Follicular Lymphoma (FL)

Type:

• Indolent (slow-growing) B-cell non-Hodgkin lymphoma
• Most common indolent NHL (~20% of NHL cases)

Key Features:

• Often presents with painless lymphadenopathy
• Advanced stage at diagnosis is common (Stage III–IV)
• May follow a relapsing/remitting course
• Can transform into aggressive lymphoma (e.g., DLBCL)

Grading:

• Based on number of centroblasts per high-power field:
  • Grade 1–2: Indolent
  • Grade 3a: Still indolent
  • Grade 3b: More aggressive, treated like DLBCL

Treatment Approach:

1. Asymptomatic, low tumor burden

• Watchful waiting (no immediate therapy)

2. Symptomatic or high tumor burden

• Chemoimmunotherapy (e.g., BR: bendamustine + rituximab or obinutuzumab)
• Other regimens: R-CHOP, R-CVP (less preferred for indolent disease)

3. Maintenance

• Rituximab maintenance (every 8 weeks x 2 years) after induction may prolong PFS

4. Relapsed/Refractory

• Re-treatment with prior regimen if long remission
• Targeted therapies:
  • PI3K inhibitors, EZH2 inhibitors (e.g., tazemetostat)
  • CAR T-cell therapy (for later-line)

Pharmacist Considerations:

• HBV screening prior to anti-CD20 therapy (risk of reactivation)
• Monitor for infusion reactions with rituximab/obinutuzumab
• Myelosuppression common—monitor CBC
• Risk of TLS, especially in bulky disease
• Consider infection prophylaxis (e.g., PJP, antivirals) if prolonged immunosuppression