Follicular Lymphoma Management: Future Directions

Christopher Flowers, MD: This patient’s situation addressed one of the key unmet needs with follicular lymphoma, and that’s patients who experience early relapse. I’ve been engaged in a US intergroup trial that evaluates those 3 arms with therapies for those patients who experience early relapse. I think that’s a very important trial to accrue patients to, to help answer this question.

The other unmet needs that are being addressed are those patients with aggressive forms of relapse or transformation.

CAR [chimeric antigen receptor] T cells are another promising therapy that is available for patients with follicular lymphoma, and I think new trials need to be explored to ascertain where those might be best utilized in the relapsed and refractory setting, particularly for patients who experience more aggressive disease.

There are now many new, novel targeted immunotherapies for patients with follicular lymphoma, and we’re moving into an era where chemotherapy-free regimens may be possible for patients in the first line of therapy and with each subsequent line of relapse.

It’s a very promising time for new therapies and new clinical trials for patients with follicular lymphoma.

Transcript edited for clarity.

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