What are the symptoms of follicular lymphoma?

Symptoms of Follicular Lymphoma

Follicular lymphoma typically presents with painless, diffuse lymphadenopathy, often accompanied by bone marrow involvement and splenomegaly, while constitutional B symptoms (fever, night sweats, weight loss) are notably uncommon unless transformation to aggressive lymphoma has occurred. 1, 2

Common Presenting Features

Lymph Node Enlargement

• Patients characteristically present with a long history of symptomless lymph node enlargement 3
• Diffuse lymphadenopathy is the hallmark presentation 1, 2
• Multiple nodal areas are frequently involved at diagnosis 1

Bone Marrow and Splenic Involvement

• Bone marrow involvement is common at presentation 1, 2
• Splenomegaly frequently occurs 1, 2
• These findings often indicate advanced stage III-IV disease 4

Extranodal Disease

• Extranodal involvement occurs but is less common than nodal disease 1, 2

Symptoms That Warrant Treatment Initiation

The following symptoms indicate need for therapy in advanced stage disease: 4

• B symptoms (fever, night sweats, weight loss) - though these are uncommon and suggest possible transformation 1, 2
• Hematopoietic impairments including cytopenias 4
• Bulky disease 4
• Rapid lymphoma progression 4

Important Clinical Distinctions

Asymptomatic Presentation

• Many patients present with extensive, symptomless disease, particularly those under 40 years of age 3
• Asymptomatic patients with low tumor burden and no cytopenias can be observed without immediate treatment 1, 2
• The disease is characterized by spontaneous regressions in 15-20% of cases 4

Constitutional Symptoms Are Red Flags

• Constitutional B symptoms (fever, night sweats, weight loss) are uncommon in follicular lymphoma 1, 2
• When present, they should raise concern for transformation to diffuse large B cell lymphoma 1
• Transformation represents an abrupt change in disease character with rapid clinical deterioration 3

Hematologic Manifestations

• Cytopenias can occur but are relatively common findings 1, 2
• A syndrome resembling chronic lymphocytic leukemia may occur, characterized by the presence of notched nucleus cells when present 3

Clinical Pitfall

The most critical pitfall is mistaking the indolent nature of follicular lymphoma for benign disease. While patients often have prolonged symptomless periods with extensive lymphadenopathy, proper tissue diagnosis via excisional lymph node biopsy is mandatory to confirm the diagnosis and exclude transformation 4, 5.