Follicular lymphoma patients display heterogeneous overall survival and variable risk of transformation. Recent studies have highlighted the role of the microenvironment. The contribution of microvessel density to follicular lymphoma survival remains controversial. We used a quantitative tumor mapping approach to determine whether the degree of vascularization correlated with outcome in a uniformly treated cohort. Whole-tissue sections of diagnostic biopsies from 84 cases were stained for CD34 and tumor-to-vessel-distance that encompassed 90% of the tumor (TVD 90) was determined using image analysis. Twenty-one cases with lower TVD 90 showed inferior overall survival (P= 0.0001) and high risk of transformation (P= 0.01). These cases significantly correlated with increased Lymphoma-Associated Macrophages (χ 2= 0.025). In multivariate analysis macrophages content, IPI and TVD 90 were independent predictors of overall survival (P= 0.05, P= 0.001 and P= 0.01, respectively) and IPI and TVD 90 predicted risk of transformation (P= 0.008 and P= 0.08, respectively). Increased angiogenesis is an independent marker of inferior survival and may promote transformation.