A 71-Year-Old Woman With Relapsed/Refractory Follicular Lymphoma

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Hematology/oncology expert, John P. Leonard, MD, describes the rationale for treating an elderly patient with relapsed/refractory follicular lymphoma with a PI3K inhibitor in the third-line setting.

 Case: A 72-Year-Old Woman With Follicular Lymphoma

Initial Presentation 

  • A 71-year-old woman complains of a 5-month history of occasional fevers, decreased appetite, fatigue, and an unintentional 7-lbs. weight loss
  • PMH: unremarkable 
  • PE: palpable left axillary lymph nodes ~ 4 cm and bilateral cervical lymph nodes ~ 3 cm; spleen palpable 4.5 cm below costal margin 
     

Clinical Work-Up 

  • Labs: ANC 1.5 x 109/L, WBC 11.8 x 109/L, 42% lymphocytes, Hb 9.6 g/dL, plt 100 x 109/L, LDH 325 U/L, B2M 3.7 µg/mL; HBV negative 
  • Excisional biopsy of the axillary lymph node on IHC showed CD 20+, CD 3+, CD5+, 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 left axillary, mediastinal, and bilateral para-aortic lymphadenopathy (4.2 cm, 5.3 cm, 3.6 cm, and 3.5 cm respectively) 
  • Ann Arbor Stage IV; ECOG 0 
     

Treatment 

  • She was treated with R-CHOP for 6 cycles; continued rituximab maintenance 375 mg/m3; achieved partial response 
  • 6 months later, she complained of increasing frequency of fevers and chills 
  • Repeat PET/CT revealed progression of disease 
  • She was started on bendamustine + obinutuzumab for 6 cycles and continued maintenance on obinutuzumab 
  • Repeat lymph node biopsy grade 2 follicular lymphoma 
  • 12 months later, she complained of increased weight loss and fatigue 
  • She was started on idelalisib 150 mg PO BID and achieved partial response 
  • She experienced grade 2 diarrhea, which was successfully managed 
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1 expert in this video
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Jamie L. Koprivnikar, MD, an expert on MDS
Jamie L. Koprivnikar, MD, an expert on MDS
Jamie L. Koprivnikar, MD, an expert on MDS
Jamie L. Koprivnikar, MD, an expert on MDS
Jamie L. Koprivnikar, MD, an expert on MDS
Jamie L. Koprivnikar, MD, an expert on MDS
Jamie L. Koprivnikar, MD, an expert on MDS
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