A 60-Year-Old Man with Newly Diagnosed Follicular Lymphoma - Episode 1

Case Overview: A 60-Year-Old Man with Newly Diagnosed Follicular Lymphoma

Alan Skarbnik, MD, presents the case of a 60-year-old man with newly diagnosed follicular lymphoma.

Alan Skarbnik, MD: Hello, my name is Alan Skarbnik. I’m the director of the lymphoma and CLL [chronic lymphocytic leukemia] program at Novant Health Cancer Institute.

We are going to talk today about follicular lymphoma. I have a case to discuss. This is a 60-year-old man who presented with a 4-month history of fatigue, decreased appetite, occasional fevers, and a 7-lb unintentional weight loss; no significant past medical history.

Upon physical examination, the patient presented with palpable right axillary lymph nodes, maximum of 2.5 cm, and bilateral cervical lymph nodes up to 3 cm in size. The spleen was palpable 4 cm below the left costal margin.

In the clinical work-up, the patient presented with ANC [absolute neutrophil count] of 1600, white blood cell count of 11,000, with lymphocytes accounting for 42% of the white blood cell count, anemia with a hemoglobin of 9.7 g/dL, thrombocytopenia with platelets 97,000, LDH [lactate dehydrogenase] was elevated at 402 U/L, beta-2 microglobulin was 3.4 μg/mL, hepatitis B panel was negative.

An excisional biopsy of the axillary lymph node was performed, and on IHC [immunohistochemistry] it showed CD20-positive, CD3+, CD5+, BCL2+, follicular lymphoma grade 2. A bone marrow biopsy was performed and showed paratrabecular lymphoid aggregates with up to 38% involvement. Cytogenetics were positive for t(14;18). Molecular testing was performed, and EZH2 was wild type.

A PET [positron emission tomography] scan showed right axillary, bilateral cervical, and mediastinal lymphadenopathy. The patient was characterized as Ann Arbor stage IV with an ECOG performance status of 1.

This patient was treated with obinutuzumab plus CHOP [cyclophosphamide, doxorubicin, vincristine, prednisone] and completed 6 cycles. The treatment was well tolerated. He continued on obinutuzumab maintenance. Nineteen months later, the patient complained again of fever, chills, and worsening fatigue.

The initial impression of this case is this is a patient with certainly advanced follicular lymphoma, presenting with B symptoms, splenomegaly, bone marrow involvement, cytopenias, lymphocytosis. This is not necessarily the most common presentation in patients. A number of times we see patients with asymptomatic lymphadenopathy, and upon biopsy we can diagnosis follicular lymphoma, and these patients can be monitored. Rarely, patients present with early stage disease, and we can treat with radiation or monitor. There’s high variability and heterogeneity in the presentation of follicular lymphoma. So we can see patients in all spectrums of the disease, but generally, patients don’t present with this much disease and this many symptoms, but it certainly can happen.

Transcript edited for clarity.

A 60-Year-Old Man with Follicular Lymphoma

Initial presentation

A 60-year-old man presents with a 4-month history of fatigue, decreased appetite, occasional fevers, and a 7-lb unintentional weight loss

PMH: Unremarkable

PE: palpable right axillary lymph nodes, ~2.5 cm and bilateral cervical lymph nodes, ~3 cm, spleen palpable 4 cm below left costal margin

Clinical workup

Labs: ANC 1.6 x 10^9, WBC 11.4 x 10^9, lymphocytes 42%, HB 9.7 g/dL, plt 97 x10^9, LDH 402U/L, 3.4 B2M ug/mL; HBV negative

Excisional biopsy of axillary lymph node on IHC showed CD20+, CD3+, CD5+, BCL2+, Follicular lymphoma grade 2

Bone marrow biopsy showed paratrabecular lymphoid aggregates, 38% involvement

Cytogenetics: t(14:18) (Q32;q21)

Molecular testing: EZH2 wild type

PET/CT showed right axillary, bilateral cervical, and mediastinal lymphadenopathy (3.1 cm, 3.1 cm, and 2.6 cm respectively)

Ann Arbor Stage IV, ECOG PS is 1

Treatment

Patient was treated with obinutuzumab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) chemotherapy. He completed 6 cycles and treatment was well tolerated.

He continued on obinutuzumab maintenance.

19 months later, he complains of fevers, chills, and worsening fatigue.