groups according to their initial treatment: watchful waiting (WW), chemotherapy alone (CT), radiotherapy alone (RT), combined radiotherapy and chemotherapy (RT-CT), rituximab alone (Ri), and immunochemotherapy (Ri-CT). RESULTS Of the 145 patients, 84 (57.9%) had stage I disease and 61 (42.1%) stage II. The complete response (CR) rate varied from 57% for the Ri group to 95% for the RT-CT group. Overall survival (OS) at 7.5 y of patients treated after 2000 was better than that of those treated prior to 2000. OS did not significantly differ from one treatment to another. In contrast, a significant difference was found for progression-free survival (PFS) at 7.5 y, which favored Ri-CT (60%) therapy versus the others (p=0.00135). CONCLUSION Delayed therapy initiation was associated with a similar OS than that observed in patients receiving immediate intervention. The "watchful waiting" strategy may thus be proposed as first-line therapy, similar to stage III and IV FL patients with a low tumor burden. However, when treatment is required, immunochemotherapy appears to be the best option.
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Affiliation(s)
- Anne-Sophie A S Michallet
- Department of Hematology, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, France.
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Early stage W.H.O. grade I and II follicular lymphoma treated with radiation therapy alone. PLoS One 2013; 8:e65156. [PMID: 23762303 PMCID: PMC3675117 DOI: 10.1371/journal.pone.0065156] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Accepted: 04/21/2013] [Indexed: 11/19/2022] Open
Abstract
Objectives This retrospective study was undertaken to evaluate the outcome of patients with stage I or II (limited stage), grade I–II follicular non-Hodgkin’s lymphoma (FL) treated with radiation therapy (RT) alone as initial management. Methods Patients with stage I or II and pathologically confirmed WHO grade I or II FL treated initially with RT alone between 1982 and 2008 were identified from a population based cancer registry. Results Forty patients with a mean age 61.3 years at diagnosis were identified. The median follow up was 6.9 years from the end of radiation therapy. Stage was I (n = 26) and II (n = 14). None had B symptoms. The Follicular Lymphoma International Prognostic Index (FLIPI) was low risk in 26 patients and intermediate risk in 5. Doses ranged from 15 Gy to 48 Gy, with a median dose of 35 Gy. All patients achieved a complete clinical response (CR). 5 and 10 year overall survival (OS) was 86% and 59%, progression free survival (PFS) 67% and 54%. Age ≥60 at diagnosis was associated with reduced OS, p = 0.029, but did not affect PFS. No other clinical features including grade or FLIPI were significant for outcomes. Local failure was uncommon occurring in 8% (3/40) although this was 21% (3/14) of all recurrences. Conclusions OS and PFS outcomes for radiation alone in limited stage low grade FL patients from this single institution study are consistent with previously published data. No predictors were prognostic for PFS. A dose of ≤35 Gy may be appropriate. In this highly selected homogeneous group the FLIPI loses discriminating ability. Local control is excellent, and a majority of patients are free of disease after 5 years.
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Abou-Nassar KE, Vanderplas A, Friedberg JW, Abel GA, Niland J, Rodriguez MA, Czuczman MS, Millenson M, Crosby A, Gordon LI, Zelenetz AD, Kaminski M, Lacasce AS. Patterns of use of 18-fluoro-2-deoxy-D-glucose positron emission tomography for initial staging of grade 1–2 follicular lymphoma and its impact on initial treatment strategy in the National Comprehensive Cancer Network Non-Hodgkin Lymphoma Outcomes database. Leuk Lymphoma 2013; 54:2155-62. [DOI: 10.3109/10428194.2013.770151] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Casulo C, Friedberg JW. Treatment of early-stage follicular lymphoma: do as I say, not as I do. Int J Hematol Oncol 2013. [DOI: 10.2217/ijh.12.26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Carla Casulo
- James P Wilmot Cancer Center, University of Rochester, 601 Elmwood Avenue, Box 704, Rochester, NY 14642, USA
| | - Jonathan W Friedberg
- James P Wilmot Cancer Center, University of Rochester, 601 Elmwood Avenue, Box 704, Rochester, NY 14642, USA.
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Westin JR, Neelapu SS. Therapy of newly diagnosed follicular lymphoma. Front Oncol 2012; 2:188. [PMID: 23248775 PMCID: PMC3518764 DOI: 10.3389/fonc.2012.00188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Accepted: 11/19/2012] [Indexed: 11/13/2022] Open
Abstract
Newly diagnosed follicular lymphoma is relatively common and can be effectively treated with several differing approaches. Although the disease is often considered incurable, it is highly responsive to therapy when indicated. This review discusses the indications for treatment, risk stratification systems, treatment options with supporting clinical trial data, and expected therapeutic outcomes in newly diagnosed follicular lymphoma.
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Milgrom SA, Yahalom J. Indolent non-Hodgkin lymphoma primarily involving the hard palate: outcome following radiotherapy. Leuk Lymphoma 2012; 54:1208-11. [DOI: 10.3109/10428194.2012.741232] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
PURPOSE OF REVIEW In this article, we focus on the epidemiology, outcomes, and treatment options of early stage follicular lymphoma. RECENT FINDINGS Radiation therapy has been the predominant treatment for patients with early stage follicular lymphoma for decades. It is associated with a 10-year progression-free survival of 45-60%, thought to represent cures in this otherwise incurable disease with conventional modalities. Limiting the radiation field and dose does not diminish outcomes. On the contrary, the addition of chemotherapy does not benefit this patient population as a whole. The use of polymerase chain reaction for Bcl-2 gene rearrangements to detect molecular disease, however, may identify patients with early occult disseminated disease, who are at risk for relapse and would benefit from the addition of systemic therapy. For patients in whom radiation would be too toxic or prefer to not have radiation, observation is a reasonable alternative and a proportion of patients observed do not require therapy for a number of years. Despite the potential cures achieved by radiation therapy, a minority of patients in the United States receive such therapy; the majority are instead observed or treated with chemoimmunotherapy. SUMMARY Patients with early stage follicular lymphoma enjoy excellent outcomes following definitive radiation therapy, many of whom may even be cured. The addition of other therapies has not enhanced cure rates but identifying patients at greatest risk for disease relapse may change this paradigm. Despite the proven success of radiation, the majority of early stage follicular lymphoma patients in the United States do not receive radiation.
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Chen Q, Ayer T, Nastoupil LJ, Seward M, Zhang H, Sinha R, Flowers CR. Initial management strategies for follicular lymphoma. Int J Hematol Oncol 2012; 1:35-45. [PMID: 23476737 PMCID: PMC3587762 DOI: 10.2217/ijh.12.7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Follicular lymphoma (FL) can vary markedly in its initial presentation, and no single standard approach for its initial management has been adopted. Available options for the initial management of FL include watchful waiting, radiation, single-agent rituximab and combination of rituximab and chemotherapy with strategies segregated for patients who have low and high tumor burden disease based on established criteria. However, marked debate occurs regarding the role of watchful waiting in the modern era for low tumor burden, asymptomatic patients, the optimal timing of rituximab, the selection of chemotherapy regimen to partner with rituximab in high tumor burden patients, and strategies for the management of relapsed disease. We provide an evidence-based discussion on these and other issues regarding the management of FL, and propose a mathematical modeling approach for addressing some of these questions.
