OpenOnco · Treatment Plan

Treatment plan — Follicular Lymphoma

PLAN-VERIFIED-FL-L2-FL_2L_OBG_BENDA-V1 · v1 · 2026-07-15

Patient

VERIFIED-FL-L2-FL_2L_OBG_BENDA · Algorithm: ALGO-FL-2L

DiagnosisFollicular Lymphoma

MOH / ICD-10C82.0

ICD-O-39690/3

Clinical significance of mutations (ESCAT)

Tumor-board context — the engine does not use these tiers to rank tracks

Biomarker	Variant	ESCAT	Evidence	Clinical significance	Drugs	Sources
No clinically actionable variants matched in this profile.

Primary current-line option

Standard plan

★ DEFAULT

Indication

IND-FL-2L-OBG-BENDA

Regimen

Obinutuzumab + Bendamustine (GADOLIN)

Drugs + NSZU

Obinutuzumab (DRUG-OBINUTUZUMAB) 1000 mg · Days 1, 8, 15 of cycle 1; day 1 of cycles 2-6 · IV ⚠ NSZU — not for this indication
Bendamustine (DRUG-BENDAMUSTINE) 90 mg/m² · Days 1-2 of each cycle · IV ⚠ NSZU — not for this indication

Hard contraindications

CI-HBV-NO-PROPHYLAXIS

Reason

Primary current-line option selected by ALGO-FL-2L at step 3.

Other current-line alternatives (1 tracks)

Same treatment line; review when biomarker, access, contraindication, or patient-context assumptions change.

Aggressive plan

Indication

IND-FL-2L-R2

Regimen

Rituximab + Lenalidomide (R²/AUGMENT)

Drugs + NSZU

Rituximab (DRUG-RITUXIMAB) 375 mg/m² · Day 1 of each 28-day cycle · IV ✓ NSZU covered
Lenalidomide (DRUG-LENALIDOMIDE) 20 mg · QD days 1-21 of each 28-day cycle · PO ⚠ NSZU — not for this indication

Reason

Current-line alternative presented for HCP consideration

Sequencing / non-current-line candidates

Shown for audit and future-line context; not part of the current treatment choice.

Indication	Authored line	Regimen	Why separated
`IND-FL-3L-MOSUNETUZUMAB`	line 3	Mosunetuzumab IV step-up (8 cycles, 21-day; up to 17 if not in CR by C8) — r/r FL	Later-line sequencing candidate: indication line 3, patient line 2; not a current treatment option
`IND-FL-3L-AXICEL-CART`	line 3	Axicabtagene ciloleucel (axi-cel) CAR-T for r/r FL — single infusion after lymphodepletion (ZUMA-5)	Later-line sequencing candidate: indication line 3, patient line 2; not a current treatment option
`IND-FL-3L-TAZEMETOSTAT`	line 3	Tazemetostat 800 mg PO BID continuous — r/r FL (EZH2-mut OR EZH2-WT after ≥2 lines)	Later-line sequencing candidate: indication line 3, patient line 2; not a current treatment option

Pre-treatment investigations

Investigations before treatment start · critical / standard / desired · merged across tracks

ID	Name	Priority	Category	Where to order	Needed for
TEST-CBC	Complete Blood Count with Differential	Critical	lab	—	all tracks
TEST-CECT-CAP	CECT chest/abdomen/pelvis	Critical	imaging	—	all tracks
TEST-CMP	Comprehensive Metabolic Panel	Critical	lab	—	all tracks
TEST-HBV-SEROLOGY	Hepatitis B Serology Panel (HBsAg, anti-HBc total, anti-HBs)	Critical	lab	—	all tracks
TEST-HCV-ANTIBODY	HCV Antibody	Critical	lab	—	all tracks
TEST-HIV-SEROLOGY	HIV Antibody/Antigen	Critical	lab	—	all tracks
TEST-LDH	Lactate Dehydrogenase	Critical	lab	—	standard
TEST-LFT	Liver Function Tests (ALT, AST, bilirubin, ALP, GGT, albumin)	Critical	lab	—	all tracks
TEST-PREGNANCY	Beta-HCG	Critical	lab	—	aggressive
TEST-PET-CT	FDG PET/CT (whole body)	Standard	imaging	—	all tracks

What NOT to do

Explicit prohibitive rules, each grounded in a regimen / supportive care / contraindication entity

Standard plan (IND-FL-2L-OBG-BENDA)

Do NOT use in CrCl <30 mL/min — bendamustine is renally cleared; contraindicated in severe renal impairment.
Do NOT start without HBV screening + prophylaxis — obinutuzumab is anti-CD20 class; HBV reactivation risk.
Do NOT use without confirmation of rituximab-refractoriness — obinutuzumab benefit is specifically established in the rituximab-refractory setting (GADOLIN).
Do NOT skip infusion premedication (acetaminophen + diphenhydramine + IV steroid) — obinutuzumab carries higher infusion-related reaction risk than rituximab.

