Standard Approaches to Relapsed Indolent Non-Hodgkin’s Lymphoma

Although the addition of rituximab to induction chemotherapy regimens has resulted in an improved time to progression (TTP) and overall survival (OS) in patients with advanced indolent lymphoma, approximately 50% of patients will still relapse and require therapy. In the evaluation of the relapsed patient, important landmarks in the patient’s lymphoma history, such as original date of diagnosis, Follicular Lymphoma International Prognostic Index (FLIPI) score, initial absolute lymphocyte count, and the response and TTP from each treatment received to date, should be noted. Other comorbid medical conditions may also impact the choice of therapy. A rebiopsy is useful to identify patients who have undergone transformation to a large cell lymphoma. Tumor imaging with computed tomography (CT) or positron emission tomography (PET) is necessary to identify patients with high-bulk disease and to compare with prior scans to establish the pace of the relapse. Patients with high-risk relapse should be considered for salvage chemotherapy and stem cell transplant. Those patients with standard relapse are candidates for radioimmunotherapy or any of a multitude of chemotherapy regimens. The choice of chemotherapy will depend on what agents the patient has been previously exposed to and their response to those agents. In summary, the treatment of relapsed indolent lymphoma has improved substantially with the addition of rituximab and radioimmunotherapy. New drugs that are now being tested in current phase I and II trials will likely contribute further to this improvement when they become integrated with or sequenced after the standard regimens.