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Non-Hodgkin's Lymphoma

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Treatment for Aggressive, Noncontiguous Stage II / III / IV Adult NHL

    The treatment of choice for patients with advanced stages of aggressive non-Hodgkin lymphoma (NHL) is combination chemotherapy, either alone or supplemented by local-field radiation therapy.[1]

    The following drug combinations are referred to in this section:

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    • ACVBP: doxorubicin + cyclophosphamide + vindesine + bleomycin + prednisone.
    • CHOP: cyclophosphamide + doxorubicin + vincristine + prednisone.
    • CNOP: cyclophosphamide + mitoxantrone + vincristine + prednisone.
    • m-BACOD: methotrexate + bleomycin + doxorubicin + cyclophosphamide + vincristine + dexamethasone + leucovorin.
    • MACOP-B: methotrexate + doxorubicin + cyclophosphamide + vincristine + prednisone fixed dose + bleomycin + leucovorin.
    • ProMACE CytaBOM: prednisone + doxorubicin + cyclophosphamide + etoposide + cytarabine + bleomycin + vincristine + methotrexate + leucovorin.
    • R-CHOP: rituximab, an anti-CD20 monoclonal antibody, + cyclophosphamide + doxorubicin + vincristine + prednisone.

    Standard Treatment Options for Aggressive, Noncontiguous Stage II/III/IV Adult NHL

    Standard treatment options for Aggressive, Noncontiguous Stage II/III/IV Adult NHL include the following:

    1. R-CHOP.
    2. Other combination chemotherapy.

    R-CHOP

    The following studies established R-CHOP as the standard regimen for newly diagnosed patients with diffuse large B-cell lymphoma.[2]

    Evidence (R-CHOP):

    1. The combination of rituximab and CHOP (R-CHOP) showed improvement in event-free survival (EFS) and overall survival (OS) compared with CHOP alone in 399 advanced-stage patients with diffuse large B-cell lymphoma older than 60 years (EFS = 57% vs. 38%, P = .002, and OS = 70% vs. 57%, P = .007 at 2 years).[3][Level of evidence: 1iiA] At 10-years' median follow-up, the OS of patients who received R-CHOP compared with patients who received CHOP was 44% versus 28%, P < .0001.[4]
    2. Similarly, for 326 evaluable patients younger than 61 years, R-CHOP showed improvement in EFS and OS compared with CHOP alone (EFS = 79% vs. 59%, P = .001, and OS = 93% vs. 84%, P = .001 at 3 years).[5][Level of evidence: 1iiA]
    3. A randomized study (DSHNHL-1999-1A) of 1,222 patients older than 60 years compared R-CHOP given every 2 weeks for six or eight cycles to CHOP given every 2 weeks for six or eight cycles.[6] With a median follow-up of 35 months, the EFS favored R-CHOP given every 2 weeks for six or eight cycles (EFS, relative risk [RR] = 0.5 [0.40–0.65], P < .001). The OS favored R-CHOP for only six cycles because of increased toxicity in the eight-cycle arm (RR of death = 0.63 [0.46–0.85], P = .003).[6][Level of evidence: 1iiA] There was no comparison to standard R-CHOP or CHOP given every 3 weeks.
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