From the Guidelines
After diagnosing follicular lymphoma of the base of tongue, a comprehensive staging workup is essential to determine disease extent and guide treatment, including a complete blood count, comprehensive metabolic panel, lactate dehydrogenase (LDH) level, and beta-2 microglobulin, as well as imaging studies such as contrast-enhanced CT scans and a PET-CT scan, bone marrow biopsy and aspiration, and additional testing for hepatitis B, C, and HIV serology, as recommended by the most recent guidelines 1.
The staging workup should include:
- A complete blood count to assess for hematopoietic impairments
- Comprehensive metabolic panel to evaluate liver and kidney function
- Lactate dehydrogenase (LDH) level to assess for tumor burden
- Beta-2 microglobulin to evaluate prognosis
- Imaging studies:
- Contrast-enhanced CT scans of the neck, chest, abdomen, and pelvis to evaluate for nodal and extranodal disease
- PET-CT scan to detect additional disease sites and assess for FDG avidity
- Bone marrow biopsy and aspiration to assess for marrow involvement
- Additional testing:
- Hepatitis B, C, and HIV serology to guide treatment decisions and prevent reactivation of viral infections
- Echocardiogram or MUGA scan if anthracycline-based chemotherapy is being considered
The pathology specimen should undergo:
- Immunohistochemistry to confirm the diagnosis and determine the grade of follicular lymphoma
- Flow cytometry to assess for lymphomatous tissue
- Molecular studies for BCL2 rearrangement to confirm the diagnosis in challenging cases
This comprehensive workup allows for accurate staging according to the Ann Arbor classification system, which is crucial for determining the appropriate treatment approach, whether that be watchful waiting for limited asymptomatic disease or more aggressive therapy for advanced or symptomatic cases, as recommended by the most recent guidelines 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Diagnosis and Staging
- After a patient has been diagnosed with follicular lymphoma of the base of tongue, further work-up and testing are necessary to determine the extent of the disease and to develop an appropriate treatment plan 2, 3, 4.
- The diagnosis is based on histology from a biopsy of a lymph node or other affected tissue, and immunohistochemical staining is positive in virtually all cases for cell surface CD19, CD20, CD10, and monoclonal immunoglobulin, as well as cytoplasmic expression of bcl-2 protein 2, 3, 4.
Imaging Studies
- CT scanning of the neck, thorax, and abdomen should be performed to assess how far the disease has spread, together with bone marrow biopsy and, if required, PET/CT 5, 6.
- PET/CT evaluation can be used to assess treatment responses and survival outcomes, and to explore correlations between interim Deauville scores and baseline PET/CT parameters 5.
Prognostic Factors
- The Follicular Lymphoma International Prognostic Index (FLIPI) uses five independent predictors of inferior survival: age >60 years, hemoglobin <12 g/dL, serum LDH > normal, Ann Arbor stage III/IV, and number of involved nodal areas >4 2, 3, 4.
- Other factors such as time to relapse of less than 2 years from chemoimmunotherapy and specific gene mutations may also be useful for prognosis 2, 3.
Treatment Planning
- Observation continues to be appropriate for asymptomatic patients with low bulk disease and no cytopenias, with no overall survival advantage for early treatment with either chemotherapy or single-agent rituximab 2, 3, 4.
- For patients needing therapy, most patients are treated with chemoimmunotherapy, which has improved overall response rates, duration of response, and overall survival (OS) 2, 3, 4.
- Randomized studies have shown additional benefits for maintenance of rituximab, and lenalidomide was non-inferior to chemoimmunotherapy in a randomized front-line study 2, 3.