Determining Prognosis of Follicular Lymphoma

Ajay Gopal, MD:The second case is of a 66-year-old gentleman who presented with inguinal and axillary lymphadenopathy. Initial biopsy of the lymph nodes showed grade 2 follicular lymphoma, and further staging studies with CT scan showed widespread disease with bulky disease up to almost 10 cm, as well as pleural effusion. Bone marrow showed 70% involvement, and patient also had anemia and elevated LDH. We don’t have any additional data on the PET scan regarding this patient, but he was treated with R-CHOP, responded, achieved a complete remission, but unfortunately relapsed after 19 months. At the time of relapse, the patient was then, again, treated with bendamustine/rituximab, this time only achieving a partial response that lasted 6 months. Six months after completing the bendamustine/rituximab, the patient presented to clinic with complaints of fatigue and abdominal fullness. CT scans showed, again, progressive lymphadenopathy, particularly in the abdomen and pelvis, and he was started on idelalisib.

In contrast to our first case, this is a much tougher situation. This is a gentleman who had a short initial remission duration, less than 2 years, and now has had an even shorter remission duration after only achieving a partial response to second-line chemoimmunotherapy. We know from recent data, from the LymphoCare study from Carla Casulo and others, looking at the impact of early relapse that the FLIPI score alone is not very accurate at predicting outcomes. However, we do know from this study that patients who have a relapse within 24 months of their diagnosis have a very poor outcome. Fortunately, this is only about one-fifth of patients, but patients in this category really only have about a 50% 5-year survival.

So, this further stratification by time to initial relapse really helps guide us in terms of our therapy. For 80% of the patients, fortunately, they’ll do well. There will be a later relapse, if at all. And for those patients, the key is to use restraint to try to minimize toxicity—at least in my perspective—and not be overly aggressive. However, for the 1 in 5 patients, like this unfortunate gentleman, who’ve had an early relapse, we need to think about novel strategies. And this is where I really talk about clinical trial options because the outcomes are much poorer.

Transcript edited for clarity.

January 2014

• A 66-year-old male presents with bilateral inguinal and right axillary adenopathy.
• Past medical history includes hypercholesterolemia managed with simvastatin; moderate hypertension, managed with hydrochlorothiazide/triamterene; history of atrial fibrillation managed with apixaban.
  • Laboratory findings: hemoglobin level 10.2 g/dL, LDH elevated
  • CT scan shows widely disseminated disease, with bulky adenopathy in the pelvis, mesentery, retroperitoneum, supraclavicular region, and aortopulmonary window. The largest lymph node is 9.8 cm.
  • Chest radiography shows small bilateral pleural effusions
  • Bone marrow biopsy shows 70% involvement with FL
  • Excisional biopsy shows grade 2 follicular lymphoma
• The patient was started on R-CHOP and achieved remission for 19 months at which time he developed an enlarging adenopathy in the pelvis.

October 2015

• Upon relapse of her disease, the patient was treated with bendamustine/rituximab.
• He achieved a partial response for close to 6 months.

April 2016

• The patient reports feeling tired and abdominal fullness.
• Physical exam remarkable for palpable splenomegaly.
• PET imaging showed enlargement of pelvic and retroperitoneal nodes and development of several new lesions.
• The patient was started on idelalisib therapy.