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Bendamustne Lymphoma Case Study
Ger Walpole, CNS (Clinical Nurse Specialist), H.Dip Oncology Nursing, BNS(Hons), Sligo Regional Hospital, Sligo. Dr Andrew Hodgson, MB, BS, BSc (Hons), FRCPI, FFPath, FRCPath. Written by Karen Mas-Mollinedo MPSI.
Patient PH, age 46 years, male, presented with abdominal mass discovered 6/52 previously by patient following a deliberate dietary loss of 2 stone in body weight, patient reported no night sweats or fever and was otherwise well. Background included suspicion of sarcoidosis presented with erythema nodosum 8 years previously and appendectomy as a child (30 years ago). Performance status was zero.
Patient was electively admitted for laparotomy and biopsy of abdominal mass. Investigations included FBC, renal profile, coagulation and LFTs all found to be within normal range, with only a mild lymphopenia. The LDH was normal
CT thorax was normal, CT abdomen and pelvis showed a well-defined homogenously soft tissue mass (9cm in diameter) in the anterior aspect of the mid abdomen corresponding to the palpable abnormality. The lesion appeared centred on the mesentery. There were a number of mildly enlarged mesenteric nodes and stranding of the mesenteric fat. There were a couple of minimally enlarged retroperitoneal lymph nodes. No iliac or groin adenopathy or ascites were present. There were multiple small hypoattentuating lesions in both sides of the liver which had the appearance of cysts. There was no intra or extra hepatic biliary dilatation. Multiple cysts of various sizes were also present in each kidney. The radiological findings were suggestive of lymphoma with disease confined to below the diaphragm.
Laparotomy and incisional biopsy that were carried out. Histology confirmed features of a follicular lymphoma grade I-II/III. There was strong positivity in the lesional cells for CD20, CD79A, BCK2, CD10, BCL6 was weakly positive. There was negative staining for cyclin D1, CD5 and CD3. Bone marrow biopsy showed a sparse population of B lymphocytes expressing BCL2, they did not form lymphoid aggregates or follicles raising the suggestive of bone marrow involvement. On laparotomy it was found that the mass extended to the route of the mesentery. The patient was staged as 4B and prognostically, a FLIPI score of 2 (intermediate risk).
Treatment consisted of R-Bendamustine (90mg/m2 Day 1 and 2) repeated every 4 weeks for 6 cycles, and Rituximab (375mg/m2 Day 1 only) repeated every 5 weeks for 9 cycles. Followed by maintenance treatment with rituximab 375mg/m2 2 monthly for 12 cycles.
CT was repeated after 4th cycle of chemotherapy, revealing interval disease response with significant decrease in the size of the large mesenteric mass, decrease in fat stranding within the mesentery and interval decrease in size and resolution of the multiple enlarged mesenteric lymph nodes.
Post chemotherapy CT showed a continued interval response in the abdomen, with the mass now measuring approximately 3cm. Post treatment PET scan showed that the mesenteric mass was not metabolically active, however metabolic activity of the lymphoma pre-treatment was unknown. Bone marrow biopsy was repeated and histology showed no evidence of lymphoma.
Discussion
Follicular Lymphoma is an indolent B-Cell lymphoma, typically incurable with standard chemotherapy. Treatment goals centre on long term control of the disease whilst maintaining a good quality of life. Younger patients may be considered for allogeneic stem cell transplantation, particularly in the setting of early relapse following initial treatment.
The main treatment options discussed with the patient were CHOP-Rituximab or Bendamustine – Rituximab. The patient was keen to avoid alopecia and reduce the risk of neutropenia related infection and therefore chose Bendamustine-Rituximab. Rummel et al 2013 have demonstrated that Bendamustine-Rituximab can produce a significant improvement in progression free survival.
‘Our findings show that bendamustine and rituximab significantly improved progression-free survival compared with R-CHOP. Furthermore, bendamustine plus rituximab significantly increased rate of complete response and time to next lymphoma treatment. Notably, progression-free survival significantly improved with bendamustine and rituximab in three of four histological subgroups. This improvement is particularly notable for mantle-cell lymphoma, which has a more aggressive disease course than other lymphomas…’
Reference:
www.thelancet.com Published online February 20, 2013 http://dx.doi.org/10.1016/S0140-6736(12)61763-2
