Follicular lymphoma

Follicular lymphoma (FL) is a type of non-Hodgkin lymphoma (NHL). It develops when the body makes abnormal B-cells – the lymphoma cells. B-cells are white blood cells that fight infection. The lymphoma cells usually build up in lymph nodes but FL can start in other parts of the body.

The most common symptom is a painless swelling in the neck, armpit or groin. Other symptoms may include:

  • tiredness
  • weight loss
  • night sweats
  • high temperatures (fevers).

To diagnose FL, a doctor removes part or all of an enlarged lymph node and checks it for lymphoma cells. You will also have tests and scans to find out how many groups of lymph nodes are affected and whether the lymphoma has spread.

FL is slow-growing and does not always need to be treated straight away. If you need treatment, it often involves a combination of chemotherapy and a targeted therapy drug called rituximab. Some people may have radiotherapy. You may be invited to join a clinical trial looking at new ways of treating FL. You can talk about this with your lymphoma doctor.

What is follicular lymphoma (FL)?

It is best to read this information with our general information about non-Hodgkin lymphoma (NHL). If you have any more questions, you can ask your doctor or nurse at the hospital where you are having treatment.

Follicular lymphoma (FL) is a slow-growing type of NHL. It develops when B-cells (also called B-lymphocytes) become abnormal. B-cells are white blood cells that fight infection.

The abnormal B-cells (lymphoma cells) usually build up in lymph nodes, but they can affect other parts of the body.


Causes and risk factors for FL

The causes of FL are unknown. Like other cancers, it is not infectious and cannot be passed on to other people. The most common age to be diagnosed with FL is 60 to 65.

We have more information about risk factors for lymphoma.


Signs and symptoms of FL

Often, the first sign of FL is a painless swelling in the neck, armpit or groin. This is caused by lymphoma cells building up in the lymph nodes, which makes them bigger.

Other symptoms may include loss of appetite and tiredness (fatigue). Sometimes lymphoma cells may build up in the bone marrow, where blood cells are made. This can cause lower than normal numbers of healthy blood cells in the blood. If the number of red blood cells in your blood is too low, you may be pale, tired and get breathless easily. Doctors call this anaemia. If the number of blood-clotting cells (platelets) in your blood is too low, you may bruise or bleed easily.

B symptoms

Some people also have:

  • drenching night sweats
  • high temperatures (fevers) with no obvious cause
  • unexplained weight loss.

These are called B symptoms.


Diagnosing lymphoma

The most common test for this lymphoma is to remove part or all of an enlarged lymph node (a biopsy). This may be done under local or general anaesthetic. The biopsy is then sent to a laboratory to be checked for lymphoma cells. You may also have biopsies taken from other areas of the body.

Other tests may include:

  • blood tests
  • x-rays and scans
  • bone marrow samples.

Doctors use the information from all these tests to find out more about the lymphoma, such as its stage and grade.


Staging and grading FL

Staging

The stage of the lymphoma describes which areas of the body are affected by lymphoma. This information helps doctors plan the right treatment for you.

The stage of a lymphoma is usually described using numbers from 1 to 4. Stages 1 and 2 are also called early-stage, limited or localised lymphoma. Stages 3 and 4 are also called advanced lymphoma.

As well as giving each stage a number, doctors often add the letters A or B. A means you do not have B symptoms. B means you do have B symptoms.

Sometimes the lymphoma can affect areas outside the lymph nodes. This is called extranodal lymphoma, and the stage will include the letter E (for extranodal).

Grading

Non-Hodgkin lymphomas are divided into two groups:

  • Low-grade (indolent) lymphomas, which usually grow slowly.
  • High-grade (aggressive) lymphomas, which grow more quickly.

FL is a low-grade lymphoma and usually develops slowly. Sometimes it can change (transform) to become a high-grade lymphoma.


Treating FL

FL often develops slowly. Some people may not need treatment straight away, or even for months or years. This is called watch and wait

Even if you don’t need treatment, you will have regular check-ups at the hospital. Your specialist will examine you and do blood tests. This is to check the levels of your red blood cells, white blood cells and platelets (a full blood count – FBC).

Treatment depends on the stage of the lymphoma and whether you have symptoms that are causing problems. The most commonly used treatment is a combination of chemotherapy and the targeted therapy drug rituximab. Most people have their treatment as outpatients.

For most people, the aim of treatment is to get rid of as much of the lymphoma as possible. If there are no signs of lymphoma after treatment, this is called a complete remission.

