A 52-year-old woman presents with a 3-month history of painless lymphadenopathy in the neck and axilla, along with night sweats and a 5 kg weight loss. Biopsy shows a lymphoma with CD20+ B cells, CD5+ T cells in the background, and a t(14;18) translocation. All of the following statements regarding this lymphoma are correct EXCEPT:

Question

Accepted Answer

C. It is the most common type of non-Hodgkin lymphoma and typically presents in advanced stage. ## Follicular Lymphoma: Clinical & Pathologic Features

**Key Point:** Follicular lymphoma (FL) is the second most common NHL (15–20% of cases), but DLBCL is the most common (30–40%). This distinction is frequently tested.

### Epidemiology & Presentation

| Feature | Follicular Lymphoma | DLBCL |
|---------|-------------------|-------|
| Frequency | 2nd most common (15–20%) | Most common (30–40%) |
| Typical age | 55–60 years | 64 years |
| Stage at diagnosis | Advanced (III–IV) in 80% | Variable (I–IV) |
| Indolence | Yes, slow-growing | No, aggressive |
| Median survival | 8–10 years (without Rx) | 5–10 years (with Rx) |

**High-Yield:** The question stem says FL is "the most common type of NHL" — this is **FALSE**. DLBCL is the most common. FL is the second most common.

### Cytogenetics: t(14;18)

**Key Point:** The t(14;18) translocation is pathognomonic for follicular lymphoma.

- **Translocation:** t(14;18)(q32;q21)
- **Genes involved:** BCL2 (chromosome 18) and immunoglobulin heavy chain (IgH, chromosome 14)
- **Mechanism:** Juxtaposition of BCL2 to the IgH enhancer → constitutive BCL2 overexpression → resistance to apoptosis
- **Frequency:** Present in ~90% of follicular lymphomas

**Mnemonic:** FL = **F**ollicular, **L**ymphoma, **t(14;18)** = BCL2 ↑ = **B**ad apoptosis (anti-apoptotic)

### Histopathology

- **Pattern:** Nodular (follicular) architecture
- **Cellular composition:** Small lymphocytes (T cells) surrounding neoplastic B cells
- **Germinal center hyperplasia:** Present; the lymphoma arises from germinal center B cells
- **Grade:** I–II (low-grade, indolent); Grade III (higher risk of transformation)

**Clinical Pearl:** FL is a "germinal center lymphoma" — it originates from the germinal center of secondary lymphoid follicles.

### Clinical Course

**Indolent behavior:**
- Slow growth, often asymptomatic at diagnosis
- Median survival: 8–10 years without treatment
- Can transform to DLBCL (Richter transformation) in 3–5% of cases per year
- Often presents in advanced stage (III–IV) due to lack of early symptoms

**High-Yield:** FL is indolent but incurable with standard therapy. "Watch and wait" is an acceptable initial strategy for asymptomatic patients.

### Why Option 3 is Wrong

Option 3 states: "It is the most common type of non-Hodgkin lymphoma and typically presents in advanced stage."

- **"Most common"** is FALSE. DLBCL is the most common NHL (30–40%); FL is second (15–20%).
- **"Typically presents in advanced stage"** is TRUE (80% present with stage III–IV).

Since one part is false, the entire statement is incorrect and is the answer.

**Warning:** Do not confuse the two most common NHLs:
- **DLBCL:** Most common, aggressive, can present at any stage
- **FL:** Second most common, indolent, usually advanced stage at diagnosis

[cite:Robbins 10e Ch 13]

Answer

A. It is an indolent lymphoma with a median survival of 8–10 years without treatment

Answer

B. Histologically, it shows a nodular pattern with germinal center hyperplasia

Answer

D. The t(14;18) translocation involves BCL2 and the immunoglobulin heavy chain locus

Explanation

Follicular Lymphoma: Clinical & Pathologic Features

Epidemiology & Presentation

Cytogenetics: t(14;18)

Histopathology

Clinical Course

Why Option 3 is Wrong

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Feature	Follicular Lymphoma	DLBCL
Frequency	2nd most common (15–20%)	Most common (30–40%)
Typical age	55–60 years	64 years
Stage at diagnosis	Advanced (III–IV) in 80%	Variable (I–IV)
Indolence	Yes, slow-growing	No, aggressive
Median survival	8–10 years (without Rx)	5–10 years (with Rx)