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Follicular Lymphoma

Last updated Sept. 14, 2018

Approved by: Maulik P. Purohit MD, MPH

Follicular Lymphoma (FL) is one of the most common types of B-cell non-Hodgkin’s lymphoma. It is a slow-growing lymphoma that generally affects older adults.


What are the other Names for this Condition? (Also known as/Synonyms)

  • FL (Follicular Lymphoma)
  • Follicular Center Cell Lymphoma

What is Follicular Lymphoma? (Definition/Background Information)

  • Follicular Lymphoma (FL) is one of the most common types of B-cell non-Hodgkin’s lymphoma. It is a slow-growing lymphoma that generally affects older adults
  • This is a type of non-Hodgkin lymphoma that usually originates in the lymph nodes. It can later involve or spread to other parts of the body including the bone marrow, thyroid gland, bone, breast, testes, skin, and the gastrointestinal tract
  • Follicular Lymphoma is normally diagnosed using a biopsy of the involved lymph node or the affected region. Depending upon the pathology report, FL is graded as Grade 1, Grade 2, and Grade 3 Follicular Lymphoma. Other tests and procedures may be performed to understand the extent of disease spread and its severity
  • Chemotherapy using a combination of drugs forms part of the treatment measures due to systemic (whole body) involvement of the cancer. The treatment of Follicular Lymphoma also depends upon the stage of the condition and the organs involved
  • The prognosis depends on many factors including the subtype and grade of lymphoma, progression of the condition, response to treatment, and overall health of the individual. In general, the prognosis of Follicular Lymphoma is guarded despite treatment

General information on lymphoma and lymphocytes:

  • Lymphoma is a type of cancer stemming from uncontrollably dividing lymphocytes (type of white blood cells). There are two types of lymphomas:
    • Hodgkin lymphoma
    • Non-Hodgkin lymphoma
  • Lymphocytes are the main white blood cells found in the lymph, which is the fluid of the lymphatic system; just as blood is the fluid of the circulatory system
  • Lymphocytes are made in bone marrow, and can develop into either B-cells or T-cells. Follicular Lymphoma arises from cancerous B-cells
  • Lymph results from filtration of blood as it travels to and from tissues. Lymph is colorless because it lacks red blood cells; instead, it contains lymphocytes. It is central to the immune system
  • There are 3 different kinds of lymphocytes:
    • T-lymphocytes or T cells: They help combat infections and abnormalities within the cells (cell-mediated immunity). They fight viruses and cancerous cells
    • B-lymphocytes or B cells: They produce antibodies that are bodily defense proteins, which target foreign invaders outside the cells (humoral immunity). They fight bacterial cells, cell fragments, and other immunogenic elements
    • Natural killer cells or NK cells: They perform diverse functions related to both cell-mediated and humoral immunity. They also scout for cancer cells, a process called immune surveillance

Who gets Follicular Lymphoma? (Age and Sex Distribution)

  • Follicular Lymphoma is the second most common type of non-Hodgkin lymphoma
  • It generally affects middle-aged and older adults; the average age at diagnosis is around 60 years
  • Both males and females are affected; some studies show a slight female predominance
  • All races and ethnic groups can be affected, though the condition is less common in Asians and African Americans

What are the Risk Factors for Follicular Lymphoma? (Predisposing Factors)

No specific risk factors have been identified for Follicular Lymphoma. However, the following factors may contribute towards lymphoma formation and development:

  • Family history of immune disease
  • Age 60 years and older
  • Decreased immunity, especially due to HIV/AIDS
  • The presence of any systemic disease
  • Smoking
  • Exposure to radiation and industrial chemicals
  • Chemotherapy
  • Viruses (in some rare cases); Epstein-Barr virus infection
  • X-ray, CT scan exposure
  • Profession involving radiation exposure, which may include nuclear plant workers, pilots, astronauts, etc.
  • Certain medications and drugs

International Prognostic Index: According to some scientists, the International Prognostic Index may not be very helpful in evaluating Follicular Lymphoma. However, some scientists believe that it is helpful in some cases, to determine the prognosis.

