Follicular Lymphoma


Once you’ve been diagnosed with follicular lymphoma, the next step for doctors is to determine the stage of the disease and develop an appropriate treatment plan.

To stage follicular lymphoma, doctors will order tests to find out how far the disease has spread and which areas of the body it’s affecting. (See Diagnosis for more information about diagnostic tests.) Based on the results of these diagnostic tests, the doctor will assign a stage to the disease. The Ann Arbor staging system for follicular lymphoma is the most commonly used system (see Table 1). The higher the stage number, the more advanced the disease.

Table 1. The Ann Arbor Staging System*

Stage Definition
I The disease is in only one lymph node area or lymphoid organ, such as the thymus.
IE The disease is in only one area of a single organ outside the lymph system.
II The disease is in two or more lymph node areas on the same side (above or below) of the diaphragm.
IIE The disease extends from one lymph node area to a nearby organ, with possible spread to one or more lymph node areas on the same side of the diaphragm.
III The disease is in lymph node areas on both sides (above and below) of the diaphragm.
IIIE The disease is in lymph node areas above and below the diaphragm and has spread directly to an adjacent organ.
IV  The disease has spread outside the lymph system to an organ that is not directly next to the involved lymph node area(s); or it has spread to the bone marrow, lungs, cerebrospinal fluid or liver.
Various letters can be added to the stage to indicate additional factors (all possible combinations not shown above):
A: Fever, night sweats and weight loss are not present.
B: Fever, night sweats and weight loss are present.
E: The cancer affects an organ or tissue outside the lymph system.
*This staging system is for Hodgkin lymphoma but it is often applied to non-Hodgkin lymphoma, including follicular lymphoma.


In addition to the Ann Arbor staging system, oncologists use the Follicular Lymphoma International Prognostic Index (FLIPI) to predict the risk of disease recurrence and overall survival. The FLIPI takes into account the age and general health of the person, the stage of the disease, the hemoglobin level, the number of involved lymph nodes, and the presence or absence of elevated levels of an enzyme called lactate dehydrogenase (LDH) in the blood.

The FLIPI assigns one point for each of the following risk factors:

  • Age older than 60 years
  • Late-stage disease (Stage III or IV)
  • Hemoglobin level less than 12 g/dL
  • More than four involved lymph node areas
  • High LDH level

The lower the score, the better the prognosis (predicted outcome from treatment).

The World Health Organization recommends that follicular lymphoma be assigned a histologic grade, which is determined by the number of centroblasts (a special kind of B-lymphocyte) found when examining a sample with a microscope (see Table 2). The grade defines how aggressive the cancer cells are likely to be and helps doctors make various treatment decisions, including when treatment should start. The higher the grade, the more likely the disease is to progress. To determine your prognosis, your doctor may also test how well you are able to function and carry out daily activities by using a functional assessment scale.

Table 2. Histologic Grades of Follicular Lymphoma

Grade Definition
1 0-5 centroblasts per high-power field
2 6-15 centroblasts per high-power field
3 More than 15 centroblasts per high-power field
3A More than 15 centroblasts, but centrocytes (smaller cells) still present
3B Solid sheets of centroblasts with no residual centrocytes


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