The importance of extra-nodal disease has been well recognized in follicular lymphoma, and is incorporated into various prognostic tools. However, the optimal treatment strategy for this subgroup remains unclear. In this multicenter retrospective study, we analyzed 143 patients who received either R-CHOP or Bendamustine-Rituximab (BR), with a median follow-up of 69.7 months. Our findings indicate that extra-nodal disease confers poorer PFS (5-year PFS 58% vs 66%, = 0.03) while high-risk relapse predict poorer OS (5-year OS 56% vs 94%, < 0.001). Subgroup analysis on 98 patients with extra-nodal disease revealed that BR induction conferred superior PFS compared to R-CHOP (HR 0.49, = 0.032) while maintenance rituximab also improved PFS (HR 0.44, = 0.033). Patients who received R-CHOP without maintenance rituximab had significantly worse PFS (5-year PFS 41% vs 68%, = 0.005) and OS (5-year OS 83% vs 100%, = 0.007) compared to those with maintenance rituximab. Role of maintenance rituximab post BR remained unclear. In this retrospective study of follicular lymphoma patients with extra-nodal disease, BR induction yielded favorable PFS compared to R-CHOP and could be a preferred treatment approach. Maintenance rituximab after R-CHOP significantly improve PFS and OS and should be considered in all appropriate patients.
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