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Follicular Lymphoma: A retrospective study ( 68 cases). M. BENDARI, M. Rachid, S. Marouane , A. Quessar , S. Benchekroun Department of Hematology-Oncology pediatric Hospital 20 Aout , CHU Ibn Rochd Casablanca . Background.
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Follicular Lymphoma: A retrospective study (68 cases) M. BENDARI, M. Rachid, S. Marouane, A. Quessar, S. Benchekroun Department of Hematology-Oncology pediatric Hospital 20 Aout, CHU IbnRochd Casablanca.
Background • Follicular lymphomas (FL) :30% of malignant non-Hodgkin B Lymphoma. • They are indolent. • The cells of FL express surface immunoglobulin more frequently IgM. • CD5-, CD23-/+, CD43-, CD 10+, and CD11c-. • Translocation (14.18).
Background • Incurable disease. • The transformation into an aggressive lymphoma diffuse B cell is possible. • No chemotherapy regimen for first-line therapy of FL has been established as a standard regimen worldwide.
Purpose • The aim of this study is to investigate the epidemiology and clinical evolution of patients followed in our department.
Materials and methods: • Descriptive study including all patients with FL treated between January 2004 and December 2011 • Follicular lymphoma of any histological grade expressing. The diagnosis was done by histological study of lymph biopsy or primary lesion biopsy. • Histological type according to WHO classification. • Pathologic diagnostic obtained by standard staining procedures and immunohistochemical analysis comprising a panel of antibodies.
Materials and methods: • The staging was systematically done : • Physical exam • Blood test • Chest X ray • Abdominal ultrasonography • CT scan • Bone marrow biopsy • LDH • Pre- therapeutic exam: • liver and kidney fonction • serology : HIV, HVB, HVC
Materials and methods • Each patient received a FLIPI score based on: • Age < 60 vs. 60 • Hemoglobin level ≥ 12g/dLvs. < 12g/dL • Serum LDH level ≤ ULN vs. > ULN • Ann Arbor stage I – II vs. III – IV • Number of nodal sites involved ≤ 4 vs. > 4
Materials and methods: • Positif diagnosis: histologicalstudy
Histopathology Follicularlymphomashowingcharacteristic pattern of closelypacked nodules withsome variation in size and shape
GRADING Grade 1 Grade 2 Grade 3
Materials and methods :Treatment • Therapeutic decision : • Localised Stage : abstention or radiotherapy • Advanced Stage , Bulkylesion : treatmentisnecessary • Use of Rituximab in maintenance therapy
Materials and methods: evolution Clinical response criteria: • Disease response and progression : physical examination and scannography : • Before chemotherapy, • After 3 or 4 cycles of therapy • At the end of chemotherapy. • A complete remission : • Resolution of all palpable peripheral adenopathy, • Disappearance of imaging evidence of disease and of all disease related symptoms, • Normalization of the standard biochemical abnormalities assignable to the lymphoma.
Materials and methods: Statistical analysis: • Follow-up time was calculated using Kaplan-Meier, after completion of therapy • Patients were followed every 3 months. • Progression-free survival (PFS) was calculated from entry into the study until disease progression in patients with CR or PR.
Results • Characteristics of patients: N 68
Results: Grading Histological grade The grade was not specified in 6 cases
Results: N 68 % Bulkylesion • <5 cm 55 80 • 5 – 10 cm 11 16 • >10 cm 2 3 LDH hight 30 44 Bonemarrow Negative 35 51,5 Positive 33 48,5
Results One patient could not be classified because of insufficient data
Treatment 10 patients died or were lost to follow-up before treatment
Discussion • Follicularlyphoma: is one of the mostcommon types of Non Hodgkin’sLymphomas (~ 20-25%)
Discussion • FL: 2004 – 2011 : 68 cases / 1600 NH L ( ~ 4%)
Discussion Incidence : 6% vs 25% in literature report ? • Delay to diagnosis? • Transformedforms? • ethnicparticulatity of ourregion
Molecularbiology : • Transformedforms • DLBCL • National LymphomaRegister
Discussion FL : indolent lymphoma / incurable disease Treatment ? no consensus exists as to the optimal selection or sequence of availableregimens
In the past : • Alkylant: Clorambucil, Cyclofosphamid • Radiotherapy • Anthracycline ( CHOP) • Interféron-alpha • Fludarabine • Auto or allogeneic stem cell transplantation • Rituximab(alone , withchemotherapy or on maintenance therapy)
Rituximab • The addition of Rituximab to chemotherapy potentiates of the antitumor effect of chemotherapy. • Recently, it has been shown, that Rituximab has a clear benefit.
Rituximab : CVP versus rituximab + CVP Time to progression, relapse or death Marcus R, JCO 2008
Rituximab FL2000: Event-free survival (medianfollow-up 60 months) Salles G, Blood 2008
Rituximab : maintenance therapy • The use of Rituximab for maintenance therapy is well tolerated and improved overall survival Ghielmini M, et al. J ClinOncol 2010
Conclusion • The FL is typically indolent lymphoma: • Successive relapses, • Decreasing chemosensitivity, • Shorter duration of remission, with successive courses of chemotherapy. • Significant improvement in outcome for patients with FL has been accomplished in recent years especially with use of Rituximab combined to chemotherapy.
Conclusion: • The treatment of patients with FL must be adapted to the patient’s individual status depending on the aggressiveness of the disease. • In Casablanca: low incidence/ Heterogeneoustherapy ( CVP / CHOP): Try to establish a standard regimenincludingRituximab • Maintenance therapywithRituximab: increasinglyused • Necessary to have a National Registerincluding all cases of lymphomastreating in all Moroccancenters. • Maghreb Register of lymphoma