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

Reference 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

Reference 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

References 6 and 7.

References

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.