Follicular Lymphoma Treatment

Follicular lymphoma is one of the most common types of non-Hodgkin lymphoma, accounting for approximately 20% of all cases diagnosed in the United States. The cancer develops in the B lymphocytes within lymph nodes and typically grows slowly. However, it can sometimes transform into a more aggressive form of lymphoma, such as diffuse large B cell lymphoma, over time.

Because follicular lymphoma often behaves as a chronic condition, its treatment focuses on managing symptoms and maintaining quality of life. Treatment options may include active surveillance and possibly radiation therapy for slow-growing or early-stage cancer. More advanced or symptomatic cases are often treated with chemotherapy, immunotherapy or targeted therapy to control the cancer growth. For relapsed or aggressive disease, chimeric antigen receptor (CAR)-T cell therapy or bone marrow transplantation (BMT) may be considered.

Active surveillance for follicular lymphoma

If follicular lymphoma is growing slowly and not causing symptoms, the physician may recommend regular checkups, blood tests and imaging scans instead of starting treatment right away. This “watchful waiting” approach may allow the patient to avoid unnecessary therapy and potential side effects while ensuring treatment can begin promptly if the cancer shows signs of progression.

Radiation therapy for follicular lymphoma

Radiation therapy is often recommended for early-stage follicular lymphoma confined to a limited number of lymph nodes. This common treatment approach—which uses powerful, highly targeted energy beams to destroy cancerous cells—has been shown to be effective in achieving long-term remission in patients with localized lymphoma. In more advanced cases, radiation therapy may be used to shrink enlarged lymph nodes and help relieve the related symptoms, such as pain and swelling.

Side effects and risks of radiation therapy for follicular lymphoma

Radiation therapy for follicular lymphoma is generally well tolerated, but side effects can occur depending on the treatment site and dose. Common short-term issues include fatigue, skin irritation and hair loss in the treated area. If the radiation beam is directed near the neck or chest, the patient might also experience a sore throat, dry mouth or swallowing discomfort. If the abdomen or pelvis is treated, some patients may notice nausea, diarrhea or reduced appetite.

Most side effects of radiation therapy are mild, temporary and begin to improve shortly after treatment ends. Long-term risks are uncommon but may include tissue stiffness or scarring near the treatment site or a slightly increased risk of developing another cancer years later. To reduce the likelihood of complications, the healthcare team will use highly precise radiation delivery techniques to minimize exposure to nearby healthy tissues.

Preparation and recovery from radiation therapy for follicular lymphoma

Before beginning radiation therapy, the patient will attend a planning session (simulation), where imaging scans will be taken to help the physician map the exact treatment area. This process will help the healthcare team deliver the radiation as accurately as possible while protecting the surrounding healthy tissues. To further guide treatment, small markings may be placed on the skin.

Radiation therapy is typically administered five days per week over several weeks, with each session lasting only a few minutes. During treatment, the patient will be encouraged to maintain good nutrition, hydration and rest to help manage any fatigue. Gentle skin care—such as using mild soaps and avoiding the use of scented lotions and deodorants on the treated skin—can help reduce irritation.

Most patients can continue their normal activities during radiation therapy, with mild fatigue being the most common side effect. After completing treatment, follow-up appointments will be scheduled to monitor healing, evaluate the treatment response and address any lingering symptoms.

Chemotherapy for follicular lymphoma

Chemotherapy may be considered if follicular lymphoma advances and begins to cause disruptive symptoms. Commonly used drug regimens include BR, which consists of bendamustine combined with rituximab, and R-CHOP, which includes rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone. After entering the bloodstream, these powerful medications will circulate throughout the body to target rapidly dividing cells. Chemotherapy is often combined with immunotherapy for enhanced treatment effectiveness.

