1. Stephen Ansell, MD, PhD Mayo Clinic
Follicular lymphoma grade 1/2 High risk FLIPI – The Case for Maintenance Rituximab
Stephen Ansell, MD, PhD
Mayo Clinic

2. Key Points from the Case
High Risk FLIPI – what do we expect from high-risk patients?
Young patient – how do young patients typically do?
Responded to chemoimmunotherapy (just not a CR) – how to patients with a PR to initial therapy do?
How would maintenance rituximab improve the outcome?
Would RIT or ASCT be better?

3. TTF of advanced-stage Follicular Lymphoma patients treated with front-line R-CHOP by the FLIPI score.
Buske C et al. Blood 2006;108:

4. Overall Survival of Follicular lymphoma in young adults (<40 years) by the FLIPI score (n=78)
Duarte IX, et al. Mod Pathol Sep;26(9):

5. Most patients had a PR to R-CHOP
Time to treatment failure after CHOP and R-CHOP as Initial therapy for Follicular lymphoma.
Overall response rates were 96% with R-CHOP and 90% with CHOP alone (P = .011);
CR rates were not statistically different (20% vs 17%)
Most patients had a PR to R-CHOP
Hiddemann W et al. Blood 2005;106:

6. Salles et al. Lancet. 2011 Jan 1;377(9759):42-51.
Rituximab maintenance in patients with high risk follicular lymphoma responding to rituximab plus chemotherapy (PRIMA)
Salles et al. Lancet Jan 1;377(9759):42-51.

7. Event-Free Survival according to autologous transplant or Interferon after CHOP-like initial therapy (no rituximab, p=.11).
Sebban C et al. Blood 2006;108:

8. Treatment with R-CHOP + maintenance compared to High-Dose chemotherapy and a stem cell transplant - GITMO/IIL trial.
Ladetto M et al. Blood 2008;111:

9. Treatment with R-CHOP + maintenance compared to High-Dose chemotherapy and a stem cell transplant - GITMO/IIL trial.
Ladetto M et al. Blood 2008;111:

10. Treatment with R-CHOP + maintenance compared to High-Dose chemotherapy and a stem cell transplant - GITMO/IIL trial.
Ladetto M et al. Blood 2008;111:

11. TTP and Overall survival analysis for 90Y ibritumomab tiuxetan compared to rituximab
Witzig, T. E. et al. J Clin Oncol; 20:

12. Progression-free and overall survival of 532 patients with advanced-stage follicular lymphoma treated with either six cycles of CHOP-R or six cycles of CHOP-RIT
Press O W et al. JCO 2013;31:

13. Causes of Death Observed on Protocol S0016 by Treatment Arm
Press O W et al. JCO 2013;31:

14. Conclusions
Most patients with follicular lymphoma treated with R-CHOP fail to achieve a CR but may still do well.
Rituximab maintenance significantly improves the outcome of patients compared to observation with little additional toxicity.
RIT has no advantage over rituximab and may increase toxicity.
Stem cell transplantation has increased long term toxicities – a concern in young patients.
Maintenance rituximab is the treatment of choice for this patient.