Case Review: Progression in Follicular Lymphoma - Episode 4

Risk Prognostication in Follicular Lymphoma

John Pagel, MD:As I mentioned, this patient had a high FLIPI score, or a Follicular Lymphoma International Prognostic Index score. There are 2 FLIPI scores. There’s a FLIPI-1 and a FLIPI-2. FLIPI-2 is essentially the results in prognostic information that we need to know about a follicular lymphoma patient in the era of the use of rituximab.

FLIPI-1 or 2 are both important to know and to use, and they’re important to prognosticate for patients to really put them in different risk groups so that we all understand, including the patient, their risk for progression and their risk for needing additional treatment by a certain amount of time.

The Follicular Lymphoma International Prognostic Index scores 1 and 2 are a little bit differentand the parameters are as well.It’s actually not necessary to memorize them and to know the different factors in how to calculate a score. Because you can just go to the internet and type in the Follicular Lymphoma International Prognostic Index, or FLIPI, and you’ll get a calculator and you can put in there the age of the patient, their beta-2 microglobulin, how big the mass of their disease is, and if they have bulky disease or not. You can put in their LDH [lactate dehydrogenase] or their hemoglobin. It’ll give you a score and put you into different risk groups so that you can know for prognostic information how the patient’s going to do. But, that’s really for the time of diagnosis. We really don’t use that at the time of relapse for most patients.

At the time of diagnosis, this patient didn’t need treatment, and watch and wait—as we like to say, watchful waiting—was very appropriate. We don’t treat patients still, in this day and age, with follicular lymphoma unless we have a reason to. Why is that? Because we’ve never had anything that’s shown that if we treat someone at the time of presentation, if they’re asymptomatic without a need for treatment, that we’re going to make them live any longer. If we give people treatment when they’re asymptomatic and don’t need anything, we’re only going to perhaps make them feel worse. So, we don’t do anything. Watchful waiting is perfectly appropriate and reasonable for patients.

How do we know, though, when we need to treat someone with follicular lymphoma? Fortunately, we do have some criteria that are very well defined that help us make that decision. They’re called the GELF [Group d’Etude des Lymphomes Folliculaires] criteria, or G-E-L-F, and they come from a French study that looked at the parameters that really drove the need for treatment. And there are a variety of them—again, you can go to the internet and find these easily—but they’re simple. They’re things like more than 3-centimeter disease in at least 3 sites. They’re bulky disease. They’re symptoms. They’re symptomatic splenomegaly. You get the idea. GELF criteria are really what should drive if someone needs a treatment or not.

Transcript edited for clarity.

Case:A 70-Year-Old Man With Follicular Lymphoma

H & P:

  • A 70-year-old man presents with night sweats and general fatigue
  • PMH: hypertension, no history of MACE
  • PE: Groin is tender to touch, no tenderness in abdomen
  • Initially diagnosed with bilateral axillary contiguous stage II FL 5.5 years ago
    • Grade 2 FL, 4 masses (each >3 cm)
    • FLIPI status: high risk

Current biopsy and labs:

  • Biopsy: grade 2 FL without transformation
  • ECOG performance status: 1
  • Hematologic results
    • ANL: 1200 /µL
    • Platelets: 105,000 /µL
    • Hemoglobin: 11.9 g/dL
  • LDH: 335 U/L
  • eGFR: 75 mL/min/1.732
  • Imaging: PET/CT reveals inguinal lymphadenopathy, with largest mass 8.5 cm

Treatment and disease history

  • Front-line BR
    • Completed 6 cycles, achieved PR by 3 months
    • Maintained PR for 20 months before developing fever and mediastinal lymphadenopahty
  • Second-line R-CHOP
    • Competed 6 cycles, achieved PR at 3 months
    • PR maintained for 5 months
    • Time since completion of last treatment: 5 months

Current treatment

  • Started on single-agent idelalisib 150 mg twice a day