FLIPI Calculator For Follicular Lymphoma

How does this FLIPI calculator for follicular lymphoma work?

This health tool is a risk stratification tool in the prognosis of follicular lymphoma. FLIPI is the acronym from Follicular Lymphoma International Prognostic Index which is the result of research on 4,167 patient collected data. The study took place during 1985 and 1992 on patients diagnosed with follicular lymphoma and treated with a range of chemotherapy drugs, excluding rituximab.

Statistical analysis revealed 5 risk factors (adverse prognostic factors) which could potentially be used in outcome prognosis as they were independently correlated with poor outcomes in patients with NHL.

The result from the FLIPI calculator for follicular lymphoma is correlated with one of the 3 risk categories (low, intermediate and high risk) and presents as well the survival rate over 5, respectively 10 years.

The FLIPI benefits from derivation and external validation and has helped in improving treatment plans but is also recommended to be used in comparing clinical trials and new studies.

The prognosis parameters are reunited under the mnemonic NoLASH:

■ Number of nodal areas – enlarged limph nodes in single nodel areas which are defined as any of the following: left cervical, right cervical, left axillary, right axillary, mediastinal, mesenteric, paraaortic, left inguinal, right inguinal, others (incl. epitrochlear, popliteal).

■ LDH – lactate dehydrogenase level slightly or very elevated, in most FL patients, serum LDH levels are still maintained closer to the normal range of 140 – 280 U/L.

■ Age – this is an age adjusted model in which the prognosis was observed in 2 separate age groups, one of patients of 60 years of age and above and one of patients below 60.

■ Stage – Ann Arbor FL staging explained below.

■ Hemoglobin level – the protein distribution oxygen through the blood to tissues with a cut off value placed at 12.0 g/dL.

FLIPI score interpretation

A simple and quick to administer prognosis tool, the FLIPI sums only 5 adverse factors, awarding the presence of each with 1 point.

■ Age 60 and above;

■ 4 or more nodal areas;

■ Elevated LDH level;

■ Hemoglobin level below 12.0 g/dL;

■ Ann Arbor staging III, IV.

Therefore the overall score ranges between 0 and 5 and the three risk categories to stratify outcome are as follows:

■ Scores of 0 and 1: Low risk with 91% estimated survival over 5 years and 71% over 10 years.

■ Scores of 2: Intermediate risk with 78% estimated survival over 5 years and 51% over 10 years.

■ Scores of 3, 4 and 5: High risk with 53% estimated survival over 5 years and 36% over 10 years.

Follicular lymphoma staging

The staging system for FLs, which account for a third of non-Hodgkin lymphomas NHLs, consists of 3 histologic grades:

■ Grade 1: 0 - 5 centroblasts/high-power field (HPF);

■ Grade 2: 6 - 15 centroblasts/HPF;

■ Grade 3: >15 centroblasts/HPF.

The Ann Arbor staging system, the one also used in FLIPI was developed based on the standard staging but adds information on bulky disease, X and regions of lymph node involvements, E:

■ Stage I: Single lymph node group;

■ Stage II: Multiple lymph node groups on same side of diaphragm;

■ Stage III: Multiple lymph node groups on both sides of diaphragm;

■ Stage IV: Multiple extranodal sites or lymph nodes and extranodal disease;

■ X: Bulk larger than 10 cm;

■ E: Extranodal extension or single isolated site of extranodal disease;

■ A/B: B symptoms: weight loss > 10%, fever, drenching night sweats.

References

1) Solal-Céligny P, Roy P, Colombat P, et al. (2004) Follicular lymphoma international prognostic index. Blood; 104(5):1258-65.

2) Montoto S, Lopez-Guillermo A, Altes A et al. (2004) Predictive value of Follicular Lymphoma International Prognostic Index (FLIPI) in patients with follicular lymphoma at first progression. Oxford Journals Medicine & Health Annals of Oncology (15)10P. 1484-1489

3) Luminari S, Bellei M, Biasoli I, Federico M. (2012) Follicular lymphoma - treatment and prognostic factors. Rev Bras Hematol Hemoter; 34(1): 54–59.

4) Atkins CD. (1994) A predictive model for non-Hodgkin's lymphoma. N Engl J Med; 330(8):574.