Managing Relapsed Follicular Lymphoma - Episode 6
Nathan H. Fowler, MD:Twelve months later, the patient presented with symptoms, again, night sweats, but she had an excellent performance status, and she was still exercising regularly. Her ECOG performance status was 0. She had a PET/CT that showed enlargement of the same nodes that we had seen previously, namely in the axilla, the hilum, and the bilateral cervical region, and she was started on copanlisib. After 4 weekly doses, she was found to be in a partial remission, and she remains on treatment.
In this case, we have a woman who has now multiple relapses. She’s relapsed after induction therapy and has relapsed following lenalidomide and rituximab, and now she’s on her third line of treatment. This is not an uncommon scenario in patients with follicular lymphoma. And, many times, the disease is marked by relapses that occur every 3 to 4 months to sometimes longer. But sometimes, again, patients can relapse at early intervals between 12 and 18 months. And, generally, when I think about this group of patients, I think about novel treatment options, about using something that has a different mechanism and something that could potentially put these patients in remission that is durable.
Over the past few years, we’ve seen, I think, a revolution in different therapies that are available for patients with follicular lymphoma. Many of these new drugs are currently FDA approved, and many of them will soon be FDA approved, we hope, within the next several years.
So, the landscape of treatments that are currently available for patients with relapsed follicular lymphoma, especially patients who are in a third line, would include the 2 PI3-kinase inhibitors. Those 2 PI3-kinase inhibitors include a drug called idelalisib and a drug called copanlisib. Both of these drugs hit the PI3-kinase pathway; these are drugs that target the PI3-kinase pathway. We know that this pathway is essential in the function and development of normal B cells. And it’s evolved as a target for drugs that are very active both in lymphoma and in leukemia.
As I mentioned, the 2 drugs that are currently FDA approved are idelalisib and copanlisib. And they have slightly different mechanisms of action. Idelalisib hits mainly PI3-kinase delta. This is a specific isoform of PI3-kinase. And copanlisib hits the PI3-kinase, mainly the PI3-kinase alpha and delta isoform, although it does hit beta and gamma as well at a lower extent.
Transcript edited for clarity.