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Follicular Lymphoma Diagnostic Workup

Panelists: Ian W. Flinn, MD, PhD, Sarah Cannon Research Institute; Joshua Brody, MD, Icahn School of Medicine at Mount Sanai; Nathan H. Fowler, MD, University of Texas MD Anderson Cancer Center; John P. Leonard, MD, New York Presbyterian/Weill Cornell Medical Center; Matthew Lunning, DO, University of Nebraska Medical Center; Sonali M. Smith, MD, University of Chicago
Published: Tuesday, Jul 24, 2018



Transcript: 

Ian W. Flinn, MD, PhD: Hello, and thank you for joining this OncLive® Peer Exchange® titled “Management of Follicular Lymphoma.” Despite the fact that follicular lymphoma remains an incurable disease, outcomes are good for most patients, with a median survival exceeding 12 years. However, for the subgroup of patients who have high-risk disease and who developed early relapse or histologic transformation, clinical outcomes after immunochemotherapy are still poor. In this OncLive® Peer Exchange® we will discuss evolving research surrounding the treatment of follicular lymphoma. We’ll talk about how to incorporate newly available agents into your treatment regimen approach, and we’ll highlight the studies from the 2018 ASCO meeting.

I’m Dr. Ian Flinn, and I’m the director of the Blood Cancer Research Program at the Sarah Cannon Research Institute in Nashville, Tennessee. Participating today on our distinguished panel are: Dr. Joshua Brody, director of the Lymphoma Immunotherapy Program at the Icahn School of Medicine at Mount Sanai Hess Center for Science and Medicine in New York, New York. Dr. Nathan Fowler, associate professor in the Department of Lymphoma and Myeloma at the University of Texas MD Anderson Cancer Center in Houston, Texas. Dr. John Leonard, the Richard T. Silver Distinguished Professor of Hematology and Oncology at New York-Presbyterian/Weill Cornell Medical Center In New York, New York. Dr. Matthew Lunning, assistant professor of internal medicine in the Division of Oncology and Hematology at the University of Nebraska Medical Center in Omaha, Nebraska. And Dr. Sonali Smith, Elwood Jenson Professor of Medicine in the Section of Hematology and Oncology, as well as the director of the Lymphoma Program, at the University of Chicago. Thank you so much for joining us. Let’s begin.

John, I think it all starts with the workup of a patient with follicular lymphoma, and the startup involves a biopsy. I don’t know what happens at your institution, but we get a lot of needle biopsies, core needle biopsies. Is that what happens there, and is that sufficient? Do you repeat them with an incisional biopsy? What’s your approach?

John P. Leonard, MD: There are a number of steps to the diagnosis of follicular lymphoma, and obviously I think that the first, and the main presentation the patients have, is a painless lymph node. That’s the most common presentation in my experience. Sometimes it’s in the neck, in the groin, under the arm, sometimes on a mammogram. Typically, patients are not presenting with bulky disease, although in some cases they do. When they get to the medical oncologist, it can be a mixture of different ways. Sometimes they have a partial diagnosis, or a suspected diagnosis, and we’re asked to participate. The whole issue of fine needle aspiration (FNA), core needle biopsy, and excisional biopsy is one that’s of great interest. Sonali and I are on a panel that is looking at guidelines for this.

I would say that, traditionally speaking, excisional biopsies are the best, but around the country, it seems like core needle biopsies are probably most commonly done. I think it’s also fair to say, based on some expert opinion in the literature if you look at it closely, that on occasion, fine needle aspirates can be helpful if they’re accompanied by flow cytometry and a cell block that can really make the diagnosis. I would say that most patients are diagnosed with a core needle biopsy. Sometimes you can get away with an FNA, and obviously most preferred would be an excisional biopsy. But that seems to be, in our experience, a minority of the cases.

The next step, and others should certainly comment, I think that patients who are typically seen clinically get a fairly standard panel of laboratory tests, and a PET scan is a key part of the diagnosis. I would say that bone marrow biopsies are of relatively little value in managing patients and even in clinical trials, not particularly helpful in changing things. Of course, if the patient has cytopenias of that nature, they can be helpful. But those are the key aspects of the workup.

Ian W. Flinn, MD, PhD: Nate, are you getting PET scans on everybody with follicular lymphoma?

