Patient education: Follicular lymphoma in adults (Beyond the Basics)
- Arnold S Freedman, MD
Arnold S Freedman, MD
- Section Editor — Lymphoproliferative Disorders
- Professor of Medicine
- Harvard Medical School
- Jonathan W Friedberg, MD
Jonathan W Friedberg, MD
- Professor of Medicine
- James P Wilmot Cancer Center, University of Rochester
FOLLICULAR LYMPHOMA OVERVIEW
Lymphoma is a cancer of lymphocytes, a type of white blood cell. Lymphocytes circulate in the body through a network referred to as the lymphatic system, which includes the bone marrow, spleen, thymus, and lymph nodes. The organs and vessels of the lymphatic system work together to produce and store cells that fight infection (figure 1).
There are two main types of lymphoma:
●Hodgkin lymphoma (HL)
●Non-Hodgkin lymphoma (NHL)
NHL is the most common type of lymphoma. Follicular lymphoma is one form of NHL. In contrast to some of the other forms of NHL, follicular lymphoma usually grows slowly and thus may not require treatment for many years.
The following discussion will review the risk factors, classification, symptoms, and treatment of follicular lymphoma.
FOLLICULAR LYMPHOMA RISK FACTORS
Age, gender, and ethnicity affect a person's likelihood of developing follicular lymphoma. Follicular lymphoma is slightly more likely to be diagnosed in women than men, and is less common among Asians and Blacks than among people of other ethnicities. Nearly everyone diagnosed with follicular lymphoma is an adult, with the average age at diagnosis being 65 years.
Follicular lymphoma is not an inherited disease. Siblings and children of patients with follicular lymphoma do not have a substantially increased risk of developing follicular lymphoma.
FOLLICULAR LYMPHOMA SYMPTOMS
The initial symptoms of follicular lymphoma include painless swelling in one or more lymph nodes, particularly in the neck, armpit, or groin areas. Often, people with follicular lymphoma complain that their lymph nodes have been swollen for a long time; the size may increase and decrease several times before they seek medical attention.
Some people with follicular lymphoma develop large tumors in the abdomen. These may cause no symptoms, but can block normal flow in the digestive or urinary system or in a blood vessel.
FOLLICULAR LYMPHOMA DIAGNOSIS AND STAGING
The diagnosis of follicular lymphoma is confirmed by removing all or part of an enlarged lymph node to examine its cells under a microscope, a procedure known as a biopsy.
Once the diagnosis is confirmed, additional tests are performed to obtain more information about the extent to which the disease has spread in the body. This process is called staging. The results of these tests will help determine the most effective course of treatment.
History and physical exam — A careful interview and physical examination will help determine the extent of the disease. The physical exam may reveal swollen lymph nodes in various locations (figure 1).
Staging tests — A number of tests are available to help determine which areas of the body have been affected by follicular lymphoma. Tests that may be done include:
●Bone marrow biopsy (removal of a small sample of tissue from the bone marrow, the spongy area in the middle of large bones, for analysis)
●Computed tomography (CT) scan
●Positron emission tomography (PET) scan
Staging terms — The following are terms used in the staging criteria:
●Lymph node regions – An area of lymph nodes and the surrounding tissue. Examples include the cervical nodes in the neck (figure 2), the axillary nodes in the armpit, the inguinal nodes in the groin, or the mediastinal nodes in the chest (figure 3).
●Lymph structures – Organs or structures that are part of the lymphatic system, such as the lymph nodes, spleen, and thymus gland.
●Diaphragm – A large muscle that separates the chest cavity from the abdominal cavity.
Stage grouping — Staging involves dividing patients into groups (stages) based on how much of the lymphatic system is involved at the time of diagnosis. Staging helps determine a person's prognosis and treatment options (table 1).
The stages of lymphoma are defined as follows:
●Stage I – Only one lymph node region is involved, or only one lymph structure is involved.
●Stage II – Two or more lymph node regions or lymph node structures on the same side of the diaphragm are involved.
●Stage III – Lymph node regions or structures on both sides of the diaphragm are involved.
