From the Guidelines
The standard treatment for high-risk Diffuse Large B-Cell Lymphoma (DLBCL) with an International Prognostic Index (IPI) score of 3-5 is R-CHOP chemotherapy (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone). This regimen typically consists of six cycles administered every 21 days, as recommended by the most recent guidelines 1.
Key Components of R-CHOP
- Rituximab is given at 375 mg/m²
- Cyclophosphamide at 750 mg/m²
- Doxorubicin at 50 mg/m²
- Vincristine at 1.4 mg/m² (capped at 2 mg) on day 1
- Prednisone at 100 mg daily for days 1-5 of each cycle For patients with high-risk disease, CNS prophylaxis may be considered, particularly if there is involvement of specific high-risk sites like testes, breast, or paranasal sinuses, as suggested by the guidelines 1. Some centers may use more intensive regimens such as R-EPOCH (rituximab, etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) for selected high-risk patients, though this remains somewhat controversial.
Considerations for Treatment
- After completion of therapy, PET/CT scanning is recommended to assess treatment response 1
- The rationale for this approach is that rituximab targets CD20 on B-cell surfaces while the chemotherapy components disrupt cell division through various mechanisms, providing a multi-targeted approach to killing lymphoma cells
- High-risk DLBCL patients have historically poorer outcomes, making appropriate initial therapy crucial for improving survival rates It's worth noting that while other studies provide valuable insights into the management of DLBCL, the most recent and highest quality study 1 provides the basis for the current standard of care.
From the FDA Drug Label
The efficacy of POLIVY was evaluated in POLARIX (NCT03274492), a randomized double-blind, placebo-controlled, multicenter trial in patients with previously untreated large B-cell lymphoma. Eligible patients were aged 18–80 and had an International Prognostic Index (IPI) score of 2–5 and ECOG performance status of 0–2 POLIVY in combination with a rituximab product, cyclophosphamide, doxorubicin, and prednisone (R-CHP) is indicated for the treatment of adult patients who have previously untreated diffuse large B-cell lymphoma (DLBCL), not otherwise specified (NOS) or high-grade B-cell lymphoma (HGBL) and who have an International Prognostic Index score of 2 or greater.
The best treatment for Diffuse Large B-Cell Lymphoma (DLBCL) with an International Prognostic Index (IPI) score of 3-5 is POLIVY in combination with R-CHP 2.
- Key points:
- POLIVY is indicated for the treatment of adult patients with previously untreated DLBCL and an IPI score of 2 or greater.
- The POLARIX trial demonstrated the efficacy of POLIVY in combination with R-CHP in patients with previously untreated large B-cell lymphoma and an IPI score of 2-5.
- Treatment regimen:
- POLIVY 1.8 mg/kg intravenously
- Rituximab 375 mg/m2 intravenously
- Cyclophosphamide 750 mg/m2 intravenously
- Doxorubicin 50 mg/m2 intravenously
- Prednisone 100 mg orally once daily on Days 1-5 for 6 cycles 2.
From the Research
Treatment Options for DLBCL with IPI Score 3-5
- The standard treatment regimen for patients with newly diagnosed diffuse large B-cell lymphoma (DLBCL) is R-CHOP therapy (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) 3.
- For patients with high-risk DLBCL (IPI score 3-5), a phase 2 UK NCRI trial demonstrated favorable outcomes with front-line R-CODOX-M/R-IVAC chemotherapy, with a 2-year progression-free survival rate of 67.9% and a 2-year overall survival rate of 76.0% 4.
- Alternative treatment options, such as polatuzumab vedotin, anti-CD19 chimeric antigen receptor T-cell (CAR-T) therapy, and bispecific antibodies, are being investigated for relapsed or refractory DLBCL 3, 5.
Efficacy of R-CHOP Regimen
- A study published in 2013 found that R-CHOP-14 (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone every 14 days) was not superior to R-CHOP-21 (every 21 days) in terms of overall survival and progression-free survival for previously untreated DLBCL 6.
- Another study published in 2004 demonstrated the effectiveness of R-CHOP in treating early-stage gastric DLBCL, with a complete remission rate of 87% and a partial remission rate of 13% 7.
Considerations for Treatment
- The choice of treatment regimen should take into account the patient's age, performance status, and other clinical factors, as well as the specific characteristics of the disease 4.
- Further research is needed to determine the optimal treatment approach for patients with high-risk DLBCL and to investigate the potential benefits of newer treatment options 3, 5.