R-CHOP Regimen for Non-Hodgkin Lymphoma
R-CHOP-21 (rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone administered every 21 days) is the Category 1 evidence-based standard first-line treatment for diffuse large B-cell lymphoma and other aggressive B-cell non-Hodgkin lymphomas. 1
Standard R-CHOP-21 Dosing
The complete regimen consists of the following medications administered every 21 days for 6-8 cycles 1, 2:
- Rituximab: 375 mg/m² intravenous on day 1 2, 3
- Cyclophosphamide: 750 mg/m² intravenous on day 1 2, 3
- Doxorubicin (Hydroxydaunorubicin): 50 mg/m² intravenous on day 1 2, 3
- Vincristine (Oncovin): 1.4 mg/m² intravenous on day 1 (maximum total dose 2 mg) 2, 3
- Prednisone: 40-100 mg/m² orally on days 1-5 2, 3
Treatment Duration and Monitoring
- Standard course: 6-8 cycles of R-CHOP-21 are administered depending on disease stage and response 1, 2
- Favorable prognosis patients: Young patients (18-60 years) with stage I-II disease, normal LDH, ECOG 0-1, and non-bulky disease may receive only 4 cycles of R-CHOP plus 2 additional rituximab doses, as this has been proven non-inferior to 6 cycles 4
- Hepatitis B screening: All patients must undergo hepatitis B testing before rituximab initiation 1
Alternative Dosing Schedules
R-CHOP-14 (every 14 days) is NOT superior to R-CHOP-21 and should not be used as standard therapy. 3 A large randomized trial of 1,080 patients demonstrated no improvement in 2-year overall survival (82.7% vs 80.8%) or progression-free survival (75.4% vs 74.8%) with dose intensification, while R-CHOP-14 caused higher rates of grade 3-4 thrombocytopenia (9% vs 5%) and febrile neutropenia (11% vs 5%). 3
Modified Regimens for Cardiac Dysfunction
For patients with poor left ventricular function, doxorubicin-sparing alternatives include 1:
- RCEPP: Rituximab, cyclophosphamide, etoposide, prednisone, procarbazine
- RCDOP: Rituximab, cyclophosphamide, liposomal doxorubicin, vincristine, prednisone
- RCNOP: Rituximab, cyclophosphamide, mitoxantrone, vincristine, prednisone
- RCEOP: Rituximab, cyclophosphamide, etoposide, vincristine, prednisone
Critical caveat: Any anthracycline or anthracenedione use in cardiac-impaired patients requires more frequent cardiac monitoring. 1
Growth Factor Support
- Patients >60 years: Should receive filgrastim (G-CSF) 5 mcg/kg/day starting in cycle 1 to maintain dose intensity and reduce febrile neutropenia risk (22% in older patients vs 10% in younger patients without prophylaxis) 5
- Younger patients: May receive filgrastim after first neutropenic event rather than prophylactically 5
Cardiovascular Monitoring Requirements
Heart failure occurs in 4.62% of patients receiving R-CHOP, but this increases to 11.72% when cardiac function is systematically evaluated post-chemotherapy, indicating substantial underdiagnosis. 6 This mandates:
- Baseline cardiac assessment before treatment initiation 6
- Serial cardiac monitoring during and after chemotherapy completion 6
- Prompt initiation of heart failure treatment in presymptomatic phases 6
- Consider dexrazoxane as cardioprotectant if additional anthracycline exposure is needed 1
Important Clinical Distinctions
R-CHOP is NOT appropriate for Hodgkin lymphoma 7. Hodgkin lymphoma cells express CD30, not CD20, making rituximab (a CD20-directed antibody) ineffective in this disease. 7 R-CHOP is specifically indicated for CD20-positive B-cell non-Hodgkin lymphomas. 2
Post-Treatment Considerations
- PET-CT scanning is essential post-treatment for response assessment, particularly in primary mediastinal large B-cell lymphoma where residual masses are common 1
- Biopsy of PET-positive masses is recommended if additional treatment is contemplated 1
- Maintenance rituximab may be considered in follicular lymphoma patients achieving complete or partial response 2