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

 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