A 35-year-old woman is diagnosed with diffuse large B-cell lymphoma (DLBCL) with IPI score of 2 (low-intermediate risk). Staging CT shows stage II disease with no CNS involvement. What is the drug of choice / first-line regimen for this patient?

Question

Accepted Answer

C. R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisolone). ## Diagnosis: Diffuse Large B-Cell Lymphoma (DLBCL) — Low-Intermediate Risk

**Key Point:** R-CHOP is the gold-standard first-line regimen for DLBCL in fit patients, regardless of stage or IPI score. The addition of rituximab (anti-CD20 monoclonal antibody) to CHOP significantly improves overall survival and disease-free survival.

### Evidence for R-CHOP

**High-Yield:** Landmark trials (RICOVER-60, MInT) demonstrated that:
1. R-CHOP improves 5-year overall survival to ~70–80% in DLBCL
2. Rituximab monotherapy is insufficient for DLBCL
3. CHOP without rituximab is now considered substandard
4. R-CHOP is tolerated well in fit patients aged 18–80 years

### Regimen Components

| Component | Mechanism | Role |
|-----------|-----------|------|
| Rituximab | Anti-CD20 monoclonal antibody | Targets B-cell antigen; improves survival |
| Cyclophosphamide | Alkylating agent | DNA cross-linking |
| Doxorubicin | Anthracycline | Intercalates DNA; topoisomerase II inhibitor |
| Vincristine | Vinca alkaloid | Microtubule inhibitor |
| Prednisolone | Corticosteroid | Immunosuppression; apoptosis induction |

**Clinical Pearl:** R-CHOP is typically given every 21 days for 6–8 cycles. Prophylactic G-CSF is often used to prevent febrile neutropenia.

### Why Other Options Are Incorrect

**CHOP alone (option 1):** Historical regimen; now considered substandard. Rituximab addition improves outcomes significantly and should not be omitted in CD20+ DLBCL.

**Rituximab monotherapy (option 2):** Insufficient for DLBCL. Monotherapy has response rates <50% and is used only in specific scenarios (e.g., small lymphocytic lymphoma, follicular lymphoma with low tumor burden).

**Etoposide and dexamethasone (option 3):** Not standard for DLBCL. This combination may be used for salvage therapy (e.g., DHAP in relapsed/refractory disease) or for CNS prophylaxis, but not as first-line.

**Mnemonic:** **R-CHOP for DLBCL:**
- **R** = Rituximab (anti-CD20)
- **C** = Cyclophosphamide
- **H** = doxorubicin (Hydroxydaunorubicin)
- **O** = Oncovine (vincristine)
- **P** = Prednisolone

**High-Yield:** Even in elderly patients (>60 years), R-CHOP is preferred over CHOP alone; dose modifications may be needed based on comorbidities and renal/hepatic function.

Answer

A. Etoposide and dexamethasone

Answer

B. CHOP alone (without rituximab)

Answer

D. Rituximab monotherapy

A 35-year-old woman is diagnosed with diffuse large B-cell lymphoma (DLBCL) with IPI score of 2 (low-intermediate risk). Staging CT shows stage II disease with no CNS involvement. What is the drug of choice / first-line regimen for this patient?

Explanation

Diagnosis: Diffuse Large B-Cell Lymphoma (DLBCL) — Low-Intermediate Risk

Evidence for R-CHOP

Regimen Components

Why Other Options Are Incorrect

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Component	Mechanism	Role
Rituximab	Anti-CD20 monoclonal antibody	Targets B-cell antigen; improves survival
Cyclophosphamide	Alkylating agent	DNA cross-linking
Doxorubicin	Anthracycline	Intercalates DNA; topoisomerase II inhibitor
Vincristine	Vinca alkaloid	Microtubule inhibitor
Prednisolone	Corticosteroid	Immunosuppression; apoptosis induction