Aggressive plan (IND-FL-2L-R2)

Do NOT use in pregnancy — lenalidomide is Category X teratogen; dual contraception mandatory + monthly pregnancy tests (REMS/equivalent program).
Do NOT skip VTE prophylaxis (aspirin 81-325 mg QD minimum, or LMWH for high-risk) — lenalidomide-associated thrombosis risk.
Do NOT use in severe renal impairment (CrCl <30 mL/min) without lenalidomide dose adjustment per labeling.
Do NOT start without HBV screening + prophylaxis if HBsAg+ or anti-HBc+ — rituximab = reactivation risk.

Timeline

Treatment timeline — derived from regimen + monitoring schedule

Standard plan

Induction · Obinutuzumab + Bendamustine (GADOLIN)

28-day cycles × 6

Aggressive plan

Induction · Rituximab + Lenalidomide (R²/AUGMENT)

28-day cycles × 12

MDT brief

Discussion questions (3, 1 blocking)

BLOCKING OQ-CD20-CONFIRMATION
Is CD20+ status confirmed by histology (IHC)? Without CD20+, rituximab/obinutuzumab are not indicated.
Anti-CD20 therapy is the backbone of most lines of treatment; absence of CD20 expression fully changes the regimen.
→ pathologist
OQ-STAGING-COMPLETE
Has complete staging been done (Lugano + PET/CT or CT)?
Prognosis and track selection depend on stage and tumor burden.
→ radiologist
OQ-LDH-CURRENT
What is the current LDH? Marker of tumor burden and transformation.
LDH is part of the prognostic indices of indolent lymphomas.
→ hematologist

MDT talk tree (4 steps)

#	Owner	Topic	Action
1	pathologist	Pathology confirmation BLOCKING	Is CD20+ status confirmed by histology (IHC)? Without CD20+, rituximab/obinutuzumab are not indicated.
2	hematologist	Staging / disease burden	What is the current LDH? Marker of tumor burden and transformation.
3	radiologist	Staging / disease burden	Has complete staging been done (Lugano + PET/CT or CT)?
4	clinical_pharmacist	Specialist review	Chemoimmunotherapy regimen — drug-drug interactions, dose adjustments, premedication.

Skills (required) — mandatory virtual specialists (1)

Hematologist / oncohematologist required
Lymphoma diagnosis — leading specialty for treatment management.
Owns: OQ-LDH-CURRENT

Skills (recommended) — for consideration (2)

Clinical pharmacist recommended
Chemoimmunotherapy regimen — drug-drug interactions, dose adjustments, premedication.
Pathologist (general) recommended
Confirm lymphoma histology + assess transformation risk (DLBCL/Richter).
Owns: OQ-CD20-CONFIRMATION

Data quality

Incomplete for MDT sign-off. MDT sign-off is incomplete until critical clinical data gaps are resolved.

Biomarker coverage: 0/0 known (100%), 0 missing, 0 default-track gaps
Missing critical: cd20_ihc_status, lugano_stage
Missing recommended: ldh_ratio_to_uln, fib4_index, pet_ct_date
Unevaluated RedFlags: RF-FL-EZH2-Y641-ACTIONABLE, RF-FL-FRAILTY-AGE, RF-FL-HIGH-TUMOR-BURDEN-GELF, RF-FL-INFECTION-SCREENING, RF-FL-ORGAN-DYSFUNCTION, RF-FL-TRANSFORMATION-SUSPECT, RF-FOLLICULAR-TRANSFORMATION, RF-GELF-CRITERIA-MET, RF-GELF-LOW-BURDEN

