Follicular Lymphoma International Prognostic Index (FLIPI)
FLIPI is designed to be used in patients with follicular lymphoma and to risk stratify patients based on prognosis. This can help guide when and how to treat such patients.
- The FLIPI, while a useful general prognostic tool, does not reliably predict those at diagnosis who will have an extremely rapid decline. Rather it assists with providing prognostic information. Ultimately, clinical judgement and comprehensive review of the patient’s previous workup are critical to make this assessment.
- The GELF Criteria can help identify those patients with follicular lymphoma at higher risk for rapid disease progression and in whom immediate therapy may be needed.
The FLIPI score is easy to use with information most providers will already have available. Clinical evaluation, laboratory testing, and imaging are all that is needed to risk stratify patients and estimate prognosis.
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.
Facts & Figures
Score Interpetation
| Score | Risk Group | 10-year Overall Survival |
|---|---|---|
| ≤1 | Low | 70% |
| 2 | Intermediate | 50% |
| ≥3 | High | 35% |
Useful Mnemonic - NoLash
- Nodal areas
- LDH
- Age
- Stage
- Hemoglobin level
Nodal Sites
Staging Diagram
Evidence Appraisal
The FLIPI score was developed based on 4,167 patients with follicular lymphoma providing characteristics at diagnosis. Univariate and multivariate analyses were then used to develop a prognostic index. This was then validated in a cohort of 919 patients. Age, Ann Arbor stage, hemoglobin level, number of nodal areas, and serum LDH level were identified as adverse prognostic factors. The FLIPI was validated in a subsequent study and the performance improved by further stratifying age and including the presence of cerebrovascular disease.
Literature
Original/Primary Reference
Solal-Celigny et al. Follicular Lymphoma International Prognostic Index. Blood 104:1258-1265. (2004)
About the Creator
Philippe Solal-Céligny, MD, Ph.D, is a professor and principal investigator at Laboratoire Central d’Hematologie at Centre Jean Bernard in Le Mans, France.
To view Dr. Philippe Solal-Céligny's publications, visit PubMed