Nathan H. Fowler, MD: Yes. I agree with John; PET scans are a great tool when you’re first looking at a patient with follicular lymphoma. Not only will you sometimes pick up extra nodal disease, but also—I know the data are a little controversial about the importance of SUV—I do think in patients who have very high SUV, especially if that SUV is high in the node that I didn’t biopsy, I’ll go on and try to biopsy that node to rule out transformed disease or some other malignancy.

Joshua Brody, MD: In guiding which node you’re going to biopsy, right? Because patients have multiple nodes and we have one SUV 15 and everything else has to be 11. You might as well try to get the most FDG-avid node.

Matthew Lunning, DO: You might consider, if you’re thinking about a transformative disease process, an incisional biopsy to give your pathologist the best tools, because I think that may definitely change your up-front management.

Ian W. Flinn, MD, PhD: Yes, sometimes I really think we handicap the pathologists by giving the small samples. I look forward to hearing what your panel comes up with and what the recommendations are.

John P. Leonard, MD: There’s a lot of lore around this, but when you really look at the data closely, it’s not great data. We can certainly all recount cases where a fine needle aspiration, or a needle biopsy, was done, and then you get more tissue when you change the diagnosis. But really, the literature is pretty weak in this regard. So, I think, if you can get more tissue, it’s better.

Matthew Lunning, DO: I think it helps with the grading—if you still believe in the grading of follicular lymphoma, between the 1-2 and then getting into the 3s. So, more tissue is better in that situation.

Sonali M. Smith, MD: It’s controversial whether or not that matters, right?

Joshua Brody, MD: Like Nathan said, if you have a PET, which tells you homogeneity across the lesions, you’re less worried about making sure—if everything is SUV 9—the sample you have is probably representative of everything else there.

Nathan H. Fowler, MD: The difficult part is when you have a patient that has, for example, a difficult-to-access mediastinal node or something, even a mesentery. At least in clinical practice, I think those are often the most challenging when you have a diagnosis. It’s probably correct, but you have to go with the best guess.

Ian W. Flinn, MD, PhD: Do you want to put the person at the increased risk of the bone marrow biopsy?

Nathan H. Fowler, MD: Right. Especially if it’s a low-grade lymphoma, and its low volume, and this patient doesn’t have threatened disease, how much are you willing to risk for an excision?

Ian W. Flinn, MD, PhD: Yes, I think that’s a good point.

Sonali M. Smith, MD: I don’t always do a PET at baseline, unless I’m worried about transformation. If they are asymptomatic and have a normal LDH, just as John said, I don’t do a bone marrow biopsy. The PET is really only if there’s some question of transformation.

Transcript Edited for Clarity 

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Transcript: 

Ian W. Flinn, MD, PhD: Hello, and thank you for joining this OncLive® Peer Exchange® titled “Management of Follicular Lymphoma.” Despite the fact that follicular lymphoma remains an incurable disease, outcomes are good for most patients, with a median survival exceeding 12 years. However, for the subgroup of patients who have high-risk disease and who developed early relapse or histologic transformation, clinical outcomes after immunochemotherapy are still poor. In this OncLive® Peer Exchange® we will discuss evolving research surrounding the treatment of follicular lymphoma. We’ll talk about how to incorporate newly available agents into your treatment regimen approach, and we’ll highlight the studies from the 2018 ASCO meeting.

I’m Dr. Ian Flinn, and I’m the director of the Blood Cancer Research Program at the Sarah Cannon Research Institute in Nashville, Tennessee. Participating today on our distinguished panel are: Dr. Joshua Brody, director of the Lymphoma Immunotherapy Program at the Icahn School of Medicine at Mount Sanai Hess Center for Science and Medicine in New York, New York. Dr. Nathan Fowler, associate professor in the Department of Lymphoma and Myeloma at the University of Texas MD Anderson Cancer Center in Houston, Texas. Dr. John Leonard, the Richard T. Silver Distinguished Professor of Hematology and Oncology at New York-Presbyterian/Weill Cornell Medical Center In New York, New York. Dr. Matthew Lunning, assistant professor of internal medicine in the Division of Oncology and Hematology at the University of Nebraska Medical Center in Omaha, Nebraska. And Dr. Sonali Smith, Elwood Jenson Professor of Medicine in the Section of Hematology and Oncology, as well as the director of the Lymphoma Program, at the University of Chicago. Thank you so much for joining us. Let’s begin.

John, I think it all starts with the workup of a patient with follicular lymphoma, and the startup involves a biopsy. I don’t know what happens at your institution, but we get a lot of needle biopsies, core needle biopsies. Is that what happens there, and is that sufficient? Do you repeat them with an incisional biopsy? What’s your approach?

