Monitoring for Recurrence in Follicular Lymphoma

Video

Kami Maddocks, MD, highlights what findings may trigger a change in therapy or the introduction of a new agent into a patient’s current treatment.

Kami Maddocks, MD: When I treat a patient for follicular lymphoma [FL], if they achieve a complete remission to their initial therapy such as this patient did, I usually follow them every 3 to 4 months. I see them in the clinic, take a good history, do a good physical exam, and then check their labs, CVC [central venous catheter], chemistry panel, LDH [lactate dehydrogenase] for any indications of disease progression. I typically check CT [computed tomography] scans every 6 months for those first 2 years, so monitoring them in the high-risk period. After patients reach that 2 years of follow up standpoint, I usually extend their visits out to 6 months and see them every 6 months through year 5 and then go to yearly. I do CT scans from year 2 to year 5, and sometimes I will do them at most once each year to just get an idea if there’s been any progression.

Otherwise, I just use CT scans if patients call in with symptoms if I detect new lymphadenopathy on exam or if something in their lab is concerning to me. I do not do a routine PET [positron emission tomography] scan for monitoring in FL. I do like to get a PET for their end of therapy, to ensure that they’re negative by PET scan.

Transcript edited for clarity.


Case: A 74-Year-Old Man With Relapsed/Refractory Follicular Lymphoma

Initial presentation

  • A 74-year-old man complains of a 6-month history of fatigue, occasional fevers, decreased appetite, fatigue, and an 8-lb weight loss
  • PMH: unremarkable
  • PE: palpable right axillary and cervical lymph nodes, palpable ~ 3 cm in both locations; spleen palpable 4.5 cm below left costal margin
     

Clinical Workup

  • Labs: ANC 1.6 x 109/L, WBC 11.2 x 109/L, 44% lymphocytes, Hb 9.6 g/dL, plt 98 x 109/L, LDH 315 U/L, B2M 3.5 µg/mL; HBV negative
  • Excisional biopsy of the axillary lymph node on IHC showed CD 20+, CD 3+, CD5+, CD 10+, BCL2+; follicular lymphoma grade 2
  • Bone marrow biopsy showed paratrabecular lymphoid aggregates, 4% involvement
  • Molecular genetics: t(14;18) (q32;q21)
  • PET/CT showed enlargement of right axillary, cervical, and mediastinal lymphadenopathy (3.3 cm, 3.1, cm and 4.6 cm respectively)
  • Ann Arbor Stage IV; ECOG 0
     

Treatment

  • He was treated with R-CHOP for 6 cycles, achieved complete response and continued rituximab maintenance
  • 24 months later he complained of increasing weight loss, fever and drenching sweats as well as more enduring fatigue and new onset itching; he was currently taking antibiotics for his 3rd bacterial infection in the past year
    • Repeat PET/CT revealed progression of disease
    • He was started on bendamustine + rituximab for 6 cycles and continued on rituximab maintenance
    • Repeat lymph node biopsy grade 2 follicular lymphoma
  • 12 months later he complained of continued weight loss, increased itching and worsening fatigue; recurrent infections continued
    • He was started on idelalisib 150 mg PO BID
Related Videos
Hannah Choe, MD, an expert on GVHD
Corey Cutler, MD, MPH, an expert on GVHD
Corey Cutler, MD, MPH, and Hannah Choe, MD, experts on GVHD
Corey Cutler, MD, MPH, and Hannah Choe, MD, experts on GVHD
Guillermo Garcia-Manero, MD, an expert on MDS
Related Content