Risk of, and survival following, histological transformation in follicular lymphoma in the rituximab era. A retrospective multicentre study by the Spanish GELTAMO group

The diagnostic criteria for follicular lymphoma (FL) transformation vary among the largest series, which commonly exclude histologically-documented transformation (HT) mandatorily. The aims of this retrospective observational multicentre study by the Spanish Grupo Espanol de Linfoma y Transplante Autologo de Medula Osea, which recruited 1734 patients (800 males/934 females; median age 59 years), diagnosed with FL grades 1-3A, were, (i) the cumulative incidence of HT (CI-HT); (ii) risk factors associated with HT; and (iii) the role of treatment and response on survival following transformation (SFT). With a median follow-up of 6.2 years, 106 patients developed HT. Ten-year CI-HT was 8%. Considering these 106 patients who developed HT, median time to transformation was 2.5 years. High-risk FL International Prognostic Index [Hazard ratio (HR) 2.6, 95% confidence interval (CI): 1.5-4.5] and non-response to first-line therapy (HR 2.9, 95% CI: 1.3-6.8) were associated with HT. Seventy out of the 106 patients died (5-year SFT, 26%). Response to HT first-line therapy (HR 5.3, 95% CI: 2.4-12.0), autologous stem cell transplantation (HR 3.9, 95% CI: 1.5-10.1), and revised International Prognostic Index (HR 2.2, 95% CI: 1.1-4.2) were significantly associated with SFT. Response to treatment and HT were the variables most significantly associated with survival in the rituximab era. Better therapies are needed to improve response. Inclusion of HT in clinical trials with new agents is mandatory.