Differential Diagnosis and Staging of Follicular Lymphoma


Ian Flinn, MD: Follicular lymphoma remains a chronic incurable disease. Outcomes are good for most patients, with median overall survival exceeding 12 years. However, for the subgroup of patients who have high-risk disease and who develop early relapse or histological transformation, clinical outcomes after immunochemotherapy are still poor.

Today I am joined by a group of my colleagues who are renowned experts in the field of lymphoma research. We will discuss evolving research surrounding the treatment of follicular lymphoma. We’ll talk about how to incorporate newly available agents into your treatment approach, and we’ll highlight the studies from the 2019 ASH [American Society of Hematology] Annual Meeting & Exposition.

I am Dr Ian Flinn, the director of lymphoma research at the Sarah Cannon Research Institute and Tennessee Oncology in Nashville, Tennessee.

Today I am joined by Dr John Gribben, the president of the EHA [European Hematology Association] and a professor of medical oncology at Barts Cancer Institute in London, England;

Dr John Leonard, a professor of medicine and the Richard T. Silver Distinguished Professor of Hematology and Medical Oncology at Weill Cornell Medical College in New York, New York;

Dr Lori Leslie, an assistant professor of medicine at Hackensack Meridian School of Medicine at Seton Hall and a lymphoma oncologist at the John Theurer Cancer Center in Hackensack, New Jersey;

And Dr Pier Luigi Zinzani, a professor of hematology and the head of the Lymphoma Group at the Institute of Hematology, University of Bologna, in Bologna, Italy.

Thank you for joining us. Let’s begin. John, let’s start with you. Can we just go through how to work up a patient with follicular lymphoma? We start with making the diagnosis, so talk about that a little.

John Gribben, MD, DSc: Most of these patients are going to present with painless lymphadenopathy. My usual passion is that people have been going to see their own physician several times, so you’ve got some persistent lymphadenopathy. For us, the most important thing is to make an accurate diagnosis. That requires, of course, staging the disease but most important, a histopathologic diagnosis. You need some tissue, and that tissue needs to be in the hands of an expert hematopathologist who’s going to give you an accurate diagnosis of that disease.

What you’re looking for here is to differentiate follicular lymphoma from the other subtypes of indolent lymphoma. In particular, to make sure you aren’t missing an aggressive lymphoma or even someone who is presenting with follicular lymphoma but also has evidence of transformation of the disease. Although that’s pretty rare, it’s something we don’t want to miss at the time of the initial diagnosis.

So getting a tissue: We used to do it almost always by excisional biopsies. Nowadays, we’re almost usually doing it by radiological guided biopsy. An important kind of learning we talk about a lot is that needle biopsies are not good ways to make this diagnosis. They’re a good way to pick up whether the differential is something reactive versus lymphoma, but to make an accurate lymphoma diagnosis, you really need sufficient tissue in the hands of an expert hematopathologist who can help you make the proper diagnosis.

Ian Flinn, MD: Lori, John touched on perhaps the initial transformation of patients. I find some of the patients that he’s talking about important: how do we use PET [positron emission tomography] scanning in the initial evaluation? Sometimes we get these core biopsies come back and they may be the most easily accessible lymph node but perhaps not the most important lymph node. And then we don’t want to handicap our hematopathologist in making sure we get sufficient tissue. How do you incorporate PET scanning and guiding biopsies perhaps, or just PET scan in general in the initial evaluation of patients with follicular lymphoma?

Lori A. Leslie, MD: Absolutely. Follicular lymphoma, even when you do make the diagnosis of 1 of the other indolent lymphomas or aggressive lymphomas, the grading is so important. Whether it’s a grade 1 to 2, grade 3a, grade 3b, all are treated very differently. And PET scan is crucial at baseline for 2 main reasons. One is if you have a patient with an early stage disease—so stage I or localized stage II—considering potential radiation therapy as part of the treatment, I think a PET scan is critical there. Then also for transformation, to guide the biopsies, area of low-grade follicular lymphoma, 1 area of a higher FDG [fluorodeoxyglucose] avidity on the PET scan, that helps target your biopsy to get a good sample and really find what’s representing the most aggressive part of the heterogeneous follicular lymphoma with a potential transformation.

Ian Flinn, MD: Theoretically, we’re trying to get the part that’s the highest grade and by going with something with the highest FDG avidity, maybe we’re picking that up. That’s important advice.

Transcript Edited for Clarity

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