A 74-Year-Old Man With Relapsed/Refractory Follicular Lymphoma

Case: A 74-Year-Old Man With Relapsed/Refractory Follicular Lymphoma

Initial presentation

• A 74-year-old man complains of a 6-month history of fatigue, occasional fevers, decreased appetite, fatigue, and an 8-lb weight loss
• PMH: unremarkable
• PE: palpable right axillary and cervical lymph nodes, palpable ~ 3 cm in both locations; spleen palpable 4.5 cm below left costal margin
   

Clinical Workup

• Labs: ANC 1.6 x 109/L, WBC 11.2 x 109/L, 44% lymphocytes, Hb 9.6 g/dL, plt 98 x 109/L, LDH 315 U/L, B2M 3.5 µg/mL; HBV negative
• Excisional biopsy of the axillary lymph node on IHC showed CD 20+, CD 3+, CD5+, CD 10+, BCL2+; follicular lymphoma grade 2
• Bone marrow biopsy showed paratrabecular lymphoid aggregates, 4% involvement
• Molecular genetics: t(14;18) (q32;q21)
• PET/CT showed enlargement of right axillary, cervical, and mediastinal lymphadenopathy (3.3 cm, 3.1, cm and 4.6 cm respectively)
• Ann Arbor Stage IV; ECOG 0
   

Treatment

• He was treated with R-CHOP for 6 cycles, achieved complete response and continued rituximab maintenance
• 24 months later he complained of increasing weight loss, fever and drenching sweats as well as more enduring fatigue and new onset itching; he was currently taking antibiotics for his 3rd bacterial infection in the past year
  • Repeat PET/CT revealed progression of disease
  • He was started on bendamustine + rituximab for 6 cycles and continued on rituximab maintenance
  • Repeat lymph node biopsy grade 2 follicular lymphoma
• 12 months later he complained of continued weight loss, increased itching and worsening fatigue; recurrent infections continued
  • He was started on idelalisib 150 mg PO BID