Initiating Therapy in Follicular Lymphoma

Transcript: Carla Casulo, MD: The GELF [Groupe d'Etude des Lymphomes Folliculaires] criteria are a series of criteria that were established many years ago to help us understand what groups of patients will most likely benefit from treatment in follicular lymphoma. There have been studies looking at patients with limited disease, low tumor burden disease, or high tumor burden disease, and those studies have taught us that patients with low tumor burden follicular lymphoma don’t necessarily benefit from chemotherapy versus observation, or rituximab versus observation. What those studies have taught us is that if they have high tumor burden disease, they’re much more likely to benefit from chemotherapy. The GELF criteria tell us that if a patient has a large burden of disease—7 cm—or if they have 3 lymph nodes that are greater than 3 cm, or cytopenias, or several other factors, then that patient is more likely to suffer symptoms from follicular lymphoma. They’re more likely to have morbidity from follicular lymphoma, and they’re most likely to benefit from treating their follicular lymphoma.

In that capacity that is not really a prognostic tool, but rather a tool that we use to say, do they meet these certain criteria, and are they in a group of patients that will most likely benefit from treatment?

PET [positron emission tomography] is actually considered a standard of care, in terms of staging. The Lugano criteria have demonstrated to us that follicular lymphoma is FDG [fluorodeoxyglucose]-avid, so that means that it does take up that fluorodeoxyglucose. It does light up on the PET. It helps the oncologist differentiate stage much more accurately than with a CT [computed tomography] scan, and that’s already been very well established and is considered a standard of care in the NCCN [National Comprehensive Cancer Network] guidelines in our staging criteria.

In terms of following patients over time, I think that is still a little bit lesser-known, because we don’t do surveillance with PET after a patient’s been treated. That’s not considered a standard. In fact, a lot of our guidelines from ASH [American Society of Hematology] and ASCO [American Society of Clinical Oncology] suggest that we should do less surveillance for patients in whom there’s no clear benefit to surveillance.

For patients with untreated follicular lymphoma, if you’re suspecting that something has evolved or that they have transformation, then the use of a PET may help you in terms of providing your treatment selection or maybe re-biopsying. In terms of just regular surveillance—getting a PET scan done every 6 to 12 months—there’s not a lot of utility in that.

If they have low tumor burden disease, you can offer rituximab as a single agent. You can also observe the patient. That is a very long discussion, typically, with your consult because a lot goes into that. If a patient has low tumor burden disease, yet they are symptomatic, that would be an indication to treat. They could be symptomatic because they have pain, they have anxiety regarding their diagnosis, or they have some other symptom or issue regarding the diagnosis.

For patients with high tumor burden disease, some don’t get treated because, despite having more disease burden, they actually feel great. They don’t really desire treatment; they want to delay treatment. I think that it really depends on the individual.

If you find that your patient has impending organ failure or, within a certain period, you worry that they will have some kind of morbidity from delaying treatment, then that would be someone that I’d act upon sooner.

If someone has just several lymph nodes in their chest, abdomen, and pelvis, and they don’t have any other compelling reason outside of size, for example, you may easily delay treatment for that patient without a lot of compromise. Now, if you suspect that someone is transforming to an aggressive lymphoma, that’s something that really should be expedited, and you shouldn’t delay treating somebody in whom you suspect that that’s happening.

If they have cytopenias because they have bone marrow failure due to the presence of a very high amount of lymphoma in their bone marrow, that would be something that—if they may become transfusion-dependent or they might develop anemia from which they’re very tired or they have shortness of breath—also would trigger treatment.

The presence of a pleural effusion, again, would be something that technically would warrant treatment. However, you have some patients who have asymptomatic pleural effusions that they’re not aware of. If that’s the only site of disease, although that would be less likely, that would be another reason to initiate treatment.

Transcript Edited for Clarity