Synopsis
Classify indolent lymphoma accurately, distinguish observation from treatment need, select local or systemic therapy by subtype and recognise transformation, paraprotein and treatment complications early.
- Indolent NHL includes follicular and nodal, splenic and extranodal marginal-zone lymphomas; lymphoplasmacytic lymphoma and some mantle-cell presentations need their own biology-led pathways.
- Reference-standard diagnosis is excision biopsy or adequate cores with architecture, flow, immunohistochemistry and genetics; do not label subtype from blood or PET alone.
- Advanced stage without symptoms is not a treatment indication: active monitoring is first-line for low-burden asymptomatic follicular lymphoma.
Key red flags
One node enlarging rapidly, new severe pain, extranodal mass, disproportionate LDH rise or new B symptoms suggests transformation and requires urgent PET-directed biopsy.
One rapidly enlarging painful site, major LDH rise or new severe B symptoms requires urgent targeted biopsy.
Investigation priorities
Preserve architecture and establish exact indolent subtype and grade.
Management branches
Biopsy suggests a small B-cell or follicular lymphoma.
- Complete specialist pathology with grade, phenotype and defining genetics and resolve mantle-cell, CLL and lymphoplasmacytic alternatives.
- Stage with subtype-appropriate imaging and assess symptoms, bulk, organ threat, marrow, paraprotein and infection.
Key medicines
RituximabGive 375 mg/m² IV on day 1 of each protocol cycle, or use the licensed subcutaneous formulation only after at least one tolerated full IV dose; monotherapy schedules and maintenance intervals are indication specific.
Bendamustine with rituximabA common follicular or marginal-zone regimen gives bendamustine 90 mg/m² IV on days 1 and 2 with rituximab 375 mg/m² day 1 every 28 days for up to six cycles, using exact centre modifications.