A 72-year-old man is found to have enlarged lymph nodes on CT (cervical, axillary, abdominal). Biopsy shows a follicular lymphoma (Grade 1-2), FLIPI score 3. He is asymptomatic with no B symptoms, no bulky disease, normal LDH. What is the preferred initial management?

• A Immediate R-CHOP immunochemotherapy
• B Autologous stem cell transplant in first remission
• C Single-agent rituximab induction followed by maintenance
• D Watch and wait (active surveillance) — treatment deferred until GELF criteria met ✓

Explanation

Grade 1-2 follicular lymphoma is an indolent lymphoma and in asymptomatic patients without high tumour burden (GELF criteria — no single nodal mass > 7 cm, < 3 nodal areas > 3 cm each, no B symptoms, normal LDH, no compression symptoms, no organ involvement), a watch-and-wait strategy is the standard of care. Multiple clinical trials (including the British National Lymphoma Investigation study) show no survival benefit with early treatment versus observation in low-burden indolent follicular lymphoma. Treatment begins when GELF or Lugano criteria for high burden are met. First-line therapy when treatment is needed is typically R-CHOP, BR, or single-agent rituximab depending on burden.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.