The International Prognostic Index, for aggressive non-Hodgkin Lymphoma, lists a few factors that determine the overall risk:

  • Age over 60 years
  • Elevated level of serum lactate dehydrogenase - LDH (a type of enzyme)
  • Performance status, i.e. the overall health condition of the individual, which could range from being fully active (low risk) to being completely disabled (very high risk)
  • Individual, who have already suffered from lymphoma, or other types of blood cancers, may have a relapse or a recurrence
  • Presence of an immunodeficiency syndrome, like AIDS, is a high risk factor
  • Those infected with Epstein-Barr virus are also prone to FL

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases ones chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Follicular Lymphoma? (Etiology)

Lymphocytes are a type of white blood cells that are responsible for providing immunity in the human body. B-cells and T-cells are the two different types of lymphocytes. When under certain circumstances, the lymphocytes grow and multiply abnormally, it leads to a condition called as lymphoma, which is a most common type of cancer. There are 2 types of lymphoma:

  • Hodgkin lymphoma
  • Non-Hodgkin lymphoma

The cause for this type of non-Hodgkin lymphoma is unknown. Follicular Lymphoma may be caused by certain genetic defects, such as translocation, which is a juxtaposition of regions of chromosomes that may result in:

  • Change of regulatory elements of certain cancer-causing genes called as oncogenes, which can lead to increased production of their mRNA (overexpression), thus increasing their protein levels
  • Exchange of protein coding regions of gene, giving rise to new proteins that can stimulate the inappropriate growth of cells

It is believed that the abnormal development of lymphocytes gives rise to cancerous cells leading to the formation of this condition. Nevertheless, how this occurs and the factors that cause it remain under investigation.

What are the Signs and Symptoms of Follicular Lymphoma?

The signs and symptoms of Follicular Lymphoma may include:

  • Non-painful swelling of lymph nodes in the neck, armpits, or groin
  • Unintentional weight loss; changes in appetite
  • Fatigue and weakness, headache
  • High temperatures and excessive night sweats (may be recurrent)
  • Anemia (low red blood cell count)
  • Low lymphocyte count, established by a blood test
  • Frequent infections
  • Trouble breathing
  • Low blood pressure
  • Back pain
  • Swelling of the legs
  • Abdominal pain and swelling; constipation
  • Frequent urination

If organs are affected, then specific signs and symptoms of Follicular Lymphoma may be manifested that include:

  • The bone marrow is affected in a majority of individuals
  • Associated autoimmune disorders, which can cause joint and muscle pain, heat intolerance, recurrent rashes, abdominal pain, and a general feeling of illness
  • If the brain is involved, then neurological symptoms such as the following may be observed:
    • Confusion
    • Tinnitus (ringing in the ears)
    • Hearing and visual impairment
  • If the gastrointestinal (GI) tract is involved, then GI tract symptoms such as the following may be observed:
    • Ulcers
    • Diarrhea
    • Inflammation
    • GI bleeding
  • Liver and spleen enlargement
  • Joint inflammation and fluid accumulation (edema) can occur, if the joints are affected
  • If the skin is affected, skin lesions may form that can ulcerate and spread to other parts of the body

How is Follicular Lymphoma Diagnosed?

