A 48-year-old woman is diagnosed with follicular lymphoma grade 3B. Staging shows Ann Arbor stage IIIA. Which feature of grade 3B follicular lymphoma influences the treatment decision most significantly compared to grade 1–2 or 3A?
- A Presence of t(14;18) BCL2-IgH translocation mandating BCL2 inhibitor therapy
- B Higher FLIPI-2 score requiring autologous stem cell transplant upfront
- C Exclusively solid sheet growth pattern makes it biologically and therapeutically equivalent to DLBCL ✓
- D EZH2 mutation mandating tazemetostat therapy in first line
Correct answer: C. Exclusively solid sheet growth pattern makes it biologically and therapeutically equivalent to DLBCL
Explanation
Follicular lymphoma grade 3B is defined by solid sheets of centroblasts without intermixed centrocytes, making it pathologically distinct from grades 1–3A. It is biologically similar to DLBCL and is treated with DLBCL-like regimens (R-CHOP) rather than the watch-and-wait or rituximab-based approaches used for indolent FL grades 1–3A. Grades 1–3A retain the t(14;18) BCL2-IgH in most cases; grade 3B less frequently carries this translocation. EZH2 mutations are common in FL but tazemetostat is used in relapsed/refractory setting, not first line.
Reference: Robbins & Cotran Pathologic Basis of Disease, 10th ed.
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