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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.
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.
References
Your opinion matters
Which of the following would most increase your confidence in referring patients with R/R large B-cell lymphoma for CAR T-cell therapy?