A 77-Year-Old Man With Follicular Lymphoma

June 19, 2020
Christopher R. Flowers, MD

Christopher Flowers, MD, describes the management of an elderly patient with relapsed follicular lymphoma using newer novel therapy.


Case:A 77-Year-Old Man With Follicular Lymphoma

Initial Presentation

  • A 77-year-old man complains of a 4-month history of occasional fevers, decreased appetite, and an unintentional 7-lbs. weight loss
  • PMH: unremarkable
  • PE: palpable left axillary lymph nodes ~ 4 cm; spleen palpable 4.5 cm below costal margin

Clinical Work-up

  • Labs: ANC 1.5 x 109/L, WBC 10.6 x 109/L, 42% lymphocytes, Hb 10.1 g/dL, plt 100 x 109/L, LDH 325 U/L, B2M 3.3 µg/mL; HBV negative
  • Follicular lymphoma grade 2
  • Bone marrow biopsy showed lymphoid aggregates, 35% 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

  • He was treated with R-CHOP for 6 cycles; continued rituximab maintenance 375 mg/m3; achieved partial response
  • 6 months later he complained of increasing frequency of fevers
    • Repeat PET/CT revealed progression of disease
    • He was started on bendamustine + obinutuzumab for 6 cycles and continued maintenance obinutuzumab
    • Repeat lymph node biopsy grade 2 follicular lymphoma
  • 8 months later he complained of increased weight loss
    • He was started on idelalisib 150 mg PO BID