Follicular lymphoma

This page was reviewed under our medical and editorial policy by

Maurie Markman, MD, President, Medicine & Science.

This page was reviewed on May 31, 2022.

Follicular lymphoma is considered a form of non-Hodgkin lymphoma that typically grows and spreads slowly and doesn’t exhibit many signs or symptoms. However, some follicular lymphomas may grow more rapidly.

Non-Hodgkin lymphoma is a type of cancer that begins in the lymphatic system, which is part of your immune system. The lymphatic system is made up of:

  • Lymph (a clear liquid that carries lymphocytes)
  • Lymphocytes (white blood cells)
  • Lymph nodes
  • Spleen
  • Tonsils
  • Thymus gland
  • Bone marrow

The three types of lymphocytes are:

Follicular lymphoma begins in the B lymphocytes, typically affecting the lymph nodes, although it may also metastasize to the bone marrow and/or spleen. Twenty percent of all lymphomas in the United States are follicular lymphomas, according to the American Cancer Society.

Follicular lymphoma causes and risk factors

The exact cause of follicular lymphoma is unknown, but researchers believe environmental and immunological factors—such as exposure to pesticides and prior use of immunosuppressive therapy—and certain genetic influences may be at play. According to the National Organization for Rare Disorders, the majority of follicular lymphoma patients (about 85 percent) have a genetic abnormality called a translocation in the cancer cells, in which portions of chromosomes 14 and 18 break off and switch places.

Follicular lymphoma affects slightly more women than men, and it’s less likely to occur in people of Asian or African descent. It’s rare in young people—in fact, the median age at diagnosis is 60-65.

Follicular lymphoma symptoms

Though follicular lymphoma doesn’t always cause noticeable symptoms, you may experience enlarged lymph nodes in your:

  • Armpits
  • Neck
  • Groin
  • Abdomen

You may also have:

  • Fatigue
  • Night sweats
  • Unexplained weight loss
  • Shortness of breath

Follicular lymphoma diagnosis

Your doctor can work out a diagnosis of follicular lymphoma through specific testing.

First, your doctor will check for outward signs of lymphoma. During a physical examination, the doctor typically palpates any hardened or enlarged lymph node in your body and examines other organs for swelling or an abnormal buildup of fluid. You may also be asked questions about any symptoms you’ve noticed.

If lymphoma is suspected, you’ll likely undergo:

Blood test: Your doctor will order blood work to check your red blood cell, white blood cell, platelet and LDH levels. LDH (lactate dehydrogenase) is an enzyme that’s often elevated in progressed cases of lymphoma.

Biopsy: If your doctor orders a biopsy, a portion of your lymph node or an entire lymph node will be removed under local or general anesthesia to be examined in a laboratory. Sometimes, a laparoscopy is necessary to take a tissue sample from abdominal organs. This procedure involves using a special instrument called a laparoscope. A biopsy is the only way to confirm a follicular lymphoma diagnosis.

Imaging tests: A positron emission tomography (PET) and computed tomography (CT) scan, which is called a PET/CT scan when combined, may be used to obtain 3D images of your tissues and organs. This procedure uses a radioactive sugar that’s injected into your body (cancer cells tend to absorb more of this substance than normal cells and appear on the scan as brighter images).

Bone marrow testing: Your doctor may suggest a biopsy of your bone marrow to confirm the presence of lymphoma.

FISH test: A fluorescence in situ hybridization (FISH) test attaches probes marked by a bright dye to your chromosomes so that any translocations are visible.

PCR: A polymerase chain reaction (PCR) test identifies and copies small segments of DNA to detect genetic alterations.

Follicular lymphoma treatment

Follicular lymphoma is considered a chronic disease. Treatment depends on the severity of your symptoms, as well as how fast the cancer is growing.

If you have mild or no symptoms, your care team may advise a period of watchful waiting, monitoring your follicular lymphoma with regular checkups and laboratory and imaging tests. If you do have bothersome symptoms or the disease is spreading, you may undergo one of the following treatments:

  • Radiation therapy or a combination of radiation and chemotherapy: Follicular lymphoma is responsive to these treatments, and in many cases radiation itself suffices. If the cancer is more advanced, radiation may be used in conjunction with chemotherapy or the drug Rituxan® (rituximab), a monoclonal antibody.
  • Monoclonal antibody therapy: These drugs target markers on B cells. This treatment involves using your immune system to destroy tumor cells and increasing your body’s response to other forms of treatment.

Common monoclonal antibody therapies for follicular lymphoma include:

  • R-Bendamustine (rituximab and bendamustine)
  • R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone)
  • R-CVP (rituximab, cyclophosphamide, vincristine and prednisone)

Newer second-line treatments are emerging for the treatment of follicular lymphoma, such as CAR-T therapy options, which have received U.S. Food and Drug Administration approval in some instances. These therapies take white blood cells, change the gene coding in them to harm lymphoma cells, and then inject them back into your body.

Clinical trials are underway and showing promising results for additional CAR-T therapies as well.

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