Info
Management: Symptomatic Stages III–IV (or bulky Stage II), Front-line
Enrollment in clinical trial should be encouraged Commonly accepted indications for Rx include: Sx, any node >7 cm or 3 nodes >3 cm, cytopenias, fluid collections (ascites, pleural effusions), organ impairment & leukemic phase of disease (JCO 1998;16:2332) Multiple front-line therapeutic options. Choice of Rx is based on pt & disease characteristics, including: volume & distribution of disease, age & functional status of the pt, potential need for rapid response, or concern for transformed disease (see below) Rituximab is a monoclonal Ab directed at the B-cell Ag CD-20. Efficacy has been shown w/ both single-agent & combination Rx Rituximab monotherapy (4 weekly doses) is used 1° in pts w/ low volume disease. ORR ~70–75%, CR ~40–45% in untreated pts (JCO 2005;23:1103) Rituximab plus chemotherapy is more often used. Standard regimens include R-CHOP, R-Bendamustine, R-CVP. Addition of rituximab to chemotherapy improves RR, PFS, & OS over chemo alone. No single regimen is preferred, & individual pt factors guide choice Obinutuzumab plus chemotherapy → obinutuzumab maintenance should be given if maintenance anti-CD20 therapy is planned. Obinutuzumab-chemo → obinutuzumab maintenance improves PFS compared to rituximab plus chemotherapy → rituximab maintenance (GALLIUM Study, ASH 2016). Maintenance and Consolidation Therapy Maintenance dosing of rituximab after completing initial Rx improves PFS but not OS (JNCI 2011;103:1799) No trials have directly evaluated the role of maintenance obinutuzumab. If maintenance therapy is recommended, obinutuzumab-chemo → obinutuzumab maintenance is superior to R-chemo → R maintenance (GALLIUM Study, ASH 2016). RIT also improves PFS but not OS, converts some PRs to CRs (JCO 2008;26:5156)