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Auditing Your Report: A Guide to Your Pathology Findings

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An excisional biopsy is the gold standard for diagnosing follicular lymphoma. Your pathology report should detail the biopsy type, growth pattern, protein markers (like CD20 and BCL2), genetic mutations (like the t(14;18) translocation), and the grade of the lymphoma.

Key Takeaways

  • • An excisional biopsy of a whole lymph node is the gold standard for diagnosing follicular lymphoma.
  • • Immunohistochemistry (IHC) testing confirms the disease by checking for specific protein markers like CD20, BCL2, BCL6, and CD10.
  • • Genetic tests like FISH and NGS look for mutations, such as the t(14;18) translocation, that drive the lymphoma.
  • • Your pathology report should include the tumor's grade (1, 2, or 3A) to help guide treatment decisions.
  • • Grade 3B is now often classified as Follicular Large B-cell Lymphoma and is treated as a more aggressive disease.

Receiving a pathology report can be overwhelming, but it is one of the most important documents in your medical journey. Think of it as the “instruction manual” for your specific case of follicular lymphoma. By learning how to read it, you can ensure your diagnosis is complete and have more productive conversations with your care team [1][2].

The Gold Standard: Excisional Biopsy

The first thing to look for is how the sample was taken. While needle biopsies (like FNA or core needle biopsy) are less invasive, an excisional biopsy—where a surgeon removes an entire lymph node—is the “gold standard” for follicular lymphoma [3][4].

This is because follicular lymphoma is defined by its architecture (how the cells are arranged). A whole lymph node allows the pathologist to see the “nodular” or “follicular” growth patterns that a small needle sample might miss [3][5]. If your diagnosis was made via a needle biopsy, your doctor may sometimes recommend a surgical biopsy to confirm the grade or check for transformation into a more aggressive lymphoma [6][7].

The Protein Profile (Immunohistochemistry)

To confirm the diagnosis, pathologists use immunohistochemistry (IHC). This lab test uses antibodies to check for specific proteins, or “markers,” on the surface of the cancer cells [8][9].

A typical follicular lymphoma report will show these results:

  • CD20 Positive (+): Confirms the cancer started in B-cells [9].
  • BCL2 Positive (+): Shows the “anti-death” protein is active, which is a hallmark of this disease [9][10].
  • BCL6 and CD10 Positive (+): These markers prove the cells came from the “germinal center” of the lymph node, which is where follicular lymphoma begins [8][11].
  • Ki-67: This is a “proliferation index.” It tells you what percentage of the cells are actively dividing. A higher percentage can sometimes indicate a more active disease [10][12].

The Molecular Map (FISH and NGS)

Beyond proteins, your report should look at your genes.

  • FISH (Fluorescence In Situ Hybridization): This test specifically looks for the t(14;18) translocation, the genetic “on switch” for most follicular lymphomas [13][2].
  • NGS (Next-Generation Sequencing): This is a deeper dive into your DNA. It is especially useful for t(14;18)-negative cases, where the classic translocation is missing [14][15]. NGS can find other mutations in genes like KMT2D, CREBBP, or EZH2, which help confirm the diagnosis and may even help predict how well certain treatments will work [13][16].

Your Completeness Checklist

When you review your report, check for these five essential elements. If any are missing, it is worth asking your doctor why.

  1. Biopsy Method: Was it an excisional biopsy or a needle biopsy? [3]
  2. Growth Pattern: Does it say “nodular” (common), “follicular,” or “diffuse” (which can sometimes mean the disease is more aggressive)? [5][3]
  3. Protein Markers: Are CD20, BCL2, BCL6, and CD10 listed? [9][8]
  4. Genetic Testing: Were FISH or NGS performed to check for the t(14;18) translocation or other mutations? [13][14]
  5. Grading: Is a grade (1, 2, or 3A) provided? While the latest guidelines make this optional for some cases, many doctors still find it helpful for planning treatment [5][17].

Note: If your report mentions “Grade 3B,” it is now often classified as Follicular Large B-cell Lymphoma, which is typically treated as an aggressive disease [18][5].

Frequently Asked Questions

Why is an excisional biopsy preferred over a needle biopsy for follicular lymphoma?
An excisional biopsy removes the entire lymph node, allowing the pathologist to see how the cells are arranged. This architecture is crucial for an accurate diagnosis, whereas a small needle sample might miss important details.
What do CD20 and BCL2 positive mean on my pathology report?
These are protein markers found using a test called immunohistochemistry. CD20 positive confirms the cancer started in B-cells, while BCL2 positive shows that an anti-death protein is active, which is a hallmark of follicular lymphoma.
What is the t(14;18) translocation?
The t(14;18) translocation is a genetic mutation that acts as the 'on switch' for most cases of follicular lymphoma. Pathologists look for this mutation using a FISH test to help confirm the diagnosis.
What does the Ki-67 percentage mean?
Ki-67 is a proliferation index that measures what percentage of the lymphoma cells are actively dividing. A higher Ki-67 percentage can sometimes indicate that the disease is growing more actively.
What happens if my report says I have a diffuse growth pattern?
While follicular lymphoma typically has a nodular or follicular growth pattern, a diffuse pattern can sometimes mean the disease is behaving more aggressively. Your oncologist will use this information to help plan your treatment.

Questions for Your Doctor

  • • Was my diagnosis made from an excisional biopsy or a needle biopsy, and does that affect the accuracy of the grading?
  • • My report shows I am t(14;18) negative—how does that change my diagnosis or the expected behavior of the lymphoma?
  • • Did the lab perform Next-Generation Sequencing (NGS) to look for mutations like EZH2 or CREBBP?
  • • Does the report mention a 'diffuse' growth pattern, and if so, what does that mean for my prognosis?
  • • What was my Ki-67 percentage, and how does it relate to the aggressiveness of the lymphoma?

Questions for You

  • • Do I have a copy of my full pathology report, including the immunohistochemistry (IHC) and molecular (FISH/NGS) results?
  • • Was my biopsy performed on a newly enlarged lymph node or one that has been present for a long time?
  • • Are there any specific markers mentioned in the report that I don't understand and need my doctor to explain?

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References

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This page explains follicular lymphoma pathology terminology for educational purposes. Your oncologist and pathologist are the best sources for interpreting your specific report.

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