59-Year-Old Man With Relapsed Follicular Lymphoma

Jonathan Friedberg, MD:This is a 59-year-old man who initially presented to his physician complaining about a 10-pound weight loss and some night sweats that have been lasting for about 2 or 3 months. He also complained of intermittent fatigue with decreased energy. But he’s still been exercising, and he’s been able to maintain his current work. On exam at that time he had bilateral enlarged axillary lymphadenopathy, and his spleen was palpated on exam, a few finger breaths below the costal margin.

Blood counts suggested mild cytopenia with a normal white [blood cell] count, a platelet count of 103,000 [mm³], and a hemoglobin of 9 g/dL. LDH [lactate dehydrogenase] was 400 U/L, and the patient was referred for a lymph node biopsy. And an excisional biopsy of the axillary node showed grade 2 follicular lymphoma, with a classic immunophenotype, CD20+, CD10+, BCL2+.

Subsequent evaluation included a bone marrow biopsy, which did demonstrate involvement by classic paratrabecular follicular lymphoma. And the imaging study performed was a PET [positron emission tomography or] CT [computed tomography scan] that demonstrated widespread lymphadenopathy, large splenic mass. The mass around the spleen was about 10 cm, and the diagnosis was made of stage IV follicular lymphoma.

The patient was assessed by medical oncologists and started on R-CHOP [rituximab, cyclophosphamide, hydroxydaunorubicin, hydrochloride, vincristine, prednisone] treatment. The patient tolerated this treatment very well. Symptoms disappeared quite quickly, and he was able to get through 6 full cycles of R-CHOP [rituximab, cyclophosphamide, hydroxydaunorubicin, hydrochloride, vincristine, prednisone] on time without major complications.

A post-therapy PET scan did demonstrate some residual FTD [frontotemporal dementia] avidity in some of the lymphadenopathy. Although the patient did have marked diminution in size of these lymph nodes, which was felt to be consistent with a partial remission.

Then the patient was placed on rituximab maintenance treatment every 2 months with a plan to do this until evidence of disease progression. The patient did well initially, although within a year of the rituximab maintenance, there was some concern over progression of lymphadenopathy. And a core biopsy was then performed of the largest lymph node that confirmed really the same follicular lymphoma of original diagnosis. There was no evidence of transformation.

The PET scan at that time also demonstrated some mild increase in size of mass around the spleen. His performance status remained very favorable. At that point the decision was made to start the patient on bendamustine and obinutuzumab.

There are several features about this case that were typical, and features, I would say, that were atypical. The amount of symptoms this patient had was a little more than you might expect for follicular lymphoma. Generally speaking, follicular lymphoma is often diagnosed in a completely asymptomatic patient who just feels some lymphadenopathy. The LDH, mildly increased, also would make one concerned that if this is follicular lymphoma as demonstrated on the biopsy, there could be some sites of transformation. And in such a case I would pay very close attention to the PET scan, not only the extent of involvement and the size of the lymphadenopathy, but what the SUV, or standardized uptake value is. If that SUV is high, maybe more than 10 or 15, the risk of transformation goes up. And I would certainly seek, at least consider, a biopsy of the highest SUV lymphadenopathy if that were possible.

Also, note that this patient had a fairly bulky mass. That in and of itself is not so atypical with follicular lymphoma. With follicular lymphoma, you can often see masses that get fairly large because the patient can remain asymptomatic, particularly if there are abdominal masses. But it sometimes is the case that when you see a bulky mass like that, it can confer a higher degree of symptomatology and some higher-risk factors of the follicular lymphoma.

The last thing I’ll say about this presentation is that we don’t have a very robust way of categorizing how follicular lymphoma is likely to behave when a patient walks in the door. I’ve seen patients who seem to have a lot of risk factors do very well, and patients who have what appears to be very indolent disease really become resistant to therapy quickly. We often use the FLIPI [Follicular Lymphoma International Prognostic Test] score as a way to categorize how a patient does, and this patient does have several risk factors on the FLIPI score—the number of lymph node sites, the advanced stage of disease. His age is borderline; his hemoglobin is low. So this patient would be considered a high-risk FLIPI situation, which in general would suggest that he may have an inferior outcome that’s compared [with] some other patients walking in the door.

Transcript edited for clarity.

Case: A 59-Year-Old Man With Symptomatic Follicular Lymphoma

A 59-year-old man presented to his physician with a 10-lb weight loss and chronic night sweats for the past couple of months. He complained of intermittent fatigue but is able to maintain his current exercise regimen.

H & P

• PE: enlarged bilateral axillary lymph nodes; enlarged spleen, palpable
• CBC: WBC, 12 X 10⁴/L; platelets,103 X 10⁹/L; Hgb, 9.2 g/dL
• LDH: 400 U/L

Biopsy

• Excisional biopsy showed grade 2 follicular lymphoma; CD20+, CD10+
• Bone marrow biopsy; 60% involved

Imaging

• PET/CT showed widespread lymphadenopathy and a large splenic mass measuring 10 cm
• Diagnosis: Stage IV follicular lymphoma

Teatment

• Started on R-CHOP; tolerated induction well
• Post-therapy PET showed partial remission
• Followed by Rituximab maintenance until evidence of disease progression

Follow-up

• Core needle biopsy; performed confirmed persistent follicular lymphoma; no transformation
• PET at 12 months showed increased size of splenic mass
• ECOG, 0
• Patient started on obinutuzumab + bendamustine