Case Discussion: Transformation to Aggressive Lymphoma and Escalation of Care

This segment presents the program’s second case: a 72-year-old man with prior R-CHOP and R2 exposure who now demonstrates rapid progression, rising lactate dehydrogenase (LDH), B symptoms, and bulky lymphadenopathy, features highly suggestive of transformation to an aggressive lymphoma. The faculty walk through the clinical evaluation, emphasizing the importance of biopsy confirmation, especially when rising LDH and bulky disease raise suspicion for high-grade transformation. This segment highlights how transformed disease often behaves aggressively and requires a distinct treatment paradigm from indolent follicular lymphoma. NP Bailey outlines key considerations, including assessment of performance status, organ function, comorbidities such as diabetes and renal impairment, and the patient’s ability to tolerate intensive therapies. The discussion then shifts to potential treatment strategies, including CAR T-cell therapy, which may offer curative potential even for older adults. Dr. Mehta describes the roles of “holding” and “bridging” therapies in CAR T workflows, noting that rapid disease control may be necessary before leukapheresis or cell infusion. He comments on the limited data surrounding the addition of tafasitamab or epcoritamab after recent R2 exposure but emphasizes that clinical judgment and disease biology guide decision-making. This segment provides a comprehensive view of managing transformation, underscoring how clinicians must pivot quickly from indolent lymphoma strategies to aggressive lymphoma principles, while still considering the unique needs of older, comorbid patients.