What is the R-CHOP (Rituximab, Cyclophosphamide, Hydroxydaunorubicin, Oncovin, and Prednisone) regimen for non-Hodgkin lymphoma treatment?

R-CHOP Regimen for Non-Hodgkin Lymphoma Treatment

R-CHOP is the standard first-line treatment regimen for CD20-positive diffuse large B-cell lymphoma (DLBCL) and consists of rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone, with dosing and cycles adjusted based on patient age and risk factors. 1

Components of R-CHOP

The R-CHOP regimen consists of:

• Rituximab (R): 375 mg/m² intravenously on day 1 of each cycle
• Cyclophosphamide (C): 750 mg/m² intravenously on day 1
• Hydroxydaunorubicin/Doxorubicin (H): 50 mg/m² intravenously on day 1
• Oncovin/Vincristine (O): 1.4 mg/m² (maximum 2 mg) intravenously on day 1
• Prednisone (P): 100 mg orally on days 1-5

Dosing Schedule Based on Patient Characteristics

Young Patients (≤60 years) with Good Risk (aaIPI 0-1)

• Six cycles of R-CHOP given every 14 days (R-CHOP-14) with eight doses of rituximab 1
• Alternatively, patients with early-stage disease (I-II) may receive three cycles of R-CHOP plus involved field radiation 1

Young Patients with High Risk (aaIPI ≥2)

• Six to eight cycles of R-CHOP given every 14-21 days 2
• Consider clinical trials for more intensive regimens 2

Elderly Patients (>60 years)

• Eight cycles of R-CHOP given every 21 days (R-CHOP-21) or six cycles of R-CHOP-14 (given every 14 days) 1
• For patients >80 years old, R-miniCHOP (attenuated doses) may be considered 2

Patients with Poor Left Ventricular Function

Alternative regimens should be considered, such as:

• RCEPP (rituximab, cyclophosphamide, etoposide, prednisone, procarbazine)
• RCDOP (rituximab, cyclophosphamide, liposomal doxorubicin, vincristine, prednisone)
• RCNOP (rituximab, cyclophosphamide, mitoxantrone, vincristine, prednisone)
• DA-EPOCH + rituximab (etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin) 1

Efficacy and Outcomes

The addition of rituximab to CHOP has significantly improved outcomes compared to CHOP alone:

• Higher complete response rates (76% vs 63%) 3
• Improved 2-year event-free survival (57% vs 38%) 3
• Better 2-year overall survival (70% vs 57%) 3

Recent evidence suggests that in young patients with favorable prognosis DLBCL, four cycles of R-CHOP may be non-inferior to six cycles, with reduced toxicity 4.

Treatment Monitoring and Follow-up

• PET-CT scan is highly recommended for post-treatment assessment to define complete remission 1
• Abnormal radiological tests at baseline should be repeated after 3-4 cycles and after the last cycle 1
• Bone marrow biopsy should be repeated at the end of treatment only if initially involved 1
• Follow-up should include:
  • History and physical examination every 3 months for 1 year, every 6 months for 2-3 more years, then annually 1, 2
  • Blood count and LDH at 3,6,12, and 24 months 1
  • CT scan at 6,12, and 24 months after treatment 1

Special Considerations and Precautions

• Tumor Lysis Syndrome: Special precautions are required in cases with high tumor load 1
• Hematological Toxicity: Dose reductions due to hematological toxicity should be avoided; consider growth factor support instead 1, 2
• Infusion Reactions: Rituximab can cause severe infusion-related reactions, particularly with the first infusion 5
• CNS Prophylaxis: Consider prophylactic instillation of methotrexate and/or cytarabine in high-risk patients 1
• Cardiac Monitoring: More frequent cardiac monitoring is required when anthracyclines are used in patients with impaired cardiac function 1

Relapsed/Refractory Disease

For patients with relapsed/refractory disease:

• Transplant-eligible patients (<65-70 years): Salvage regimens (rituximab plus chemotherapy) followed by high-dose therapy with stem cell support 1

  • Options include R-DHAP, R-ESHAP, R-ICE, etc. 1

• Non-transplant candidates:

  • Clinical trials
  • CEPP ± rituximab
  • DA-EPOCH ± rituximab
  • GDP ± rituximab
  • GemOx ± rituximab
  • Lenalidomide ± rituximab
  • Rituximab monotherapy 1

Common Pitfalls to Avoid

1. Inadequate staging: Ensure proper staging with CT scan, bone marrow biopsy, and PET/CT before treatment 1, 2
2. Dose reductions: Avoid dose reductions due to hematological toxicity in curative settings 1, 2
3. Overlooking CNS prophylaxis: Consider CNS prophylaxis in high-risk patients 2
4. Inadequate follow-up: Follow recommended schedule for monitoring during and after treatment 1, 2
5. Ignoring cardiac function: Assess cardiac function before treatment, especially in elderly patients 1

R-CHOP has transformed the treatment landscape for non-Hodgkin lymphoma, particularly DLBCL, making this once fatal disease potentially curable in a significant proportion of patients.