Side effects and risks of chemotherapy for follicular lymphoma

Chemotherapy can be a highly effective treatment for follicular lymphoma. However, it may cause side effects as it targets fast-growing cells within the body. Common issues include fatigue, nausea, vomiting, temporary hair loss, decreased appetite and increased susceptibility to infection due to lowered white blood cell counts. Some patients may also experience mouth sores, easy bruising or numbness and tingling in their hands or feet (neuropathy), depending on the specific drugs used.

While most side effects of chemotherapy are temporary and improve after treatment ends, certain medications can occasionally cause longer-term issues, such as heart strain or reduced fertility. The oncology team will carefully monitor the patient and tailor the dose throughout treatment to reduce the risks and promptly address any side effects. Supportive therapies—such as anti-nausea medications, infection prevention strategies and nutrition counseling—can further help the patient maintain strength and comfort during treatment.

Preparation and recovery from chemotherapy for follicular lymphoma

Before starting chemotherapy, the patient will undergo blood tests, heart and lung evaluations and imaging scans to help the medical team develop a safe and effective treatment plan. Chemotherapy for follicular lymphoma is typically administered in cycles, allowing time between treatments for the body to recover.

During chemotherapy, the patient will be encouraged to stay hydrated, eat nutritious meals and get adequate rest. The healthcare team may prescribe medications to control nausea, protect blood cell counts and prevent infection. Maintaining open communication with the providers is essential to managing any side effects that arise.

The recovery timeline after chemotherapy can vary, although most patients gradually regain their energy and appetite. Through follow-up appointments and lab work, the oncology team will evaluate the success of treatment, monitor the patient’s progress and support their long-term health and well-being.

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Immunotherapy for follicular lymphoma

Immunotherapy often plays a key role in follicular lymphoma treatment. Rituximab, a monoclonal antibody that targets the CD20 protein on B cells, is frequently used alone or in combination with chemotherapy to enhance the natural ability of the body’s immune system to destroy lymphoma cells. Patients who experience relapse may also benefit from CAR-T cell therapy, which involves modifying their own immune cells to better recognize and attack the cancer cells.

Additionally, in July 2024, the U.S. Food and Drug Administration (FDA) approved epcoritamab, an immunotherapy specifically designed to address relapsed and refractory follicular lymphoma. This bispecific antibody is designed to bind to two different antigens simultaneously, allowing it to engage two different targets: proteins on T cells and proteins on follicular lymphoma cells. By latching onto both types of proteins, epcoritamab can guide the T cells directly to the cancer cells. This highly targeted treatment approach can allow the immune system to destroy follicular lymphoma cells more precisely.

Side effects and risks of immunotherapy for follicular lymphoma

Immunotherapy for follicular lymphoma is often well tolerated, but it may cause certain side effects as the immune system becomes more active. Patients treated with rituximab or other monoclonal antibodies may experience fever, chills, fatigue or mild allergic reactions during or shortly after infusion. These symptoms are usually temporary and manageable with premedication and careful monitoring.

More advanced forms of immunotherapy, such as CAR-T cell therapy, may lead to more significant side effects, including cytokine release syndrome (CRS)—a flu-like response that can cause fever, low blood pressure or shortness of breath—and neurological symptoms, such as headache and confusion. These reactions typically occur within a few days after treatment and can be managed by an experienced healthcare team. In most cases, the side effects resolve with appropriate medical care and supportive treatment.

Preparation and recovery from immunotherapy for follicular lymphoma

Before beginning immunotherapy, the patient will undergo a thorough medical evaluation to help ensure treatment safety and effectiveness. Patients receiving rituximab are usually given medications beforehand—such as acetaminophen and antihistamines—to help prevent infusion-related reactions. During each infusion, the patient will be monitored closely by the healthcare team to ensure prompt detection of any changes in blood pressure, breathing or comfort.

For patients receiving CAR-T cell therapy, preparation begins with the collection of their own T cells, which will be modified in a lab to better recognize and attack lymphoma cells. Before the modified cells are reinfused into the patient’s body, the patient will receive a short course of chemotherapy to prepare the immune system for treatment.

