Diagnosis & Staging

Follicular lymphoma FL is the most common indolent lymphoma.1,2 Most patients with FL are asymptomatic even though lymphadenopathy may come and go for years prior to diagnosis.1,2 Patients may report unusual symptoms when tumors become large enough to disturb deep areas.2 Although enlarged lymph nodes at superficial sites may be detected earlier, these size changes may be unnoticed or neglected.2 Most patients tend to report a healthy status, but some patients have B symptoms indicating advanced disease.2

reference3bReference 3.


Tests and Workup

Patients with suspected FL should receive a complete physical exam, with special attention to node-bearing areas.4 Additional procedures for workup include assessment of liver and spleen size, listing of symptoms, and classification of performance status.4 Labs should include complete blood count, serum lactate dehydrogenase, testing for hepatitis B virus, and a metabolic panel.4 Follicular lymphoma should be confirmed histologically; cytogenetics and/or immunophenotyping will establish the diagnosis.4 Imaging can assess the extent of disease, with 18Fflurodeoxyglucose positron emission tomography (FDG-PET) currently recommended for diagnosis and monitoring tumor response.2,5 An incisional or excisional biopsy of the bone marrow should be performed prior to any course of treatment, but it may be delayed for select patients.4

reference4bReference 4.


Staging and Prognosis

The World Health Organization WHO classifies FL into 3 grades—FL1-2, FL3A, and FL3B— based on the number of centroblasts within the tumor, which is considered prognostic of outcome.6 In general, FL3A tumors tend to be indolent, FL3B tumors behave aggressively, and the clinical importance of FL1-2 is unclear.1,2 Additional tools for evaluating prognosis for overall survival include the Follicular Lymphoma International Prognostic Index FLIPI.6 Another prognostic model—FLIPI2— is best suited for predicting response to chemoimmunotherapy.7

reference 6-7bReferences 6 and 7.



  1. Freedman AS. Follicular lymphoma: 2015 update on diagnosis and management. Am J Hematol. 2015;90:1172-1178.
  2. Salles GA. Clinical features, prognosis and treatment of follicular lymphoma. Hematology Am Soc Hematol Educ Program. 2007;216-222.
  3. Bonander R. Lymphoma B symptoms. LymphomaInfo.net. Available at www.lymphomainfo.net/articles/lymphoma/lymphoma-b-symptoms. Accessed June 3, 2016.
  4. Zelenetz AD, Abramson JS, Advani RH, et al. Non-Hodgkin’s lymphomas. J Natl Compr Canc Netw. 2011;9:484-560.
  5. Swerdlow SH, Campo E, Harris NL, et al. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. Lyon, France: IARC Press; 2008.
  6. Solal-Céligny P, Roy P, Colombat P, White J, et al. Follicular Lymphoma International Prognostic Index. Blood. 2004;104:1258-1265.
  7. Arcaini L, Merli M, Passamonti F, et al. Validation of Follicular Lymphoma International Prognostic Index 2 (FLIPI2) score in an independent series of follicular lymphoma patients. Br J Haematol. 2010;149:455-457.





Additional Reading