Follicular Lymphoma diagnosis is performed by obtaining biopsy samples from the affected region and examining them under a microscope to detect the cancerous cells. Other methods to aid in the study may include:

  • A thorough physical examination and a complete medical history, which is very important
  • Blood tests that may include:
    • Complete blood cell count (CBC) blood test
    • Absolute lymphocyte count on peripheral blood; about 50% of the patients have tumor cells in the peripheral blood
    • Liver function blood test (LFT)
    • Lactate dehydrogenase (LDH) blood test
    • Chemistry panel
    • Serum calcium levels
    • Serum albumin levels
    • HIV testing
  • Since the lymphoma involves the lymph nodes, biopsies of enlarged lymph nodes are taken and examined in a lab to determine if the cells are malignant or benign. The biopsies may be performed under general or local anesthesia. Normally, the entire lymph node is removed to help determine the subtype of lymphoma
  • Tissue biopsy from the affected area:
    • A biopsy of the tumor is performed and sent to a laboratory for a pathological examination. A pathologist examines the biopsy under a microscope. After putting together clinical findings, special studies on tissues (if needed) and with microscope findings, the pathologist arrives at a definitive diagnosis. Examination of the biopsy under a microscope by a pathologist is considered to be gold standard in arriving at a conclusive diagnosis
    • Biopsy specimens are studied initially using Hematoxylin and Eosin staining. The pathologist then decides on additional studies depending on the clinical situation
    • Sometimes, the pathologist may perform special studies, which may include immunohistochemical stains, molecular testing, flow cytometric analysis and very rarely, electron microscopic studies, to assist in the diagnosis
  • Radiological imaging may be performed to determine the extent of lymphoma in the body including:
    • X-ray of the affected region
    • Ultrasound scan of the affected region
    • Computerized tomography (CT) scan of the affected region
    • Vascular radiological studies
    • Whole body bone scan
    • Whole body CT-PET scans to determine how far the lymphoma has spread, by checking the size and metabolic rate (a reflection of uncontrolled growth) of lymph nodes, throughout the body. This can also help determine, if the cancer has spread to other organ systems
    • Brain MRIs are used if neurological symptoms are present, which can help determine if the cancer has spread to the brain, or to tissues that cover the brain
  • Bone marrow aspiration and biopsy is performed and sent to a laboratory for a pathological examination, to determine if the bone marrow is involved. Sometimes, the pathologist may perform special studies, which may include immunohistochemical stains, histochemical stains, molecular testing, and very rarely electron microscopic studies. However, a bone marrow biopsy is not needed in the early stages of the condition
  • Flow cytometry to identify cells as they flow through an instrument, called a flow cytometer. Flow cytometry measures the number and percentage of cells in a blood sample, and cell characteristics such as size, shape, and the presence of biomarkers on the cell surface. This method helps to sub-classify leukemias and also to detect residual levels of disease after treatment. This tool can help in diagnosing relapse and restart treatment as needed
  • Fluorescence in situ hybridization (FISH): It is a test performed on the blood or bone marrow cells to detect chromosome changes (cytogenetic analysis) in blood cancer cells. The test helps in identifying genetic abnormalities that may not be evident with an examination of cells under a microscope
  • Immunophenotyping to identify a specific type of cell in a sample, which can help determine the best treatment course to be followed
  • Polymerase chain reaction (PCR): It is used to measure the presence of certain biomarkers in blood or bone marrow cells. The test is ultrasensitive and detects extremely low amounts of biomarkers remaining in blood, which can be missed by cytogenetic methods, such as FISH, karyotype, or flow cytometry. PCR allows a more sensitive follow-up of patients in remission and can help determine whether additional treatment is necessary
  • GI endoscopy: It may be performed to assess the extent of tumor spread
  • Multigated acquisition (MUGA) scan or echocardiography to identify cardiotoxicity as a result of chemotherapy
  • Lumbar puncture to determine if the brain is involved
  • In addition, the cerebrospinal spinal fluid (CSF) may be collected by inserting a needle in the spine and subjected to microscopic, flow cytometric, PCR, and biochemical analysis, to diagnose central nervous system (CNS) involvement, if any
  • Exploratory laparoscopy (diagnostic laparoscopy) may be required, if gastrointestinal symptoms are present. In this procedure, the abdomen is examined using a minimally-invasive technique, and a tissue biopsy and tissue for culture obtained. Minimally-invasive approaches help decrease complications and the length of stay at the hospital. A diagnostic laparoscopy is also helpful in staging of the tumor. Nevertheless, this procedure is not very much used

Note: Differential diagnoses, to eliminate other tumor types are often considered, before arriving at a definitive diagnosis.

