Expert hematologist-oncologist Lori Leslie, MD, provides insight to the incidence and prognosis of follicular lymphoma, highlighting a patient case of refractory disease.
Lori Leslie, MD: Hello, and welcome to this OncLive® Insights® program on treatment approaches in relapsed/refractory follicular lymphoma. I’m Dr Lori Leslie, a lymphoma specialist and the director of the indolent lymphoma and chronic lymphocytic leukemia programs at the John Theurer Cancer Center in Hackensack, New Jersey. I’m pleased to discuss how I approach a patient with relapsed/refractory follicular lymphoma. Let’s get started.
There are 80,000 new cases of non-Hodgkin lymphoma diagnosed in the United States each year. Approximately 25% of those are follicular lymphoma, which is the most common type of indolent B-cell non-Hodgkin lymphoma. The majority of patients with follicular lymphoma present with nonlocalized disease. Whether a patient presents with nonlocalized stage II, stage III, or stage IV disease, treatment considerations are similar.
Follicular lymphoma is a heterogeneous disease with variability based on the grade of the follicular lymphoma, the Ki-67, and potentially molecular features. About 20% of patients with follicular lymphoma will have an aggressive disease course, characterized as relapsing within 24 months of their frontline chemoimmunotherapy. Though nonlocalized follicular lymphoma is considered incurable, for many it’s characterized by periods of treatment followed by periods of treatment-free interval, during which surveillance is appropriate. The long-term outcomes with follicular lymphoma, however, have improved dramatically over the past few years and decades. I always like to encourage patients that the 10-year survival or long-term outcomes for patients diagnosed with follicular lymphoma and access to our therapies is unknown, because the treatment landscape is changing rapidly in an encouraging way. It’s shifting away from chemoimmunotherapy for all and into the targeted therapy era.
Let’s start with a case presentation. This is a 66-year-old woman who presents with a 4-month history of occasional fevers, decreased appetite, fatigue, and an unintentional 8-pound weight loss. Her past medical history is unremarkable. On physical exam, she has a palpable left axillary lymph node about 4 cm and bilateral cervical lymph nodes about 3 cm. Her spleen is palpable 4.5 cm below the costal margin. On laboratory work-up, her white blood cell count is 11.8 per mm3 with 42% lymphocytes. Absolute neutrophil count is 1.5. Hemoglobin is 9.6 per mm3. Platelets are 100,000 per mm3. Her LDH [lactate dehydrogenase] is normal at 325 U/L. Her beta-2 microglobulin is 3.7 μg/mL, and our hepatitis B serology is negative.
She undergoes excisional lymph node biopsy of an axillary lymph node showing a clonal B-cell population positive for CD20, CD10, and BCL2, negative for CD5, CD3, and cyclin D1. Ki-67 is 20%. A diagnosis of follicular lymphoma, grade 1 to 2 out of 3 is rendered. Bone marrow biopsies are performed, showing apparent trabecular lymphoid aggregate, about 45% involvement of the overall cellularity. Molecular genetics show the presence of a translocation 14;18. PET [positron emission tomography]–CT is performed, showing enlargement of a left axillary mediastinal bilateral paraaortic lymph node measuring up to 4.5 cm in largest diameter with a maximum SUV [standardized uptake value] of 8.2. She’s Ann Arbor stage IV, and her ECOG performance status is 0.
She was treated with R-CHOP [rituximab, cyclophosphamide, hydroxydaunorubicin hydrochloride, vincristine, prednisone] chemimmunotherapy in the frontline setting for 6 cycles. Then she continued to get maintenance rituximab every 2 months at 375 mg/m2, achieving a partial response as her best response. Six months later, she complained of increasing fatigue, fevers, and chills. She underwent repeat PET-CT that revealed disease progression. She underwent repeat lymph node biopsy of the most FDG [fluorodeoxyglucose]–avid lymph node, showing grade 1 to 2 out of 3 follicular lymphoma. She was started on bendamustine-obinutuzumab for the second-line treatment. She received 6 cycles of therapy and then continued maintenance of obinutuzumab. Twelve months later, she complained of increasing weight loss and fatigue. She underwent PET-CT, revealing disease progression. She’s presenting to you to discuss third-line treatment options.
Transcript edited for clarity.