Synthetic educational example. Do not self-treat: a qualified treating physician must verify the sources, patient data, contraindications, and final plan.
Patient
VERIFIED-FL-L2-FL_2L_OBG_BENDA · Algorithm: ALGO-FL-2L
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
- 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.
- 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)
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 | Sign-offs | Domain |
|---|
| Cellular therapy specialist (CAR-T) | cellular_therapy_specialist | v0.1.0 | 2026-04-25 | 0 | cellular_therapy |
| Clinical pharmacist | clinical_pharmacist | v0.1.0 | 2026-04-25 | 0 | clinical_pharmacy |
| Hematologist / oncohematologist | hematologist | v0.1.0 | 2026-04-25 | 0 | hematology_oncology |
| Hematopathologist (lymphoma / leukemia / myeloma) | hematopathologist | v0.1.0 | 2026-04-25 | 0 | hematopathology |
| Infectious disease / hepatology | infectious_disease_hepatology | v0.1.0 | 2026-04-25 | 0 | infectious_diseases |
| Medical oncologist (solid-tumor chemotherapist) | medical_oncologist | v0.1.0 | 2026-04-25 | 0 | solid_oncology |
| Molecular geneticist / molecular oncologist | molecular_geneticist | v0.1.0 | 2026-04-25 | 0 | molecular_oncology |
| Palliative care | palliative_care | v0.1.0 | 2026-04-25 | 0 | palliative_care |
| Pathologist (general) | pathologist | v0.1.0 | 2026-04-25 | 0 | pathology |
| Primary care / family physician | primary_care | v0.1.0 | 2026-04-25 | 0 | primary_care |
| Psycho-oncologist | psychologist | v0.1.0 | 2026-04-25 | 0 | psychosocial |
| Radiation oncologist | radiation_oncologist | v0.1.0 | 2026-04-25 | 0 | radiation_oncology |
| Radiologist | radiologist | v0.1.0 | 2026-04-25 | 0 | diagnostic_imaging |
| Social worker / case manager | social_worker_case_manager | v0.1.0 | 2026-04-25 | 0 | psychosocial |
| Surgical oncologist | surgical_oncologist | v0.1.0 | 2026-04-25 | 0 | surgical_oncology |
| Transplant specialist (BMT) | transplant_specialist | v0.1.0 | 2026-04-25 | 0 | 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)
Last synced: 2026-09-09 · ctgov.
No active trials matched this scenario in ctgov.
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 |
Cost information is orientation. Verify with a specific pharmacy / foundation / trial site. Status updated: 2026-09-09.