It is considered that patients with follicular non-Hodgkin lymphomas in the IV stage IIE have advanced disease and can not be cured with standard treatment approaches. All follicular lymphomas which follow are treated identically.
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International Working Formulation |
Lymphoma Classification European review US |
| Follicular cell small indented | Follicle center cell (grade 1) |
| Follicular mixed small and large cell | Follicle center cell (grade 2) |
A variety of factors influence the decision of patients to receive treatment for cancer. The purpose of treatment may be to improve symptoms through local control of the cancer, increase a patient’s chance of cure, or prolong your life. The benefits expected from cancer treatment must be carefully balanced with respect to their potential risks.
Below is general information about the treatment of advanced-stage follicular lymphoma. Circumstances unique to your situation and prognostic factors of your cancer are what influences, ultimately, on how these general treatment principles are applied to your situation. The information on this website is intended to help educate you about treatment options and facilitates decision-making process, mutual or shared with the oncologist treating physician.
Most new treatments are developed in clinical trials, ie studies that evaluate the effectiveness of new drugs or treatment strategies. The development of more effective cancer treatments requires the evaluation of new and innovative therapies in cancer patients. Participation in a clinical trial may offer access to better treatments and advance the existing knowledge about treatment of this cancer. Clinical trials are available for most stages of cancer. Patients interested in participating in a clinical trial should discuss the risks and benefits together with their physicians. To ensure that you are getting the best treatment for your cancer, it is important to be aware of the latest news about cancer, so having knowledge about new treatments and the results of clinical trials.
Follicular lymphoma is considered a very indolent or slow-growing cancer. Because cancer growth is slow, it is very difficult to cure because traditional chemotherapy for cancer treatments or radiation therapy destroy rapidly growing cells. Although cure patients with advanced follicular lymphoma is rare, patients can live a long time with their illness. In fact, the average life expectancy of patients with follicular lymphoma is 6-10 years after diagnosis.
Because it is difficult for follicular lymphoma are cured, many treatment strategies are directed today to prolong the time that patients can live with their illness. As the cancer grows slowly, it may be that the initial treatment is not necessary for many months to years after diagnosis. However, many patients require early treatment. This usually begins a year later, for the following reasons:
To relieve symptoms caused by lymphoma, among which may be fever, sweating and weight loss.
The treatment may be necessary to prevent the growth of lymphoma in an area that affects the function of other organs such as kidney blockage.
Improve low blood count caused by lymphoma involving bone marrow, which increases the risk of infection, bleeding or anemia.
Stop the growth or progression of lymphoma.
Patient preference: Some patients are uncomfortable living with lymphoma and prefer to be treated even in the absence of the above reasons.
Due to the incurability of follicular lymphomas, participation in a clinical trial to evaluate new drugs or treatment strategies is an appropriate initial treatment option.
Because of the wide range of existing treatment options for advanced follicular lymphomas, a treatment plan can be confusing. Although most patients with advanced follicular lymphoma is not curable with standard treatment options, all approaches to approved therapies have been shown to improve survival.Each treatment was associated with side effects or toxicity only. When a treatment is chosen, it may be more appropriate for some patients selecting therapy with less toxicity, while other patients may want a treatment regimen based only on long-term survival without cancer. The patient might also consider how a treatment option may affect the decision following treatment for cancer relapse. At present, the initial standard treatment available for advanced follicular lymphoma includes:
Single agent chemotherapy: Clinical experiments have indicated that the Fludara® seems to be the single most effective agent for initial treatment of follicular lymphoma chemotherapy. As an initial treatment, Fludara® only induces complete remissions in approximately 40% of patients. Other individual chemotherapy agents that are approved for the initial treatment of follicular lymphoma include purine nucleoside analog 2-clorodeoxidenosina, the rental agent cyclophosphamide and chlorambucil with or without steroids.
Combinations of chemotherapy drugs: many schemes are available multi-drug chemotherapy can induce complete responses in more than 50% of patients. Usually, chemotherapy combinations used to treat follicular lymphoma include, but are not limited to, the following:
The most used combination chemotherapy is cyclophosphamide, doxorubicin, Oncovin® and prednisone (CHOP).
Other combinations include:
CPV: cyclophosphamide, and prednisone Oncovin®.
