Case Overview: A 77-Year-Old Man With Follicular Lymphoma

Christopher Flowers, MD: The case I’m going to discuss is a typical case of a patient with follicular lymphoma. This is a 77-year-old gentleman who initially presented with a 4-month history of some occasional fevers. He also noticed that he was having a decrease in his appetite, and then ultimately noticed that he had weight loss of about 7 pounds that was unintentional. Upon evaluation, he was noted to have a left axillary lymph node that was palpable and measured about 4 cm, and then also had a spleen that was palpable at 4 cm below the costal margin.

During the initial evaluation by the oncologist, he was noted to have a white blood cell count of 10.6 x 109/L, a hemoglobin of 10.1 [g/dL], and a platelet count of 100 x 109/L. His lactate dehydrogenase [LDH] was 325 [U/L]. His beta2 microglobulin was also elevated, at 3.3 [µg/mL]. That LDH was above the upper limit of normal, which was 200 [U/L] for that laboratory test. He had a hepatitis B test done that turned out to be negative, and ultimately had an excisional biopsy of that axillary lymph node that determined it to be a CD10-positive, CD3-negative, CD5-negative, CD20-positive lymph node. It was also BCL2-positive. It was read by the pathologist as follicular lymphoma grade 1/2.

At the same time, he underwent evaluation with a bone marrow aspiration and biopsy, and that bone marrow biopsy showed lymphoid aggregates with 35% involvement with follicular lymphoma. Molecular genetics of both the lymph node and the bone marrow showed evidence of translocation 14;18, and he eventually underwent a PET [positron emission tomography]/CT scan that showed enlargement of the left axillary lymph node, mediastinal lymph node enlargement, and bilateral paraaortic lymph node enlargement, with the largest of those lymph nodes being 4.2 cm in the left axilla, 5.3 cm in the mediastinum, and other lymph nodes of about 3.6 and 3.5 cm, also with a large spleen that had been noted on a physical examination.

He was diagnosed at that time to have Ann Arbor stage IV disease with an ECOG performance status of 0.

After he completed evaluation, he was initially treated with the R-CHOP [rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone] chemoimmunotherapy regimen. He received 6 total cycles of therapy and then proceeded to have rituximab maintenance. He received a dose of 375 mg/m2 once every 2 months with a plan of 2 total years of rituximab maintenance. He achieved a partial response after completion of his induction therapy. During his maintenance therapy, approximately 6 months later he complained of increasing fevers. Then he had a repeat PET/CT scan that revealed progression of disease, again with a large lymph node in his axilla and other sites of lymphadenopathy.

He was evaluated and determined to have relapse of his disease. He was started on bendamustine plus obinutuzumab. He received 6 cycles of therapy and then continued on with maintenance obinutuzumab. His repeat lymph node biopsy at the time of his relapse also showed follicular grade 1/2 lymphoma, and there was no evidence of transformation.

Approximately 8 months after completion of his bendamustine and obinutuzumab treatment, he again noted some increase in weight loss. At that time, he was noted to have a second relapse of his disease and was started on idelalisib at 155 mg given orally twice daily.

Transcript edited for clarity.

Case:A 77-Year-Old Man With Follicular Lymphoma

Initial Presentation

• A 77-year-old man complains of a 4-month history of occasional fevers, decreased appetite, and an unintentional 7-lbs. weight loss
• PMH: unremarkable
• PE: palpable left axillary lymph nodes ~ 4 cm; spleen palpable 4.5 cm below costal margin
  
  

Clinical Work-up

• Labs: ANC 1.5 x 109/L, WBC 10.6 x 109/L, 42% lymphocytes, Hb 10.1 g/dL, plt 100 x 109/L, LDH 325 U/L, B2M 3.3 µg/mL; HBV negative
• Follicular lymphoma grade 2
• Bone marrow biopsy showed lymphoid aggregates, 35% involvement
• Molecular genetics: t(14;18) (q32;q21)
• PET/CT showed enlargement of left axillary, mediastinal and bilateral para-aortic lymphadenopathy (4.2 cm, 5.3 cm, 3.6 cm and 3.5 cm respectively)
• Ann Arbor Stage IV; ECOG 0
  
  

Treatment

• He was treated with R-CHOP for 6 cycles; continued rituximab maintenance 375 mg/m3; achieved partial response
• 6 months later he complained of increasing frequency of fevers
  • Repeat PET/CT revealed progression of disease
  • He was started on bendamustine + obinutuzumab for 6 cycles and continued maintenance obinutuzumab
  • Repeat lymph node biopsy grade 2 follicular lymphoma
• 8 months later he complained of increased weight loss
  • He was started on idelalisib 150 mg PO BID