After treatment, many people have a period of time with no signs of active disease. This is called remission. If the lymphoma comes back, it can be treated again and it can often be controlled for many years.

Targeted therapy

Targeted therapies are sometimes known as biological therapies. They interfere with the way cancer cells grow. These drugs only ‘target’ the cancer cells, so they have less effect on healthy cells.

Rituximab

A targeted therapy drug called rituximab is commonly used to treat FL. It works by targeting proteins on the surface of B-cells. This makes the body destroy these cells.

Rituximab is given as a drip into a vein or as an injection under the skin. It can be given on its own, but it is usually given with chemotherapy. Some people who have a good response to chemotherapy and rituximab may then have rituximab on its own for up to 2 years. This is called maintenance treatment

Other targeted therapies

Other types of targeted therapy are occasionally used to treat FL

One type is called 90Y-ibritumomab tiuxetan (Zevalin®). It is attached to a low dose of a radioactive substance. It carries radiation into the lymphoma cells.

Chemotherapy

Chemotherapy is an important treatment for FL and can often get the lymphoma into remission. It is usually given in combination with rituximab.

Chemotherapy can be given as tablets or into a vein (intravenously). You may be given just one chemotherapy drug or you may be given two or more chemotherapy drugs together (combination chemotherapy).

Chemotherapy treatments for FL include the following:

  • R-CVP – this is made up of rituximab, the chemotherapy drugs cyclophosphamide and vincristine, and prednisolone (a steroid). It's given as a drip into a vein, usually once every three weeks.
  • R-CHOP– this is made up of rituximab, the chemotherapy drugs cyclophosphamide, doxorubicin (hydroxydaunomycin) and vincristine (Oncovin®), and prednisolone. These are given as a drip into a vein, usually once every three weeks.
  • R-chlorambucil – this is made up of rituximab and chemotherapy tablets called chlorambucil.
  • R-bendamustine – this is made up of rituximab and the chemotherapy drug bendamustine. This treatment is given as a drip into a vein. This is usually given on 2 consecutive days every 4 weeks.

There are other chemotherapy drugs and combinations that can be used to treat FL. Your lymphoma doctor can tell you which are most appropriate for you.

Steroid therapy

Steroids are drugs that are often given with chemotherapy to help treat lymphomas. They also help you feel better and can make you feel less sick. Prednisolone tablets are the most commonly used steroid to treat FL.

Stem cell treatment (transplants)

This treatment is sometime used to treat lymphoma that has come back after treatment. It is an intensive treatment, so it is not suitable for everyone.

Stem cells are a type of blood cell that can make all other types of blood cells. There are two different types of stem cell treatment:

High-dose treatment with stem cell support (autologous stem cell transplant)

Some people have treatment to put the lymphoma into remission. Then some of their own stem cells are collected from their blood and stored. Then they have high doses of chemotherapy to try to destroy any remaining lymphoma cells. After this, their stem cells are returned through a drip (like a blood transfusion). The stem cells help their blood cell numbers recover from the effects of chemotherapy.

Donor transplant (allogeneic transplant)

Some people have chemotherapy to put the lymphoma into remission and are then given stem cells from another person (a donor)

Radiotherapy

Radiotherapy uses high-energy rays to destroy cancer cells, while doing as little harm as possible to nearby healthy cells. FL is usually very sensitive to radiotherapy.

It may be used as a first treatment if the lymphoma cells are contained in 1 or 2 groups of lymph nodes in the same part of the body (stage 1 or 2). In some people, this may cure the lymphoma.

Radiotherapy can also be used to treat lymphoma that has come back in one area of lymph nodes. Radiotherapy is also sometimes given to treat symptoms, such as pain.

Clinical trials

Your lymphoma doctor may talk to you about having treatment as part of a clinical trial. Clinical trials test new treatments or new ways of giving treatments.


Follow-up after treatment

After treatment, you will have regular check-ups. These appointments are a good opportunity for you to talk to your doctor or nurse about any concerns you have. Your doctor will want to know how you are feeling generally, and to check you are recovering from any side effects of treatment. We have more information about follow-up.


Getting support

Everyone has their own way of dealing with illness and the different emotions they experience. You may find it helpful to talk things over with family and friends or your doctor or nurse. You can also call our cancer support specialists free on 0808 808 00 00. The organisations below also offer information and support:

  • Bloodwise offers support and information to people affected by blood cancers, including lymphoma.
  • The Lymphoma Association gives emotional support, advice and information on all aspects of Hodgkin lymphoma and non-Hodgkin lymphoma. It has a national network of people with lymphoma, and local groups.