Complete remission with G-ESHAP and maintenance Obinutuzumab in Stage IVB follicular lymphoma after R-CHOP failure. A case report

Background: Follicular lymphoma is a common indolent B-cell non-Hodgkin lymphoma characterized by high relapse rates despite initial treatment responses. Rituximab-based chemoimmunotherapy, such as R-CHOP, is a standard first-line approach. However, a subset of patients experience early relapse or refractory disease. Obinutuzumab, a type II glycoengineered anti-CD20 monoclonal antibody, has shown improved outcomes over rituximab in both treatment-naïve and relapsed settings. Here, we present the case of a 64-year-old man diagnosed with stage IVB follicular lymphoma with B symptoms and extensive lymphadenopathy. After an incomplete response to six cycles of R-CHOP, disease progression was observed, including extranodal involvement. Due to prior radiation exposure, the patient was not eligible for further radiotherapy. A salvage regimen with G-ESHAP plus obinutuzumab was initiated, achieving complete metabolic response after four cycles. Maintenance therapy with obinutuzumab was commenced. At 18-month follow-up, the patient remains in complete remission with no signs of progression or severe toxicity. This case illustrates the efficacy of combining obinutuzumab with intensive salvage chemotherapy and highlights its role in maintaining long-term remission. The findings support emerging evidence on obinutuzumab’s superiority over rituximab, especially in difficult-to-treat scenarios. Additionally, the sustained remission without grade 3–4 adverse events suggests good tolerability. Although further evidence is needed to standardize obinutuzumab use post-G-ESHAP, this case contributes valuable clinical insight. Prolonged immunotherapy may offer significant benefit in patients with extranodal refractory disease. Keywords: follicular lymphoma, obinutuzumab, G-ESHAP, maintenance therapy, R-CHOP failure, salvage treatment