- A 44-year-old man presented to his physician with submandibular swelling. He reports losing weight over the past few months.
- Excisional biopsy showed grade 2 follicular lymphoma that was positive for CD20, CD10, Bcl-6 and Bcl-2 co-expression, and t(14;18); KI-67, 15%
- Imaging showed widespread lymphadenopathy and a large mesenteric mass measuring 11.2 cm
- LDH elevated (400 U/L), stage IV follicular lymphoma with bone marrow involvement
- The patient was started on R-CHOP
- PET/CT imaging at end of therapy was consistent with a complete remission.
- Follow-up PET/CT at 9 months showed increasing size of the mesenteric mass and progression in the axillary lymph nodes.
- A biopsy was pursued at that time confirming relapsed follicular lymphoma.
- The patient was initiated on obinutuzumab + bendamustine with plan for obinutuzumab maintenance.
- Eleven months later, the patient reported having fever and fatigue along with increased swelling in the submandibular node.
- PET/CT showed widespread progression with increased size of the mesenteric mass to 12.5 cm and 3 new lesions (3.2 cm, 2.4 cm, 1.8 cm) in the inguinal region.
- The patient was started on therapy with idelalisib.
- He experienced severe diarrhea from this treatment which was successfully managed with enteric budesonide and systemic corticosteroids.