166 American Society of Hematology Managing Indolent Lymphomas in Relapse: Working Our Way Through a Plethora of Options Fernando Cabanillas (Chair), Sandra Horning, Mark Kaminski, and Richard Champlin The front-line management of stage IV indolent non-Hodgkin’s lymphoma has ranged from the watch-and-wait approach to intensive experimental regimens such as high-dose chemotherapy and bone marrow transplant. With this broad spectrum of regimens to choose from, the decision has become a challenging exercise for both patients and oncologists. With the recent introduction of new agents such as rituximab, fludarabine, and combinations based on these, the management of relapsed cases can be similarly confusing. More aggressive approaches such as high-dose chemo- therapy with autologous bone marrow transplant and more recently allogeneic bone marrow trans- plant have also been used. Recently the technique of “mini-allo transplants” has been introduced. It utilizes a less myelosuppressive conditioning chemotherapy regimen based on fludarabine which is immunosuppressive enough to allow engraft- ment of the donor marrow. Since it is less myelo- toxic it is better tolerated, and this has allowed us to significantly extend the age cut-off for allogeneic transplants. All these advances provide us with a more extensive armamentarium, but at the same time they confront physicians with new challenges in choosing from a large and continuously growing therapeutic menu. In this review of the alternative therapies a panel of three expert hemato-oncologists each discuss their approach to the management of a 49- year-old patient with a relapsed indolent follicular lymphoma. Dr. Horning discusses the traditional alternatives available for this patient such as standard chemotherapy combinations or the watch- and-wait approach in Section I. In Section II, Dr. Kaminski reviews the different therapeutic mono- clonal antibody options such as rituximab, Bexxar (Iodine-labeled anti-CD20) and Ytrium-labeled anti- CD20 antibody. Allogeneic transplants are increas- ingly more popular for the treatment of indolent lymphomas because they can provide an immune- mediated graft-versus-lymphoma effect. In Section III, Dr. Richard Champlin reviews various transplant options including autologous, allogeneic and mini- allogeneic transplants. CASE PRESENTATION Fernando Cabanillas, M.D.* A 49-year-old male patient presents to you in consulta- tion with a history of having been treated for a stage IV- A follicular center cell grade I non-Hodgkin’s lymphoma (NHL) (follicular small non-cleaved cell) with bone mar- row involvement. His treatment had consisted of six courses of CHOP (cyclophosphamide, doxorubicin, vin- cristine and prednisone) in April 1997. He had achieved a complete remission but relapsed in a neck node in June 2000. A biopsy done in July 2000 revealed follicular cen- ter cell grade II NHL (follicular mixed lymphoma). Af- ter you interview him, you don’t find any abnormalities on examination and he doesn’t have any constitutional symptoms. He has two brothers and one sister, all healthy. You order restaging to be performed including chest x- ray, CT scan of abdomen/pelvis, and bilateral bone mar- row biopsies. Routine blood work reveals a normal com- plete blood count, lactic dehydrogenase and  -2 microglobulin. The CT scan reveals enlarged nodes in the retroperitoneum, the largest being 3 cm in size, the chest x-ray is normal, and the bone marrow biopsy is negative bilaterally. What would be your next step in management? 1. Watch and wait 2. FND (fludarabine, mitoxantrone, dexamethasone) 3. Rituximab 4. Radiolabeled anti-CD 20 monoclonal antibody 5. Autologous bone marrow transplant 6. Allogeneic bone marrow transplant if one of the sib- lings is HLA identical * Department of Lymphoma-Myeloma, M.D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston TX 77030-4009