Follicular Lymphoma (Grade 1 and 2)
Follicular Lymphoma, grade one and two, is a slow growing type of non Hodgkin's lymphoma that has a long natural history regardless of treatment.
Low grade follicular lymphoma is considered a chronic disease. In fact, for a limited asymptomatic disease, “observation” is still part of the standard of care. Having said that, once an individual is given a diagnosis of lymphoma the “panic” mode sets in and most patients demand to be treated.
Parameters that are looked at to determine prognosis are age, LDH level, hemoglobin level, advanced stage III or IV, and greater than four nodal sites of involvement. Bulky disease with anemia and elevated LDH confer poor prognosis as well as the presence of P53 mutations and alteration in chromosome 6P. For limited disease (stage I or II) asymptomatic observation or radiation therapy are standard of care. For advanced (stage III or IV) for asymptomatic non bulky disease, observation is still an option. For symptomatic disease chemotherapy and immunotherapy are therapeutic options.
Many treatment options are available and the choice should be based on the patient's comorbidities and treatment tolerance. Treatment mainly improves disease free survival and to a lesser extent overall survival.
Standard chemotherapy regimens like CHOP, CVP and FMD have all high response rates but have much better response and time to treatment failure with the addition of the monoclonal antibody Rituxan.
Not popular but very effective are the radio labeled monoclonal antibodies Bexxar and Zevalynare convenient, with excellent response rates and long disease free survival of six years and in some cases up to 10 years. The duration of therapy with the radio labeled monoclonal antibodies is much shorter than six months.
Thanks to the development of monoclonal antibodies, bone marrow transplant is rarely performed nowadays.
Ofatumumab is a new generation monoclonal antibody anti CD20 fully humanized which has been very effective in refractory disease or disease relapsed after Rituxan therapy as single agent. Ofatumumab is also being evaluated in combination with chemotherapy.
Two additional monoclonal antibodies, tositumomab (targeting CD20) and epratuzumab (targeting CD22) are currently in phase I and II trials and will be available in the near future.
The latest development in low grade NHL has been targeting the microenvironment surrounding the lymphoma cells, to suppress growth. Lenalidomide is an immunomodulatory drug currently being tested for that purpose. The combination of lenalidomide, Rituxan and decadron showed a very high response rate in refractory and relapsed patients.
In elderly patients with multiple comorbidities single agent Rituxan has been used very successfully with little or no side effects. The therapeutic options are numerous.