Risk-Based Management of Follicular Lymphoma: Case 1 - Episode 1

Preliminary Workup for Follicular Lymphoma

Ajay Gopal, MD:The first case we have is a very typical presentation of follicular lymphoma. This is a case of a 75-year-old woman who presented with palpable lymphadenopathy, cervical and inguinal adenopathy. She had an excisional biopsy that showed a grade 2 follicular lymphoma with CD10 expression, and CT scan showed widespread adenopathy, but no lymph nodes bigger than 2.5 cm. Other studies included a CBC, which was normal, and a normal LDH.

This patient demonstrates a very common presentation of follicular lymphoma. Many patients present with asymptomatic disease. By GELF criteria, this patient has low tumor burden disease, no lymph nodes are over 7 cm, she does not have 3 lymph nodes over 3 cm, no splenomegaly, no effusions or ascites, and she’s otherwise asymptomatic. So, this is a typical patient where we would often, short of a clinical trial, recommend observation.

In terms of workup for a patient like this, most of the tests have already been performed. Other pathologic tests such as Ki-67, if this is elevated, can be prognostic. However, it doesn’t really guide our therapy at this point. There are other prognostic markers that can be used, still really in an investigational sense. There is the FLIPI score, which we all are very well aware of using clinical factors. This patient has a FLIPI score of 3 based on her age, her stage, and her number of nodal areas. However, the FLIPI is really not very good at distinguishing the high-risk patient. So, anyone with a score of 3 or higher is considered high-risk, and we would expect about a 35% 10-year survival based on the FLIPI score. But, within that range, there’s quite a bit of diversity in terms of outcomes within that high-risk range. There are other prognostic scores. There’s FLIPI2, which includes the beta-2 microglobulin, bone marrow involvement, as well as the largest lymph node size. And more recently, there’s something called the M7FLIPI, which is a molecular test looking at specific gene expression along with ECOG score. However, we still don’t yet know how to incorporate these prognostic markers into choosing the initial therapy or even when to start therapy.

In terms of other risk stratification factors, we look at the patient’s histologic grade. This patient had grade 2, and usually we think of grade 1/2 as the low-grade follicular lymphoma. We treat these patients as a typical indolent lymphoma. Grade 3b is at the other end of the spectrum, and this really is like diffuse large B-cell lymphoma. We should approach it like a diffuse large B-cell lymphoma. Grade 3a is somewhere in between. This is somewhat controversial. In my practice, I tend to give patients the benefit of the doubt. If they’re candidates for anthracycline-based therapies, I usually treat them with R-CHOP or some similar regimen if they have grade 3a, but this is another way to further risk-stratify patients.

Transcript edited for clarity.

June 2015

A 75-year-old female presents to her physician with bilateral inguinal adenopathy. She is otherwise healthy.

  • Laboratory findings: CBC count and LDH WNL
  • CT scan shows scattered adenopathy in the pelvis, mesentery, retroperitoneal regions. The largest lymph node is 2.6 cm.
  • Chest radiography, normal
  • Bone marrow biopsy is negative
  • Excisional biopsy, IHC staining for CD10 shows grade 1 follicular lymphoma