Early progression of follicular lymphoma: a view of the problem and personal experience

Abstract

Follicular lymphoma (FL) refers to indolent mature B-cell lymphomas and, despite the recurrent course, is generally characterized by a favorable prognosis with long-term overall survival. However, in about 20 %, the disease has an aggressive course with early progression and 5-year overall survival of only 50 %, which indicates the biological heterogeneity of FL. Due to the extremely poor prognosis, cases with disease progression within 2 years from the start of treatment represent a major clinical problem. What predictive risk models of FL early progression are available to us and what regimens of the second and subsequent lines of anticancer therapy should be used? Is high-dose consolidation necessary and when? Choosing the optimal therapy in early progression of FL is a complex task and depends both on the variant of the previous treatment and the patient’s status, as well as the objectively available therapeutic options. In the case of FL early progression after immunochemotherapy, an alternative regimen is used based on a previously unused anti-CD20 monoclonal antibody (rituximab or obinutuzumab) and non-cross-acting chemotherapeutic agents. For CHOP-like induction therapy, the optimal second-line drug is bendamustine. In addition to cytostatics in combination with anti-CD20 monoclonal antibodies, new agents are currently actively used in FL therapy (such as immunomodulators, inhibitors of B-cell receptor and histone methyltransferase signaling pathways, BCL-2 inhibitors, etc.). Numerous clinical trials continue to actively search for promising therapeutic options for the treatment of FL, with testing of new drugs to other B-cell targets and with different mechanisms of action. We present a clinical case of FL with early generalized progression, ineffectiveness of subsequent intensification of treatment with autologous hematopoietic stem cell transplantation and the choice of salvage therapy in the realities of 2009–2012.