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Affiliation(s)
- Qiushi Chen
- H Milton Stewart School of Industrial & Systems Engineering , Georgia Institute of Technology, Atlanta, GA 30332, USA
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Vidal L, Gafter-Gvili A, Gurion R, Raanani P, Dreyling M, Shpilberg O. Bendamustine for patients with indolent B cell lymphoid malignancies including chronic lymphocytic leukaemia. Cochrane Database Syst Rev 2012; 2012:CD009045. [PMID: 22972131 PMCID: PMC7387870 DOI: 10.1002/14651858.cd009045.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Indolent B cell lymphoid malignancies include follicular lymphoma, small lymphocytic lymphoma, mantle cell lymphoma, lymphoplasmacytic lymphoma and marginal zone lymphomas. Chronic lymphocytic leukaemia (CLL) is a lymphoid malignancy similar to small lymphocytic lymphoma (SLL) in its leukaemic phase.Indolent lymphoid malignancies including CLL are characterised by slow growth, a high initial response rate and a relapsing and progressive disease course. Advanced-stage indolent B cell lymphoid malignancies are often incurable. If symptoms or progressive disease occur, chemotherapy plus rituximab is indicated. No chemotherapy regimen has been shown to improve overall survival compared to a different regimen.Bendamustine is efficacious in the treatment of patients with indolent B cell lymphoid malignancies. A number of randomised controlled trials have examined the effect of bendamustine compared to other chemotherapy regimens in these patients. Improved disease control with no survival benefit is shown. OBJECTIVES To evaluate the efficacy of bendamustine therapy for patients with indolent B cell lymphoid malignancies including CLL. SEARCH METHODS We electronically searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 2), MEDLINE (1966 to May 2012), EMBASE (1974 to November 2011), LILACS (1982 to May 2012), databases of ongoing trials (accessed 30 April 2012) and relevant conference proceedings. We searched references of identified trials and contacted the first author of each included trial. SELECTION CRITERIA Randomised controlled trials that compared a bendamustine-containing regimen to other chemotherapy with or without immunotherapy. DATA COLLECTION AND ANALYSIS Two authors independently appraised the quality of each trial and extracted data from included trials. We estimated and pooled hazard ratios (HR) and risk ratios (RR) with 95% confidence intervals (CI). MAIN RESULTS We included five trials randomising 1343 adult patients in the systematic review. Allocation and blinding were unclear in three trials and adequate in two. Incomplete outcome data and selective reporting were adequate in all trials. Trials varied in the type of lymphoid malignancy, bendamustine regimen and the comparator regimen. In the three trials that included patients with follicular lymphoma, mantle cell lymphoma and other indolent lymphomas the comparator treatment was cyclophosphamide, a combination of cyclophosphamide, vincristine, doxorubicin and prednisone, and fludarabine. Two trials included only patients with CLL and compared bendamustine to chlorambucil, and to fludarabine. We did not conduct a meta-analysis due to the clinical heterogeneity among trials. Bendamustine had no statistically significant effect on the overall survival of patients with indolent B cell lymphoid malignancies in any of the included trials (trials of moderate quality). Progression-free survival was statistically significantly improved with bendamustine treatment compared to other chemotherapy in three of the four trials that reported on it. One trial demonstrated a non statistically significant improvement of PFS. The risk of grade 3 or 4 adverse events was similar when bendamustine was compared to CHOP and fludarabine, and higher when compared to chlorambucil. Compared to chlorambucil quality of life was unaffected by bendamustine treatment (one trial, no meta-analysis). AUTHORS' CONCLUSIONS As none of the currently available chemotherapeutic protocols for induction therapy in indolent B cell lymphoid malignancies confer a survival benefit and due to the improved progression-free survival in each of the included trials, and a similar rate of grade 3 or 4 adverse events, bendamustine may be considered for the treatment of patients with indolent B cell lymphoid malignancies. However, the unclear effect on survival and the higher rate of adverse events compared to chlorambucil in patients with CLL/SLL does not support the use of bendamustine for these patients.The effect of bendamustine combined with rituximab should be evaluated in randomised clinical trials with more homogenous populations and outcomes for specific subgroups of patients by type of lymphoma should be reported. Any future trial should evaluate the effect of bendamustine on quality of life.
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MESH Headings
- Adult
- Antineoplastic Agents, Alkylating/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/administration & dosage
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Bendamustine Hydrochloride
- Cyclophosphamide/administration & dosage
- Cyclophosphamide/therapeutic use
- Doxorubicin/administration & dosage
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Lymphoma, B-Cell/drug therapy
- Lymphoma, B-Cell/mortality
- Lymphoma, Follicular/drug therapy
- Lymphoma, Follicular/mortality
- Lymphoma, Mantle-Cell/drug therapy
- Lymphoma, Mantle-Cell/mortality
- Nitrogen Mustard Compounds/therapeutic use
- Prednisone/administration & dosage
- Recurrence
- Vincristine/administration & dosage
- Waldenstrom Macroglobulinemia/drug therapy
- Waldenstrom Macroglobulinemia/mortality
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Affiliation(s)
- Liat Vidal
- Department of Medicine E, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel.
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Friedberg JW, Byrtek M, Link BK, Flowers C, Taylor M, Hainsworth J, Cerhan JR, Zelenetz AD, Hirata J, Miller TP. Effectiveness of first-line management strategies for stage I follicular lymphoma: analysis of the National LymphoCare Study. J Clin Oncol 2012; 30:3368-75. [PMID: 22915662 DOI: 10.1200/jco.2011.40.6546] [Citation(s) in RCA: 136] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The optimal management of stage I follicular lymphoma, according to consensus guidelines, is based on uncontrolled experiences of select institutions. Diverse treatment approaches are used despite guidelines that recommend radiation therapy (XRT). PATIENTS AND METHODS We analyzed outcomes of patients with stage I follicular lymphoma enrolled onto the National LymphoCare database. RESULTS Of 471 patients with stage I follicular lymphoma, 206 patients underwent rigorous staging as defined by both a bone marrow aspirate and biopsy and an imaging study (a computed tomography [CT] scan of the whole body, a positron emission tomography [PET]/CT scan, or both). Rigorously staged patients had superior progression-free survival (PFS) compared with nonrigorously staged patients (hazard ratio [HR], 0.63). Treatments given to rigorously staged patients were rituximab/chemotherapy (R-chemo; 28%), XRT (27%), observation (17%), systemic therapy + XRT (13%), rituximab monotherapy (12%), and other (3%). With a median follow-up of 57 months for PFS, there were 44 progression events (in 21% of patients) for rigorously staged patients. For these patients, PFS was significantly improved with either R-chemo or systemic therapy + XRT compared with patients receiving XRT alone after adjustment for histology, LDH, and the presence of B symptoms. There were no differences in overall survival. CONCLUSION In this largest, prospectively enrolled group of patients with stage I follicular lymphoma, variable treatment approaches resulted in similar excellent outcomes, which challenges the paradigm that XRT should be standard for this presentation.
