Follicular Lymphoma — Living With an Indolent Lymphoma

Diagnosis and when to treat

Diagnosis requires a lymph node biopsy with immunohistochemistry; grading and proliferation index are recorded. Staging uses imaging, and bone marrow assessment is considered if it will change management. Asymptomatic patients without bulky disease or cytopenias are often observed with regular review. The GELF criteria help identify patients who need treatment.

• Excisional biopsy with immunohistochemistry and grading
• Staging imaging and selective bone marrow assessment
• Observation for asymptomatic, low-burden disease
• Treatment for bulky, symptomatic or progressive disease
• Fertility and infection screening before therapy

Treatment options and follow-up

First-line options include chemoimmunotherapy, lenalidomide with rituximab, and radiotherapy for limited disease. Maintenance rituximab may prolong remission in selected patients. Relapsed disease is managed with further targeted or chemoimmunotherapy, and transplant or CAR-T is considered in selected high-risk cases. Transformation to aggressive lymphoma should be investigated promptly if behaviour changes.

• Chemoimmunotherapy or lenalidomide-based first-line therapy
• Radiotherapy for limited-stage disease
• Maintenance rituximab in selected patients
• Watch for transformation — new symptoms, rapid growth, rising LDH
• Autologous transplant or CAR-T in selected relapsed disease

Guidelines referenced:

• NCCN Guidelines — B-Cell Lymphomas
• ESMO Clinical Practice Guidelines — Follicular Lymphoma
• GELF criteria for initiation of treatment