Observation is most appropriate for this 60-year-old asymptomatic patient with follicular lymphoma who has nonbulky disease, no vital organ involvement or impingement, and a normal complete blood count. Follicular lymphoma accounts for 20% of all cases of non-Hodgkin lymphoma (NHL) in the United States and Europe and 70% of all indolent NHL, ranking second in incidence to diffuse large-cell lymphoma (30%). It is characterized by surface B-cell markers (CD10, 19, 20, and 22) and small cells on morphologic analysis. The incidence increases with age, and the median age at presentation is 60 years. There is no sex predilection. Diagnosis is confirmed by biopsy of palpable lymph nodes and cytogenetic studies showing a translocation [t(14:18)] that causes overexpression of the BCL2 oncogene. Therapy is not curative, and early initiation of treatment does not improve survival in patients with grade 1 and 2 follicular lymphoma. Treatment is therefore withheld until patients become symptomatic. Some patients do not require therapy for several decades after the initial diagnosis.

Lenalidomide, used in combination with rituximab, is a new therapy that may be effective for patients with advanced symptomatic disease, which this patient does not have.

Systemic disease–causing symptoms require multiagent therapy that traditionally includes one of three combinations: (1) rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP); (2) rituximab plus cyclophosphamide, vincristine, and prednisone (R-CVP); or (3) rituximab plus bendamustine. Radioimmunoconjugates (tositumomab and ibritumomab) have been used effectively to induce long-term remissions. Any of these approaches are suitable for patients requiring treatment.

Lymphoma causing localized symptoms can be treated effectively with involved-field radiation therapy in combination with rituximab, but such treatment is not yet needed for this patient.