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Radiotherapy alone for stage I-III low grade follicular lymphoma: long-term outcome and comparison of extended field and total nodal irradiation. Radiat Oncol 2012; 7:103. [PMID: 22726938 PMCID: PMC3432005 DOI: 10.1186/1748-717x-7-103] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Accepted: 06/17/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To analyze long-term results of radiotherapy alone for stage I-III low grade follicular lymphoma and to compare outcome after extended field irradiation (EFI) and total nodal irradiation (TNI). METHODS AND MATERIALS Between 1982 and 2007, 107 patients were treated with radiotherapy alone for low grade follicular lymphoma at Ann Arbor stage I (n = 50), II (n = 36) and III (n = 21); 48 and 59 patients were treated with EFI and TNI, respectively. The median total dose in the first treatment series of the diaphragmatic side with larger lymphoma burden was 38 Gy (25 Gy - 50 Gy) and after an interval of median 30 days, a total dose of 28 Gy (12.6 Gy - 45 Gy) was given in the second treatment series completing TNI. RESULTS After a median follow-up of 14 years for living patients, 10-years and 15-years overall survival (OS) were 64% and 50%, respectively. Survival was not significantly different between stages I, II and III. TNI and EFI resulted in 15-years OS of 65% and 34% but patients treated with TNI were younger, had better performance status and higher stage of disease compared to patients treated with EFI. In multivariate analysis, only age at diagnosis (p < 0.001, relative risk [RR] 1.06) and Karnofsky performance status (p = 0.04, RR = 0.96) were significantly correlated with OS. Freedom from progression (FFP) was 58% and 56% after 10-years and 15-years, respectively. Recurrences outside the irradiated volume were significantly reduced after TNI compared to EFI; however, increased rates of in-field recurrences and extra-nodal out-of-field recurrence counterbalanced this effect resulting in no significant difference in FFP between TNI and EFI. In univariate analysis, FFP was significantly improved in stage I compared to stage II but no differences were observed between stages I/II and stage III. In multivariate analysis no patient or treatment parameter was correlated with FFP. Acute toxicity was significantly increased after TNI compared to EFI with a trend to increased late toxicity as well. CONCLUSIONS Radiotherapy alone for stage I and II follicular lymphoma resulted in long-term OS with high rates of disease control; no benefit of TNI over EFI was observed. For stage III follicular lymphoma, TNI achieved promising OS and FFP and should be considered as a potentially curative treatment option.
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Fakhrian K, Klemm S, Keller U, Bayer C, Riedl W, Molls M, Geinitz H. Radiotherapy in stage I-III follicular non-Hodgkin lymphoma. Retrospective analysis of a series of 50 patients. Strahlenther Onkol 2012; 188:464-70. [PMID: 22349634 DOI: 10.1007/s00066-011-0057-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Accepted: 11/23/2011] [Indexed: 11/27/2022]
Abstract
PURPOSE The goal of this work was to analyze the response rate and outcome of patients with stage I-III follicular lymphoma (FL) treated with radiotherapy (RT) alone. PATIENTS AND METHODS The records of 50 consecutive patients with stage I-III FL treated with RT alone at our department from 1988-2009 were analyzed. The median age was 60 years (range 32-80 years) with a median follow-up duration of 8 years (range 4-11 years). Clinical staging was performed according to the Ann Arbor system. Stage I: 30 patients (60%), stage II: 15 patients (30%), stage III: 5 patients (10%). Thirty-two patients (64%) presented with nodal disease, 14 patients (28%) presented with disease in extranodal sites, and 4 patients (8%) had nodal and extranodal involvement. The RT field encompassed only the involved Ann Arbor nodal regions (involved-field RT) in 26 patients (52%), mantle and whole abdominopelvic fields in 6 patients (12%), mantle field in 10 patients (20%), whole abdominopelvic fields in 5 patients (10%), and a so-called mini-mantle in 3 patients (6%). The total RT dose ranged from 26-56 Gy (median 40 Gy) in daily fractions of 1.2-2.5 Gy. RESULTS Complete remission (CR) and partial remission (PR) were observed in 39 (76%) and 9 (20%) patients, respectively. Only 2 of 8 patients (25%) with tumor bulk > 5 cm reached CR, whereas 37 of 42 patients (88%) with a maximum lymphoma diameter < 5 cm achieved CR (p = 0.0001). The median overall survival (OS) and median event-free survival (EFS) were 18 years (CI 95% 10-26 years) and 7 years (6-8 years), respectively. The 2-, 5-, and 10-year OS were 96 ± 3%, 90 ± 5%, and 70 ± 9%, respectively. The 2-, 5-, and 10-year EFS were 90 ± 5%, 70 ± 7%, and 38 ± 9%, respectively. Fifteen patients developed a recurrence outside the radiation field (30%) and 4 patients developed an in-field recurrence (8%). All in-field recurrences were observed in regions without clinical (macroscopic) involvement, which were irradiated with a dose of ≤ 26 Gy. Pretreatment maximum lymphoma diameter < 5 cm (p = 0.039) and complete remission after RT (p = 0.021) were significantly associated with a better OS in the univariate analysis. CONCLUSION RT is a curative option in the treatment of limited stage FL. If RT of microscopically uninvolved area is necessary, a reduction in the radiation dose should be carefully weighed against the risk of in-field recurrences.
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Affiliation(s)
- K Fakhrian
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.
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Beyzadeoglu M, Ozyigit G, Selek U, Selek U. Lymphomas and Total Body Irradiation. Radiat Oncol 2012. [DOI: 10.1007/978-3-642-27988-1_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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McNamara C, Davies J, Dyer M, Hoskin P, Illidge T, Lyttelton M, Marcus R, Montoto S, Ramsay A, Wong WL, Ardeshna K. Guidelines on the investigation and management of follicular lymphoma. Br J Haematol 2011; 156:446-67. [PMID: 22211428 DOI: 10.1111/j.1365-2141.2011.08969.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Rossier C, Schick U, Miralbell R, Mirimanoff RO, Weber DC, Ozsahin M. Low-Dose Radiotherapy in Indolent Lymphoma. Int J Radiat Oncol Biol Phys 2011; 81:e1-6. [DOI: 10.1016/j.ijrobp.2010.12.062] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Revised: 12/10/2010] [Accepted: 12/19/2010] [Indexed: 10/18/2022]
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McLaughlin P. Management Options for Follicular Lymphoma: Observe; R-CHOP; B-R; Others? CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2011; 11 Suppl 1:S91-5. [DOI: 10.1016/j.clml.2011.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Revised: 04/12/2011] [Accepted: 04/12/2011] [Indexed: 01/21/2023]
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Outcomes of patients with non-Hodgkin's lymphoma treated with Bexxar with or without external-beam radiotherapy. Int J Radiat Oncol Biol Phys 2011; 82:1122-7. [PMID: 21570217 DOI: 10.1016/j.ijrobp.2010.09.044] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2010] [Revised: 09/22/2010] [Accepted: 09/24/2010] [Indexed: 01/19/2023]
Abstract
PURPOSE To compare the efficacy and toxicity of external-beam radiotherapy (EBRT) to sites of bulky lymphadenopathy in patients with chemotherapy-refractory low-grade non-Hodgkin's lymphoma (NHL) immediately before receiving Bexxar (tositumomab and (131)I) vs. in patients receiving Bexxar alone for nonbulky disease. METHODS AND MATERIALS Nineteen patients with chemotherapy-refractory NHL were treated with Bexxar at our institution (University of Florida, Gainesville, FL) from 2005 to 2008. Seventeen patients had Grade 1-2 follicular lymphoma. Ten patients received a median of 20 Gy in 10 fractions to the areas of clinical involvement, immediately followed by Bexxar (EBRT + Bexxar); 9 patients received Bexxar alone. The median tumor sizes before EBRT + Bexxar and Bexxar alone were 4.8 cm and 3.3 cm, respectively. All 5 patients with a tumor diameter >5 cm were treated with EBRT + Bexxar. A univariate analysis of prognostic factors for progression-free survival (PFS) was performed. RESULTS The median follow-up was 2.3 years for all patients and 3.1 years for 12 patients alive at last follow-up. Of all patients, 79% had a partial or complete response; 4 of the 8 responders in the EBRT + Bexxar group achieved a durable response of over 2 years, including 3 of the 5 with tumors >5 cm. Three of 9 patients treated with Bexxar alone achieved a durable response over 2 years. Actuarial estimates of 3-year overall survival and PFS for EBRT + Bexxar and Bexxar alone were 69% and 38% and 62% and 33%, respectively. The median time to recurrence after EBRT + Bexxar and Bexxar alone was 9 months. Having fewer than 4 involved lymph-node regions was associated with superior PFS at 3 years (63% vs. 18%). There was no Grade 4 or 5 complications. CONCLUSIONS Adding EBRT immediately before Bexxar produced PFS equivalent to that with Bexxar alone, despite bulkier disease. Hematologic toxicity was not worsened. EBRT combined with Bexxar adds a safe and effective therapeutic treatment for managing recurrent low-grade follicular NHL.
