Follicular Lymphoma: A Clinicopathological Analysis from a Tertiary care Institute in Southern India

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Mary Theresa Sylvia
Biswajit Dey
Debdatta Basu
Sajini Elizabeth Jacob
Rakhee Kar
Biswajit Dubashi


Follicular lymphoma, Granuloma, Grade, High-proliferation-index



Follicular lymphoma (FL) is an indolent chronic lymphoproliferative disorder of B-cells with variable clinical behaviour. It is the second most common subtype of Non-Hodgkin lymphoma in western countries but reported to have a lower incidence in Asia.

Materials and methods

Cases of FL diagnosed in the Department of Pathology of our Institute from January 2009 to June 2015 were included in the study. The clinicopathological parameters including staging, histological details and immunohistochemical markers CD20, CD10, Bcl2 and Ki67 were recorded in all the cases.


Of the 497 cases of Non-Hodgkin Lymphoma reported during the study period, 36 (7.2%) cases were follicular lymphoma. The mean age was 50 years with male to female ratio of 3.2:1. Grade 1/ 2 was seen in 70% cases. 22 % cases had low grade with high proliferation index (Ki67 > 40%). Granulomatous response was seen in two cases. Diffuse large cell lymphoma component was present in four cases. Bone marrow involvement and peripheral blood spill was seen in 12 (37.5%) and six cases (18.8%) respectively. 72% cases were in stage 3 or 4.


Incidence of FL was lower in our study than other Indian studies. FL presented in the elderly, with male predominance and disseminated stage. Features of low grade with high proliferation index, granulomatous response, leukemic involvement and transformation to high grade lymphoma are highlighted in the study.


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1. Lossos IS, Gascoyne RD. Transformation of Follicular Lymphoma. Best Pract Res Clin Haematol 2011; 24:147–163.

2. Das S, Basu D, Dubashi B, Jain A. Low grade follicular lymphoma with high proliferation index; diagnostic and management issues. Indian J Pathol Microbiol 2012;55:516-518.

3. Kojima M, Nakamura S, Ichimura K, Suzuki R, Kagami Y, Kondo E et al. Centroblastic and centroblastic/centrocytic lymphoma associated with a prominent epitheliod granulomatous response:A clinicopathologic study of 50 cases. Mod Pathol 2002;15:750-758.

4. Prochazka V, Papajik T, Jarosova M, Indrak K. Prognostic factors in follicular lymphoma in the rituximab era: How to identify a high-risk patient? Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2011;155:99–108.

5. Salles GA .Clinical features, prognosis and treatment of follicular lymphoma. Hematology Am Soc Hematol Educ Program 2007:216-225.

6. Naresh KN, Srinivas V, Soman CS. Distribution of various subtypes of non- Hodgkin's lymphoma in India: A study of 2773 lymphomas using R.E.A.L. and WHO classifications. Ann Oncol 2000;11:S63-S67.

7. Mondal SK, Mandal PK, Samanta TK, Chakaborty S, Roy SD, Roy S. Malignant lymphoma in Eastern India: A retrospective analysis of 455 cases according to World Health Organization classification. Indian J Med Paediatr Oncol 2013;34:242-246.

8. Relander T, Johnson NA, Farinha P, Connors JM, Sehn LH, Gascoyne RD. Prognostic factors in follicular lymphoma. J Clin Oncol 2010; 28:2902-2913.

9. Gaman A M. Follicular non-Hodgkin’s lymphoma: correlation between histology, pathophysiology, cytogenetic, prognostic factors, treatment, survival. Rom J Morphol Embryol 2013; 54:71–76.

10. Bhardwaj A, Kishore S, Kusum A. Comparative Analysis of the Distribution of Various Subtypes of Lymphoid Malignancies in Uttarakhand with other Regions in India. Ind Med Gaz 2012: 147-152.

11. Sharma M, Mannan R, Madhukar M, Navani S, Manjari M, Bhasin TS et al. Immunohistochemical (IHC) analysis of Non-Hodgkin’s lymphoma (NHL) spectrum according to WHO/REAL classification: A single centre experience from Punjab, India. J Clin Diagn Res 2014;8:46-49.

12. Torlakovic E, Torlakovic G, Brunning R D. Follicular pattern of bone marrow involvement by follicular lymphoma. Am J Clin Pathol 2002;118:780-786.

13. Thiele J, Zirbes T K, Kvasnicka H M, Fischer R. Focal lymphoid aggregates (nodules) in bone marrow biopsies: differentiation between benign hyperplasia and malignant lymphoma-a practical guideline. J Clin Pathol 1999;52:294-300.

14. Kluin P M. Origin and migration of follicular lymphoma cells. Haematologica 2013;98:1331-1333.

15. Catovsky D. Chronic lymphocytic leukaemia and other B-cell disorders.In: Hoffbrand AV, Catovsky D, Tuddenham EGD ,eds. Postgraduate Hematology. Victoria , Australia. Blackwell Publishing Asia Pty Ltd. 2005;619-643.

16. Beltran BE, Castillo JJ, Quinones P, Morales D, Alva JC, Miranda RN et al. Follicular lymphoma with leukemic phase at diagnosis: An aggressive disease. Report of seven cases and review of the literature. Leuk Res 2013; 37:1116–1119.

17. Sarkozy C, Baseggio L, Feugier P, Callet-Bauchu E, Karlin L, Seymour JF et al. Peripheral blood involvement in patients with follicular lymphoma: a rare disease manifestation associated with poor prognosis. Br J Hematol 2014;164:659-67.

18. Xin He ,Zhigang Chen, Tao Fu, Xueli Jin, Teng Yu, Yun Liang et al. Ki-67 is a valuable prognostic predictor of lymphoma but its utility varies in lymphoma subtypes: evidence from a systematic meta-analysis. BMC Cancer 2014,14:153.

19. Wang SA, Wang L, Hochberg EP, Muzikansky A, Harris NL, Hasserjian RP et al. Low histologic grade follicular lymphoma with high proliferation index: morphologic and clinical features. Am J Surg Pathol 2005;29:1490-6.

20. Olteanu H, Fenske TS, Harrington AM, Szabo A, He P, Kroft SH. CD23 expression in follicular lymphoma clinicopathologic correlations. Am J Clin Pathol 2011;135:46-53.

21. Kridel R, Sehn L H, Gascoyne R D. Pathogenesis of follicular lymphoma. J Clin Invest. 2012; 122:3424–3431.

22. Akasaka T, Lossos IZ, Levy R. BCL6 gene translocation in follicular lymphoma: a harbinger of eventual transformation to diffuse aggressive lymphoma. Blood 2003;102:1443-1447.

23. Solal-Celigny P, Roy P, Colombat P, White J, Armitage JO, Arranz-Saez R et al. Follicular lymphoma international prognostic index. Blood 2004;104:1258-1265.