About Diagnosis and Treatment for Follicular Lymphoma

Follicular lymphoma is a paradox: a slow-growing cancer that is very easy to treat, but also very difficult to cure. For many years, there have been chemotherapy regimens that can cause partial or even complete remissions. However, the disease almost always returns. Still, there are a number of exciting new drugs for follicular lymphoma that hold out hope for patients with this terrible disease.About 20,000 Americans are diagnosed with follicular lymphoma every year.

How Follicular Lymphoma is Diagnosed

Until the disease is very advanced, most people with follicular lymphoma notice no serious symptoms. They usually go to their doctor when they notice one or more swollen lymph nodes, especially ones which are rubbery or hard, longer than half an inch, and/or steadily growing bigger. Lymph nodes can enlarge for all kinds of reasons, almost always benign ones. However, because of the connection to cancer, it is important to know when to worry about a swollen lymph node.

As lymphoma progresses, it gradually affects more lymph nodes and other parts of the body, including the bone marrow. As this happens, serious symptoms can develop. These include so-called "B symptoms": drenching night sweats, weight loss, and a fever. If you suspect you may have lymphoma, however, don't wait -- check with your doctor.

Diagnosing follicular lymphoma typically begins with several non-specific tests, including a Complete Blood Count (CBC), an ultrasound of lymph nodes in the stomach or neck, a chest X-ray, and/or a CT scan. Malignant lymph nodes can show up as normal with these tests even when they are cancerous, and the CBC usually comes back normal in any event. For this reason, the most important test (which will be ordered if the doctor is still suspicious) is a biopsy of the lymph node, either a fine needle biopsy or an excision biopsy. In an excision biopsy, the entire suspicious lymph node is taken out for analysis.

How Follicular Lymphoma is Treated

Follicular lymphoma is known as an "indolent" lymphoma, meaning it is very slow-growing and in some patients even grows and shrinks and grows back again over a multi-year period. For this reason, many patients are first told to take no treatment -- known as "watch & wait," or, among patients, "watch & worry." Treatment often only begins when B symptoms appear, when the disease spreads to the bone marrow, or when one or more lymph nodes grows to a very large size, such as over 2 inches long.

The standard treatment for follicular lymphoma combines old chemotherapy drugs (cyclophosphamide, prednisone, vincristine, and sometimes doxorubicin) with a new monoclonal antibody called rituximab, forming a regimen called "R-CHOP." R-CHOP has very good response rates, with 95% of people having their tumour load shrink at least in half, and 20% of people getting a complete remission (disappearance of the disease). Sometimes a slightly lighter combination is given, without the doxorubicin, in which case it is known as "R-CVP." Doxorubicin is left out because multiple uses of this drug are associated with serious heart damage.

Unfortunately, follicular lymphoma almost always returns, usually within several years of chemotherapy even in patients who achieved remission. At that time more radical therapies are available, including fludarabine, bone marrow transplants or stem-cell transplants. Zevalin and Bexxar are two drugs which are similar to rituximab, but also contain a radioactive component that kills tumours. A number of other exciting drugs are also in clinical trials as we speak, such as CAL-101. These drugs may be widely used by the time people diagnosed with follicular lymphoma today are in need of a second-line treatment.