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Abstract
Limited stage (I-II) follicular lymphoma is an uncommon entity, since most patients with this disease have generalized adenopathy (stage III) or bone marrow involvement (stage IV). Although patients who present with stage III-IV disease often are considered to be incurable, ~50% of patients with limited disease will enjoy long-term freedom-from progression, usually following treatment with radiation therapy. Relapse among these patients is uncommon after 10 years and exceedingly rare after 15 years. Radiation treatment is generally restricted to the involved nodal region(s) with modest (~5 cm.) extension proximally and distally. Radiation dose is generally 30 Gy, but may be boosted slightly (36 Gy total) in the presence of bulky disease. Randomized clinical trials have been insufficiently powered to define the value of any additional treatment beyond radiation therapy, although single arm studies suggest a benefit to the addition of chemotherapy. There have been no reported experiences with chemo-immunotherapy or radioimmunotherapy. Patients should be monitored during follow up to identify transformation to a more aggressive lymphoma.
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Affiliation(s)
- Richard T Hoppe
- Department of Radiation Oncology, 875 Blake Wilbur Drive, Room CC-G224, Stanford University, Stanford, CA 94305, USA.
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Schmatz AI, Streubel B, Kretschmer-Chott E, Püspök A, Jäger U, Mannhalter C, Tiemann M, Ott G, Fischbach W, Herzog P, Seitz G, Stolte M, Raderer M, Chott A. Primary follicular lymphoma of the duodenum is a distinct mucosal/submucosal variant of follicular lymphoma: a retrospective study of 63 cases. J Clin Oncol 2011; 29:1445-51. [PMID: 21383289 DOI: 10.1200/jco.2010.32.9193] [Citation(s) in RCA: 153] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
PURPOSE Small series with limited follow-up have suggested primary follicular lymphoma of the duodenum (FL-D) to be an indolent disease. We report our experience on a large series of patients followed for a median time period of longer than 6 years. PATIENTS AND METHODS The study comprised 63 patients with primary FL-D defined as stage I disease. Endoscopy and detailed pathologic work-up was performed at diagnosis and at restaging to monitor the behavior of the neoplastic process. RESULTS Histologically, all 63 patients had FL, low grade (1 to 2). Duodenal endosonography demonstrated lesions confined to mucosa/submucosa in 19 of 20 patients. At an overall median follow-up of 77 months (range, 12 to 177 months), only two untreated patients had developed nodal disease, the remaining 61 patients never experienced extrasmall intestinal disease and large cell transformation did not occur at all. Among 24 patients followed by watch and wait strategy, seven showed spontaneous complete regression and 17 had stable disease; radiotherapy resulted in complete regression in all 19 patients; anti-CD20 antibody monotherapy achieved complete regression in four patients and stable disease in one patient. Various chemotherapy protocols in eight patients caused complete regression in all of them, but local relapses occurred in three. No patients required surgery or died of disease. CONCLUSION These findings characterize primary FL-D as a remarkably indolent FL variant, which, even left untreated, does not develop tumorous growth, very rarely disseminates (two of 63 patients) and does not transform to high grade disease. A watch and wait approach appears to be the most sensible strategy.
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Affiliation(s)
- Ana-Iris Schmatz
- Medical University Vienna, Vienna General Hospital, Vienna, Austria
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72
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Burdick MJ, Neumann D, Pohlman B, Reddy CA, Tendulkar RD, Macklis R. External Beam Radiotherapy Followed by 90Y Ibritumomab Tiuxetan in Relapsed or Refractory Bulky Follicular Lymphoma. Int J Radiat Oncol Biol Phys 2011; 79:1124-30. [DOI: 10.1016/j.ijrobp.2009.12.030] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2009] [Revised: 11/24/2009] [Accepted: 12/10/2009] [Indexed: 10/19/2022]
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73
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Ganem G, Cartron G, Girinsky T, Haas RL, Cosset JM, Solal-Celigny P. Localized Low-Dose Radiotherapy for Follicular Lymphoma: History, Clinical Results, Mechanisms of Action, and Future Outlooks. Int J Radiat Oncol Biol Phys 2010; 78:975-82. [DOI: 10.1016/j.ijrobp.2010.06.056] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2010] [Revised: 06/16/2010] [Accepted: 06/17/2010] [Indexed: 11/27/2022]
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Campbell BA, Voss N, Woods R, Gascoyne RD, Morris J, Pickles T, Connors JM, Savage KJ. Long-term outcomes for patients with limited stage follicular lymphoma: involved regional radiotherapy versus involved node radiotherapy. Cancer 2010; 116:3797-806. [PMID: 20564082 DOI: 10.1002/cncr.25117] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Given the indolent behavior of follicular lymphoma (FL), it is controversial whether limited stage FL can be cured using radiotherapy (RT). Furthermore, the optimal RT field size is unclear. The authors of this report investigated the long-term outcomes of patients with limited stage FL who received RT alone and studied the impact of reducing the RT field size from involved regional RT (IRRT) to involved node RT with margins up to 5 cm (INRT<or=5 cm). METHODS Eligible patients had limited stage, grade 1 through 3A FL diagnosed between 1986 and 2006 and treated were with curative-intent RT alone. IRRT encompassed the involved lymph node group plus>or=1 adjacent, uninvolved lymph node group(s). INRT<or=5 cm covered the involved lymph node(s) with margins<or=5 cm. RESULTS In total, 237 patients were identified (median follow-up, 7.3 years) and included 48% men, 54% aged>60 years, stage IA disease in 76% of patients, elevated lactate dehydrogenase (LDH) in 7% of patients, grade 3A tumors in 12% of patients, and lymph node size>or=5 cm in 19% of patients. The 2 RT groups were IRRT (142 patients; 60%) and INRT<or=5 cm (95 patients; 40%). At 10 years, the progression-free survival (PFS) rate was 49%, and the overall survival (OS) rate was 66%. Only 2 patients developed recurrent disease beyond 10 years. The most common pattern of first failure was a distant recurrence only, which developed in 38% of patients who received IRRT and in 32% of patients who received INRT<or=5 cm. After INRT<or=5 cm, 1% of patients had a regional-only recurrence. Significant risk factors for PFS were lymph nodes>or=5 cm (P=.008) and male gender (P=.042). Risk factors for OS were age>60 years (P<.001), elevated LDH (P=.007), lymph nodes>or=5 cm (P=.016), and grade 3A tumors (P=.036). RT field size did not have an impact on PFS or OS. CONCLUSIONS Disease recurrence after 10 years was uncommon in patients who had limited stage FL, suggesting that a cure is possible. Reducing RT fields to INRT<or=5 cm did not compromise long-term outcomes.
