Follicular Lymphoma International Prognostic Index (FLIPI)
Why Use
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.
When to Use
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.
Pearls / Pitfalls
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.
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.
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.
More Information
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