What is the standard first‑line R‑CHOP (Rituximab, Cyclophosphamide, Doxorubicin, Vincristine, Prednisone) chemotherapy regimen—including dosing, schedule, pre‑medication, growth‑factor support, monitoring, and alternatives—for adults with diffuse large B‑cell lymphoma?

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Last updated: February 11, 2026 • View editorial policy

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R-CHOP Chemotherapy for Diffuse Large B-Cell Lymphoma

Standard Dosing and Schedule

The established first-line treatment for CD20-positive diffuse large B-cell lymphoma is R-CHOP-21 (every 21 days), consisting of rituximab 375 mg/m² IV on Day 1, cyclophosphamide 750 mg/m² IV on Day 1, doxorubicin 50 mg/m² IV on Day 1, vincristine 1.4 mg/m² (maximum 2 mg) IV on Day 1, and prednisone 40-100 mg/m² orally on Days 1-5. 1, 2

  • The number of cycles depends on age and risk stratification, ranging from 6-8 cycles. 3, 4, 1
  • R-CHOP-14 (every 14 days) has not demonstrated survival benefit over R-CHOP-21 and should not be used. 4, 5

Treatment Stratification by Age and Risk

Young Patients (Age <60 Years)

  • Low-intermediate risk (aaIPI ≤1): Administer 6 cycles of R-CHOP-21 plus radiotherapy to sites of bulky disease. 4
  • High/high-intermediate risk (aaIPI ≥2): Administer 6-8 cycles of R-CHOP-21; preferably enroll in clinical trials given lack of established optimal therapy. 4
  • Alternative option: R-ACVBP (rituximab, doxorubicin, vindesine, cyclophosphamide, bleomycin, prednisolone) every 2 weeks followed by sequential consolidation has demonstrated superior survival compared to 8 cycles of R-CHOP. 4

Patients Aged 60-80 Years

  • All risk categories: Administer 8 cycles of R-CHOP-21 with 8 doses of rituximab. 3, 4, 1
  • If R-CHOP-14 is used (not recommended), 6 cycles with 8 total rituximab doses are sufficient. 4
  • Consolidation radiotherapy provides no proven benefit in localized disease. 3, 4

Patients Aged >80 Years

  • Mandatory comprehensive geriatric assessment before initiating therapy to determine fitness. 4, 6
  • R-CHOP can typically be used in fit patients up to age 80. 3, 4, 1
  • R-miniCHOP (attenuated chemotherapy with rituximab) can achieve complete remission and long survival in healthy patients over 80. 4
  • Consider doxorubicin substitution with etoposide or liposomal doxorubicin, or omission entirely, in patients with cardiac dysfunction. 4
  • Dose reduction to 70% of standard CHOP doses may be reasonable for patients aged 70+ with comorbidities. 7

Critical Pre-Treatment Measures

Tumor Lysis Syndrome Prevention

  • Administer prednisone 100 mg orally daily for 5-7 days as "prephase" treatment in patients with high tumor burden (bulky disease, extensive nodal involvement, elevated LDH, advanced stage) before starting R-CHOP. 4, 6
  • Ensure adequate hydration and consider prophylactic allopurinol or rasburicase in highest-risk patients. 4, 1
  • Begin monitoring metabolic parameters (potassium, uric acid, phosphate) when prephase corticosteroids are initiated and continue through Day 7 post-chemotherapy. 6

Infectious Disease Screening

  • Screen all patients for hepatitis B (HBsAg and anti-HBc) before initiating rituximab. 1
  • Administer prophylactic entecavir for HBsAg-positive patients. 1
  • Screen for HIV and hepatitis C. 3

Growth Factor Support and Dose Management

  • Prophylactic granulocyte colony-stimulating factor (G-CSF) is indicated for febrile neutropenia in patients treated with curative intent and in all elderly patients (age >65 years). 3, 4, 6
  • Avoid dose reductions due to hematological toxicity to maintain treatment efficacy; reductions are reserved only for severe, life-threatening toxicity. 3, 4, 6
  • Do not reduce chemotherapy doses after prephase treatment due to hematological concerns unless absolutely necessary, as this compromises efficacy. 4, 6

CNS Prophylaxis

  • CNS prophylaxis is recommended for patients with high-intermediate and high-risk IPI, particularly those with >1 extranodal site or elevated LDH. 3, 4, 1
  • Intravenous high-dose methotrexate is superior to intrathecal methotrexate alone. 4
  • Testicular lymphoma mandates CNS prophylaxis with contralateral testis irradiation for stage I-II disease. 3, 4, 1
  • Consider CNS prophylaxis for paranasal sinus, upper neck, or bone marrow involvement, though evidence is less established. 3

Special DLBCL Subtypes

Primary CNS DLBCL

  • Treatment must contain high-dose methotrexate. 3, 4, 1
  • Addition of high-dose cytarabine improves complete remission rates and outcomes. 3, 4
  • CNS irradiation is usually associated. 3

Primary Testicular DLBCL

  • Standard treatment is R-CHOP-21 with mandatory CNS prophylaxis and contralateral testis irradiation for localized disease. 3, 4, 1

Primary Mediastinal Large B-Cell Lymphoma (PMBL)

  • R-CHOP-21 is not established as the definitive treatment option and radiotherapy remains controversial. 3

Response Evaluation and Monitoring

  • Perform response evaluation after 3-4 cycles and after completion of treatment. 3, 1
  • PET-CT is highly recommended for post-treatment assessment to define complete remission according to revised criteria. 3, 1
  • Use the Deauville 5-point scale to standardize PET-CT response interpretation. 4
  • If PET-positive at end of treatment with therapeutic consequences, histological confirmation is strongly recommended. 3
  • Repeat bone marrow aspirate and biopsy only at end of treatment if initially involved. 3

Common Pitfalls to Avoid

  • Do not use R-CHOP-14 based on outdated pre-rituximab era data; it provides no survival benefit over R-CHOP-21. 4, 5
  • Do not omit CNS prophylaxis in high-risk patients, particularly those with testicular involvement. 4, 1
  • Do not skip comprehensive geriatric assessment in patients over 80 years before committing to full-dose therapy. 4, 6
  • Do not delay definitive chemotherapy beyond 7 days after completing prephase treatment. 6
  • Do not substitute intrathecal methotrexate alone for CNS prophylaxis in high-risk patients; use intravenous high-dose methotrexate. 4

References

1
Guideline

First-Line Treatment Protocol for B-Cell Lymphoma

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

3
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

4
Guideline

Initial Treatment for Diffuse Large B-Cell Lymphoma

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

6
Guideline

Prephase Treatment for High-Grade Diffuse Large B-Cell Lymphoma

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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