Risk-Based Management of Follicular Lymphoma: Case 2 - Episode 1
Ajay Gopal, MD:The second case is of a 66-year-old gentleman who presented with inguinal and axillary lymphadenopathy. Initial biopsy of the lymph nodes showed grade 2 follicular lymphoma, and further staging studies with CT scan showed widespread disease with bulky disease up to almost 10 cm, as well as pleural effusion. Bone marrow showed 70% involvement, and patient also had anemia and elevated LDH. We don’t have any additional data on the PET scan regarding this patient, but he was treated with R-CHOP, responded, achieved a complete remission, but unfortunately relapsed after 19 months. At the time of relapse, the patient was then, again, treated with bendamustine/rituximab, this time only achieving a partial response that lasted 6 months. Six months after completing the bendamustine/rituximab, the patient presented to clinic with complaints of fatigue and abdominal fullness. CT scans showed, again, progressive lymphadenopathy, particularly in the abdomen and pelvis, and he was started on idelalisib.
In contrast to our first case, this is a much tougher situation. This is a gentleman who had a short initial remission duration, less than 2 years, and now has had an even shorter remission duration after only achieving a partial response to second-line chemoimmunotherapy. We know from recent data, from the LymphoCare study from Carla Casulo and others, looking at the impact of early relapse that the FLIPI score alone is not very accurate at predicting outcomes. However, we do know from this study that patients who have a relapse within 24 months of their diagnosis have a very poor outcome. Fortunately, this is only about one-fifth of patients, but patients in this category really only have about a 50% 5-year survival.
So, this further stratification by time to initial relapse really helps guide us in terms of our therapy. For 80% of the patients, fortunately, they’ll do well. There will be a later relapse, if at all. And for those patients, the key is to use restraint to try to minimize toxicityat least in my perspective—and not be overly aggressive. However, for the 1 in 5 patients, like this unfortunate gentleman, who’ve had an early relapse, we need to think about novel strategies. And this is where I really talk about clinical trial options because the outcomes are much poorer.
Transcript edited for clarity.