Approach to High-Risk Follicular Lymphoma

March 15, 2018

Approach to High-Risk Follicular Lymphoma


January 2016

  • A 62-year-old male presented with left axillary lymphadenopathy
  • PMH: DVT managed on warfarin, CMV infection
    • Laboratory findings: CBC count and LDH WNL
    • Excisional biopsy, IHC staining CD10+, grade 2 follicular lymphoma
    • PET/CT, multicompartmental adenopathy and splenomegaly consistent with stage IV disease
    • Bone marrow biopsy, 30% involvement
    • FLIPI 2 (intermediate-risk)
  • The patient was started on bendamustine + rituximab (6 cycles)
  • She achieved an unconfirmed complete response

June 2017

  • 18 months later, he developed recurrent cervical adenopathy with weight loss and fatigue
  • Imaging revealed adenopathy in 2 cervical lymph nodes (4.6 cm and 2.4 cm), a mediastinal node (2 cm) and left inguinal node (3.1 cm) with splenomegaly.
  • The patient was treated with R-CHOP
  • After 2 cycles he developed anemia and grade 2 fatigue
  • He achieved a partial response

November 2017

  • Five months later, the patient reports feeling tired and abdominal fullness
  • Physical exam remarkable for palpable splenomegaly
  • Laboratory evaluation showed marked anemia, thrombocytopenia
  • PET imaging showed enlargement of pelvic and retroperitoneal nodes and development of several new mediastinal lesions
  • Repeat biopsy showed grade 3 follicular lymphoma, 90% bone marrow involvement
  • The patient was started on idelalisib therapy
  • After 2 months on therapy, he developed grade 3 colitis which was managed
  • After four months on therapy, the patient has stable disease