My Treatment Approach: Relapsed/Refractory Follicular Lymphoma - Episode 1

Follicular Lymphoma Background and Introduction to a Patient Case

Brian T. Hill, MD, PhD briefly reviews the diagnosis and staging of FL, typical prognoses for patients with the disease, and begins to outline a patient case of R/R FL.

Dr. Brian T. Hill: So let me get this up a little higher so I can try to look into the camera a little bit more if possible. Hello and welcome to this OncLive Insights program on treatment approaches in follicular lymphoma. I’m Dr. Brian Hill, I'm the Director of the Lymphoid Malignancies Program and a staff physician at the Cleveland Clinic Taussig Cancer Institute. I'm pleased to discuss how I approach a patient with relapsed or refractory follicular lymphoma. So let's get started.

Stage four or advanced stage follicular lymphoma occurs in about 20 to 25% of cases. And if you add stage three in there as being advanced stage, that's probably another 20 to 30%. So probably about half of the patients with newly diagnosed follicular lymphoma have advanced-stage disease. Stage four is noteworthy for diffuse extranodal involvement including bone marrow or other extranodal sites. This incidence of stage four is probably going up a little bit and that may be more related to the more widespread use of PET scanning at the time of initial staging and diagnosis. But in general, stage four and advanced age is associated with poor overall survival and response to treatment relative to early stage follicular lymphoma.

Yeah. So the prognosis of follicular lymphoma although overall we think of this as an indolent disease for most patients with a typical favorable response to most frontline therapies, there is a wide range if, so heterogeneity in the outcomes. Much of this can be estimated in large groups by use of prognostic scores like the FLIPI score or the Follicular Lymphoma International Prognostic Index. So this takes into account factors including age, again advanced-stage disease, number of extranodal sites, whether or not there's a high serum lactate dehydrogenase level, and whether or not there's anemia. And for each of these factors, there's a point. And for higher points or higher scores, the survival and progression-free survival of treatment tends to diminish.

Let's start with a typical case of a patient with follicular lymphoma. This would be common that you may see in your clinic. So this is a 72 year old man who complains of about a six month history of fatigue, occasional fevers, decreased appetite, and unintentional weight loss of about ten or 12 pounds. He's otherwise been pretty healthy as many of our patients with newly diagnosis, newly diagnosed lymphoma may be. So he doesn't have significant past medical history or comorbidities. He sees his primary care physician and is examined and found to have palpable right axillary and cervical lymph nodes about three centimeters. And on more thorough physical exam of the abdomen, the spleen is palpable about four and a half centimeters below the costal margin. Laboratory studies in a case such as this with follicular lymphoma would be typical for a normal CDC. So this patient had a neutrophil count of 1600. Total white blood cell count was about 11,000 with a normal differential. He did have anemia. In this case the hemoglobin was nine point six, and actually the platelet count was diminished at 98,000. And additional laboratory studies showed a serum LDH level of 315. Beta two microglobulin levels was also elevated. And testing for HIV infection was negative. He was referred for an excisional biopsy of the left axillary lymph node, and the specimen demonstrated abnormal B cell infiltrate with immunohistochemistry staining positive for CD20, CD10, BCL2, and the diagnosis of follicular lymphoma grade two was rendered. A bone marrow biopsy also demonstrated paratrabecular lymphoid aggregates with low level involvement about three percent of the total marrow cellularity. And FISH testing was also performed which was notable for the detection of translocation 14-18, which is the canonical BCL2 translocation. Additional testing including a PET scan showed enlargement again of the left axillary and cervical lymph nodes, but also was noteworthy for mediastinal lymphadenopathy. All of these nodes measured between three and four centimeters. And so he was diagnosed because of the bone marrow involvement as Ann Arbor stage four. ECOG performance status was one.