Initial management of follicular lymphoma in adults

FL: follicular lymphoma; CT: computed tomography; PET/CT: positron emission tomography/computed tomography; R-CHOP: rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone; FDG: fludeoxyglucose.
* FL is graded on a scale from 1 to 3 according to the number of centroblasts per high powered field. Grade 3 FL has been subdivided for investigational purposes into grade 3a, in which centrocytes are present, and grade 3b, in which there are solid sheets of centroblasts.
¶ Features of aggressive clinical presentations include lymph nodes enlarging over weeks to months, systemic B symptoms (eg, fever, weight loss, drenching night sweats), elevated lactate dehydrogenase.
Δ Baseline imaging can use whole body FDG PET/CT or contrast-enhanced CT of diagnostic quality. FDG PET/CT is strongly preferred for patients with suspected stage I disease being evaluated for radiation therapy. Unilateral bone marrow biopsy is performed to rule out bone marrow involvement in patients with suspected stage I disease. We generally do not perform a bone marrow biopsy in patients with more advanced disease.
◊ The decision to use single agent rituximab versus bendamustine plus rituximab depends on the aggressiveness of the tumor and the patient's physical status/comorbidities that may impact his/her ability to tolerate bendamustine. Bendamustine plus rituximab is preferred for fit patients with highly symptomatic disease. In contrast, single agent rituximab is preferred for patients with comorbid conditions that make them poor candidates for chemotherapy and for those with a low tumor burden and/or disease progressing slowly over years. There is a paucity of data regarding the use of bendamustine plus rituximab in patients with the more aggressive histologic grade 3a disease; R-CHOP may be preferred in this setting for fit patients with clinically aggressive disease.
§ While we prefer to observe these patients, initial treatment with rituximab alone is an acceptable option for patients seeking immediate treatment, although this approach has not been associated with a survival advantage. In the small subset of patients with coexisting hepatitis C virus infection, treatment directed at hepatitis C may result in regression of FL.