Surveillance Assessments for Patients in Remission from Follicular Lymphoma
During surveillance visits for patients in remission from follicular lymphoma, clinicians should perform history and physical examination every 3 months for 2 years, every 6 months for 3 additional years, and then annually with special attention to transformation and secondary malignancies. 1, 2
Clinical Assessment
- History and physical examination should focus on detecting signs of relapse, transformation to aggressive lymphoma, and secondary malignancies including secondary leukemia 1, 2
- Evaluate for B symptoms (fever, night sweats, weight loss) which may indicate disease recurrence or transformation 1
- Assess for lymphadenopathy, hepatosplenomegaly, or other signs of disease progression 1
- Monitor for symptoms of bone marrow involvement such as fatigue, easy bruising, or recurrent infections 1
Laboratory Evaluations
- Complete blood count at 3,6,12, and 24 months, then only as needed for evaluation of suspicious symptoms 1, 2
- Lactate dehydrogenase (LDH) at the same intervals as complete blood count, as elevated levels may indicate disease recurrence 1
- Immunoglobulin levels should be monitored periodically, especially after rituximab therapy, as hypogammaglobulinemia may develop 1, 2
- For patients who received rituximab, monitor for hepatitis B reactivation for up to 2 years after exposure if the patient has positive hepatitis B serology 2
Imaging Surveillance
- Minimal adequate radiological or ultrasound examinations at 6,12, and 24 months after end of treatment 1, 2
- PET-CT is not routinely recommended for surveillance in asymptomatic patients in remission, as studies have shown no significant difference in overall survival between clinical and radiological detection of relapse 3
- If clinical concerns arise during follow-up, appropriate imaging should be performed to evaluate for potential relapse 3
Special Considerations
- Evaluation of thyroid function at 1,2, and 5 years in patients with irradiation to the neck 1, 2
- Any suspicious new or rapidly growing lesion should prompt consideration of biopsy to rule out transformation to aggressive lymphoma 2
- The risk of transformation to diffuse high-grade lymphoma is approximately 32% with long-term follow-up and is associated with a poor prognosis 4
Important Pitfalls to Avoid
- Over-reliance on imaging for surveillance - clinical examination remains crucial for detecting relapses 2, 3
- Inadequate surveillance may result in delayed detection of relapse or transformation 2
- Failure to consider biopsy for suspicious lesions may delay diagnosis of transformation 2
- Neglecting to monitor for treatment-related complications such as thyroid dysfunction in patients who received neck irradiation 1, 2
By following these surveillance recommendations, clinicians can optimize the detection of relapse while avoiding unnecessary testing in patients with follicular lymphoma in remission.