What are the NCCN treatment guidelines for follicular lymphoma?

Updated: Mar 03, 2020
  • Author: Lauren C Pinter-Brown, MD; Chief Editor: Emmanuel C Besa, MD  more...
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The NCCN and ESMO offer similar treatment recommendations, as follows [19, 68] :

  • Involved-site radiation therapy (ISRT), 24-30 Gy, is the preferred treatment option for stage I or II
  • If significant toxicity is expected from radiotherapy, initial observation may be more appropriate
  • Other first-line treatment options include rituximab, alone or in combination with other agents, and radioimmunotherapy
  • Combination treatment with involved-field radiation therapy (IFRT) and chemotherapy (see below) and/or radioimmunotherapy is recommended for more advanced stages
  • In asymptomatic patients with advanced-stage, low tumor burden disease, initiate treatment when the patients become symptomatic, as there is no survival advantage with immediate treatment versus a watch-and-wait approach

The NCCN lists the following regimens as preferred first-line therapy [19] :

  • Bendamustine plus obinutuzumab or rituximab
  • CHOP (cyclophosphamide, doxorubicin [hydroxydaunorubicin], vincristine [Oncovin], prednisone) plus obinutuzumab or rituximab
  • CVP (cyclophosphamide, vincristine, prednisone) plus obinutuzumab or rituximab
  • Lenalidomide plus rituximab 

For second-line and subsequent therapy of FL, the NCCN recommends the following as preferred regimens [19] :

  • Bendamustine plus obinutuzumab or rituximab
  • CHOP plus obinutuzumab or rituximab
  • CVP plus obinutuzumab or rituximab
  • Rituximab
  • Lenalidomide, alone or plus rituximab

Other recommended regimens are as follows:

  • Ibritumomab tiuxetan
  • PI3K inhibitors (idelalisib, copanlisib, or duvelisib) – For relapsed/refractory after 2 prior therapies

For elderly or infirm patients who are unlikely to tolerate those regimens, the NCCN recommends the following as first-line, second-line, and subsequent regimens:

  • Rituximab (preferred) (375 mg/m 2 weekly for 4 doses)
  • Chlorambucil, alone or plus rituximab
  • Cyclophosphamide, alone or plus rituximab
  • Chlorambucil
  • Cyclophosphamide
  • Ibritumomab tiuxetan (category 2B)

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