Case study: 56-year old man with relapsed follicular lymphoma

Professor Bertrand Coiffier is a world renowned expert in lymphoma. See below for an excerpt from the transcript. To access the transcript in full please visit www.lymphomahub.com. Hello, I'm Bertrand Coiffier, Professor of Hematology at the University of Lyon and I have specialized in lymphoma treatment for the last 30 years. I will be presenting the case of a patient with follicular lymphoma that has been treated with R-CHOP. He had a large tumor bulk in the abdomen at the time of diagnosis and after R-CHOP the patient was prescribed a maintenance regimen, and the patient progressed during the maintenance course of treatment. It's not a frequent case because usually most of these patients progress after, but not during, the maintenance [regimen]. For the interest of this discussion I've chosen the case of a patient that progressed during maintenance because there are more questions to be discussed. So the first question is: What to do for this young patient? He was 56 years old at the time of progression and he has been treated with R-CHOP so you could not prescribe a new regimen with doxorubicin. We have to use [doxorubicin] as a regimen but the problem is the plan is just chemotherapy-sufficient, or we need to move on more intensive chemotherapy with autologous transplant. I think this is a typical case of a patient that is refractory to rituximab because he progressed during rituximab and also into refractory to chemotherapy; most of the patients that are refractory to rituximab are also refractory to chemotherapy. What I propose usually to these [early relapse] patients is a salvage regimen followed by autologous transplant. There is no standard for treating these patients and there are several physicians who think that for this type of patient that refractory and relapsed are only on after a good treatment. You have to go on with more intensive treatment than palliation with just new drugs or new combination without any transplant. This is what we do in the department for this type of patient and the success is good. We have also found that patients who respond to salvage chemotherapy and then, after that, transplants, have a median progression-free survival of seven to ten years. What are the options for second-line therapy? Second-line therapy is a range of options depending on two things; the age of the patient at the time of relapse and the duration of the first response. If the duration is long, it's not the same problem as if the duration is short. In this case it was a short duration, but if you have a patient with a long duration that experiences a relapse four, five or six years after the first-line chemotherapy, the prognosis of such a patient is certainly better. You may [treat the relapse] a lot of different [ways] and probably you don't have to go on for salvage plus auto transplant, [but can prescribe] another regimen with rituximab like bendamustine rituximab, one other type of chemotherapy if you prefer another type. You may even do rituximab alone in [such a] case for a patient with long-duration forced relapse. The median progression-free of rituximab alone is more than one year, you may use a single new agent: a targeted agent like idelalisib or other agents currently being explored in follicular lymphoma. So there are a lot of different possibilities but for a patient with a short duration after first-line treatment or a patient like this one that progressed during rituximab maintenance, these two things [act as] witness for "refractoriness" to chemotherapy. This indicates to me that you need to do more than just [implement] another regimen or another single agent that may have activity.