Table 1: Treatment history demonstrating duration of treatment,
progression free survival and best treatment response.
Discussion:
Relapsed follicular lymphoma can be treated with a variety of modalities
including chemoimmunotherapy, immune modulators, hematopoietic stem cell
transplant and CAR-T (Table 2). Rituximab has been studied in heavily
pretreated and in patients who had previously responded to rituximab and
resulted in overall response rate (ORR) 40% and complete response (CR)
in 11% of patients.4 Chemotherapy can also be added
to monoclonal antibodies in patients with untreated and relapsed
follicular lymphoma to achieve an improved overall survival compared to
patients with chemotherapy alone.5 In the GADOLIN
trial, rituximab refractory indolent non-Hodgkin lymphoma was treated
with obinutuzumab plus bendamustine. In the intention-to-treat group the
median progression-free survival was 25.8 months and 14.1 months, in the
combination and monotherapy arms respectively.6Combination was given for 6 cycles followed by maintenance obinutuzumab
every 2 months for 2 years until progression. Immune modulators have
also been incorporated into these regimens. Lenalidomide can be combined
with rituximab or obinutuzumab for early or late relapse. In the AUGMENT
trial, patients received lenalidomide or placebo for 12 cycles plus
rituximab weekly.7 The median PFS was improved from 14
months to 39 months. Obinutuzumab was combined with lenalidomide after
rituximab-containing therapy in a phase Ib trial with 63% of patients
achieving a response, as seen in this patient.8 While
these regimens have a higher toxicity profile, combining these agents in
patients with a good performance status appears to be beneficial.