Lung Cancer | Symptoms, Causes, Treatment and Survival Rates

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symptoms of follicular lymphoma :: Article Creator

Case Study: Relapsed Follicular Lymphoma

A 58-year-old male with low-grade follicular lymphoma presents to oncology clinic with worsening bilateral cervical lymphadenopathy and fatigue over the past month. He was initially diagnosed 4 years ago, when he presented with bulky cervical and inguinal lymphadenopathy. He achieved a complete remission with 6 cycles of bendamustine and rituximab (BR), and has been monitored clinically since then. He has a history of hypertension, for which he takes lisinopril 10 mg daily. He states that he has been taking naps at the end of the work day for the past two weeks.

The Bottom Line
  • Patients with follicular lymphoma can often be monitored clinically, as the early intervention of chemotherapy or immunotherapy in asymptomatic low tumor burden patients has not demonstrated an overall survival benefit.
  • Treatment is typically indicated when the patient develops constitutional symptoms, progressive lymphadenopathy, splenomegaly, effusions, organ compression, or cytopenias.
  • There are several options with unique mechanism of action approved and in development for patients with relapsed or refractory follicular lymphoma.

    • Vital signs are: temperature 98.0 F, blood pressure 130/80, heart rate 89, pulse oximetry 98% on room air. His physical exam is notable for bilateral enlarged cervical lymph nodes, largest 4 x 5 cm, and bilateral inguinal lymphadenopathy. His complete blood count indicates hemoglobin of 9.4 and platelet count of 94. Based on these findings, he undergoes a staging evaluation. PET-CT indicates enlarged hypermetabolic in the cervical, retroperitoneal , and inguinal regions, with a maximum SUV of 9. Bone marrow biopsy indicates 60% involvement with low grade follicular lymphoma. 

    Indications for Treatment in Follicular Lymphoma

    The most common form of indolent non-Hodgkin lymphoma, patients with follicular lymphoma can often be monitored clinically with the "watch and wait" approach, as the early intervention of chemotherapy or immunotherapy in asymptomatic low tumor burden patients has not demonstrated an overall survival benefit. Treatment is typically indicated when the patient develops constitutional symptoms, progressive lymphadenopathy (a single lesion > 7 cm, three nodal sites > 3 cm), splenomegaly, effusions, threat of or evidence of organ compression, or cytopenias.1

    Treatment Options for Previously Untreated Follicular Lymphoma

    Chemoimmunotherapy has traditionally been considered the standard front-line option for patients with advanced stage high tumor burden disease. The German Study Group of Indolent Lymphomas (StiL) NHL-2 study and the BRIGHT study have both demonstrated comparable efficacy and better tolerability with BR in comparison to older regimens such as R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone).2, 3 Despite high overall response rates (ORR) with chemoimmunotherapy, complete response rates (CR) are inferior and patients inevitably relapse. In attempts to improve upon our current standards, biologic combinations such as rituximab and lenalidomide have also been explored. The combination of these two agents has demonstrated significant efficacy, with an ORR of 90% to 96% (CR 71%-80%).4,5 This combination is being compared to chemoimmunotherapy in the phase III RELEVANCE study, results of which have not been reported yet.

    Next Steps: Treatment Options for Relapsed Follicular Lymphoma

    There are several options with unique mechanism of action approved and in development for patients with relapsed or refractory follicular lymphoma. Chemoimmunotherapy could be considered again in this patient, with either RCHOP or even BR, given the previously achieved durable remission. Alternatively, bendamustine could be paired with obinutuzumab, a second generation, type II glycoengineered, humanized, anti-CD20 monoclonal antibody. In the phase III GADOLIN study, the combination of obinutuzumab and bendamustine (OB) produced an ORR of 69% (CR 11%) in patients with rituximab-refractory follicular lymphoma.6  Radioimmunotherapy is an older form of CD20 directed therapy previously approved for relapsed and refractory disease; however, its use has declined over the years due to the cumbersome nature of administration.7,8 Idelalisib, a PI3K-d inhibitor, was the first oral small molecule kinase inhibitor to be approved for follicular lymphoma, based on a phase II study demonstrated an ORR of 56%.9 The median progression-free survival for those who achieved a complete remission was 27 months. Targeted therapies currently under investigation include but are not limited to ibrutinib (BTK inhibitor), venetoclax (BCL-2 inhibitor), polatuzumab vedotin (CD79b antibody drug conjugate), and immune checkpoint inhibitors. 


    Follicular Lymphoma

    Follicular lymphoma is the most common of the indolent non-Hodgkin's lymphomas, and the second-most-common form of non-Hodgkin's lymphomas overall. It is defined as a lymphoma of follicle center B-cells (centrocytes and centroblasts), which has at least a partially follicular pattern. It is positive for the B-cell markers CD10, CD19, CD20, and CD22 but almost always negative for CD5.

    There are several synonymous and obsolete terms for this disease, such as CB/CC lymphoma (Centroblastic and Centrocytic lymphoma), nodular lymphoma and Brill-Symmers Disease.


    Hodgkin Vs. Non-Hodgkin Lymphoma

    Lymphoma is a type of cancer that forms in the lymphatic system, which is a network of vessels, tissues, and organs that maintain the fluids in your body. The fluid that circulates through this network carries important substances, including lymphocytes, which are white blood cells that produce antibodies to help the body fight off infections.

    The two main categories of lymphomas are Hodgkin lymphoma and non-Hodgkin lymphoma, both named for Dr. Thomas Hodgkin, the researcher who chronicled symptoms of the diseases. Hodgkin lymphoma is sometimes referred to as Hodgkin's disease or Hodgkin disease.

    The main difference between Hodgkin lymphoma and non-Hodgkin lymphoma is the type of cells where the cancer develops. People with Hodgkin lymphoma have a mutated lymphocyte called a Reed-Sternberg cell, which is named for two scientists who first identified them under a microscope. Reed-Sternberg cells are much larger than normal lymphocytes and are not present in non-Hodgkin lymphoma.





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