Recovery from immunotherapy can vary depending on the type of treatment used. Rituximab and similar therapies are often given in an outpatient setting, allowing the patient to return home the same day. CAR-T cell therapy typically requires a short hospital stay for observation and management of any immune-related side effects. After treatment, ongoing follow-up visits can help the physician assess the treatment response, monitor the patient’s recovery and provide continued support to maintain long-term health.

Targeted therapy for follicular lymphoma

Targeted therapy uses specialized drugs designed to attack specific molecules or interfere with signaling pathways that help the lymphoma cells grow and thrive. Drugs that may be used for follicular lymphoma treatment include PI3K inhibitors, such as copanlisib and idelalisib, and immune-modulating agents, such as lenalidomide. Targeted therapy offers a potentially effective treatment option with fewer side effects than traditional chemotherapy, especially for relapsed or refractory disease.

Side effects and risks of targeted therapy for follicular lymphoma

Because targeted drugs do not affect healthy cells, they generally cause fewer side effects than traditional chemotherapy drugs, although some patients may still experience a mild to moderate reaction. Possible issues include fatigue, nausea, diarrhea and changes in appetite. Certain targeted drugs can also lower blood cell counts, increasing the risk of infection, bleeding or anemia.

Depending on the specific treatment regimen, the patient may also experience high blood pressure, skin rashes, liver enzyme changes or muscle and joint aches. These effects are usually manageable with dose adjustments or supportive medications. Serious complications of targeted therapy are rare, and the healthcare team will monitor the patient closely with regular bloodwork and physical exams to ensure the treatment remains safe and effective.

Preparation and recovery from targeted therapy for follicular lymphoma

Before starting targeted therapy, the patient will undergo blood testing and, in some cases, molecular testing to determine whether the lymphoma has specific characteristics that make it more likely to respond to targeted drugs. Many of these drugs can be taken orally at home or given as an outpatient infusion, allowing the patient to maintain much of their normal daily routine.

Throughout treatment, the patient will be scheduled for routine lab tests and follow-up visits to monitor their organ function and blood cell counts. The patient should stay well hydrated, eat a balanced diet and promptly report any new or worsening side effects, such as fatigue, bruising or digestive changes, to their physician.

Most patients tolerate targeted therapy well and recover quickly between treatment cycles. Because targeted therapy is often taken long-term, consistent communication with the oncology team can help ensure that the treatment remains effective and any side effects are managed promptly.

Bone marrow transplantation for follicular lymphoma

BMT may be an option for a patient whose follicular lymphoma returns after multiple treatments. Autologous transplantation, which uses the patient’s own blood-forming cells, can help restore bone marrow function after high-dose chemotherapy. Allogeneic transplantation, which uses donor cells, may be considered for a patient with aggressive or treatment-resistant disease. This intensive treatment approach is usually reserved for recurrent or difficult-to-treat follicular lymphoma.

Side effects and risks of bone marrow transplantation for follicular lymphoma

BMT can offer some patients with follicular lymphoma the potential for long-term remission, particularly if the cancer returns after other treatments. However, because it is an intensive procedure, it carries several risks.

In the short term, the patient may experience fatigue, nausea, vomiting, mouth sores, loss of appetite and hair loss from the high-dose chemotherapy used to prepare the body for the transplant. The greatest risk immediately after transplantation is a weakened immune system, which can increase susceptibility to infections and bleeding until the new cells begin producing healthy blood cells.

If the patient undergoes an allogeneic transplant, there is also a possibility of graft-versus-host disease (GVHD), a condition in which the donor immune cells attack the patient’s tissues. GVHD may cause skin rashes, digestive issues or liver problems, but the condition can be carefully managed with immunosuppressive medications and close monitoring. Long-term complications, such as organ damage or secondary cancers, are rare but possible. The healthcare team will take every precaution to minimize these risks and ensure patient safety throughout the transplant process.

