Evaluation of a High-Risk Follicular Lymphoma Patient

Jeff P. Sharman, MD:We’re going to evaluate a patient today who’s a 62-year-old man who presents with lower abdominal discomfort and rapid weight loss over a 3-month period. His past medical history is notable for hypertension and hypercholesterolemia managed by statin. He had palpable inguinal lymphadenopathy.

From a diagnostic perspective, his absolute neutrophil count is 1200. His platelets are 89,000. Both beta2 microglobulin and LDH [lactic acid dehydrogenase] are elevated. Imaging studied by PET/CT [positron emission tomography/computed tomography] scan revealed axillary and bilateral inguinal adenopathy. He has at least 5 masses measuring approximately 3 cm each. Biopsy confirms the presence of grade 2 follicular lymphoma. His FLIPI [Follicular Lymphoma International Prognostic Index] status is high risk. Bone marrow biopsy is positive confirming Ann Arbor classification stage IV, and his ECOG [European Cooperative Oncology Group] performance status is 1.

It is determined the patient would proceed with therapy, and he receives 6 cycles of bendamustine in combination with obinutuzumab, to which he achieves a complete response.

This is a patient who’s generally not going to do as well as many of our other typical patients with low-grade follicular lymphoma. And we have to be thinking about alternative treatment strategies for him moving forward, because it’s anticipated that this patient is going to have a less favorable outcome.

So FLIPI has been utilized for quite a while. Originally there was the IPI [International Prognostic Index], which was developed for aggressive lymphomas. And when that was applied to indolent lymphoma, such as follicular lymphoma, it didn’t work particularly well because there was a small number of individuals characterized as high risk by IPI. So the FLIPI, which stands for Follicular Lymphoma International Prognostic Index, was created. And that looks at 5 variables, and those 5 variables include age, stage, LDH, number of nodal sites, and hemoglobin—hemoglobin less than 12.

The FLIPI was created though before the routine incorporation of rituximab to frontline therapy. And so the FLIPI2 was developed after rituximab use was much more common, and it really looks at many of the same variables. Instead of looking at stage III/IV, it looks at bone marrow involvement; instead of the number of nodal sites it looks at whether any of them are larger than 6 cm. And instead of LDH it looks at beta2 microglobulin. Overall, I think they’re relatively similar.

I don’t so much use the FLIPI or FLIPI2 to select therapy, but in some ways, it helps me think about what I might expect for outcomes for a patient following frontline therapy. And perhaps how I phrase it to them in my discussion.

Transcript edited for clarity.

Case: A 62-Year-Old Male with Follicular Lymphoma

H & P:

• A 62-year-old man presents with lower abdominal discomfort and rapid weight loss over last 3 months
• PMH: Hypertension managed by statin
• PE: palpable inguinal lymphadenopathy

Diagnostic Work-Up

• Hematologic results
  • ANC: 1200 /µL
  • Platelets: 89,000 /µL
  • β₂-microglobulin: 3.5 mg/L
  • Serum LDH: 230 IU/L
• Imaging: PET/CT reveals axillary and bilateral inguinal lymphadenopathy; 5 masses (~3cm each)
• Biopsy: FL, grade 2
• FLIPI status: High-risk
• Ann Arbor: Stage IV
• ECOG PS: 1

Treatment

• Patient treated with obinutuzumab + bendamustine
  • Completed 6 cycles, achieved CR