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Follicular Lymphoma

Indolent B-cell lymphoma defined by t(14;18) BCL2 translocation, often diagnosed at advanced stage and managed with watchful waiting or rituximab-based therapy.

Written by: Saygı Hospital Health Guide Editorial Board
Last updated:

This content has been compiled by the Saygı Hospital Health Guide Editorial Board and is periodically reviewed by a specialist physician.

References (5)

This content is for informational purposes only and does not constitute medical advice. You can book an appointment at our Hematoloji department. Book Appointment →

What is Follicular Lymphoma?

Follicular lymphoma (FL) is the second most common B-cell non-Hodgkin lymphoma in Western countries, accounting for approximately 20–25% of all NHL cases. It arises from germinal center B cells and is characterized by the t(14;18)(q32;q21) chromosomal translocation that places BCL2 under control of the immunoglobulin heavy chain enhancer, leading to BCL2 overexpression and resistance to apoptosis.

FL is graded 1–3 by histology, with grades 1–2 considered indolent and grade 3B managed similarly to diffuse large B-cell lymphoma. Most patients (80%) present with advanced stage III/IV disease yet pursue an indolent course over many years. Histologic transformation to aggressive lymphoma (typically DLBCL) occurs in 20–40% over a lifetime and changes prognosis dramatically.

Treatment is risk-adapted: asymptomatic, low-tumor-burden disease (GELF criteria) is observed; symptomatic or high-tumor-burden disease receives rituximab monotherapy, bendamustine plus rituximab (BR), R-CHOP, or obinutuzumab combinations. Maintenance rituximab prolongs remission. Relapsed/refractory disease is treated with PI3K inhibitors (copanlisib), tazemetostat (EZH2 mutated), CAR T-cell therapy, bispecific antibodies (mosunetuzumab), or autologous transplant.

Symptoms

Painless slowly enlarging lymphadenopathy
Waxing-waning lymph node size
Splenomegaly
Bone marrow involvement with cytopenias
B symptoms (fever, night sweats, weight loss) less common than in DLBCL
Fatigue
Recurrent infections
Compressive symptoms (rare)
Symptoms of transformation (rapid growth, B symptoms, elevated LDH)
Asymptomatic incidental finding
Hepatomegaly
Pleural or peritoneal effusion
Tumor lysis (rare unless transformed)
Skin involvement (rare)
GI tract involvement

Risk Factors

Age 60–65 (median)
Caucasian ethnicity
Family history of lymphoma
t(14;18) BCL2 translocation
Chromosomal aberrations (1p, 6q, 17p)
EZH2, KMT2D, CREBBP, EP300 mutations
Immunosuppression (HIV, transplant — less specific than DLBCL)
Autoimmune disease (Sjögren, RA)
Hepatitis C (debated)
Pesticide exposure (farming)
Hair dye exposure (debated)
Smoking (weak)
Obesity (weak)
Idiopathic in most
No clear lifestyle prevention

When to See a Doctor?

If you experience any of the following symptoms, seek medical attention promptly:

  • Persistent painless lymphadenopathy
  • Lymph nodes lasting more than 4 weeks without infection
  • B symptoms in known FL patient (concerning for transformation)
  • Rapid growth of previously stable lymph node
  • Cytopenias
  • Splenomegaly
  • Weight loss
  • Compressive symptoms (jaundice, ureteral obstruction)
  • Family history of lymphoma with adenopathy
  • Recurrent infections in FL patient on therapy

Treatment Methods

01
Excisional lymph node biopsy preferred for diagnosis and grading
02
Immunohistochemistry (CD10, BCL2, BCL6, CD20, CD23) and FISH for t(14;18)
03
Bone marrow biopsy for staging (involvement in 40–70%)
04
PET-CT for initial staging and response assessment
05
FLIPI and FLIPI-2 prognostic scores
06
GELF or BNLI criteria to identify high tumor burden
07
Watchful waiting for asymptomatic, low-tumor-burden disease
08
Rituximab monotherapy (4 weekly induction) for low burden requiring therapy
09
Bendamustine plus rituximab (BR) — common first-line for high burden
10
R-CHOP for grade 3B or high-risk presentation
11
Obinutuzumab plus chemotherapy (GADOLIN, GALLIUM) as alternative anti-CD20
12
Maintenance rituximab every 2 months for 2 years (PRIMA regimen)
13
Lenalidomide plus rituximab (R2) for relapsed disease
14
PI3K inhibitor copanlisib (parsaclisib) for relapsed disease
15
Tazemetostat for EZH2-mutated relapsed disease
16
CAR T-cell therapy (axicabtagene, tisagenlecleucel) for relapsed/refractory
17
Mosunetuzumab and other bispecifics for refractory disease
18
Autologous stem cell transplant in selected high-risk relapse
19
Long-term surveillance for transformation, second cancers, infections

Which Department to Visit?

You can visit our Hematoloji department for these complaints. Our specialist physicians will create the most suitable treatment plan for you.

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Health Disclaimer: The information on this page is prepared for general informational purposes only. It does not replace medical diagnosis and treatment. Please consult your physician for your complaints. Saygı Hospital does not accept responsibility for actions taken based on the information on this page.