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Non-Hodgkin's Lymphoma

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Treatment for Aggressive, Stage I and Contiguous Stage II Adult NHL

    Patients with stage I or contiguous stage II diffuse large B-cell lymphoma are candidates for combination chemotherapy with or without involved-field radiation therapy (IF-XRT).

    The following drug combinations are referred to in this section:

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    Standard Treatment Options for Aggressive, Stage I and Contiguous Stage II Adult NHL

    Standard treatment options for aggressive, stage I and contiguous stage II adult NHL include the following:

    1. R-CHOP with or without IF-XRT.

    R-CHOP with or without IF-XRT

    Four prospective randomized trials have evaluated the comparison of CHOP or more intensive CHOP-based chemotherapy alone versus combined–modality therapy with CHOP and IF-XRT.[1,2,3,4,5]

    Evidence (CHOP vs. CHOP with IF-XRT):

    1. In a randomized trial with 7 years' median follow-up, 576 patients older than 60 years with early-stage disease received four cycles of CHOP with or without IF-XRT; there was no difference in 5-year event-free survival (EFS) (61% vs. 64%, P = .5) or overall survival (OS) (72% vs. 68%, P = .6).[1][Level of evidence: 1iiA]
    2. A randomized trial of 401 patients comparing eight cycles of CHOP to three cycles of CHOP with IF-XRT was initially reported as having an OS advantage for the combined–modality arm at 5 years,[2] but a re-evaluation for OS at 9 years showed no difference in either arm of the study.[3][Level of evidence: 1iiA]
    3. A randomized study (EST-1484) of 210 patients who attained a radiologic complete remission after eight cycles of CHOP compared IF-XRT with no further therapy; there was no difference in OS at 10 years (68% vs. 65%, P = .24).[4][Level of evidence: 1iiA]
    4. A randomized trial of 631 patients younger than 60 years compared more intensive CHOP-based chemotherapy versus three cycles of CHOP with IF-XRT; with 4 years' median follow-up, the intensive chemotherapy was superior in 5-year EFS (82% vs. 74%, P > .001) and 5-year OS (90% vs. 81%, P = .001).[5][Level of evidence: 1iiA]

    The confirmation of efficacy for rituximab in advanced-stage disease as evidenced in SWOG-S0014 (NCT00005089), for example, has suggested the use of R-CHOP with or without radiation therapy but its use is only supported by retrospective comparisons.[6][Level of evidence: 3iiiDiii]

    • R-CHOP (rituximab + cyclophosphamide + doxorubicin + vincristine + prednisone); four to six cycles.
    • R-CHOP (three to six cycles) + IF-XRT.
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