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Affiliation(s)
- Belinda A Campbell
- Department of Radiation Oncology, British Columbia Cancer Agency, Vancouver, British Columbia, Canada.
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75
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Relander T, Johnson NA, Farinha P, Connors JM, Sehn LH, Gascoyne RD. Prognostic Factors in Follicular Lymphoma. J Clin Oncol 2010; 28:2902-13. [DOI: 10.1200/jco.2009.26.1693] [Citation(s) in RCA: 119] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Follicular lymphoma (FL) is one of the most common types of non-Hodgkin's lymphoma. It is usually diagnosed at an advanced stage, for which many treatment options exist, however, no curative standard therapy has been identified. The outcome is highly variable with a median survival of approximately 10 years. The life expectancy of patients with FL has been extended with the use of rituximab, a monoclonal antibody targeting the CD20 antigen on FL cells, but there remains a group of patients who fail to respond to chemoimmunotherapy and die early of their disease. Transformation of FL to an aggressive histology is an important event with high morbidity and mortality. The Follicular Lymphoma International Prognostic Index has become the clinically useful prognostic tool, but gives only a rough estimate of expected outcome. There is a need for useful biomarkers for prediction of the disease course of single patients to individualize therapy, especially in the new era of chemoimmunotherapy.
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Affiliation(s)
- Thomas Relander
- From the Departments of Pathology & Laboratory Medicine and the Division of Medical Oncology, British Columbia Cancer Agency and the University of British Columbia, Vancouver, British Columbia, Canada
| | - Nathalie A. Johnson
- From the Departments of Pathology & Laboratory Medicine and the Division of Medical Oncology, British Columbia Cancer Agency and the University of British Columbia, Vancouver, British Columbia, Canada
| | - Pedro Farinha
- From the Departments of Pathology & Laboratory Medicine and the Division of Medical Oncology, British Columbia Cancer Agency and the University of British Columbia, Vancouver, British Columbia, Canada
| | - Joseph M. Connors
- From the Departments of Pathology & Laboratory Medicine and the Division of Medical Oncology, British Columbia Cancer Agency and the University of British Columbia, Vancouver, British Columbia, Canada
| | - Laurie H. Sehn
- From the Departments of Pathology & Laboratory Medicine and the Division of Medical Oncology, British Columbia Cancer Agency and the University of British Columbia, Vancouver, British Columbia, Canada
| | - Randy D. Gascoyne
- From the Departments of Pathology & Laboratory Medicine and the Division of Medical Oncology, British Columbia Cancer Agency and the University of British Columbia, Vancouver, British Columbia, Canada
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76
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Abstract
The expansion of older population segments and the continuous increase in the incidence of non-Hodgkin's lymphoma (NHL) makes this group of neoplasms an important and growing problem. Older NHL patients have increased risk of therapy-related toxicity as a result of age-related physiological changes and frequent co-morbidities. A functional assessment of the elderly patient is necessary to determine the likelihood of tolerating and responding to therapy. The comprehensive geriatric assessment (CGA) is one multidisciplinary tool that has been applied successfully to older cancer patients and aids in identification of subjects who will or will not benefit from anti-neoplastic treatment. Although indolent lymphomas present more frequently at advanced stage, randomized trials do not show better outcomes with early therapy, supporting close observation until specific therapeutic indications arise. Use of the monoclonal antibody rituximab as a single agent or in combination with chemotherapy improves survival and has become the standard of care in first-line treatment. Radioimmunoconjugates, bendamustine, and other monoclonal antibodies as well as novel targeted agents also are active against indolent lymphomas. Diffuse large B-cell lymphoma is an aggressive but potentially curable disease. Several trials performed exclusively in elderly patients have demonstrated improved response rates and survival with the addition of rituximab to CHOP (cyclophosphamide, doxorubicin [adriamycin], vincristine, prednisone) chemotherapy in the front-line setting. Salvage chemotherapy followed by autologous haematopoietic cell transplant (autoHCT) has been shown to have better failure-free and overall survival in randomized trials involving younger patients. Highly selected individuals up to age 70 years may attain long-term survival benefit from autoHCT, although transplant-related mortality is higher than in younger patients.
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Affiliation(s)
- Paolo F Caimi
- Department of Medicine, Case Comprehensive Cancer Center, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio 44106, USA
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77
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Hallam S, Montoto S. Follicular lymphoma: managing an indolent malignancy. Br J Hosp Med (Lond) 2010; 71:258-62. [PMID: 20448493 DOI: 10.12968/hmed.2010.71.5.47905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Follicular lymphoma is by far the most common indolent non-Hodgkin lymphoma worldwide. Management is complicated by difficulty in accurately predicting individual outcomes and judging whether, when and how best to intervene. This article illustrates key issues in the management of this fascinating and enigmatic disease.
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Affiliation(s)
- Simon Hallam
- Centre for Meidcal Oncology, Barts, and the London School of Medicine, Queen Mary University of London, London, UK
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78
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79
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Akamatsu T, Kaneko Y, Ota H, Miyabayashi H, Arakura N, Tanaka E. Usefulness of double balloon enteroscopy and video capsule endoscopy for the diagnosis and management of primary follicular lymphoma of the gastrointestinal tract in its early stages. Dig Endosc 2010; 22:33-8. [PMID: 20078662 DOI: 10.1111/j.1443-1661.2009.00915.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIM The aim of this study is to evaluate the usefulness of double balloon enteroscopy (DBE) and video capsule endoscopy (VCE) in patients with primary follicular lymphoma (FL) of the gastrointestinal (GI) tract. Furthermore, we estimate the effectiveness of chemotherapy (cyclophosphamide, doxorubicin, vincristine, and prednisone) including rituximab for them. METHODS Thirteen consecutive patients who were diagnosed of having FL in the duodenum between July 2005 and September 2008 were studied. All patients were given the conventional staging examinations, including total enteroscopy using DBE and/or VCE procedures. Chemotherapy was performed after written informed consent. Response assessment was performed every 6-12 months. The median follow-up period was 30.2 months. RESULTS FL was diagnosed in each patient as low grade (grade 1, n = 7; 2, n = 6) and, in all but 4 patients, localized lymphoma (stage I, n = 8; II(1), n = 1; II(2), n = 4). DBE revealed multifocal lesions in the jejunum in 10 of the patients, and in the ileum in 6. VCE showed similar findings in the jejunum in the recent 2 patients. Eleven of 13 patients finally received chemotherapy, and all of them achieved complete regression. They showed no evidence of recurrence after that. CONCLUSION Total examination of the small intestine using DBE should be performed before treatment to choose a suitable treatment procedure for primary FL of the GI tract. On the other hand, VCE is useful for screening and following the small intestine in the patients with it. Chemotherapy is effective to achieve complete regression of primary FL of the GI tract.