●Stage IV – There is widespread involvement of a number of organs or tissues other than lymph node regions or structures, such as the bone marrow.
When a stage is assigned, it also includes a letter, A or B, to denote whether fever, weight loss, or night sweats are present. "A" means these symptoms are not present; "B" means they are. For example, a person with stage IB disease has evidence of cancer in one lymph node region and has "B" symptoms (fever, weight loss, or night sweats). (See 'Follicular lymphoma symptoms' above.)
FOLLICULAR LYMPHOMA DISEASE PROGRESSION
The progression of follicular lymphoma varies from one person to another, depending on the speed of the tumor's growth and the involvement of other organs. Sometimes, people with follicular lymphoma have no symptoms for many years and do not need treatment. In other people, treatment may be required for symptoms. Examples of symptoms that may lead to treatment include fever, night sweats, weight loss, pain, blockage of organs, and anemia or other changes in blood counts.
Some cases of follicular lymphoma either behave like or transform into a more aggressive form of lymphoma, such as diffuse large B cell lymphoma, which grows more rapidly and requires more intensive treatment. (See "Patient education: Diffuse large B cell lymphoma in adults (Beyond the Basics)".)
FOLLICULAR LYMPHOMA TREATMENT
Treatment for follicular lymphoma depends on the person's symptoms, the aggressiveness of the tumor, age, and general health. The majority of people with follicular lymphoma have widespread disease when first diagnosed. However, because follicular lymphoma is slow growing, it may take many years for the disease to progress, during which time treatment may not be needed. Early treatment does not always improve overall survival if a person has no symptoms and the disease is not affecting their organs. Thus, close observation (a "watch and wait" approach) is often recommended.
Furthermore, the slow-growth characteristics make the tumors relatively less responsive to standard forms of cancer treatment (compared with the more aggressive lymphomas). As a result, a cure is not usually possible; the main reason to treat is to improve symptoms.
Features that may warrant treatment include one or more of the following:
●Progressively enlarging lymph nodes
●Fever, weight loss, or night sweats
●Low blood counts
People without these features are usually monitored with periodic physical examination and blood testing.
Early stage disease — Some patients with early stage follicular lymphoma (stage I or II) may be treated with radiation therapy alone.
Radiation therapy — Radiation therapy uses high-energy beams to slow or stop the growth of cancer cells and is administered to the region of affected lymph nodes (called involved-site radiation). Radiation therapy must be given in small daily doses over a period of weeks to minimize the side effects; the number of weeks depends on the amount of radiation to be administered.
Advanced stage disease — Advanced stage disease includes stage III and IV follicular lymphoma. Some patients with stage II disease will be treated as though they have advanced stage disease.
There are many treatment options for patients with advanced stage disease. The choice of treatment depends on the patient's preference and the need for the treatment to act quickly (if organ function is threatened by the follicular lymphoma). People with advanced stage disease are generally treated first with chemotherapy plus anti-CD20 antibodies, sometimes called chemoimmunotherapy. The most common antibody used is a medication called rituximab (brand name: Rituxan), which selectively targets follicular lymphoma tumor cells. For older people who have symptoms but have no evidence of organ dysfunction, treatment with rituximab alone may be recommended. (See 'Anti-CD20 antibodies' below.)
Patients with follicular lymphoma that decreases in size after being treated with chemoimmunotherapy may choose to receive further antibody treatments as "maintenance therapy." Maintenance therapy postpones progression of the lymphoma. It is not yet clear whether maintenance therapy improves survival.
Newly developed drugs for treating follicular lymphoma ("novel oral agents"), stem cell (bone marrow) transplantation, and radioimmunotherapy are reserved for patients with relapsed disease.
Anti-CD20 antibodies — These are medications that target a particular protein (CD20) that is found on the surface of tumor cells. The most frequently used anti-CD20 antibody is rituximab (brand name: Rituxan); however, there are other drugs in this category as well. An anti-CD20 antibody is often combined with chemotherapy treatments.
