A 69-Year-Old Woman With Follicular Lymphoma - Episode 1

Diagnosis of a 69-Year-Old Woman With Follicular Lymphoma

Ajay K. Gopal, MD: Today we’re going to be discussing the case of a 69-year-old woman who presents to clinic with a 5-month history of fatigue, decreased appetite, and a 10-lb weight loss. Her past medical history is otherwise unremarkable. When you examine her, you palpate right axillary and bilateral cervical lymph nodes measuring up to about 3 cm. An abdominal examination shows a spleen palpable about 4 cm below the left costal margin.

Her laboratory work-up includes a CBC [complete blood count test], which shows an ANC [absolute neutrophil count] of 1600, a total white cell count of 11,800, about 40% lymphocytes in the differential. Her hemoglobin is 8.9 g/dL, and her platelet count is 98,000. Her LDH [lactate dehydrogenase] is borderline elevated—at 308 [U/L]—and her beta2 microglobulin is 3.7 [μg/mL]. Hepatitis B testing is negative.

You send her for an excisional biopsy of one of her lymph nodes, and the IHC [immunohistochemistry] shows a CD20-positive, CD10-positive, BCL2 [B-cell lymphoma 2 protein] follicular lymphoma grade 1/2. You fully stage her with a bone marrow biopsy, used also to evaluate her cytopenias, and it shows, not surprisingly, paratrabecular lymphoid aggregates, about 45% bone marrow involvement.

Not surprisingly, the molecular genetic studies come back showing a translocation of t(14;18), and PET [positron emission tomography]/CT staging confirms your physical exam findings, showing lymph nodes of about 3.1 to 3.2 cm as well as diffusely enlarged lymph nodes throughout the retroperitoneum and lumbar region. She is staged Ann Arbor Stage IV based on her bone marrow involvement. Her ECOG performance status is 1.

She was initially treated with R-CHOP [rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone] for 6 cycles followed by rituximab maintenance—375 mg/m2 every 2 months—and she achieved a partial response as her best response. Five months after completing rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone, she unfortunately again complained of increasing fatigue. A repeat PET/CT showed diffuse disease progression. She was started on bendamustine/obinutuzumab for 6 cycles, and continued on maintenance obinutuzumab.

It’s important to note that prior to starting second-line therapy, she underwent a repeat lymph node biopsy that, again, showed grade 1/2 follicular lymphoma with no evidence of transformation.

Unfortunately, 9 months after completing her bendamustine component, she again complained of symptoms—this time, chills and a low-grade fever—and she was started on idelalisib dosed at 150 mg PO BID [orally twice a day].

Transcript edited for clarity.


Case:A 69-Year-Old Woman With Follicular Lymphoma

Initial Presentation

  • A 69-year-old woman complains of a 5-month history of fatigue, decreased appetite and a 10-bs. weight loss
  • PMH: unremarkable
  • PE: right axillary and bilateral cervical lymph nodes palpated ~ 3 cm; spleen palpable 4 cm below costal margin

Clinical Work-up

  • Labs: ANC 1.6 x 109/L, WBC 11.8 x 109/L, 40% lymphocytes, Hb 8.9 g/dL, plt 98 x 109/L, LDH 308 U/L, B2M 3.7 µg/mL; HBV negative
  • Excisional biopsy of the lymph node on IHC showed CD 20+, 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 right axillary lymph nodes (3.1 cm, 3.2 cm), diffusely enlarged nodes in the retroperitoneal and lumbar lymph nodes
  • Ann Arbor Stage IV; ECOG 1

Treatment

  • She was treated with R-CHOP for 6 cycles with rituximab maintenance; achieved partial response
  • 5 months later she complained of increasing fatigue
    • Repeat PET/CT revealed progression of disease
    • She was started on bendamustine + obinutuzumab for 6 cycles and continued maintenance obinutuzumab
    • Repeat lymph node biopsy remained grade 1-2 follicular lymphoma
  • 9 months later she complained of chills and low-grade fever
    • She was started on idelalisib 150 mg PO BID