Colombian consensus document for the treatment of follicular non Hodgkin lymphoma
Keywords:
follicular lymphoma, diagnosis, therapy, drug therapy, radiation therapy, lymphoma non hodgkin, Colombia, Consenso Colombiano de Hematología OncológicaAbstract
Introduction: The Colombian Malignant Hematological Diseases Consensus Conference is a project supported by the Instituto Nacional de Cancerología, ESE, and the Colombian Society of Hematology and Clinical Oncology The purpose of the Consensus is to improve outcomes for cancer patients, to assist practioners in applying the best available research evidence to clinical decisions, and to promote responsible use of health care resources.
The core activity of the Consensus is the development of practice guidelines using the nominal group methodology. The resulting reports are convenient and up-to-date sources of the best available evidence on clinical topics, developed through systematic reviews, evidence synthesis and input from a broad community of practitioners. They are intended to promote evidence-based practice. This report has been formally approved by the whole group of the Colombian Consensus Conference o f Malignant. Hematological Diseases whose membership includes hematologist, oncologists, hematopatologist, radiologist, other health providers and community representatives. Formal approval of a practice guideline by members of the Consensus does not necessarily mean that it has been adopted as a policy. The decision to adopt a practice guideline as a policy rests with each regional cancer network which is expected to consult with relevant stakeholders.
Methods: Medline (1966-2005), the Cochrane Library (Issue 2, 2005), Embase (1974-2005), Biosis (1992-2005), Lilacs (1989-2005) and other relevant databases were searched for evidence relevant, to this report. Evidence was selected and reviewed by members of Central Committee of the Colombian Malignant Hematological Diseases Consensus Conference.
This document has been reviewed and approved by all members of the Consensus. External review of the original practice guideline report was done by three independent international hematologists. Its generation follows a formal standardized process to ensure the accuracy of each report. It consists of periodic review and evaluation of the scientific literature, and when appropriates, its inclusion to the original document information.
Target population. These recommendations apply to adult patients with follicular lymphoma.
Recommendations
• FLIPI prognosis score should be used in the initial evaluation of patients with follicular NHL; nevertheless, it does not allow to change or to adjust therapeutically interventions according to risk (recommendation I, level of evidence A).
• For patients with follicular NHL, cytological grade 3, there is some evidence from clinical trials suggesting that use of anthracyclines improves DFS and OS rates (recommendation IIA, level of evidence C). For patients with follicular lymphomas, cytological grade 1 and 2, anthracycklnes should be used, as part of chemotherapy combined with monoclonal antibodies antiCD20 (recommendation IIB, level of evidence C).
• Cytological 1 and 2, follicular NHL patients, asymptomatic, in an advanced stage, without any adverse prognostic factors and a low tumor volume could be referred to a "watch and wait" strategy (recommendation IIB, level of evidence C). So far, there is not a single randomized clinical trial comparing "watch and wait"vs. chemotherapy in young patients with those characteristics. Patients that for some reason want to receive chemotherapy should be treated with first line chemotherapy (recommendation IIB, level of evidence C). Follicular NHL young patients (under 60), asymptomatic, without any adverse prognostic factor must be considered for a randomized clinical trial (recommendation IA, level of evidence A).
• All symptomatic follicular NHL patients, untreated or relapsed, in advanced stages, with high tumor volume or visceral compromise, with a life expectation longer than three months, should start chemotherapy combined with anti-CD20 monoclonal antibodies (Rituximab), with or without purine analogs (taking into account potential risk infection), due to shown higher CR and DFS rates (recommendation I, level of evidence A).
• Relapsed follicular NHL patients, who had received anti-CD20 monoclonal antibodies, could be candidates for radioimmunotherapy (recommendation IIA, level of evidence B). There is not enough number of clinical trials to recommend radioimmunotherapy as a first line of treatment. Nowadays, it is not possible to recommend radioimmunotherapy as first line of treatment (recommendation II, level of evidence B).
•There is not enough evidence to recommend interferon (recommendation IA, level of evidence A) or monoclonal antibodies (recommendation IIB, level of evidence B) as maintenance treatment for follicular non-Hodgkin lymphomas. A longer follow-up is required from current studies.
• In follicular NHL patients with advanced disease and demonstrated chemosensitivity, who relapsed after anti-CD20 monoclonal antibodies or radioimmunotherapy, could be treated with i autologous bone marrow transplantation, with anti-CD20 monoclonal antibodies as a previous in vivo purge (recommendation IIA, level of evidence B)
Author Biographies
Myriam Rodriguez, Instituto Nacional de Cancerología E.S.E.
Instituto Nacional de Cancerología E.S.E.
Grupo Hematología y Trasplante de Medula Ósea,
Bogota, D.C. Colombia
Juana del Socorro García, Instituto Nacional de Cancerología E.S.E.
Grupo Hematología y Trasplante de Medula Ósea
Instituto Nacional de Cancerología E.S.E.
Bogota, D.C., Colombia
Joaquín Rosales, nstituto Nacional de Cancerología E.S.E.
Grupo Hematología y Trasplante de Medula Ósea
Instituto Nacional de Cancerología E.S.E.
Departamento de Hematología
Instituto Javeriano de Oncología
Bogota, D.C.
Colombia
Jorge Enrique Duque, Centro Medico Imbanaco
Departamento Hematología y Oncología Clínica
Centro Medico Imbanaco
Cali
Colombia
Virginia Abello, Hospital de San José
Departamento Hematología
Hospital de San José
Fundación Universitaria de Ciencias de la Salud
Grupo de Hematología y Trasplante de Medula Ósea
Clínica Marly
Bogota, D.C.
Colombia
Marco Grajales, Universidad Nacional de Colombia
Departamento de Hematología
Universidad Nacional de Colombia
Bogota, D.C.
Colombia
Mario Gómez, Clínica del Country
Departamento de Hematología
Clínica del Country
Bogota, D.C.
Colombia
Claudia Sossa, Clínica Carlos Ardila Lulle
Centro de Cáncer y Enfermedades Hematológicas
Clínica Carlos Ardila Lulle
Bucaramanga
Colombia
Claudia Casas, Hospital de San José
Departamento Hematología
Hospital de San José
Fundación Universitaria de Ciencias de la Salud
Bogota, D.C.
Colombia
Juan Felipe Combariza, Universidad Nacional de Colombia
Departamento de Hematología
Universidad Nacional de Colombia
Bogota, D.C.
Colombia
Guillermo Quintero, Instituto Nacional de Cancerología E.S.E.
Grupo Hematología y Trasplante de Medula Ósea
Instituto Nacional de Cancerología E.S.E.
Bogota, D.C.
Colombia
Andrés Felipe Cardona, Instituto Nacional de Cancerología E.S.E.
Grupo Oncología Clínica, Instituto Nacional de Cancerología E.S.E., Bogota, D.C., Colombia
Martha Daza, Clínica Asunción
Centro de Cáncer de la Clínica Asunción
Barranquilla
Colombia
Leonardo Enciso, Universidad Nacional de Colombia
Departamento de Hematología
Universidad Nacional de Colombia
Bogota, D.C.
Colombia
Alvaro Camacho, Clínica Shaio
Clínica Shaio
Bogotá, D.C.
Colombia
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