Multicenter Analysis of Advanced Stage Grade 3A Follicular Lymphoma Outcomes by Frontline Treatment Regimen

Background: Follicular lymphoma (FL) is a common form of non-Hodgkin lymphoma with a wide spectrum of presentation. While grade 1/2 FL is considered low grade and grade 3B FL is approached as an aggressive lymphoma, the management of grade 3A FL remains controversial.

Patients and methods: We performed a retrospective, multicenter analysis of patients aged ≥ 18 years with advanced stage 3/4 grade 3A FL diagnosed between January 2006 and July 2016. Patients were stratified by frontline chemotherapy regimen: anthracycline based (ATC), bendamustine (BD), and cyclophosphamide, vincristine, and prednisone (CVP). A total of 103 patients were identified from 6 contributing centers: 65 patients received ATC chemotherapy, 30 BD, and 8 CVP. The primary outcome was time to progression (TTP). Secondary outcomes included progression-free survival, overall survival, complete response rates, large cell transformation, and impact of standardized maximum uptake value on positron emission tomography/computed tomography with outcomes. Patient characteristics were similar among the 3 treatment groups.

Results: For TTP at 24 months from initiation of treatment, 72% of ATC, 79% of BD, and 50% of CVP patients had not experienced disease progression (P = .01). Multivariate analysis demonstrated a TTP benefit for ATC compared to CVP (hazard ratio 3.22; 95% confidence interval, 1.26-8.25; P = .01) but no difference when compared to BD. Similar findings were seen with progression-free survival. While overall survival was similar among the 3 arms, there was a higher risk of large cell transformation following BD and CVP. Last, standardized maximum uptake value on positron emission tomography/computed tomography did not affect TTP when comparing BD- and ATC-treated patients.

Conclusion: Although ATC was superior to CVP, clinical outcomes (TTP, progression-free survival, and overall survival) were similar compared to BD chemotherapy for patients with grade 3A FL.