Case Overview: Elderly Woman With Relapsed/Refractory FL
Prior to discussing treatment options for a 71-year-old woman with relapsed/refractory follicular lymphoma, John P. Leonard, MD, of Weill Cornell Medicine and NewYork-Presbyterian Hospital, sets the stage with an overview of the patient’s case.
John P. Leonard, MD: I’m John Leonard from Weill Cornell Medicine and NewYork-Presbyterian Hospital in New York. Today we’re discussing a 71-year-old woman with follicular lymphoma.
She presented with a 5-month history of occasional fevers, decreased appetite, fatigue, and about a 7-pound weight loss that was unintentional. She had no significant past medical history. On physical exam she demonstrated a left axillary lymph node that was about 4 cm. She had bilateral cervical lymph nodes in the 3-cm range, and a spleen that was palpable—4.5 cm below the left costal margin.
On laboratory evaluation she had an absolute neutrophil count of 1500 per mm3, a WBC [white blood cell] count of 11.8 per mm3, with 42% lymphocytes. The patient had a hemoglobin count of 9.6 g/dL, a platelet count of 100,000 per mm3, a LDH [lactate dehydrogenase] of 325 U/L, and a beta-2 microglobulin of 3.7 mcg/mL, and she was negative for hepatitis B.
The patient underwent an excisional biopsy of a left axillary lymph node that showed the characteristic immunohistochemistry for follicular lymphoma grade 2. She also underwent a bone marrow biopsy that showed paratrabecular lymphoid aggregates and about 45% involvement with lymphoma.
On molecular genetics, or cytogenetics, there a 14;18 translocation was noted. A PET [positron emission tomography] scan with CT showed enlargement of the left axillary, mediastinal, and bilateral para-aortic lymph nodes, again in the 3- to 5-cm range. Standardized update values [SUVs] were in the range of about 8 to 10, diffusely.
She was deemed to have stage IV follicular lymphoma, and her ECOG performance status was 0.
The patient underwent treatment with R-CHOP [rituximab, cyclophosphamide, hydroxydaunorubicin hydrochloride, vincristine, prednisone] for 6 cycles and achieved a partial response. She then continued rituximab maintenance at the standard dosing for 2 years. Six months later, after completing maintenance, she complained of increasing frequency of fever and chills.
She was evaluated and was found to have progression of disease on examination and by PET/CT. A repeat lymph node biopsy showed grade 2 follicular lymphoma. The patient was started on bendamustine-obinutuzumab for 6 cycles and continued maintenance obinutuzumab.
Twelve months after starting bendamustine-obinutuzumab, she again complained of symptoms of fatigue and weight loss, and was noted to have recurrent disease. There was no evidence of transformation.
The patient was started on idelalisib, 150 mg, orally twice a day, and achieved a partial response. However, several months into her treatment she experienced grade 2 diarrhea. This was ultimately successfully managed.
Transcript edited for clarity.
Case: A 72-Year-Old Woman With Follicular Lymphoma
Initial Presentation
- A 71-year-old woman complains of a 5-month history of occasional fevers, decreased appetite, fatigue, and an unintentional 7-lbs. weight loss
- PMH: unremarkable
- PE: palpable left axillary lymph nodes ~ 4 cm and bilateral cervical lymph nodes ~ 3 cm; spleen palpable 4.5 cm below costal margin
Clinical Work-Up
- Labs: ANC 1.5 x 109/L, WBC 11.8 x 109/L, 42% lymphocytes, Hb 9.6 g/dL, plt 100 x 109/L, LDH 325 U/L, B2M 3.7 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, 45% 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
- She was treated with R-CHOP for 6 cycles; continued rituximab maintenance 375 mg/m3; achieved partial response
- 6 months later, she complained of increasing frequency of fevers and chills
- Repeat PET/CT revealed progression of disease
- She was started on bendamustine + obinutuzumab for 6 cycles and continued maintenance on obinutuzumab
- Repeat lymph node biopsy grade 2 follicular lymphoma
- 12 months later, she complained of increased weight loss and fatigue
- She was started on idelalisib 150 mg PO BID and achieved partial response
- She experienced grade 2 diarrhea, which was successfully managed