C (M) OPP cyclophosphamide, Oncovin®, procarbazine and prednisone.
FM: Novantrone® Fludara® and with or without dexamethasone.
In a recent clinical trial suggested that the FM can improve the anticancer responses compared with CHOP as initial therapy in patients with follicular lymphoma; however, additional experiments are needed to confirm this finding.
Combination chemotherapy more Intron®A (interferon): Many clinical trials have shown that Intron®A injected 3 times a week in patients who achieve remission of combination chemotherapy can prolong overall survival of patients, compared with patients treated with chemotherapy alone. In a recent experiment comparing Intron®A with a combination of chemotherapy significantly prolonged survival time and increased cancer recurrence compared to treatment with chemotherapy alone.
Monoclonal antibodies: Rituxan ™ is a relatively new biological therapy appears promising in patients with non-Hodgkin B-cell low degree of
olicular, in combination with chemotherapy or after standard therapy. Rituxan ™ is a monoclonal antibody that binds to proteins on the surface of B lymphocytes This binding stimulates the immune system to attack and kill cancer B cells. The major benefit of this approach is that the Rituxan ™ focuses only on cancer cells (B cells) preventing the destruction of healthy cells. This, in contrast to chemotherapy or radiation do not differentiate between healthy or cancer cells in the body, leading to a characteristic potentially destructive side effects.
In a clinical trial to evaluate the Rituxan ™ as initial therapy in 62 patients with indolent follicular lymphoma or small lymphocytic lymphoma (SLL, for its acronym in English), patients received to start a cycle of Rituxan ™ weekly for four weeks. Patients whose disease progressed during treatment received these cycles of 4 weeks of Rituxan ™ every 6 months. Two years after starting treatment, 67% of patients had no progression of cancer. There was no difference between the group of patients with follicular lymphoma and SLL group regarding treatment response. Only 3% of patients had side effects related to the infusion were reversible. Other side effects were reported.
These results are favorable compared with other individuals or standard combinations for initial therapy of indolent non-Hodgkin lymphoma with minimal side effects. In addition, the two-year survival without progression Rituxan ™ was higher in patients previously untreated, compared with historical clinical trials involving patients who received previous treatment for the disease. These findings are consistent with previous clinical trials, which suggest that Rituxan ™ is well tolerated by patients and has high activity as initial therapy for low-grade lymphoma. This may provide an alternative treatment option for elderly patients or for patients who can not tolerate the side effects of chemotherapy. However, still in study how best to incorporate Rituxan ™ in the overall treatment strategy against low-grade lymphoma.
Furthermore, after the first treatment the original treatment with Rituxan ™ appears promising in the treatment of lymphoma. In recent time the researchers evaluated the safety and effectiveness of repeat treatment with Rituxan ™ in 58 patients with non-Hodgkin lymphoma B cells in low-grade or follicular lymphoma. All these patients received prior treatment with Rituxan ™, but said cancer recurrence. Overall, 40% of patients responded to the first treatment after the original treatment and in fact the latter responses may be of longer duration than the initial response after the first treatment. No significant different to the first treatment side effects occurred.
Combination Therapies: The combination of chemotherapy and monoclonal antibodies has shown significant anti-cancer activity in the treatment of patients with follicular lymphoma. The studies showed that the addition of chemotherapy Rituxan ™ demonstrated better anticancer activity compared to each treatment alone.
Clinical experiments have shown that the CHOP plus Rituxan ™ exceeds CHOP chemotherapy in patients with only the indolent B-cell lymphoma. In a recent clinical trial, 76% of patients who received Rituxan plus CHOP ™ achieved a partial or complete disappearance of cancer, compared with 60% of patients achieving a complete or partial disappearance of cancer when receiving CHOP alone . One year after treatment, almost 70% of patients who received Rituxan plus CHOP ™ survived without progression of cancer, compared with 49% of patients who received CHOP alone. Overall survival a year after treatment was 83% in patients who received the combination of Rituxan ™ plus CHOP compared with only 68% of patients who received CHOP alone.