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Affiliation(s)
- Taiji Akamatsu
- Department of Endoscopy, Shinshu University Hospital, Matsumoto, Japan.
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80
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Quero L, Hennequin C, Brice P. Place de la radiothérapie dans le traitement des lymphomes non hodgkiniens. Cancer Radiother 2009; 13:471-8. [DOI: 10.1016/j.canrad.2009.07.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2009] [Revised: 06/20/2009] [Accepted: 07/01/2009] [Indexed: 12/14/2022]
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81
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Feuerlein K, Zucca E, Ghielmini M. First-line treatment of follicular lymphoma–a patient-oriented algorithm. Leuk Lymphoma 2009; 50:325-34. [DOI: 10.1080/10428190802713513] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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82
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Mawardi H, Cutler C, Treister N. Medical management update: Non-Hodgkin lymphoma. ACTA ACUST UNITED AC 2009; 107:e19-33. [PMID: 19101479 DOI: 10.1016/j.tripleo.2008.08.054] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2008] [Revised: 08/11/2008] [Accepted: 08/27/2008] [Indexed: 11/19/2022]
Abstract
Lymphoma is a heterogeneous malignancy of the lymphatic system characterized by proliferation of lymphoid cells or their precursors. Non-Hodgkin lymphoma (NHL) is associated with significant morbidity and is the seventh leading cause of death in the United States. Manifestations of NHL as well as complications of the disease and its management are frequently encountered in the head and neck region and often require specific treatment and modifications in the provision of oral health care. The purpose of this article is to review current concepts of the pathophysiology, as well as medical and oral health care management of NHL.
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Affiliation(s)
- Hani Mawardi
- Department of Oral Medicine, Infection and Immunity, Harvard School of Dental Medicine, Boston, MA, USA.
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83
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Tan D, Horning SJ. Follicular lymphoma: clinical features and treatment. Hematol Oncol Clin North Am 2008; 22:863-82, viii. [PMID: 18954741 DOI: 10.1016/j.hoc.2008.07.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Follicular lymphoma (FL) is the second most common subtype of non-Hodgkin's lymphoma (NHL) in the Western world, constituting up to 22% of the total cases of NHL. This article describes the clinical characteristics of FL, its prognostic indicators, and its clinical course, including transformation to an aggressive lymphoma. Primary management and therapies for recurrent FL are detailed.
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Affiliation(s)
- Daryl Tan
- Department of Hematology, Singapore General Hospital, Outram Road, Singapore 169608.
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84
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Abstract
The malignant lymphomas, including both Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL), represent a diverse group of diseases that arise from a clonal proliferation of lymphocytes. Each of the more than 30 unique types of lymphoma is a disease with a distinct natural history. This biologic heterogeneity gives rise to marked differences among the lymphomas with respect to epidemiology, pathologic characteristics, clinical presentation, and optimal management. This article emphasizes the principles of diagnosis, including appropriate pathologic evaluation and staging considerations, and focuses on the clinical presentation, staging, and optimal management strategies for the most common types of lymphoma.
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Affiliation(s)
- Matthew J Matasar
- Medical Oncology/Hematology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
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85
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Luthy SK, Ng AK, Silver B, Degnan KO, Fisher DC, Freedman AS, Mauch PM. Response to low-dose involved-field radiotherapy in patients with non-Hodgkin's lymphoma. Ann Oncol 2008; 19:2043-7. [PMID: 18647962 DOI: 10.1093/annonc/mdn529] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The purpose of this study was to analyze response to palliative low-dose involved-field radiotherapy (LD-IF-RT) (two 2-Gy fractions), explore factors predicting for response, and determine the time course to subsequent treatment. PATIENTS AND METHODS Thirty-three patients with advanced or recurrent indolent non-Hodgkin's lymphoma (NHL) received LD-IF-RT to 43 sites. Response was assessed by physical examination and radiographic studies. Median follow-up for individual sites was 14 months. Fisher's exact test was used to evaluate prognostic factors for response and in-field progression. RESULTS Overall response was 95%. Thirty-six sites (84%) had a complete response (CR), five sites (12%) had a partial response, and two sites (5%) had progressive disease. The CR rate of head and neck sites was significantly higher than that of pelvic and/or inguinofemoral sites (95% versus 64%, P = 0.04). The CR rate was significantly higher for sites < or =40 mm than for sites >40 mm (90% versus 56%, P = 0.04). Ten sites (23%) had in-field progression diagnosed at a median of 9 months. Sixteen patients (48%) received systemic treatment at a median of 8 months. Fourteen patients (42%) did not require additional treatment. CONCLUSIONS LD-IF-RT for selected NHL subtypes has excellent local CR and in-field control rates and may postpone the need for systemic therapy.
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Affiliation(s)
- S K Luthy
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA 02115, USA
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86
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Vitolo U, Ferreri AJM, Montoto S. Follicular lymphomas. Crit Rev Oncol Hematol 2008; 66:248-61. [PMID: 18359244 DOI: 10.1016/j.critrevonc.2008.01.014] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2007] [Revised: 01/01/2008] [Accepted: 01/31/2008] [Indexed: 10/22/2022] Open
Abstract
Follicular lymphomas constitute approximately 30% of all non-Hodgkin lymphomas. These lymphomas are characterized by at least partially follicular growth pattern, but diffuse areas may be present. The proportions of follicular or diffuse areas vary also from case to case, which seems to be associated with prognosis. Follicular lymphomas should not be divided into distinct subtypes, but rather shows a continuous gradation in the number of large cells. On the bases of this grading, three groups have been defined: grades 1-3. There is a consensus that grade 3 follicular lymphomas, namely grade 3b, should be discriminated from lower-grade cases. The cells of follicular lymphomas express surface immunoglobulin, more frequently IgM+/-IgD>IgG>IgA, B-cell-associated antigens, CD10+/-; they are CD5-, CD23-/+, CD43-, and CD11c-. Follicular lymphomas express bcl-2 proteins, which is useful in distinguishing reactive from neoplastic follicles. t(14;18) is present in 70-95% of follicular lymphomas, involving rearrangement of bcl-2 gene. Clinical behavior of follicular lymphomas is heterogeneous and differs according to the histologic grade and extension of disease. Moreover, the evaluation of these malignancies is conditioned by therapeutic decision, which is also determined by main prognostic factors. The International Prognostic Index for aggressive lymphomas is not optimal for follicular lymphomas. Conversely, the Italian Lymphoma Intergroup Index and, more recently, the Follicular Lymphoma International Prognostic Index (FLIPI), designed in pre-rituximab era, seem to correlate well with outcome. Several active therapeutic approaches from the "wait and watch" strategy to the allogeneic transplantation are available for management of patients with follicular lymphoma. Therapeutic decision is mostly conditioned by patient's characteristics, stage, histologic grade, tumor burden, and risk-predicting factors.
