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