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