STRATEGIES TO IMPROVE TREATMENT
The progress that has been made in the treatment of follicular lymphoma is the result of incorporating new anticancer agents in the treatment regimens and conducting clinical trials. In the future, progress will result from continued participation in appropriate clinical trials. Today there are many areas of exploration aimed at improving the treatment of follicular lymphoma
New Chemotherapy Regimens: Scientists continue the evolution of treatment of multi-drug chemotherapy regimens that incorporate new or additional for use as a treatment for cancer therapies. The combination of Fludara® or other purine analogues with chemotherapy regimens are being investigated clinically.
Monoclonal antibodies: In recent time the monoclonal antibody Zevalin ™ for the treatment of follicular lymphoma who stopped responding to standard therapies was approved. The approval indicates that the Zevalin ™ should be used in combination with Rituxan. Are ongoing clinical trials to determine whether the Zevalin ™ may be effective in the early stages of this disease.
The Zevalin ™ (90Yttrium-2B8 ibritumomab tiuxetan) is a novel biological agent that has shown significant anti-cancer responses in the treatment of aggressive non-Hodgkin’s B cell Zevalin ™ is a type of treatment that uses two separate focus and eliminate strategies cancer cells. It consists of ibritumomab tiuxetan, which is a monoclonal antibody that binds to a radioactive substance with the name of Yttrium 90 (90Y).The portion of the monoclonal antibody Zevalin ™ binds only to proteins on the surface of B cells When Zevalin ™ binds to cancer cells, stimulates the immune system to attack cancer cells while 90Y destroys these cells by the spontaneous emission of radiation. This treatment not only provides two separate treatment strategies, but also allows the administration of large amounts of radiation to the cancer cells as compared to external beam radiation therapy, while minimizing radiation exposure to normal cells.
The results of two large clinical studies showed that Zevalin ™ plus Rituxan ™ is safe and effective in treating non-Hodgkin lymphoma low grade. In the first experiment, 54 patients with non-Hodgkin lymphoma B cells in low grade no longer responding to chemotherapy or Rituxan ™, received Zevalin ™ plus Rituxan ™. The overall response rate was 74% anticancer. In the second experiment, 143 patients with NHL of B cells in low-grade non-responders to chemotherapy but neither received Rituxan ™ received the combination of Zevalin ™ plus Rituxan ™. The anticancer overall response rate was 80%. However, other studies to determine when during the course of the disease and in what combination treatment needed Zevalin ™ may prove more effective in patients with non-Hodgkin lymphoma B cells in low grade.
Combined treatments with monoclonal antibodies: Researchers at the Mayo Clinic recently conducted an experiment to evaluate the effectiveness of adding Proleukin® to
Rituxan ™. Proleukin® is a substance that occurs naturally in the body’s immune system. In some cases, therapy with Proleukin® only appears to stimulate the immune system against cancer. In this clinical trial, 67% of patients achieved an anticancer response following Rituxan ™ and Proleukin®, and 26% of patients achieved a complete disappearance of cancer after therapy. The intermediate doses to high doses of Proleukin® produced higher responses than low doses of it. These results suggest that the addition of Proleukin® to Rituxan ™ may increase the anticancer effects; however, most clinical studies to determine the role of this combination treatment are needed.
Stem cell: High-dose chemotherapy and allogeneic stem cell transplantation or autologous transplantation as treatment for relapsed follicular non-Hodgkin lymphoma were evaluated. The administration of high-dose chemotherapy and allogeneic stem cell transplantation has been associated with a high mortality rate with 20 to 40% of patients die from complications of treatment within two years following transplantation.However, 50 to 80% of patients survive without evidence of recurrence of lymphoma for three or more years after treatment. These results are very encouraging and suggest that patients with follicular lymphoma can be cured. Since these patients were treated there have been many technological changes that could reduce the mortality associated with this therapy. These technological changes combined with the early use of this therapy in patients with the disease should be associated undoubtedly with low toxicity.Furthermore, it is carrying out the evaluation of high-dose chemotherapy and allogeneic stem cell transplantation or autologous transplantation as primary treatment for young patients with follicular NHL.
Is also evaluated in clinical trials of high-dose chemotherapy and autologous stem cell transplantation for the treatment of follicular lymphoma. Longer follow-up are needed to determine whether the anticancer responses elicited translate into improvements in long-term survival compared with other standard treatments.