Ian W. Flinn, MD, PhD: What about when they do relapse? Let’s take an example of a patient who had bendamustine-rituximab, your run-of-the-mill patient, 1 you’re not overly worried about but who relapses 4 years later. How do you approach that patient?

Pier Luigi Zinzani, MD, PhD: If it’s a young patient, I tend to do it in the second line. If I used BR [bendamustine-rituximab] in frontline, I use [R-CHOP] [rituximab, cyclophosphamide, hydroxydaunorubicin, oncovin, prednisone] for 3 full cycles, and then I do a consolidation with a bone marrow transplantation. I know that not only in the United States but also in Europe, there is a reduction concerning the role of autologous marrow transplantation in term of consolidation in follicular lymphoma. But in 2, 3 patients per year, young patients, I try to use this in second line.

Ian W. Flinn, MD, PhD: How about you, John?

John M. Pagel, MD, PhD: You know, I think it depends on the patient of course, right? Those people that progress very rapidly, I’m going to be thinking more about getting them to a transplant. And those people who have had many years of remission, I’m going to be thinking about being very conservative with them. And I’m not a big fan of using more chemotherapy in the relapse setting. I’m not a big fan of using more bendamustine if they had bendamustine up front. It’s a very myelosuppressive agent. We see this all the time as a complication of bendamustine use of over delivery of the agent. It is true that if you had many years of remission, it’s not unreasonable. But still, myelosuppression is going to be a potential big problem.

I’m more of a fan in those relapse settings, in an older person being relatively conservative, maybe single-agent rituximab. It may be a PI3 kinase inhibitor in the right patient who needs a little different therapy. And I think we’re going to talk about PI3 kinase inhibitors. But that’s a class of drugs that we really don’t think about enough in lymphomas. In the community it’s certainly not well thought of, and I think it’s a class of drugs that we don’t want to forget for the right patients with follicular lymphoma. Sometimes that’s going to be a go-to option as well.

Ian W. Flinn, MD, PhD: Yeah, and I think you bring up a good point about maybe just some single-agent rituximab. There are a lot of choices. You could alternate to a different chemotherapy. You could give rituximab. We’ll talk in a little more detail in a minute about R-squared, but that’s another option. There are those high-risk patients that Pier Luigi talks about in whom maybe transplant is used. I think in Nebraska you’re saying you’re using, you’re doing transplant for some patients?

Matthew Lunning, DO: It’s a very select population that you had a risk-benefit discussion with and what the intent of that consolidation transplant is. I think it’s interesting. As we see more bendamustine use in the up-front setting, what’s the response rate to CHOP [cyclophosphamide, hydroxydaunorubicin, oncovin, prednisone] plus an antibody in second line? I don’t know that anybody knows truly that answer. And that is the question that’s being studied in a different, high-risk group. But I think Carla Casulo had kind of early relapse data from CIBMTR [Central for International Bone Marrow Transplant Research] registry that kind of showed that perhaps there was a benefit in that population to auto. We haven’t gone down the allograft track yet, but there may be a role. I mean, at select centers that have select data from single institutions showing allotransplant in the multiply relapsed young, fit follicular lymphoma that hasn’t transformed could lead to long-term durability, obviously for risk of transplant-related mortality.

Ian W. Flinn, MD, PhD: Yeah, I think it’s very hard to be dogmatic in that setting. The frontline selection is complicated enough, much less the second line. There are so many different options, and it’s not clear to me that 1 is better than the next. And you have to be taking into consideration all these patient-factor selections.

Transcript Edited for Clarity