Note: Some citations in the text of this section are followed by a level of evidence. The PDQ editorial boards use a formal ranking system to help the reader judge the strength of evidence linked to the reported results of a therapeutic strategy. (Refer to the PDQ summary on Levels of Evidence for more information.)
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ACVBP: doxorubicin plus cyclophosphamide plus vindesine plus bleomycin plus prednisone.
CHOP: cyclophosphamide plus doxorubicin plus vincristine plus prednisone.
CNOP: cyclophosphamide plus mitoxantrone plus vincristine plus prednisone.
m-BACOD: methotrexate plus bleomycin plus doxorubicin plus cyclophosphamide plus vincristine plus dexamethasone plus leucovorin.
MACOP-B: methotrexate plus doxorubicin plus cyclophosphamide plus vincristine plus prednisone fixed dose plus bleomycin plus leucovorin.
ProMACE CytaBOM: prednisone plus doxorubicin plus cyclophosphamide plus etoposide plus cytarabine plus bleomycin plus vincristine plus methotrexate plus leucovorin.
R-CHOP: Rituximab, an anti-CD20 monoclonal antibody, plus cyclophosphamide plus doxorubicin plus vincristine plus prednisone.
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.
Doxorubicin-based combination chemotherapy produces long-term disease-free survival in 35% to 45% of patients.[2,3,4] Higher cure rates have been reported in single-institution studies than in cooperative group trials.
A prospective randomized trial of four regimens (CHOP, ProMACE CytaBOM, m-BACOD, and MACOP-B) for patients with diffuse large B-cell lymphoma showed no difference in overall survival (OS) or time-to-treatment failure (TTF) at 3 years.[Level of evidence: 1iiA] Other randomized trials have confirmed no advantage among the standard doxorubicin-based combinations versus CHOP.;[Level of evidence: 1iiA] A randomized clinical trial failed to demonstrate a beneficial effect of adjuvant radiation therapy in advanced-stage aggressive NHL.
The combination of rituximab and CHOP (R-CHOP) showed improvement in event-free survival (EFS) and 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 y).[Level of evidence: 1iiA] At 5-years' median follow-up, the OS of patients who received R-CHOP compared with patients who received CHOP was 58% versus 45%, P < .007. Similarly, for 326 evaluable patients younger than 61 years, R-CHOP showed improvement in EFS and OS compared to CHOP alone (EFS = 79% vs. 59%, P = .001, and OS = 93% vs. 84%, P = .001 at 3 years).[Level of evidence: 1iiA] These two studies established R-CHOP as the standard regimen for newly diagnosed patients with diffuse large B-cell lymphoma.
A preliminary study using CHOP with or without etoposide for patients older than 60 years suggested improvement in EFS and OS for treatment delivered every 2 weeks versus the standard 3-week regimen. 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. 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).[Level of evidence: 1iiA] There was no comparison to standard R-CHOP or CHOP given every 3 weeks.