For stage II FL (non-contiguous lymph nodes, or not amenable to radiation therapy) and advanced stage FL (stages III and IV), the decision to start treatment is guided by symptoms and disease bulk. Approximately one-third of initial presentations occur in patients with low-volume disseminated disease. The importance of ‘watch and wait’ is true even in the modern immunochemotherapy era. The frequency of clinical review during this observation is based on the tempo of the disease, the comfort the patient has with a ‘watch and wait’ approach and the likelihood that they will recognise and re-present in the event of signs of relapse.

Watchful waiting can cause significant anxiety in patients. Appropriate support should be made available (see 3.6.3 Supportive care). Alternate approaches such as treatment with rituximab monotherapy may delay the need for subsequent treatment.

Asymptomatic advance-stage nodal MZL can also be managed with a watchful waiting approach.

An indolent form of MCL, commonly a leukaemic presentation, indicated by lack of symptoms and low tumour burden, can be followed with watchful waiting.