Based upon the density of blast cells in the lymphoma, Follicular Lymphoma is graded as:

  • Grade 1 Follicular Lymphoma
  • Grade 2 Follicular Lymphoma
  • Grade 3 Follicular Lymphoma: Generally more aggressive than Grade 1 and Grade 2, and hence, its prognosis is the worst

According to World Health Organization, Grade 1 and Grade 2 are considered to be low-grade Follicular Lymphomas, while Grade 3 is considered to be high-grade Follicular Lymphomas.

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Follicular Lymphoma?

The complications due to Follicular Lymphoma may include:

  • Involvement of local and distant organs: It can spread from the lymph nodes to other parts of the body, resulting in the loss of function of the organ/area to which the cancer has spread
  • A Grade 1 Follicular Lymphoma can transform to Grade 2 or Grade 3 Follicular Lymphoma
  • In approximately 1 in 3 individuals with Follicular Lymphoma, a transformation of the lymphoma to higher grade diffuse large B-cell lymphoma (DLBCL) is noted
  • Recurrence of the lymphoma
  • Weakened immune system (or immunosuppression) can be a complication, which can become more severe during treatment. Due to this, individuals are more vulnerable to infections; there is an increased risk of developing serious complications from such infections
  • If the condition spreads to the brain and central nervous system, it can give rise to:
    • Inflammation of the meninges or brain (that can be lethal)
    • Vision changes
    • Facial numbness
  • If the abdomen is affected, it can cause intestinal obstruction that results in urine outflow obstruction and kidney damage
  • Blood loss may occur due to frequent or heavy bleeding, giving rise to severe anemia
  • The leukemic cells can overgrow and cause clogging of vessels resulting in stroke, or blurring of vision

There may be complications related to chemotherapy used in treating the condition, which may include:

  • Side effects such as dizziness, vomiting, appetite loss, mouth ulcers, and hair loss
  • By damaging healthy cells, the individual is more open or vulnerable to secondary infections
  • The treatment can also cause infertility in men and women. Hence, measures to protect the individual’s fertility must be considered, before starting chemotherapy
  • Tumor lysis syndrome: This can occur due to chemotherapy treatment and can result in kidney failure, if not recognized promptly

How is Follicular Lymphoma Treated?

Once a definitive diagnosis of Follicular Lymphoma has been made, staging is used to describe how far the cancer has spread. The stage can help describe:

  • How many lymph nodes are affected
  • Their locations in the body
  • And, if other organs are being affected

Staging is important because different treatment regimens are necessary, depending on the progression of the lymphoma. The stages of Follicular Lymphoma include:

  • Stage 1: One group of lymph nodes are affected
  • Stage 2: Two or more groups of lymph nodes on one side of the diaphragm are affected
  • Stage 3: Lymph nodes on both sides of the diaphragm are affected
  • Stage 4: The condition involves tissues other than lymphoid tissues such as spleen, liver, and bone marrow

Systemic therapy is generally used for malignant and advanced stage cancers. A combination of treatment measures may be effectively used to treat Follicular Lymphoma. It may include the following:

  • Chemotherapy: This approach uses a combination of drugs to kill the cancerous cells and can be used in patients, for all stages of the cancer
    • There can be severe side effects including fatigue, nausea, hair loss, anemia, high risk of infection, and drug-specific reactions
    • Many lymphomas can be resistant to chemotherapy. It can also damage healthy cells
    • Chemotherapy can be administered as a pill, liquid, shot, or intravenously

Note: Men and women in child-bearing age would greatly benefit from counseling regarding fertility issues. Some chemotherapy agents can cause infertility in both men and women. There can be permanent damage to the testicles and ovaries, harming their ability to produce sperms or ova. In men, sperm banking can be considered before initiating therapy. In women, in many cases, due to urgency of starting chemotherapy, it is often difficult to perform ovum banking. However, if there is sufficient time prior to chemotherapy, ovum banking may be performed. Your healthcare provider may help assess the risk-benefit analysis, depending upon each individual’s specific circumstances.