Because the anti-CD20 antibodies preferably target cancer cells, they have advantages over other cancer treatments such as chemotherapy, which targets all rapidly growing cells (see 'Chemotherapy' below). There are usually fewer side effects and long-term risks associated with anti-CD20 antibody therapies than with traditional chemotherapy.
Chemotherapy — Chemotherapy refers to the use of medicines to stop or slow the growth of cancer cells. Chemotherapy works by interfering with the ability of rapidly growing cells (like cancer cells) to divide or multiply. Because most of an adult's normal cells are not actively dividing or multiplying, they are not affected by chemotherapy. However, the bone marrow (where the blood cells are produced), the hair follicles, and the lining of the gastrointestinal (GI) tract are all growing. The side effects of chemotherapy drugs are related to effects on these and other normal tissues.
A chemotherapy drug or combination of drugs is referred to as a regimen. Regimens used for the initial treatment of follicular lymphoma are usually given intravenously in cycles. A cycle of chemotherapy refers to the time it takes to give the drugs and the time required for the body to recover. For example, a typical chemotherapy regimen is a one-hour intravenous infusion of chemotherapy given two days in a row and repeated every four weeks. This four-week period is one cycle of therapy. If this regimen were repeated for a total of six cycles, it would take six months to complete.
Novel agents — Most patients with follicular lymphoma will relapse multiple times and be treated with many available drugs at some point during their disease course. Novel agents, as referred to here, include small molecules designed to target signaling pathways that are abnormally expressed in the cancer cells. Agents that may be used to treat follicular lymphoma that has relapsed multiple times include idelalisib and copanlisib.
Radioimmunotherapy — Radioimmunotherapy (RIT) uses antibodies to deliver radiation to the tumor cells. This reduces the amount of radiation delivered to healthy tissues. However, administering RIT is cumbersome and there are potentially serious short- and long-term side effects of the treatment; as a result, it is used much less frequently than the other treatment options.
Stem cell transplantation — Stem cell transplantation (also called bone marrow transplantation or hematopoietic stem cell transplantation) is generally reserved for people whose lymphoma has recurred after treatment. (See "Patient education: Hematopoietic cell transplantation (bone marrow transplantation) (Beyond the Basics)".)
Clinical trials — A clinical trial is a carefully controlled way to study the effectiveness of new treatments or new combinations of known therapies. Clinical trials are especially important for persons with follicular lymphoma since there is no treatment currently available to cure this disease. Ask a health care provider for more information, or read about clinical trials at:
Videos addressing common questions about clinical trials are available from the American Society of Clinical Oncology (http://www.cancer.net/pre-act).
FOLLICULAR LYMPHOMA PROGNOSIS
For patients with advanced forms of follicular lymphoma (ie, stages III and IV disease) (table 1), the average survival is approximately 19 years. Despite its slow-growing nature, most cases of follicular lymphoma are not curable with currently available therapies.
Researchers have developed a way to estimate how long a person with lymphoma is likely to live based on what they call the "Follicular Lymphoma International Prognostic Index" (FLIPI). This index takes into account five factors that affect prognosis. The index can also help doctors identify which patients will benefit from specific chemotherapy treatments.
The five factors involved in the FLIPI are:
●Age older than 60 years
●Stage III or IV disease (table 1)
●Low red blood cell count
●More than four involved lymph node areas (figure 1)
●Lactate dehydrogenase level higher than normal (lactate dehydrogenase is a protein found in blood whose levels increase when tissues have been damaged)
On average, the more of these risk factors a person has, the worse his or her prognosis.
WHERE TO GET MORE INFORMATION
Your health care provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Classification of the hematopoietic neoplasms
Clinical manifestations, pathologic features, diagnosis, and prognosis of follicular lymphoma
Clinical presentation and diagnosis of non-Hodgkin lymphoma
Evaluation, staging, and response assessment of non-Hodgkin lymphoma
Autologous hematopoietic cell transplantation in follicular lymphoma
Initial treatment of limited stage (I/II) follicular lymphoma
Histologic transformation of follicular lymphoma
The following organizations also provide reliable health information:
●American Cancer Society
●National Cancer Institute
●The American Society of Clinical Oncology
●National Library of Medicine
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.