Commonly designated as an indolent non-Hodgkin lymphoma, follicular lymphoma (FL) presents with striking pathobiological and clinical heterogeneity. Initial management strategies for FL have evolved to involve combination chemoimmunotherapy and/or radio-immunoconjugates. Unfortunately even with the best available nontransplant treatment, which nowadays results in higher frequency of response, FL remains incurable. Although considered a feasible therapeutic option, the use of hematopoietic cell transplantation (HCT) remains controversial. The appropriate timing, graft source, and intensity of HCT conditioning regimens in FL are often matters of debate. Herein we review the available published data pertaining to the use of autologous or allogeneic HCT in patients with FL across different stages of the disease, discuss major recent advances in the field, and highlight avenues for future research. The current literature does not support a role of HCT for FL in first remission, but in the relapsed setting autologous HCT remains appropriate for patients with early chemosensitive relapses, while allogeneic transplantation remains the sole curative modality for this disease, in relatively younger patients without significant comorbidities. 1. Introduction Follicular lymphoma (FL) is the second most common type of non-Hodgkin lymphoma (NHL) in the western hemisphere accounting for 22% of all cases [1]. The median age at diagnosis is generally in the 6th decade, with a slight female preponderance. Being an indolent lymphoma, the disease course of FL is one of remissions and relapses with conventional chemoimmunotherapies followed not infrequently by development of resistance and/or transformation into a more aggressive histology. A subset of FL patients has a more aggressive clinical course, with approximately 15% mortality at 2 years resulting from progressive or transformed disease [2]. While clinical prognostic systems such as FL international prognostic index (FLIPI) are good in estimating overall survival (OS) [3, 4], they have limited predictive value in identifying patient groups that may (or may not) benefit from aggressive initial therapy. Management strategies include surveillance, combination chemoimmunotherapy, radio-immunotherapy, and autologous or allogeneic hematopoietic cell transplantation (HCT). The addition of rituximab to conventional chemotherapy regimens has resulted in improved progression-free survival (PFS) and OS [5–7] in several studies. Despite improved outcomes achieved with incorporation of monoclonal antibodies, namely, rituximab,
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