Managing Relapsed Follicular Lymphoma - Episode 2
Nathan H. Fowler, MD:Today, when we’re grading these lymphomas, they’re often graded into grade 1, grade 2, grade 3, 3a, and 3b. And, sometimes, one of the more difficult clinical decisions is deciding how to treat patients who are 3a or 3b. I generally think of follicular lymphoma grade 3b as a lymphoma that really acts and should be treated as an aggressive lymphoma. So, grade 3b, I generally treat as a large-cell lymphoma, and I think about that as kind of a transformed follicular. Generally, I treat them with combined chemotherapy with rituximab. Grade 3a is on the fence. And when I’m talking to patients, I generally think about this as a diagnosis that can go either way. Grade 3a means that there were more than 15 large cells in a sample, but there were still small cells, still centrocytes, within the sample.
If you look at a lot of literature, grade 3a is sometimes treated as an aggressive lymphoma, and in some studies, grade 3a is included with patients who were treated with low-grade approaches. Now, when I say it can go either way, I generally look at the other factors in a patient’s presentation when deciding how to treat a grade 3a. For example, in a patient who has 3a, if they have very low-volume disease, low SUV on PET scan, the Ki67 is low, and they have a low LDH, I generally treat them as a low-grade lymphoma. However, if they have grade 3a on pathology, but the disease is growing rapidly; their SUV is higher than 13, 14, or 15; and their LDH is high, I generally think that they may be in the process of transforming or at least have some aggressive component that potentially wasn’t seen on the biopsy, and I treat them as a large-cell lymphoma.
Transcript edited for clarity.