Wide Range of Options in Frontline Follicular Lymphoma

John Pagel, MD:The POD24 patients, [who] are these patients [who] relapse within 24 months, are not overly common, but they’re not uncommon as well. About 20%, or maybe 25% of patients, will progress within 2 years from their frontline chemo immunotherapy.

This patient, in the frontline, got bendamustine/rituximab, which was a very reasonable choice and one that’s commonly used, especially here in the United States. But, we know that there’s a large range of treatment options for these patients. They go from very conservative therapies to relatively aggressive therapies and everything in-between. It depends on the patient, the goals of the patient, the specific characteristics of the disease, and [particularly] how fast it’s growing, what the symptoms are, and what the comorbidities are of the patient that all factor in to how you’re going to treat one of these patients.

So, you could have used radioimmunotherapy in this case. Zevalin is not specifically approved for frontline treatment, although the NCCN Guidelines [National Comprehensive Cancer Network Guidelines] do recognize it as a reasonable single-agent treatment choice for patients who are medically infirmed or probably not going to be able to tolerate standard chemoimmunotherapy.

Certainly single-agent rituximab is commonly used in these patients, especially for patients who might be a little bit older or less fit. I think there are other chemoimmunotherapy regimens. R-CHOP [rituximab, cyclophosphamide, doxorubicin, vincristine (Oncovin), and prednisone] could have been used in the front line. RCVP [rituximab, cyclophosphamide, vincristine, and prednisone] is a very common regimen, and even occasionally people will use fludarabine-based regimens for these patients.

I think one of the most interesting emerging treatment choices for these patients, especially if they’re a little bit older, is to move away from chemotherapy and to use what we call the R-squared regimen. It’s Revlimid/rituximab. The data that [were] just presented at the ASH [American Society of Hematology] meeting in December of 2018 really showed from the Augment Study that R-squared was better than single-agent rituximab from a response standpoint and from a progression-free survival standpoint. There are lots of other choices that I certainly would consider or think about in the right patient at the right time in the frontline setting.

I don’t think the R-squared [regimen] would have been my treatment of choice. I like that as an option for certain patients, patients who are older who I don’t like the idea of giving chemotherapy to. But in this case, I probably would have given bendamustine/rituximab. I think it’s a very reasonable regimen and appropriate. An alternative, however, would have been to replace the rituximab with a drug known as obinutuzumab. It’s a newer-generation humanized anti-CD20 antibody, and results from a couple trials, the GADOLIN trial and the GALLIUM Trial both show significant improvements of adding obinutuzumab to bendamustine, either compared to bendamustine alone or compared to regimens of rituximab-based chemoimmunotherapy.

Transcript edited for clarity.

Case:A 70-Year-Old Man With Follicular Lymphoma

H & P:

• A 70-year-old man presents with night sweats and general fatigue
• PMH: hypertension, no history of MACE
• PE: Groin is tender to touch, no tenderness in abdomen
• Initially diagnosed with bilateral axillary contiguous stage II FL 5.5 years ago
  • Grade 2 FL, 4 masses (each >3 cm)
  • FLIPI status: high risk

Current biopsy and labs:

• Biopsy: grade 2 FL without transformation
• ECOG performance status: 1
• Hematologic results
  • ANL: 1200 /µL
  • Platelets: 105,000 /µL
  • Hemoglobin: 11.9 g/dL
• LDH: 335 U/L
• eGFR: 75 mL/min/1.73²
• Imaging: PET/CT reveals inguinal lymphadenopathy, with largest mass 8.5 cm

Treatment and disease history

• Front-line BR
  • Completed 6 cycles, achieved PR by 3 months
  • Maintained PR for 20 months before developing fever and mediastinal lymphadenopahty
• Second-line R-CHOP
  • Competed 6 cycles, achieved PR at 3 months
  • PR maintained for 5 months
  • Time since completion of last treatment: 5 months

Current treatment

• Started on single-agent idelalisib 150 mg twice a day