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.