First-line treatment and survival of transformed follicular lymphoma in the netherlands in the rituximab era; a population-based analysis

  • M.J. W
  • D.E. I
  • J.M. Z
  • et al.
ISSN: 0278-0232
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Abstract

Introduction: Treatment of transformed follicular lymphoma (TFL) is diverse as there are no randomized studies to guide therapy. Patients are treated with rituximab (R)-chemotherapy only or with R-chemo and upfront autologous stem cell transplantation (ASCT) at their physicians' discretion. We investigated different treatment modalities and outcome of patients registered in the Population-based Haematological Registry for Observational Studies (PHAROS), covering 40% of the Dutch population. Methods: From the PHAROS registry, we extracted all patients with a diagnosis of both follicular lymphoma (FL) and diffuse large B-cell lymphoma (DLBCL) between January 2004 and July 2013 and checked their histology. Only patients with biopsy-proven DLBCL and underlying FL (previously or simultaneously diagnosed) were included. A separate analysis was performed on patients below 68 years, since upfront ASCT was given up to 67 years. Results: One hundred and sixty-one patients were included, median age at transformation was 63 years (34-91), median time to TFL was 14 months (0-101) and median follow-up after transformation was 17 months (1-111). Former treatment for FL: Sixty-one per cent had been treated with chemotherapy for FL (66% of them with R), 2% had received radiotherapy only, 24% were under a watch-and-wait strategy and, in 13%, FL and DLBCL were diagnosed simultaneously. Treatment for TFL: Ten patients were unable to receive any treatment. All 151 treated patients received R-chemo as induction therapy: 62 patients (33, <68 years) received R-chemo only, and 32 (all <68 years) were in remission after induction Rchemo and received upfront ASCT [23 with R and 9 preceded by 90Y ibritumomab tiuxetan (Z)]. One patient received upfront consolidation with allogeneic SCT. Fiftysix patients (40, <68 years) were primary refractory to induction treatment, of whom 15 (all <68 years) could be rescued by ASCT. When patients had been treated for FL before, significantly more often upfront ASCT was given as treatment of TFL: 33% of untreated patients received upfront ASCT versus 63% of pretreated patients (p < 0.01). In the R-chemo-only group, 39% had been pretreated with chemo and 54% with R, versus 69% and 77% in the upfront ASCT group (p < 0.01). Median OS of all TFL patients was 52 months, with a 2-year OS of 55%. To compare survival between treatment groups, we analysed 109 patients <68 years. After successful R-chemo, 2-year OS was 90%, rising to 96% after upfront ASCT (with or without Z). Two-year OS was 40% after salvage Z-ASCT and 0% when patient was R-chemo refractory and unable to reach salvage ASCT. Conclusion: Although TFL is considered to have a poor prognosis, our data show that when induction R-chemotherapy for TFL is successful, OS is very high. Refractoriness to induction is the main cause of mortality. Physicians offer upfront ASCT more often to patients pretreated with R-chemo for FL. Upfront Z-ASCT seems to result in the highest OS rates, despite more pretreated patients in this group. Studies are needed to identify the patients benefitting most.

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M.J., W., D.E., I., J.M., Z., O., V., S., Z., & M.E., C. (2015). First-line treatment and survival of transformed follicular lymphoma in the netherlands in the rituximab era; a population-based analysis. Hematological Oncology, 33, 265–266. Retrieved from http://www.embase.com/search/results?subaction=viewrecord&from=export&id=L72040020 http://dx.doi.org/10.1002/hon.2229

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