May 28, 2020
Ajay K. Gopal, MD


Case:A 69-Year-Old Woman With Follicular Lymphoma

Initial Presentation

  • A 69-year-old woman complains of a 5-month history of fatigue, decreased appetite and a 10-bs. weight loss
  • PMH: unremarkable
  • PE: right axillary and bilateral cervical lymph nodes palpated ~ 3 cm; spleen palpable 4 cm below costal margin

Clinical Work-up

  • Labs: ANC 1.6 x 109/L, WBC 11.8 x 109/L, 40% lymphocytes, Hb 8.9 g/dL, plt 98 x 109/L, LDH 308 U/L, B2M 3.7 µg/mL; HBV negative
  • Excisional biopsy of the lymph node on IHC showed CD 20+, 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 right axillary lymph nodes (3.1 cm, 3.2 cm), diffusely enlarged nodes in the retroperitoneal and lumbar lymph nodes
  • Ann Arbor Stage IV; ECOG 1

Treatment

  • She was treated with R-CHOP for 6 cycles with rituximab maintenance; achieved partial response
  • 5 months later she complained of increasing fatigue
    • Repeat PET/CT revealed progression of disease
    • She was started on bendamustine + obinutuzumab for 6 cycles and continued maintenance obinutuzumab
    • Repeat lymph node biopsy remained grade 1-2 follicular lymphoma
  • 9 months later she complained of chills and low-grade fever
    • She was started on idelalisib 150 mg PO BID