This case differs slightly from the first in that the patient is symptomatic and requires treatment, and in this instance Dr Kahl generally recommends rituximab monotherapy with the idea of adding chemotherapy if the response is not adequate. Most of the survey respondents (MO) who use up-front chemotherapy with rituximab opt for bendamustine/rituximab (BR), but 28% use R-CHOP, a choice Dr Kahl believes is a reasonable alternative, particularly in view of the fact that as patients age the ability to tolerate anthracycline toxicity diminishes.

Ardeshna KM et al. Rituximab versus a watch-and-wait approach in patients with advanced-stage, asymptomatic, non-bulky follicular lymphoma: An open-label randomised phase 3 trial. Lancet Oncol 2014;15(4):424-35. Abstract

Hiddermann W et al. Frontline therapy with rituximab added to the combination of cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) significantly improves the outcome for patients with advanced-stage follicular lymphoma compared with therapy with CHOP alone: Results of a prospective randomized study of the German Low-Grade Lymphoma Study Group. Blood 2005;106(12):3725-32. Abstract

Rummel MJ et al. Bendamustine plus rituximab versus CHOP plus rituximab as first-line treatment for patients with indolent and mantle-cell lymphomas: An open-label, multicentre, randomised, phase 3 non-inferiority trial. Lancet 2013;381(9873):1203-10. Abstract