Follicular lymphoma: 2012 update on diagnosis and management

Am J Hematol. 2012 Oct;87(10):988-95. doi: 10.1002/ajh.23313.

Abstract

Disease overview: Follicular lymphoma (FL) is generally an indolent B-cell lymphoproliferative disorder of transformed follicular center B cells. FL is characterized by diffuse lymphoadenopathy, involvement of bone marrow, splenomegaly, and less commonly other extranodal sites of involvement. In general, cytopenias can occur but constitutional symptoms of fever, night sweats, and weight loss are uncommon.

Diagnosis: Diagnosis is based on histology of preferably a biopsy of a lymph node. Immunohistochemical staining is positive in virtually all cases for cell surface CD19, CD20, CD10, and monoclonal immunoglobulin, as well as cytoplasmic expression of bcl-2 protein. The overwhelming majority of cases have the characteristic t(14;18) translocation involving the IgH/bcl-2 genes.

Risk stratification: The FL International Prognostic Index prognostic model for FL uses five independent predictors of inferior survival: age > 60 years, hemoglobin < 12 g/dL, serum lactate dehydrogenase > normal, Ann Arbor stage III/IV, number of involved nodal areas > 4. The presence of 0, 1, 2, and ≥ 3 adverse factors defines low, intermediate, and high-risk disease with median 10-year survivals in the pre-rituximab era of ~71, 51, and 36 months, respectively. With the use of more modern therapies, specifically anti-CD20 monoclonal antibody, the outcome has improved.

Risk-adapted therapy: Observation continues to be adequate for asymptomatic patients with low bulk disease and no cytopenias. For patients needing therapy, most patients are treated with chemotherapy plus rituximab, which has improved response rates, duration of response, and overall survival. Randomized studies have shown additional benefit for maintenance rituximab both following chemotherapy-rituximab and single-agent rituximab. Autologous stem cell transplantation (SCT) has not shown a survival benefit in first remission patients. SCT including both autologous and allogeneic SCT or experimental agent therapy is considered for recurrent disease.

Publication types

  • Review

MeSH terms

  • Antibodies, Monoclonal / therapeutic use
  • Antibodies, Monoclonal, Murine-Derived / administration & dosage
  • Antibodies, Monoclonal, Murine-Derived / therapeutic use
  • Antineoplastic Combined Chemotherapy Protocols / administration & dosage
  • Antineoplastic Combined Chemotherapy Protocols / therapeutic use
  • Biomarkers, Tumor
  • Biopsy
  • Chromosomes, Human, Pair 14 / genetics
  • Chromosomes, Human, Pair 14 / ultrastructure
  • Chromosomes, Human, Pair 18 / genetics
  • Chromosomes, Human, Pair 18 / ultrastructure
  • Combined Modality Therapy
  • Cyclophosphamide / administration & dosage
  • Doxorubicin / administration & dosage
  • Genes, Immunoglobulin
  • Genes, bcl-2
  • Hematopoietic Stem Cell Transplantation
  • Humans
  • Immunoglobulin Heavy Chains / genetics
  • Immunophenotyping
  • Lymph Nodes / pathology
  • Lymphoma, Follicular / diagnosis*
  • Lymphoma, Follicular / genetics
  • Lymphoma, Follicular / therapy*
  • Prednisone / administration & dosage
  • Prognosis
  • Randomized Controlled Trials as Topic
  • Remission Induction
  • Risk
  • Rituximab
  • Salvage Therapy
  • Translocation, Genetic
  • Vaccination
  • Vincristine / administration & dosage

Substances

  • Antibodies, Monoclonal
  • Antibodies, Monoclonal, Murine-Derived
  • Biomarkers, Tumor
  • Immunoglobulin Heavy Chains
  • Rituximab
  • Vincristine
  • Doxorubicin
  • Cyclophosphamide
  • Prednisone

Supplementary concepts

  • CHOP protocol