  • Radiation: Radiation therapy is the use of high-energy radiation waves to kill cancer cells, by destroying their DNA
    • This treatment modality is generally used for early stage lymphomas. It is most commonly used in combination with chemotherapy
    • The radiation may be administered by a machine placed outside the body, or by placing a radioactive material inside the body
    • The side effects of radiation therapy include nausea, vomiting, fatigue, pain, risk of cancer later in life, and risk of heart disease
    • Radiation can damage healthy cells in addition to cancer cells, causing further complications
  • Surgery: After initial biopsies to diagnose the condition, surgery is a very uncommon treatment option, because lymphomas are systemic and might have already spread to more than one lymph node in most patients. Under such circumstances, removing all the affected lymph nodes would be extremely difficult
  • Intrathecal chemotherapy, if there is an involvement of the brain
  • Supportive treatment: Steroids, blood transfusions, anti-nausea medications, and antibiotics, may be used as supportive therapy. In combination with other treatment measures, these can help combat the symptoms of immunodeficiency, on a case-by-case basis

If Follicular Lymphoma is not fully responsive to treatment, or if the chance of recurrence is high, then bone marrow transplantation or stem cell transplantation can be considered.

  • Bone marrow transplantation: Typically systemic cases may be treated by administering high doses of chemotherapy or radiotherapy. But, high doses of chemotherapy drugs will also damage the bone marrow, preventing it from making any blood cells. Hence, before starting high-dose chemotherapy, the physicians may take out some of the patient’s bone marrow and freeze/preserve it. Collecting the bone marrow is called a bone marrow harvest. The bone marrow is then stored. After high dose chemotherapy or radiation, the bone marrow is thawed and injected back into patient through a drip (transfusion). This is called an autologous bone marrow transplant. Sometimes bone marrow donated by another matching person (usually a brother or sister) is used, if the condition recurs following transplant using one’s own cell. This is called as allogeneic bone marrow transplant
  • Stem cell transplantation: This procedure is similar to bone marrow transplantation and involves the transplantation of healthy blood-forming stem cells into the body. The procedure is also called hematopoietic progenitor cell transplantation. Stem cells can be collected from the bone marrow, circulating (peripheral) blood, and umbilical cord blood. It may either involve an autologous stem cell transplantation, where stem cells are harvested from individuals before treatment and transplanted back into the patient after treatment, or involve an allogeneic stem cell transplantation, where stem cells donated by another matching person (usually a brother or sister) is used, if the condition recurs after stem cell transplant using one’s own cell. This is called as allogeneic stem cell transplant

Note: Allogeneic bone marrow and allogeneic stem cell transplants may have more side effects and complications, and this treatment may not be suitable for every individual. If allogeneic transplants come from a healthy donor with no malignant cells, then the chances of recurrence of the condition may be reduced.

  • In order to prevent infections because the immune system is weakened by FL or by its treatment, the patient is kept in an isolated ward and treated with appropriate antibiotics
  • Nowadays, targeted therapies are being developed, that can selectively kill the lymphoma/leukemia cells. Many of them are in the stage of clinical trials
  • Clinical trials: There may be some newer treatment options, currently on clinical trials, which can be considered for some patients depending on their respective risk factors

Your healthcare provider will determine the best course of treatment depending on your individual circumstances. Also, follow-up care with regular screening and check-ups are important post-treatment.

How can Follicular Lymphoma be Prevented?

Presently, the cause of Follicular Lymphoma is unknown and there are no known methods to prevent its formation. Eliminating certain risk factors for lymphoma development may help in avoiding the condition.

