Initial Diagnostic Workup of Follicular Lymphoma (FL)

The diagnosis of FL follows a similar workup for diagnosing other types of Non-Hodgkin’s Lymphoma (NHL).¹

Diagnosis of NHL begins with a thorough history:

Evaluation of symptoms — onset, behavior, presence of B-cell symptoms (fever, night sweats, weight loss)²
Review of systems, noting any recent changes, infections¹
Quantifying performance status¹
Determining risk factors for NHL²

NCCN Clinical Practice Guidelines In Oncology (NCCN Guidelines^®) for B-Cell Lymphomas provides diagnostic recommendations for FL.

Physical Examination	The essential workup for FL includes a physical exam with particular attention to node-bearing areas.¹
Laboratory Workup	Certain laboratory studies are essential in patients suspected of having follicular lymphoma. Additional studies may be informative in specific clinical situations, depending on history and physical exam findings.¹
Immunophenotyping Cytogenetics Molecular Profiling	Immunophenotyping is required to establish a diagnosis of follicular lymphoma. Cytogenetic analyses and molecular genotyping may be useful for identifying translocations and mutations characteristic of follicular lymphoma.¹
Histology: Tumor Biopsy Bone Marrow Biopsy	NHL is complex, requiring physicians to differentiate among many different subtypes.³ Biopsies can be used to help identify follicular lymphoma and are required to document clinical stage.¹
Imaging Studies	Imaging is essential for diagnosis and staging of follicular lymphoma.¹

Below are characteristics of FL, as defined by the WHO 2016 classification system of FL:

Morphology	Immunophenotype	Cytogenetics	Molecular biology	Clinical features*
Centrocytes and centroblasts of germinal center origin	Pan-B+ CD5- CD10+ slg+	t(14;18)	Comprehensive sequencing of somatic mutations in iNHL, like FL, remains limited Distinctive mutations with functional relevance in FL have yet to be fully elucidated	Indolent behavior Often no obvious symptoms at diagnosis Common symptoms include lymphadenopathy, fatigue, dyspnea, night sweats, weight loss Some transform over time into more aggressive disease

Morphology	Centrocytes and centroblasts of germinal center origin
Immunophenotype	Pan-B+ CD5- CD10+ slg+
Cytogenetics	t(14;18)
Molecular biology	Comprehensive sequencing of somatic mutations in iNHL, like FL, remains limited Distinctive mutations with functional relevance in FL have yet to be fully elucidated
Clinical features*	Indolent behavior Often no obvious symptoms at diagnosis Common symptoms include lymphadenopathy, fatigue, dyspnea, night sweats, weight loss Some transform over time into more aggressive disease

^*Consistent with low-grade, indolent FL and may not necessarily be accurate for aggressive forms.

iNHL, indolent non-Hodgkin’s lymphoma; NCCN, National Comprehensive Cancer Network; WHO, World Health Organization.

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