Harry C. Schouten, MD, PhD

Ganti et al present quite an extensive overview of follicular lymphoma, with most of their emphasis on clinical practice. Many of the issues they touch upon demonstrate that we cannot draw firm conclusions about the superiority of various treatments over others, due to a variety of study limitations. These challenges to interpretation include the indolent course of the disease in most patients (and thus the long follow-up needed to draw firm conclusions), the often small number of patients in this category, the retrospective nature of most studies, differences in risk factors, and the relative lack of randomized studies. As is also the case with efficacy, the most beneficial treatment strategy in follicular lymphoma remains to be established.

In the early 1990s, a few Europeanphysicians met to design a trialassessing the value of high-dosetherapy followed by autologous stemcell transplantation in relapsed follicularnon-Hodgkin’s lymphoma(NHL). Extensive discussions werealso devoted to the topic of purgingthe stem cell graft. Some of us felt itdid not make sense to reinfuse tumorcells after the application of high-dosetherapy including total-body irradiation:“The tumor cells were clearlyvisible in the bone marrow.” Othersfelt there may be a difference betweenmonoclonal cells visible in the marrowand clonogenic cells that maygive rise to a relapse. It was the era ofthe first positive data on purging inAML[1] and NHL.[2,3] In those discussions,it was apparent that therewere believers and nonbelievers.

Freedman et al provide an extensive overview of the literature on high-dose therapy and transplantation in follicular non-Hodgkin’s