Follicular lymphoma (FL) is the most prevalent indolent B-cell lymphoma entity, often characterized by the t(14;18) BCL2-IGH translocation. The malignancy represents a clinically and biologically highly heterogeneous disease. Most patients have favorable prognoses; however, despite therapeutic advancements, the disease remains incurable, with recurrent relapses or early disease progression. Moreover, transformation to an aggressive histology, most often diffuse large-B-cell lymphoma, remains a critical event in the disease course, which is associated with poor outcomes. Understanding the individual patient’s risk of transformation remains challenging, which has motivated much research on novel biomarkers within the past four decades. This review systematically assessed the research on molecular biomarkers in FL transformation and outcome. Following the PRISMA guidelines for systemic reviews, the PubMed database was searched for English articles published from January 1984 through September 2024, yielding 6769 results. The identified publications were carefully screened and reviewed, of which 283 original papers met the inclusion criteria. The included studies focused on investigating molecular biomarkers as predictors of transformation or as prognostic markers of time-related endpoints (survival, progression, etc.). The effects of each biomarker were categorized based on their impact on prognosis or risk of transformation as none, favorable, or inferior. The biomarkers included genetic abnormalities, gene expression, microRNAs, markers of B cells/FL tumor cells, markers of the tumor microenvironment, and soluble biomarkers. This comprehensive review provides an overview of the research conducted in the past four decades, underscoring the persistent challenge in risk anticipation of FL patients.

Accurate discrimination of extracellular vesicles (EVs) from non-vesicular nanoparticles and robust phenotyping of individual EVs directly within complex biofluids are essential to advance understanding of EV biology and to realize their potential as biomarkers and therapeutic agents. Conventional flow cytometers, originally designed for cellular analysis, lack the scatter and fluorescence sensitivity, dynamic range, and event-rate control required for quantitative characterization of nanoscale vesicles and are particularly susceptible to coincident (swarm) detection. Dedicated nanoparticle flow cytometers have been developed to address these limitations, and here we systematically evaluate the suitability of the CytoFLEX Nano (Beckman Coulter) for EV analysis. Using a series of calibration beads of different materials, fluorescent liposomes, and EVs isolated from peritoneal fluid and cell culture medium, we assess size-detection thresholds, scatter and fluorescence sensitivity, dynamic range, and volumetric counting accuracy. These data provide practical guidance for implementing nanoscale flow cytometry in EV research and support the informed adoption of dedicated nanoparticle cytometers in studies adhering to current EV reporting standards.

Background: Follicular lymphoma (FL) is characterized by an indolent nature and generally favorable prognosis, yet poses a particular clinical challenge, since disease progression is observed in a notable subset of patients. Currently, it is not possible to anticipate which patients will be at risk of progression, highlighting the need for reliable predictive biomarkers that can be detected early in the disease. Methods: We applied tandem-mass-tag labelled nano-liquid chromatography tandem mass spectrometry (nLC-MS/MS) on 48 diagnostic formalin-fixed, paraffin-embedded tumor samples from patients with advanced-stage FL. Of these, 17 experienced subsequent progression (subsequently-progressing, sp-FL) while 31 did not (non-progressing, np-FL). Results: We identified 99 proteins that were significantly differentially expressed between sp-FL samples and np-FL samples (p < 0.05; log₂-fold changes between 0.2 and −1.3). Based on this subset of proteins, we classified patients into high-risk and low-risk subgroups using unsupervised machine learning techniques. Pathway analyses of the identified proteins revealed aberrancies within the immune system and cellular energy metabolism. In addition, two proteins were selected for immunohistochemical evaluation, namely stimulator of interferon genes 1 (STING1) and isocitrate dehydrogenase 2 (IDH2). Notably, IDH2 retained significantly lower expression levels in sp-FL samples compared with np-FL samples (p = 0.034). Low IDH2 expression correlated with shorter progression-free survival (PFS, p = 0.020). Conclusions: This study provides evidence for some of the biological mechanisms likely to be involved in FL progression and, importantly, identifies potential predictive biomarkers for improvement of risk stratification up-front at time of FL diagnosis.

Fibroblast activation protein (FAP), a transmembrane serine protease expressed primarily in pathological conditions, plays a pivotal role in tumor progression. Despite extensive studies on FAP in solid tumors, its role in hematologic cancers, particularly lymphoid malignancies, remains underexplored. This study aimed to investigate the level and activity of soluble FAP (sFAP) in pre-therapeutic serum samples from 120 lymphoma patients. We measured sFAP serum levels using time-resolved immunofluorometric assay and sFAP activity with Förster resonance energy transfer assay. In addition, immunohistochemistry was used to analyze intratumoral FAP expression in tissue biopsies from a subset of B-cell lymphoma patients (n = 34). Notably, the results revealed significantly reduced circulating sFAP levels (p = 0.002) and activity (p < 0.001) in aggressive disease subtypes compared with indolent subtypes and healthy individuals. At the time of diagnosis, low sFAP activity correlated with inferior overall survival (both p < 0.001) in patients with the aggressive entities, suggesting altered FAP functionality in these tumors. Interestingly, measuring intratumoral FAP levels revealed an inverse pattern, with diffuse large B-cell lymphoma showing higher tissue FAP localization compared with follicular lymphoma (p < 0.001). These findings provide new insights into the biological and clinical significance of FAP in lymphoid malignancies, particularly highlighting the importance of sFAP activity as a potential prognostic marker in aggressive lymphoid malignancies.

Follicular lymphoma (FL) is the most common indolent lymphoma. Despite a generally favorable prognosis and long-term survival for many patients, FL remains incurable, with disease progression occurring in approximately half of limited-stage FL cases. In this study, we employed high-throughput mass spectrometry-based proteomics to explore the differential protein expression in diagnostic lymphoma biopsies from 26 limited-stage FL patients. Of these, 9 patients experienced subsequent disease progression (sp-FL), while 17 did not (np-FL). A total of 1940 proteins were identified, with 78 showing significant differential expression between progressing and non-progressing cases. Unsupervised clustering analyses were able to separate the two patient groups based on these differential protein profiles. Notably, proteins involved in metabolism, immune regulation, and apoptosis were downregulated in sp-FL samples. Among the identified proteins, caspase 4 and 8 (CASP4 and CASP8) were further evaluated. The low expression of CASP4 in the diagnostic lymphoma tissue correlated with shorter progression-free survival (PFS) (p < 0.001), primarily with this difference apparent in the expression profiles in the intrafollicular areas (p = 0.015). Similarly, low CASP8 expression was associated with inferior PFS (p = 0.031). Interestingly, addressing the expression pattern for advanced-stage FL patients, the low protein expression of both CASP4 and CASP8 was also found to be associated with progressing cases, suggesting their potential role in disease pathogenesis independent of the disease stage. With further research, the expression pattern of CASP4 and CASP8 may enable the early prediction of disease progression in FL patients, which may ultimately improve patient stratification and allow for more individualized treatment strategies.