Clinical Challenge: Treating Relapsed Follicular Lymphoma

The currently available treatments for follicular lymphoma are not curative, meaning that most patients will experience disease relapse and progression.

Some patients with follicular lymphoma may experience long-term responses to therapy and become symptomatic of relapse after a period of 10 years or longer. Others may experience early relapse, with disease recurring within 2 years of treatment.

“In follicular lymphoma, the relapses are really heterogeneous, reflecting the nature of the disease,” said Scott Huntington, MD, MPH, MSc, of the Yale School of Medicine in New Haven, Connecticut. “Because of that, I am not someone who typically does serial imaging of patients who are asymptomatic.”

Although some physicians will still perform imaging in these patients every 4 to 6 months, it may be unnecessary, as almost all patients will be symptomatic at the time of relapse and clinical outcomes appear to be similar between patients found to have clinical relapse compared to those with relapse detected on serial imaging, he said.

“Almost all patients are educated about the signs and symptoms of progressive lymphoma,” Huntington said. “I help educate patients and advise them to listen to their body and bring new symptoms to our attention early.”

These signs and symptoms can include adenopathy or new constitutional symptoms such as fever, chills, night sweats, early satiety, or weight loss. Typically, the symptoms will mirror those the patient experienced when they were first diagnosed with the disease.

In cases of suspected relapse, repeat biopsy is strongly advised, according to Jonathan Friedberg, MD, director of the James P. Wilmot Cancer Center at the University of Rochester Medical Center in Rochester, New York.

“Repeat biopsy is important in relapsed follicular lymphoma to rule out transformation,” Friedberg said. “Although transformation is usually clinically apparent, that is not always the case.”

Biopsy is particularly important in patients who had been in remission for a long period of time in order to confirm that the disease is in fact the same lymphoma, and not another disease or malignancy. Although follicular lymphoma generally has an accessible lymph node, Friedberg said, it can occur in difficult-to-reach places, where a needle biopsy may need to be used.

Treatment Selection

Once disease relapse is confirmed, salvage regimens must be considered. Selection of salvage treatment can be highly variable and is based on a number of factors, Friedberg said.

The first thing to consider is the patient’s first-line treatment and how well it worked.

“For example,” said Huntington, “if someone had rituximab [Rituxan] monotherapy first-line and 2, 3, or 4 years later had a slow progression, going back to more rituximab monotherapy is completely reasonable.”

However, a patient treated with single-agent rituximab might be treated differently than one who was given rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) followed by rituximab maintenance, Friedberg said.

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