  • Healthy diet and exercise, as well as avoidance of unnecessary exposure to chemicals, may help decrease its risk
  • Avoidance or cessation of smoking
  • Undertaking appropriate and prompt treatment for any viral infections or other disorders
  • Using appropriate protective gear while working with x-rays and other radioactive source
  • In order to avoid a relapse, or be prepared for a recurrence, the entire diagnosis, treatment process, drugs administered, etc. should be well-documented and follow-up measures initiated

Regular medical screening at periodic intervals with blood tests, scans, and physical examinations, are mandatory. Often several years of active vigilance are crucial and necessary.

What is the Prognosis of Follicular Lymphoma? (Outcomes/Resolutions)

The Follicular Lymphoma International Prognostic Index (FLIP Index) proposes the following subgroups to assess prognosis of Follicular Lymphoma based on a set of risk factors.

The risk factors include:

  • Number of affected lymph nodes is greater than 4
  • Lactate dehydrogenase (LDH) is above normal
  • Age of the individual is over 60 years
  • The cancer is at stage III or IV
  • Hemoglobin levels are less than 12g/dl

The 10 year survival rate is indicated as per the following:

  • 62-71% with 0-1 risk factors; the risk of relapse is low
  • 48-51% with 2 risk factors; the risk of relapse is intermediate
  • 34-36% with 3-5 risk factors; the risk of relapse is high

In general, the prognosis of Follicular Lymphoma is typically guarded. The 5 year survival rate is about 75%; the median survival after diagnosis is 8 years.

  • Typically, the prognosis depends upon a set of several factors, which include:
    • Stage of tumor: With lower-stage tumors, when the tumor is confined to site of origin, the prognosis is usually excellent with appropriate therapy. In higher-stage tumors, such as tumors with metastasis, the prognosis is poor
    • Grade of Follicular Lymphoma: Grade 1 and Grade 2 do better than Grade 3 Follicular Lymphoma
    • Overall health of the individual: Individuals with overall excellent health have better prognosis compared with those with poor health
    • Age of the individual: Older individuals generally have poorer prognosis than younger individuals
    • The size of the tumor: Individuals with small-sized tumors fare better than those with large-sized tumors
    • Individuals with bulky disease have a poorer prognosis
    • Involvement of vital organs may complicate the condition
    • The surgical respectability of the tumor (meaning, if the tumor can be removed completely) - it is a rare option
    • Whether the tumor is occurring for the first time, or is a recurrent tumor. Recurring tumors have worse prognosis compared to tumors that do not recur
    • Response to treatment: Tumors that respond to treatment have better prognosis compared to tumors that do not respond to treatment
    • Progression of the condition makes the outcome worse (progressive FL)
  • An early diagnosis and prompt treatment of the tumor generally yields better outcomes than a late diagnosis and delayed treatment
  • The combination chemotherapy drugs used, may have some severe side effects (such as cardio-toxicity). This chiefly impacts the elderly adults, or those who are already affected by other medical conditions. Tolerance to the chemotherapy sessions is a positive influencing factor
  • Progression to bone marrow failure is usually associated with short survival; bone marrow involvement is seen in a majority of individuals (in around 85% of the patients)

Additional and Relevant Useful Information for Follicular Lymphoma:

  • T-cell lymphomas are less common than B-cell lymphomas
  • Treatment for Follicular Lymphoma can cause physical and emotional distress; supportive care and encouragement, help positively and can bring a measure of relief to the patients

The following article link will help you understand leukemia and lymphoma (blood cancer):

http://www.dovemed.com/diseases-conditions/leukemia-and-lymphoma/

What are some Useful Resources for Additional Information?


References and Information Sources used for the Article:


Helpful Peer-Reviewed Medical Articles:


Reviewed and Approved by a member of the DoveMed Editorial Board
First uploaded: Feb. 26, 2016
Last updated: Sept. 14, 2018