Preparation and recovery from bone marrow transplantation for follicular lymphoma

Preparation for BMT begins with a comprehensive medical evaluation, including blood work, imaging scans, heart and lung function studies and infection screenings to confirm the patient is healthy enough to undergo the procedure. Prior to the transplant, the patient will receive conditioning therapy, which consists of high-dose chemotherapy, sometimes combined with radiation therapy, to eliminate the cancer cells and make room in the bone marrow for the new, healthy blood-forming cells.

After the transplant, the patient will be closely monitored in a hospital or specialized transplant unit for several weeks to ensure the new cells start producing healthy blood cells (engraft) as expected. During this period, strict infection-prevention measures must be followed, and supportive care will be provided to manage side effects and encourage healing.

Once the patient is discharged, recovery will continue on an outpatient basis. The patient will likely be advised to avoid crowds, eat well-cooked foods and follow detailed hygiene guidelines while their immune system rebuilds. Through regular follow-up visits, the healthcare team will monitor blood cell counts, assess the success of the transplant and address any complications early. Over time, most patients gradually regain their strength and return to their normal activities as their immune system fully recovers.

Surgery for follicular lymphoma

Surgery is not a standard treatment for follicular lymphoma because the cancer usually affects multiple lymph nodes or several areas of the body. However, a surgical procedure may be performed to obtain a biopsy to confirm the diagnosis or, in rare cases, to address complications of follicular lymphoma, such as discomfort caused by enlarged lymph nodes.

Side effects and risks of surgery for follicular lymphoma

Like any surgical procedure, surgery for follicular lymphoma carries potential risks, including pain, bleeding, infection, bruising and swelling near the incision site. Some patients may also experience temporary fatigue or soreness afterward. More serious complications, such as reactions to the anesthesia or delayed wound healing, are rare. The surgical team will take all necessary precautions to minimize these risks, using the least invasive techniques possible and providing detailed instructions for recovery and care.

Preparation and recovery from surgery for follicular lymphoma

Before surgery, the patient will undergo a preoperative assessment, possibly including lab testing and imaging scans, to ensure they are in good health and help the physician plan the procedure. Depending on the purpose of the surgery—whether it will be performed for a biopsy or symptom relief—the patient may receive local or general anesthesia.

After surgery, the patient will be monitored until they are fully awake and stable. Pain medication will be provided as needed, and most patients can return home the same day or after a short hospital stay. Recovery typically involves rest, proper wound care and limited physical activity for several days to promote healing.

The patient will receive clear instructions on how to care for the incision site and recognize signs of infection, such as redness or swelling. Follow-up appointments will allow the healthcare team to oversee the healing progress and, if a biopsy was performed, review the pathology results to guide the next steps in treatment. Most patients recover quickly, with minimal long-term effects.

Clinical trials for follicular lymphoma

Clinical trials provide select patients with access to promising new treatments that are shaping the future of follicular lymphoma care. For instance, a patient may be interested in participating in a research study designed to explore new targeted drugs, advanced immunotherapies, bispecific antibodies or cellular treatments developed to improve response rates and reduce side effects. The oncology team will work closely with the patient to determine whether the trial is a safe and appropriate option based on the patient’s diagnosis, health status and treatment history.

A carefully selected clinical trial may offer a new source of hope for a patient whose lymphoma has not responded to standard therapies or has returned. In addition to benefiting from the latest advancements in frontline treatment, a participant can also contribute to medical research that may help others facing follicular lymphoma in the future.

Benefit from world-class care at Moffitt Cancer Center

Moffitt provides expert, comprehensive care for patients with follicular lymphoma. The multispecialty team in our Malignant Hematology Program includes hematologists, oncologists, radiation oncologists and BMT specialists who work together to create high individualized treatment plans. Our patients have access to targeted therapies, cell-based treatments and a robust portfolio of clinical trials, which is continually advancing the standard of care for lymphoma.

If you would like to learn more about follicular lymphoma treatment, you can request an appointment with a specialist at Moffitt by calling 1-888-663-3488 or submitting a new patient registration form online. We do not require referrals.