June 19, 2020
Christopher R. Flowers, MD


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