Follicular Lymphoma – The Symptoms And Treatments

Follicular lymphoma is a type of Non Hodgkin’s Lymphoma (NHL’s). It consists of 22 % of NHL’s worldwide and atleast 30 % of NHL’s in the U.S. It occurs around 50 to 60 years of age. It is rarely seen in childhood.

IPI (International Prognostic Index for NHL):

  • Age more than 60 years.
  • Serum lactate dehydrogenase levels elevated.
  • Ann Arbor stage 3 or 4.
  • Performance status ≥2 (ECOG) or ≤70 (Karnofsky).

Symptoms: Most common symptoms of presentation are new, painless lymph node enlargement. Multiple sites of Lymph node enlargement may be seen, in some cases uncommon locations such as epitrochlear lymph nodes too may be noticed. 42% of cases of Follicular Lymphoma may show involvement of the bone marrow and 4% may affect the gastrointestinal tract. Most patients do not complain of fever, night sweats or weight loss. About 50 % of patients have and IPI score of 0-1, only 10% have and IPI score of 4 or 5.

Staging evaluation for NHL:

Physical examination

Documentation of B symptoms

Laboratory evaluation- complete blood counts, liver function tests, uric acid, calcium, serum protein electrophoresis, serum β2 microglobulin.

Chest radiograph

CT scan of abdomen, pelvis and usually chest

Bone marrow biopsy

Lumbar puncture

PET scan.

Diagnosis: Biopsy of the lymph node must be taken. A Hematopathologist can diagnose a Follicular Lymphoma with ease. The tumor is composed of small cleaved and large cells in varying proportions organized in a follicular pattern of growth. Confirmation of B cell immunophenotype and existence of the t (14:18) and abnormal expression of BCL 2 protein are confirmatory. Patients may be further sub classified into those with predominantly small cells, those with a mixture of small and large cells and those with predominantly large cells.

Treatment: It is highly responsive to chemotherapy and radiotherapy. Almost 25% of the patients may undergo spontaneous regression without any therapy. In asymptomatic cases, no initial treatment may be given; the patient must be watched carefully. This strategy can be used especially if the patient is quite old. In a patient that requires treatment, a single agent like chlorambucil or cyclophosphamide or a combination might be used. About 50 to 70 % of the cases may achieve a complete remission. Some may retain this remission for more than 10 years. Few cases may relapse in about 2 years. In case a residual Follicular Lymphoma remains, radiotherapy may prove effective. Many new therapies too have been used like fludarabine, interferon α etc. Those cases which show large cell predominance have a shorter survival rate, but on aggressive treatment the survival rate improves to a great extent. Many patients may head to development of large B cell lymphoma; there may be symptoms such as rapid growth of lymph nodes, fever, night sweats, weight loss and weakness. These patients have a poor prognosis. In some cases however, aggressive chemotherapy has been used and it has been seen than most cases regress and leave the patient with persisting Follicular lymphoma.

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