In discussing this clinical situation, Dr Kahl points out that single-agent rituximab is less effective in high tumor-burden disease, and for that reason he often chooses BR. That said, he feels that R-CHOP — which is Dr Williams’s choice based on his desire to quickly palliate symptoms and concern about transformation — is a valid alternative. Both faculty use 2 years of rituximab maintenance in this situation.

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

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

Salles GA et al. Rituximab maintenance for 2 years in patients with high tumour burden follicular lymphoma responding to rituximab plus chemotherapy (PRIMA): A phase 3, randomised controlled trial. Lancet 2011;377(9759):42-51. Abstract