March 17, 2021
John P. Leonard, MD


 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