Missing data for doctor action

Priority	Clinical item	Owner	Why it matters	Next action	Blocks
CRITICAL	CD20 IHC status `cd20_ihc_status`	pathologist	Confirms CD20-directed therapy is biologically appropriate.	Verify CD20 IHC result, specimen, method, and report date.	-
CRITICAL	Lugano stage `lugano_stage`	radiologist	Defines lymphoma extent and supports tumor-burden and response-assessment decisions.	Document Lugano stage from PET/CT or contrast CT staging.	-
RECOMMENDED	LDH ratio to ULN `ldh_ratio_to_uln`	medical_oncologist	Supports prognostic scoring and aggressive-biology flags.	Enter LDH with local upper limit of normal.	-
RECOMMENDED	FIB-4 liver fibrosis index `fib4_index`	infectious_disease_hepatology	Screens hepatic fibrosis risk before hepatotoxic therapy or antiviral coordination.	Calculate FIB-4 from age, AST, ALT, and platelet count.	-
RECOMMENDED	PET/CT date `pet_ct_date`	radiologist	Shows whether baseline staging is recent enough for treatment planning and later response comparison.	Document baseline PET/CT date or explain alternative staging modality.	-

Technical MDT skill metadata (3/16 activated in this plan)

All registered virtual specialists. ✓ — activated for this case; ○ — not activated (available for other clinical scenarios).

Specialist	skill_id	Version	Last reviewed	Domain
Cellular therapy specialist (CAR-T)	`cellular_therapy_specialist`	v0.1.0	2026-04-25	cellular_therapy
Clinical pharmacist	`clinical_pharmacist`	v0.1.0	2026-04-25	clinical_pharmacy
Hematologist / oncohematologist	`hematologist`	v0.1.0	2026-04-25	hematology_oncology
Hematopathologist (lymphoma / leukemia / myeloma)	`hematopathologist`	v0.1.0	2026-04-25	hematopathology
Infectious disease / hepatology	`infectious_disease_hepatology`	v0.1.0	2026-04-25	infectious_diseases
Medical oncologist (solid-tumor chemotherapist)	`medical_oncologist`	v0.1.0	2026-04-25	solid_oncology
Molecular geneticist / molecular oncologist	`molecular_geneticist`	v0.1.0	2026-04-25	molecular_oncology
Palliative care	`palliative_care`	v0.1.0	2026-04-25	palliative_care
Pathologist (general)	`pathologist`	v0.1.0	2026-04-25	pathology
Primary care / family physician	`primary_care`	v0.1.0	2026-04-25	primary_care
Psycho-oncologist	`psychologist`	v0.1.0	2026-04-25	psychosocial
Radiation oncologist	`radiation_oncologist`	v0.1.0	2026-04-25	radiation_oncology
Radiologist	`radiologist`	v0.1.0	2026-04-25	diagnostic_imaging
Social worker / case manager	`social_worker_case_manager`	v0.1.0	2026-04-25	psychosocial
Surgical oncologist	`surgical_oncologist`	v0.1.0	2026-04-25	surgical_oncology
Transplant specialist (BMT)	`transplant_specialist`	v0.1.0	2026-04-25	cellular_therapy

Sources cited

SRC-AUGMENT-LEONARD-2019: AUGMENT: A Phase III Study of Lenalidomide Plus Rituximab Versus Placebo Plus Rituximab in Relapsed or Refractory Indolent Lymphoma (2019)
SRC-GADOLIN-SEHN-2016: Obinutuzumab plus bendamustine versus bendamustine monotherapy in patients with rituximab-refractory indolent non-Hodgkin lymphoma (GADOLIN): a randomised, controlled, open-label, multicentre, phase 3 trial (2016)
SRC-NCCN-BCELL-2025: NCCN Clinical Practice Guidelines in Oncology: B-Cell Lymphomas (v.2.2025)

Experimental options (clinical trials)

Third plan track — open-enrollment trials from ClinicalTrials.gov. Render-time metadata; engine selection is not affected by this block (CHARTER §8.3). Last synced: 2026-07-15.