John P. Leonard, MD: There are a number of steps to the diagnosis of follicular lymphoma, and obviously I think that the first, and the main presentation the patients have, is a painless lymph node. That’s the most common presentation in my experience. Sometimes it’s in the neck, in the groin, under the arm, sometimes on a mammogram. Typically, patients are not presenting with bulky disease, although in some cases they do. When they get to the medical oncologist, it can be a mixture of different ways. Sometimes they have a partial diagnosis, or a suspected diagnosis, and we’re asked to participate. The whole issue of fine needle aspiration (FNA), core needle biopsy, and excisional biopsy is one that’s of great interest. Sonali and I are on a panel that is looking at guidelines for this.

I would say that, traditionally speaking, excisional biopsies are the best, but around the country, it seems like core needle biopsies are probably most commonly done. I think it’s also fair to say, based on some expert opinion in the literature if you look at it closely, that on occasion, fine needle aspirates can be helpful if they’re accompanied by flow cytometry and a cell block that can really make the diagnosis. I would say that most patients are diagnosed with a core needle biopsy. Sometimes you can get away with an FNA, and obviously most preferred would be an excisional biopsy. But that seems to be, in our experience, a minority of the cases.

The next step, and others should certainly comment, I think that patients who are typically seen clinically get a fairly standard panel of laboratory tests, and a PET scan is a key part of the diagnosis. I would say that bone marrow biopsies are of relatively little value in managing patients and even in clinical trials, not particularly helpful in changing things. Of course, if the patient has cytopenias of that nature, they can be helpful. But those are the key aspects of the workup.

Ian W. Flinn, MD, PhD: Nate, are you getting PET scans on everybody with follicular lymphoma?

Nathan H. Fowler, MD: Yes. I agree with John; PET scans are a great tool when you’re first looking at a patient with follicular lymphoma. Not only will you sometimes pick up extra nodal disease, but also—I know the data are a little controversial about the importance of SUV—I do think in patients who have very high SUV, especially if that SUV is high in the node that I didn’t biopsy, I’ll go on and try to biopsy that node to rule out transformed disease or some other malignancy.

Joshua Brody, MD: In guiding which node you’re going to biopsy, right? Because patients have multiple nodes and we have one SUV 15 and everything else has to be 11. You might as well try to get the most FDG-avid node.

Matthew Lunning, DO: You might consider, if you’re thinking about a transformative disease process, an incisional biopsy to give your pathologist the best tools, because I think that may definitely change your up-front management.

Ian W. Flinn, MD, PhD: Yes, sometimes I really think we handicap the pathologists by giving the small samples. I look forward to hearing what your panel comes up with and what the recommendations are.

John P. Leonard, MD: There’s a lot of lore around this, but when you really look at the data closely, it’s not great data. We can certainly all recount cases where a fine needle aspiration, or a needle biopsy, was done, and then you get more tissue when you change the diagnosis. But really, the literature is pretty weak in this regard. So, I think, if you can get more tissue, it’s better.

Matthew Lunning, DO: I think it helps with the grading—if you still believe in the grading of follicular lymphoma, between the 1-2 and then getting into the 3s. So, more tissue is better in that situation.

Sonali M. Smith, MD: It’s controversial whether or not that matters, right?

Joshua Brody, MD: Like Nathan said, if you have a PET, which tells you homogeneity across the lesions, you’re less worried about making sure—if everything is SUV 9—the sample you have is probably representative of everything else there.

Nathan H. Fowler, MD: The difficult part is when you have a patient that has, for example, a difficult-to-access mediastinal node or something, even a mesentery. At least in clinical practice, I think those are often the most challenging when you have a diagnosis. It’s probably correct, but you have to go with the best guess.

Ian W. Flinn, MD, PhD: Do you want to put the person at the increased risk of the bone marrow biopsy?

Nathan H. Fowler, MD: Right. Especially if it’s a low-grade lymphoma, and its low volume, and this patient doesn’t have threatened disease, how much are you willing to risk for an excision?

Ian W. Flinn, MD, PhD: Yes, I think that’s a good point.

Sonali M. Smith, MD: I don’t always do a PET at baseline, unless I’m worried about transformation. If they are asymptomatic and have a normal LDH, just as John said, I don’t do a bone marrow biopsy. The PET is really only if there’s some question of transformation.

Transcript Edited for Clarity 
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