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Follicular lymphoma

Key sources
The following summarized guidelines for the evaluation and management of follicular lymphoma are prepared by our editorial team based on guidelines from the European Society of Medical Oncology (ESMO 2021), the British Society for Haematology (BSH 2020), the Italian Group for Bone Marrow Transplantation (GITMO/SIES/SIE 2013), and the Spanish Society of Hematology and Hemotherapy (SEHH 2011).
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Guidelines

1.Classification and risk stratification

Staging: as per ESMO 2021 guidelines, use the Ann Arbor classification system for the initial staging of FL.
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  • Prognostic scores

2.Diagnostic investigations

Imaging for staging
As per ESMO 2021 guidelines:
Obtain CT of the neck, chest, and abdomen in the initial evaluation of patients with FL.
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Obtain PET-CT for routine staging
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and to confirm localized stage I/II disease before involved-site radiotherapy.
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  • Laboratory evaluation

  • Cardiac evaluation

3.Diagnostic procedures

Biopsy and histopathology: as per ESMO 2021 guidelines, perform surgical specimen/excisional lymph node biopsy for the diagnosis of FL. Consider performing core biopsies if lymph nodes are not easily accessible.
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4.Medical management

General principles: treat FL grade IIIb as an aggressive lymphoma, whereas grades 1, 2, and 3A as an indolent disease.
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  • Management of localized disease (watchful waiting)

  • Management of localized disease (involved-site radiotherapy)

  • Management of localized disease (systemic therapy)

  • Management of advanced disease (general principles)

  • Management of advanced disease (watchful waiting)

  • Management of advanced disease (induction of remission)

  • Management of advanced disease (maintenance of remission)

5.Preventative measures

Antibiotic prophylaxis: administer adequate prophylaxis (antibiotics and/or IgG) in patients with symptomatic recurrent infections based on prior treatment (such as with fludarabine or bendamustine).
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  • Routine immunizations

6.Follow-up and surveillance

Serial clinical assessment
As per ESMO 2021 guidelines:
Obtain clinical monitoring every 6 months for 2 years after local radiotherapy, and once a year subsequently if clinically indicated.
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Obtain clinical monitoring every 3-6 months for 2 years after (during continuous) systemic treatment, and every 6-12 months subsequently.
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  • Serial laboratory assessment

  • Serial imaging assessment

  • Assessment of minimal residual disease

  • Management of relapse (biopsy)

  • Management of relapse (watchful waiting)

  • Management of relapse (radiotherapy)

  • Management of relapse (systemic therapy)

  • Management of relapse (stem cell transplantation)