NCT	Title	Phase	Status	Sponsor	UA	Signals
NCT06664229	Development of Pressure Sensor Based Dementia and Fall Prevention Program for Older Adults	NA	RECRUITING	Sunmi Song	—	Single country
NCT05816850	Multilayer Biological Characterization of Advanced Follicular Lymphoma: a Translational Study From FIL_FOLL12 Trial	N/A	RECRUITING	Fondazione Italiana Linfomi - ETS	—	Surrogate endpoint only Single country
NCT03314974	Myeloablative Allo HSCT With Related or Unrelated Donor for Heme Disorders	PHASE2	RECRUITING	Masonic Cancer Center, University of Minnesota	—	Single country
NCT07545603	Clinical Study of XNW5004 Tablets in the Treatment of Relapsed and Refractory Follicular Lymphoma	PHASE2	RECRUITING	Evopoint Biosciences Inc.	—	Surrogate endpoint only Single country
NCT04947618	Efficacy of Patient Management for Lymphoma Diagnosed at Nimes University Hospital From 1999 to 2018. DVR-Lym-Nim	N/A	RECRUITING	Centre Hospitalier Universitaire de Nīmes	—	Single country
NCT07328035	Remission in Adults With Severe Asthma in Thailand	N/A	RECRUITING	Thammasat University	—	Single country
NCT07042438	Fecal Microbiome Transplant to Remodel Intestinal Microbiota for Patients With Relapsed or Refractory Lymphoma With Exposure to High-Risk Antibiotics Who Are Receiving Chimeric Antigen Receptor T Cells	PHASE2	RECRUITING	City of Hope Medical Center	—	Single country
NCT07206121	Feasibility Study for the SIRA-1000, SIRA® RFA Electrosurgical Device as an Adjunct to Breast Conserving Surgery	NA	RECRUITING	Innoblative Designs, Inc.	—	Small N (<50) Single country
NCT04889716	CAR-T Followed by Bispecific Antibodies	PHASE2	RECRUITING	Abramson Cancer Center at Penn Medicine	—	Small N (<50) Single country
NCT05942885	Hypnosis: a Path to Appeasement	NA	RECRUITING	Hospices Civils de Lyon	—	Single country

Verify recruitment status directly with the trial site. ctgov data can lag behind current UA-site status.

Option availability in Ukraine

Per-track UA registration · NSZU · cost · access pathway. Render-time metadata; engine selection does not depend on these fields (CHARTER §8.3).

Option	UA registration	NSZU	Cost orientation	Access pathway
Standard plan Obinutuzumab + Bendamustine (GADOLIN) (REG-OBINUTUZUMAB-BENDA)	✓ registered	✓ covered	₴-? — verify pathway	NSZU formulary
Aggressive plan Rituximab + Lenalidomide (R²/AUGMENT) (REG-RITUXIMAB-LENALIDOMIDE-R2)	✓ registered	✓ covered	₴-? — verify pathway	NSZU formulary
Trial · NCT06664229 Development of Pressure Sensor Based Dementia and Fall Prevention Program for Older Adults No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT05816850 Multilayer Biological Characterization of Advanced Follicular Lymphoma: a Translational Study From FIL_FOLL12 Trial No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT03314974 Myeloablative Allo HSCT With Related or Unrelated Donor for Heme Disorders No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT07545603 Clinical Study of XNW5004 Tablets in the Treatment of Relapsed and Refractory Follicular Lymphoma No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT04947618 Efficacy of Patient Management for Lymphoma Diagnosed at Nimes University Hospital From 1999 to 2018. DVR-Lym-Nim No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT07328035 Remission in Adults With Severe Asthma in Thailand No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT07042438 Fecal Microbiome Transplant to Remodel Intestinal Microbiota for Patients With Relapsed or Refractory Lymphoma With Exposure to High-Risk Antibiotics Who Are Receiving Chimeric Antigen Receptor T Cells No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT07206121 Feasibility Study for the SIRA-1000, SIRA® RFA Electrosurgical Device as an Adjunct to Breast Conserving Surgery No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT04889716 CAR-T Followed by Bispecific Antibodies No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT05942885 Hypnosis: a Path to Appeasement No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor

Cost information is orientation. Verify with a specific pharmacy / foundation / trial site. Status updated: 2026-07-15.

plan_id: PLAN-VERIFIED-FL-L2-FL_2L_OBG_BENDA-V1 | version: 1 | generated: 2026-07-15T13:33:22.868363+00:00

Per FDA non-device CDS positioning (CHARTER §15): Outpatient oncology treatment planning to support tumor-board discussion. Not a medical device; not for autonomous clinical decision-making.

Per FDA non-device CDS positioning (CHARTER §15): Both treatment options below are presented for review. The engine's selection of a 'recommended' default does not constitute a clinical decision. Final treatment selection requires HCP judgment incorporating information not available to the system.

This document is an informational resource supporting tumor-board discussion (per CHARTER §11). It is not a system that makes clinical decisions. Every recommendation must be verified by the treating physician.