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    Groupe d'Etude des Lymphomes Folliculaires (GELF) Criteria

    Determines if immediate therapy for follicular lymphoma is required.
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    When to Use
    Pearls/Pitfalls
    Why Use

    The criteria can help identify those patients with follicular lymphoma at higher risk for rapid disease progression and in whom immediate therapy may be needed.

    • This tool is best used as an instantaneous assessment of a patient’s disease burden. Ultimately, clinical judgement and comprehensive review of the patient’s previous workup are critical to make this assessment.
    • For overall prognosis, the FLIPI can risk stratify further than the GELF criteria.

    The GELF criteria is easy to use with information most providers will already have available. Clinical evaluation, laboratory testing, and imaging are all that is needed to determine who has a high tumor burden based on the GELF criteria.

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    Next Steps
    Evidence
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    Advice

    Refer to the staging systems FLIPI and Lugano classification to assist with risk stratifying patients. The GELF criteria is a quick test to determine which patients should be monitored versus treated now.

    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.

    Formula

    Patients must meet ≥1 criteria to be considered “high” tumor burden; criteria below:

    • Any nodal or extranodal tumor mass >7 cm diameter
    • Involvement of at least 3 nodal sites, each with diameter >3 cm
    • Presence of any systemic or B symptoms
    • Splenic enlargement with inferior margin below the umbilical line
    • Compression syndrome (ureteral, orbital, gastrointestinal)
    • Pleural or peritoneal serous effusion (irrespective of cell content)
    • Leukemic phase (>5.0 x109/L circulating malignant cells)
    • Cytopenia (granulocyte count < 1.0 x109/L and/or platelets < 100x109/L)

    Facts & Figures

    Nodal Sites

    nodal sites

    Evidence Appraisal

    The original study compared three different intervention arms: active surveillance until clinical progression, immediate treatment with an oral alkylating agent (prednimustine), or treatment with a biologic response modifier (interferon-alpha). 193 in total were enrolled. The overall response rate of deferred treatment was 70%, with prednimustine was 78%, and with interferon-alpha was 70%. Similarly, the overall survival time at 5 years was 78%, 70%, and 84%, respectively. This showed that delayed treatment was a viable option for such an indolent lymphoma. However, those with early progression warrant treatment sooner.

    Dr. Pauline Brice

    About the Creator

    Pauline Brice, MD, is a hematologist at Hopital Saint-Louis in Paris, France. She is a member of the scientific council for GELA (Groupe d'Etude des Lymphomes de l'Adulte).

    To view Dr. Pauline Brice's publications, visit PubMed

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