Approach to High-Risk Follicular Lymphoma - Episode 2
Ajay K. Gopal, MD:One thing we think about is, obviously, which treatment do we choose? There are a number of options, and the first question often is, does the patient need chemoimmunotherapy or immunotherapy alone? This is outside the setting of a clinical trial. So, the question is, do we use rituximab by itself or do we use chemotherapy plus a monoclonal antibody? Typically, when we think of single-agent rituximab use, we think about it in patients who have low tumor burden. Most of us reference the RESORT trial, which had about a 70% response rate to single-agent rituximab; 4 doses of rituximab. It’s important to point out, regarding that trial, that those patients did not, at least based on the publication, have to meet GELF or NCCN criteria for treatment. Many of those patients may have been asymptomatic, so the response rates are probably a bit higher than you might get in symptomatic patients. Typically, when I treat a patient, I look at the burden of the disease. And for those who have high tumor burden, again, outside the setting of a clinical trial, we consider primarily chemoimmunotherapy versus rituximab alone, though patient preference, comorbidities, and other factors certainly come into play.
When we do think about chemoimmunotherapy, the question that often comes up is, which chemotherapy backbone do we use? And the bendamustine/rituximab is often chosen based on 2 prospective clinical trials: first one, the StiL trial and the second one, BRIGHT trial. These were noninferiority trials, and, at least based on the data from those trials, the bendamustine/rituximab appeared to be noninferior to R-CHOP, or R-CHOP/R-CVP in the BRIGHT trial. It’s important to remember that these trials only included grade 1/2 folliculars for those patients who had follicular lymphoma. So, when we talk about somebody with a grade 3 follicular lymphoma, which this patient did not appear to have, at least at this point, we should not apply those data to grade 3 folliculars.
Another interesting regimen that is being evaluated prospectively is the so-called R2regimen, which is lenalidomide (Revlimid) along with rituximab. There were some very provocative single-arm studies that showed this could be a very effective regimen with high response rates and good progression-free survival. For me, I tend to wait. It’s not approved. Lenalidomide is not approved for follicular lymphoma. There can be a challenge getting that paid for, and until the larger RELEVANCE trial fully reads out, which is a randomized phase III trial comparing R2to standard chemoimmunotherapy, I’m typically not using R2off label.
Transcript edited for clarity.