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Affiliation(s)
- Umberto Vitolo
- Hematology Unit, Azienda Ospedaliera S. Giovanni Battista Molinette, Turin, Italy
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87
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Wirth A, Foo M, Seymour JF, Macmanus MP, Hicks RJ. Impact of [18f] fluorodeoxyglucose positron emission tomography on staging and management of early-stage follicular non-hodgkin lymphoma. Int J Radiat Oncol Biol Phys 2008; 71:213-9. [PMID: 18295982 DOI: 10.1016/j.ijrobp.2007.09.051] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2007] [Revised: 09/18/2007] [Accepted: 09/18/2007] [Indexed: 12/22/2022]
Abstract
PURPOSE Accurate staging is critical to select patients with early-stage (I-II) follicular lymphoma (ESFL) suitable for involved-field radiotherapy (IFRT) and to define the radiotherapy portal. We evaluated the impact of fluorodeoxyglucose (FDG) PET on staging, treatment, and outcome for patients with ESFL on conventional staging. METHODS AND MATERIALS Forty-two patients with untreated ESFL (World Health Organization Grade I-IIIa, or "low grade") following a minimum of physical examination, computerized tomography, and bone marrow examination (conventional assessment) and who had staging PET from June 1997 to June 2006 were studied retrospectively. Stage allocation was based on routine imaging reports. Disease sites, stage, and management plan were recorded based on conventional assessment or conventional assessment plus PET. RESULTS FDG avidity was demonstrated in 97% of patients in whom disease was evident on conventional assessment after biopsy. PET findings suggested a change of stage or management in 19 patients: 13 (31%) who were upstaged to Stage III-IV, altering ideal management from IFRT to systemic therapy, and 6 (14%) who had the involved field enlarged, including 4 upstaged from Stage I to II. Of these 19 cases, PET findings were considered true positive in 8 patients, indeterminate in 10, and false positive in only 1 patient. CONCLUSIONS Our data confirm that ESFL is usually FDG-avid. In routine practice, PET has the potential to upstage and thereby alter management in a high proportion of patients with apparent ESFL.
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Affiliation(s)
- Andrew Wirth
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, East Melbourne, Victoria, Australia.
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88
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Abstract
Over the past two decades, the incidence of follicular lymphoma has increased. Contemporary treatments include combinations of chemotherapy and monoclonal antibodies, radioimmunotherapy, new targeted agents and stem-cell transplantation. Prognostic tools are becoming more important in helping clinicians and patients decide on the most appropriate therapeutic regimens. Gene expression profiling and biomarkers are promising additions to this armamentarium. When patients do require therapy, the addition of rituximab to chemotherapy seems to improve remission duration and may improve overall survival. Radioimmunotherapy capitalises on the capacity to target radiation directly to malignant cells, and is currently approved for the treatment of relapsed/refractory follicular lymphoma. Further investigation is needed to clarify the role of stem-cell transplantation in follicular lymphoma. Only well-designed clinical trials can provide answers to the many questions that remain regarding the optimal treatment and sequence of treatments for patients with follicular lymphoma.
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Affiliation(s)
- Vikas Aurora
- Northwestern University Feinberg School of Medicine, Division of Hematology & Oncology, Department of Medicine and the Robert H. Lurie Comprehensive Cancer Center, 676 N. St. Clair Street, Suite 850, Chicago, IL 60611, USA.
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89
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Abstract
The most common low-grade non-Hodgkin lymphomas are of B-cell origin. This review will focus on follicular lymphomas and extranodal marginal zone lymphomas, also known as mucosa-associated lymphoid tissue (MALT) lymphomas. These are radiation-sensitive lymphomas. Moderate doses (30-35 Gy) for these stage I and II low-grade lymphomas result in long-term local control and possible cure. Involved-field radiation therapy is the standard approach and produces minimal morbidity. However, a significant proportion of patients relapse with systemic disease outside of radiation fields. For follicular lymphoma, this occurs in approximately 50% of patients after 15 years and for nongastric MALT lymphoma 30% to 40% after 10 years. Patients with relapsed disease are not curable with chemotherapy, but the disease often remains indolent and prolonged survival is observed. For gastric MALT lymphomas associated with Helicobacter pylori but which did not respond to antibiotic therapy, radiation treatment is indicated and almost always curative. For localized MALT lymphomas not related to microorganisms, radiation therapy is the initial standard therapy regardless of anatomic location. Patients with stage III and IV low-grade lymphoma and local symptoms are often successfully palliated with a low dose regimen of 2 x 2 Gy (total dose 4 Gy).
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Affiliation(s)
- Richard W Tsang
- Department of Radiation Oncology, University of Toronto, Princess Margaret Hospital, Toronto, Ontario, Canada.
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90
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Lunning M, Armitage JO. The curability of follicular lymphoma. Transfus Apher Sci 2007; 37:31-5. [DOI: 10.1016/j.transci.2007.04.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2007] [Accepted: 04/24/2007] [Indexed: 11/24/2022]
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91
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Abstract
Despite advances in treatment, there was little evidence until recently that this led to improvement in the survival of patients with indolent lymphoma, with patients continuing to have an unremitting course of relapse of disease. There appears to have been a change in the natural history of these diseases with the introduction of chemoimmunotherapy that may finally result in improvements in survival. With so many agents available for the treatment of indolent lymphomas, questions that have to be addressed include the following: is there still a role for a "watch-and-wait" approach in asymptomatic patients or should they be treated at diagnosis, what are the optimal first-line and salvage treatments, what is the role of maintenance therapy, and is there any role for stem cell transplantation in these diseases? No established treatment of choice has yet emerged, and many of these questions remain unresolved. It is highly likely that our treatment approaches will continue to evolve as the results of ongoing clinical trials are released and that improvement in outcome will result from identification of therapies that target the underlying pathophysiology of the diseases.
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Affiliation(s)
- John G Gribben
- Institute of Cancer, Barts and the London, Queen Mary School of Medicine, London, UK.
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92
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Hiddemann W, Buske C, Dreyling M, Weigert O, Lenz G, Unterhalt M. Current management of follicular lymphomas. Br J Haematol 2007; 136:191-202. [PMID: 17073892 DOI: 10.1111/j.1365-2141.2006.06378.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
After decades of stagnation, the prognosis of patients with follicular lymphomas (FL) has changed substantially within the last few years due to new and effective therapeutic modalities. These include myeloablative therapy followed by autologous stem cell transplantation (ASCT) in younger patients in first remission, which showed a significant prolongation of remission duration in three prospective randomised trials while the impact on overall survival still needs to be determined. Adding the anti-CD 20 antibody Rituximab to conventional chemotherapy resulted in a significant increase in remission rate, remission duration and, in two of four currently available prospective randomised studies, even in a longer overall survival. A prolongation of remission duration was also seen when Rituximab was given as maintenance after cytoreductive therapy including Rituximab. Radio-immunotherapy (RIT) with radioisotopes coupled to monoclonal antibodies produced encouraging data in several phase II studies. New therapeutic perspectives have also emerged from increasing insights into the biology of the disease that unravel molecular targets for novel agents, some of which have entered clinical evaluation already.
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Affiliation(s)
- Wolfgang Hiddemann
- Department of Internal Medicine III, University of Munich, Munich, Germany.
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93
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Abstract
Although numerous treatment approaches are proposed for patients with follicular lymphoma, criteria to help in choosing a treatment for a given patient and for comparing trial results are lacking. Several retrospective studies have analyzed prognostic factors, but their conclusions rely on limited numbers of patients treated during long periods, and their results are discordant. The Follicular Lymphoma International Prognostic Index was designed from the data recorded over 8 years of nearly 5000 patients registered worldwide. Five factors are used (age, Ann Arbor stage, number of nodal sites, serum lactate dehydrogenase level, and hemoglobin level) to build a three-category index. This index, together with new biologic markers such as gene profiling and proteomics, could help provide an optimal treatment option for patients with follicular lymphoma.
