MDCalc

Follicular Lymphoma International Prognostic Index (FLIPI)

Estimates overall survival based on clinical information.

Age >60 years

>4 nodal sites
See Evidence for nodal diagram.
LDH elevated
Hemoglobin <120 g/L or 12 g/dL
Stage III-IV
  • Stage I: disease is located in a single region, usually one lymph node and the surrounding area.
  • Stage II: disease is located in two separate regions, an affected lymph node or organ and a second affected area. Both affected areas are confined to one side of the diaphragm. 
  • Stage III: disease involves both sides of the diaphragm, including one organ or area near the lymph nodes or the spleen.
  • Stage IV: diffuse or disseminated involvement of one or more extranodal organs, with or without associated lymph node involvement.

See Evidence for stage diagram.

Result:

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Advice

A FLIPI score of 0 to 1 is considered “low risk” with a 10 year overall survival of 70%. A score of 2 is considered “intermediate risk” with a 10 year overall survival of 50%. Finally, a score of ≥3 is considered “high risk” with a 10 year overall survival of 35%. Patients with an initial remission duration less than the median progression free survival for a particular treatment regimen and/or with a high FLIPI score are more likely to have a shorter remission duration.

Management

Treatment is varied depending on the stage and tumor burden.

Stages I-II

  • Treatment options include:
    • Involved field radiotherapy (IFRT)
    • Clinical trials
    • Active surveillance

Stages III-IV or Bulky stage II – asymptomatic

  • Treatment options include:
    • Clinical trials
    • Active surveillance

Stages III-IV or Bulky Stage II – with GELF/BNLI risk factors or high-risk FLIPI score

  • Treatment options include:
  • Rituximab + cyclophosphamide, vincristine, doxorubicin, prednisone
  • Rituximab alone
  • Bendamustine + rituximab
  • Rituximab + cyclophosphamide, vincristine, prednisone
  • Clinical trials
Critical Actions
  • There is continued controversy around when and how to treat follicular lymphoma, including in patients with relapsed/refractory disease. Questions to consider when making treatment decisions:
    • When to initiate therapy versus active surveillance
    • Deciding amongst various treatment options
    • Balancing efficacy and toxicities of treatment options
    • Determining what constitutes a complete response/endpoint of treatment
  • Finally, with follicular lymphoma, a provider should be aware of transformation to diffuse large B-cell lymphoma, which is a more aggressive disease and would require prompt treatment.
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