## First-Line Treatment of DLBCL **Key Point:** R-CHOP is the gold-standard first-line regimen for diffuse large B-cell lymphoma (DLBCL) in both low-risk and high-risk disease, including high IPI scores. ### Rationale for R-CHOP **High-Yield:** The addition of rituximab (anti-CD20 monoclonal antibody) to CHOP chemotherapy significantly improves overall survival (OS) and event-free survival (EFS) compared to CHOP alone, with a ~20% absolute improvement in 5-year OS. | Feature | R-CHOP | CHOP alone | Rituximab monotherapy | | --- | --- | --- | --- | | **5-year OS** | ~60–70% | ~40–50% | ~5–10% (inadequate) | | **Mechanism** | Chemotherapy + CD20 targeting | Chemotherapy only | Antibody only | | **Indication** | All DLBCL patients | Outdated (pre-2000s) | Indolent lymphomas, not DLBCL | | **IPI score response** | Effective in high IPI | Inferior outcomes | Inadequate | **Clinical Pearl:** Even in elderly patients (>65 years) with comorbidities, R-CHOP remains the standard, though dose modifications may be needed. Rituximab adds minimal toxicity while substantially improving outcomes. ### Why R-CHOP Over Alternatives 1. **Rituximab monotherapy** — Insufficient for aggressive lymphomas; reserved for indolent disease. 2. **CHOP alone** — Historically used but now considered substandard; rituximab addition is mandatory. 3. **Bendamustine + rituximab** — Useful in relapsed/refractory disease or as salvage; not first-line for newly diagnosed DLBCL. **Mnemonic:** **R-CHOP = Rituximab + Chemotherapy for Optimal Prognosis** — the "R" is mandatory in the modern era. [cite:Harrison 21e Ch 104]
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