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94
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Abstract
Follicular lymphoma (FL) is characterized by its responsiveness to initial therapy, a pattern of repeated relapses, and a tendency for histologic progression to a process resembling diffuse, large B-cell lymphoma. Treatment decisions are complicated by the many effective options now available including combinations of conventional chemotherapy and monoclonal antibody, radioimmunotherapy, new targeted agents, and autologous and allogeneic stem cell transplantation. For selected patients, "watch and wait" or involved field irradiation may still be the most appropriate strategy. When therapy is required, a combination of rituximab and conventional chemotherapy results in improved outcomes compared to chemotherapy alone. Radioimmunotherapy alone or in combination with chemotherapy is an attractive strategy for patients with relapsed disease and may prove to be appropriate first line therapy. The role of stem cell transplant in FL requires further investigation. Novel agents with varied mechanisms of action continue to be developed. Enrollment of patients into clinical trials designed to address the many unanswered questions in FL is essential to improving clinical outcomes.
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Affiliation(s)
- Vikas Aurora
- Division of Hematology & Oncology, Department of Medicine, Northwestern University, Feinberg School of Medicine and the Robert H. Lurie Comprehensive Cancer Center, 676 N. St. Clair Street, Suite 850, Chicago, IL 60611, USA.
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95
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Dreyling M, Schmidberger H, Hiddemann W. Aktuelle Therapieoptionen des indolenten Lymphoms. ONKOLOGE 2006. [DOI: 10.1007/s00761-006-1060-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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96
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Historical Overview and Current State of Art in Diagnosis and Treatment of Hodgkin's and Non-Hodgkin's Lymphoma. PET Clin 2006; 1:203-17. [DOI: 10.1016/j.cpet.2006.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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97
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Tomita N, Kodama F, Motohashi K, Fujita A, Hyo R, Hashimoto C, Takemura S, Yamazaki E, Taguchi J, Sakai R, Fujisawa S, Kanamori H, Motomura S, Ishigatsubo Y, Takeuchi K. Outcome of Involved-Field Radiotherapy for Stage 1 Follicular Lymphoma. Int J Hematol 2006; 83:370-2. [PMID: 16757443 DOI: 10.1532/ijh97.06041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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98
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Plancarte F, López-Guillermo A, Arenillas L, Montoto S, Giné E, Muntañola A, Ferrer A, Villamor N, Bosch F, Colomo L, Balaguer O, Campo E, Montserrat E. Follicular lymphoma in early stages: high risk of relapse and usefulness of the Follicular Lymphoma International Prognostic Index to predict the outcome of patients. Eur J Haematol 2006; 76:58-63. [PMID: 16343272 DOI: 10.1111/j.1600-0609.2005.00564.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVES Patients with follicular lymphoma (FL) in advanced stages are currently deemed incurable with standard treatments. However, FL is considered to be eradicable in the small group of patients presenting with localized disease. The objective of this study was to analyze the clinical features and the outcome of a series of patients with FL in early stages with a long follow-up. PATIENTS AND METHODS A total of 48 patients (25m/23f; median age: 50 yr) diagnosed consecutively with FL in Ann Arbor stage I (25 cases) or II (23) at a single institution with a median follow-up of 9.5 yr were included in the study. Main biological and clinical characteristics at diagnosis, including Follicular Lymphoma International Prognostic Index (FLIPI) were analyzed; treatment and response were assessed and analyzed for prognosis. RESULTS The histologic subtypes were: FL type I, 20 cases (42%); type II, 24 (50%); type III, three (6%); and unclassifiable, one (2%). Distribution according to FLIPI was: low risk (36 cases) and intermediate risk (five cases). Treatment mainly consisted of combination chemotherapy (CHOP in 34 cases) plus involved-field radiotherapy in 26 cases. Forty patients (89%) achieved a complete response (CR), three (7%) a partial response, and two (4%) were non-responders; the remaining three patients did not receive therapy. No initial variable predicted CR achievement. About 57% of the patients in CR eventually relapsed with a relapse risk of 46% at 10 yr. Intermediate-risk FLIPI predicted failure-free survival. Histologic transformation was observed in six patients with a 10-yr risk of transformation of 13%. Twelve patients died during follow-up, in two cases as a result of unrelated causes. Overall survival (OS) at 10 yr was 79%. The FLIPI was the sole variable predicting OS. CONCLUSIONS Although the majority of patients with localized FL achieve CR, the risk of relapse is high. The FLIPI is of prognostic value in these patients.
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99
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Czuczman MS. Controversies in Follicular Lymphoma: “Who, What, When, Where, and Why?” (Not Necessarily in That Order!). Hematology 2006:303-10. [PMID: 17124076 DOI: 10.1182/asheducation-2006.1.303] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
AbstractFollicular lymphoma (FL) is the most common subtype of indolent lymphoma. Specific “facts” about FL that were generated by past research and have been passed down as dogma to a majority of practicing oncologists over the past 20 to 30 years that need to be revisited, include: (1) do not initiate therapy soon after diagnosis in asymptomatic, advanced-stage patients since it does not change outcome; (2) initiate therapy with single-agent oral alkylators when intervention needed and “save” more aggressive combination chemotherapy for “later” since the standard chemotherapy regimen used did not seem to impact survival; (3) FL is an incurable disease and palliation of symptoms was an acceptable approach to the expected pattern of repeated relapses; (4) transformation of FL is independent of the type or timing of therapies received by a patient; (5) median overall survival (OS) for FL patients is 8–10 years. Although the heterogeneity of FL will never change, we are developing the scientific tools to identify and better understand the biologic and genetic features associated with its clinical variability. In the current exciting era of targeted therapies (e.g., rituximab, radioimmunoconjugates) and novel treatment approaches demonstrating an improvement in treatment outcomes (e.g., disease-free survival and OS), our old beliefs and historically accepted dogma need to be retested and revitalized. The optimal combination(s) of old and new agents and the optimal timing of when to initiate and how to sequence specific therapies will require data from well-designed clinical trials that should include important correlative laboratory studies.
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Affiliation(s)
- Myron S Czuczman
- Roswell Park Cancer Institute, Elm and Carlton Sts., Buffalo, NY 14263-0001, USA.
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100
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Girinsky T, Ghalibafian M. Les traitements par les radiations ionisantes dans les lymphomes. Indications actuelles et futures. Cancer Radiother 2005; 9:422-6. [PMID: 16226472 DOI: 10.1016/j.canrad.2005.09.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Presently, radiotherapy is rarely an upfront treatment in patients with lymphomas. The modern evolution of radiation treatment calls for the development of therapeutic niches in which radiotherapy remains absolutely necessary. The development of new imaging techniques and their use in radiation planning systems along with new sophisticated radiation delivery techniques such as IMRT and respiratory gating should permit an increased accuracy an increased accuracy in the treatment of tumor masses and a decrease in late normal tissue complications.
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Affiliation(s)
- T Girinsky
- Département des radiations, Institut Gustave-Roussy, 39, rue Camille-Desmoulins, 94805 Villejuif, France.
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