Current approaches and future perspectives for advanced-stage follicular lymphoma with a low tumor burden

The introduction of a chimeric anti-CD20 monoclonal antibody, rituximab, for the treatment of follicular lymphoma (FL) has dramatically improved the prognosis of this disease. Despite advances in therapy, the disease remains incurable with current standard therapeutic strategies. For advanced-stage and high-tumor-burden FL patients, a combination of rituximab with chemotherapy has improved the overall survival rates, and subsequent rituximab maintenance following successful rituximab-based chemotherapy induction also prolongs progression-free survival. Conversely, for advanced-stage low-tumor-burden FL patients, watchful waiting remains the appropriate approach, whereas rituximab monotherapy has also been suggested as a good alternative. However, the optimal timing of rituximab monotherapy in low-tumor-burden FL patients has not been clarified. It is important to address this issue for chemo-free treatment strategies. Furthermore, a predictive model for advanced low-tumor-burden patients is required to appropriately identify those patients who may benefit from immediate treatment. In this review, we address the current treatment approaches and present potential future management strategies for advanced-stage, low-tumor-burden patients.