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Advanced-Stage III/IV Follicular Lymphoma

Treatment Strategies for Individual Patients

Follikuläre Lymphome in fortgeschrittenen Stadien III/IV. Behandlungsstrategien für den einzelnen Patienten

  • Review Article
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Abstract

Background:

In patients with advanced-stage III/IV follicular lymphoma (FL), there are many treatment options available. The current challenge is to choose the optimal strategy for the individual patient.

Methods:

The literature was reviewed with respect to treatment strategies in patients with advanced FL by screening the PubMed databank.

Results:

In advanced-stage III/IV FL, median survival may approach 8–10 years. Treatment strategies include a watch-and-wait strategy, chemoimmunotherapy, monotherapy with rituximab, and – as an experimental approach so far – radioimmunotherapy. The use of autologous hematopoietic stem cell transplantation (HSCT) for patients in first remission or chemosensitive relapse prolongs progression-free survival while the effect on overall survival remains unclear compared to standard chemotherapy. However, long-term results are flawed by high relapse rates and risk of secondary malignancies. In patients with relapsed/chemoresistant disease, allogeneic HSCT constitutes the only curative approach but is associated with high treatment-related mortality. In the palliative setting, low-dose involved-field irradiation constitutes an effective treatment option in order to control local symptoms with potential long-lasting response.

Conclusion:

In case of advanced-disease FL, asymptomatic patients can be managed expectantly. In symptomatic patients, chemoimmunotherapy is regarded as standard therapy. In symptomatic elderly patients with relevant comorbidities, rituximab ± single-agent chemotherapy, or low-dose involved-field radiotherapy might be appropriate. For younger patients with chemoresistant/ relapsed disease, allogeneic HSCT might be considered, since advances in supportive care and better patient selection have resulted in improved outcomes.

Zusammenfassung

Hintergrund:

Für Patienten mit follikulärem Lymphom (FL) fortgeschrittener Stadien III/IV liegen mehrere etablierte Therapieoptionen vor. Die Herausforderung besteht darin, eine optimale Behandlungsstrategie für den einzelnen Patienten auszuwählen.

Methodik:

Es wurde eine Literaturrecherche unter Verwendung der PubMed-Datenbank zu Therapiestrategien bei Patienten mit fortgeschrittenen Stadien eines FL durchgeführt.

Ergebnisse:

Für fortgeschrittene Stadien III/IV eines FL beträgt das mediane Überleben 8–10 Jahre. Aktuelle Behandlungs optionen umfassen eine „watch and wait“-Strategie, eine kombinierte Chemoimmuntherapie, eine Monotherapie mit Rituximab sowie – als bislang experimentellem Ansatz – die Radioimmuntherapie. Die Anwendung der autologen Transplantation in erster Remission oder bei chemosensitivem Rezidiv kann im Vergleich zur konventionellen Chemotherapie das progressionsfreie Überleben verlängern, der Einfluss auf das Gesamtüberleben ist noch ungeklärt. Die Langzeitergebnisse werden durch hohe Rückfallraten und das Auftreten von Sekundärmalignomen beeinträchtigt. Bei Patienten im Rezidiv oder bei chemoresistenter Erkrankung ist die allogene Transplantation die einzige kurative Behandlungsoption mit allerdings hoher therapiebedingter Mortalität. Im Rahmen der Palliation stellt eine niedrigdosierte Involved-Field-Strahlentherapie eine effektive lokale Behandlungsoption mit potentiell lang anhaltender Remission dar.

Schlussfolgerung:

In fortgeschrittenen Stadien eines FL ist bei asymptomatischer Erkrankung ein abwartendes Verhalten gerechtfertigt. Bei Patienten mit symptomatischer Erkrankung wird die Chemoimmuntherapie als Standard erachtet. Bei symptomatischen älteren Patienten mit relevanter Komorbidität scheint eine Rituximabgabe ± Monochemotherapie bzw. niedrigdosierte Involved-Field-Radiotherapie angemessen. Bei jüngeren Patienten mit chemoresistenter Erkrankung oder Rezidiv eines FL kann eine allogene Transplantation erwogen werden, da ein optimales Management die Mortalitätsrate der allogenen Stammzelltransplantation gesenkt hat.

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Authors and Affiliations

  1. Department of Radiation Oncology, University of Tübingen, Tübingen, Germany

    Frank Heinzelmann, Michael Bamberg & Martin Weinmann

  2. Department of Bone Marrow Transplantation, University of Essen, Essen, Germany

    Hellmut Ottinger

  3. Department of Radiation Oncology, University of Essen, Essen, Germany

    Marianne Engelhard

  4. Department of Internal Medicine II, University of Tübingen, Tübingen, Germany

    Martin Soekler

  5. Klinik für Radioonkologie, Universitätsklinikum Tübingen, Hoppe-Seyler-Straße 3, 72076, Tübingen, Germany

    Frank Heinzelmann

Authors
  1. Frank Heinzelmann
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  2. Hellmut Ottinger
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  3. Marianne Engelhard
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  4. Martin Soekler
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  5. Michael Bamberg
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  6. Martin Weinmann
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Corresponding author

Correspondence to Frank Heinzelmann.

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Heinzelmann, F., Ottinger, H., Engelhard, M. et al. Advanced-Stage III/IV Follicular Lymphoma. Strahlenther Onkol 186, 247–254 (2010). https://doi.org/10.1007/s00066-010-2091-8

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  • DOI: https://doi.org/10.1007/s00066-010-2091-8

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