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Follicular lymphoma (FL) is the most prevalent indolent lymphoma type. Although it is characterized by slow growth and chemosensitivity, the high rate of relapse remains a concern. The introduction of targeted therapy with the CD20 antibody rituximab in 1997 was welcomed, and over the last 20 years this drug has improved the prospects of many patients with indolent non-Hodgkin lymphoma (iNHL). Prusilla and colleagues, recently published in the British Journal of Haematology results of a retrospective study looking at the impact of this and other treatments on the risk of secondary malignancy.1
Secondary hematological malignancies (SHM), with an incidence of 2.9% in 10 years, are the third most common cause of death amongst patients with FL.2 In particular, the incidences of myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML) are rising.3 One of the reasons for this increase might be improved overall survival or the use of particular therapeutic regimens. However, the risk of developing SHM amongst different lymphoma subtypes, such as FL, has not been previously studied. To find out the incidence of SHM, and therapy-associated risks, researchers evaluated hospital records of 1028 patients with FL. All patients underwent treatment after rituximab approval.
CHOP, cyclophosphamide, doxorubicin, vincristine, prednisone; FLIPI, follicular lymphoma International Prognostic Index; LDH, lactate dehydrogenase; RDT, radiation therapy; SCT, stem cell transplantation | ||
Characteristics |
n |
% |
---|---|---|
B-symptoms at diagnosis |
166 |
16.6 |
Elevated LDH at diagnosis |
226 |
29.0 |
FLIPI 0–1 2 3–5 |
335 257 317 |
36.8 28.3 34.9 |
Number of treatment lines 1 2 ≥3 |
621 220 127 |
64.2 22.7 13.1 |
Treated patients CHOP-like first-line therapy Bendamustine-containing first-line therapy Fludarabine-containing first-line therapy RDT only in first-line Rituximab in any of the treatment lines Rituximab in first-line treatment SCT in any of the treatment lines |
968 576 63 27 109 823 725 66 |
94.2 56.0 6.1 2.6 10.6 85.0 70.5 6.4 |
Secondary hematological malignancy |
Number of patients (14/1028) |
---|---|
MDS |
5 |
AML |
4 |
acute lymphoblastic leukemia |
1 |
acute promyelocytic leukemia |
1 |
large granular lymphocytic leukemia |
1 |
chronic myeloid leukemia |
1 |
multiple myeloma |
1 |
The study found that risk of SHM is low after first-line treatment but increases with subsequent lines of treatment. Using a chemo-free immunotherapy approach only would be beneficial in low-risk patients as chemotherapy was associated with higher risk of SHM. However, real SHM numbers might be underestimated due to exclusion of secondary lymphomas caused by the inability to distinguish primary from secondary tumors.
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