CHOP (chemotherapy)

CHOP is the acronym for a chemotherapy regimen used in the treatment of non-Hodgkin lymphoma. CHOP consists of:

Cyclophosphamide, an alkylating agent which damages DNA by binding to it and causing the formation of cross-
links
Hydroxydaunorubicin (also called doxorubicin or adriamycin), an intercalating agent which damages DNA by
inserting itself between DNA bases
Oncovin (vincristine), which prevents cells from duplicating by binding to the protein tubulin
Prednisone or Prednisolone, which are corticosteroids.

Sometimes the chimeric anti-CD20 monoclonal antibody, rituximab, is added to this treatment regimen to form the R-CHOP regimen.

Contents
Dosing regimen
Uses and indications
Side-effects and complications
History
[R]-CHOEP modification
See also
References

Dosing regimen
Drug Standard [R]-CHOP-14 or [R]-CHOP-21 [R]-Maxi-CHOP Mode Days

(R)ituximab 375 mg/m2 375 mg/m2 IV infusion Day 1

(C)yclophosphamide 750 mg/m2 1200 mg/m2 IV infusion Day 1

(H)ydroxydaunorubicin 50 mg/m2 75 mg/m2 IV bolus Day 1

(O)ncovin 1.4 mg/m2 (max. 2 mg) 2 mg IV bolus Day 1

(P)rednisone or (P)rednisolone 40 mg/m2 100 mg PO qd Days 1-5

R-Maxi-CHOP is used in mantle cell lymphoma and is given in 21-day intervals, alternating with R-HDAC (rituximab + high-dose
cytarabine).[1]

In most other non-Hodgkin lymphomas (excluding some aggressive forms), standard-dose [R]-CHOP is generally used as first-line
therapy.

Uses and indications

Normal cells are more able than cancer cells to repair damage from chemotherapy drugs.

This regimen can also be combined with the monoclonal antibody rituximab if the lymphoma is of B cell origin; this combination is
called R-CHOP. Typically, courses are administered at an interval of two or three weeks (CHOP-14 and CHOP-21 respectively). A
staging CT scan is generally performed after three cycles to assess whether the disease is responding to treatment.

In patients with a history of cardiovascular disease, doxorubicin (which is cardiotoxic) is often deemed to be too great a risk and is
omitted from the regimen. The combination is then referred to as COP (cyclophosphamide, Oncovin, and prednisone or prednisolone)
or CVP (cyclophosphamide, vincristine, and prednisone or prednisolone).

Side-effects and complications

The combination is generally well tolerated.[2] Chemotherapy-induced nausea and vomiting may require antiemetics (such as
ondansetron), and hemorrhagic cystitis is prevented with administration of mesna. Alopecia (hair loss) is common.

Neutropenia generally develops in the second week. During this period, many clinicians recommend pegfilgrastim or prophylactic use
of ciprofloxacin.[1] If a fever develops in the neutropenic period, urgent medical assessment is required for neutropenic sepsis, as
infections in patients with low neutrophil counts may progress rapidly.

Allopurinol is typically co-administered prophylactically to prevent hyperuricemia that results from tumor lysis syndrome, the result of
rapid death of tumor cells.

History
A pivotal study published in 1993 compared CHOP to several other chemotherapy regimens (e.g. m-BACOD, ProMACE-CytaBOM,
MACOP-B) for advanced non-Hodgkin's lymphoma.[2] CHOP emerged as the regimen with the least toxicity but similar efficacy.

However, in Germany in 2012, bendamustine has displaced [R-]CHOP to become the first line treatment of choice for indolent
lymphoma (a less aggressive subset of non-Hodgkin lymphoma).[3]

[R]-CHOEP modification
In order to develop more effective first-line chemotherapy regimen for aggressive lymphomas, some researchers tried to add
(E)toposide to the standard [R]-CHOP regimen.[4]

There were also attempts to further improve the efficacy of the [R]-CHOEP regimen with escalating the chemotherapy doses. This
mode was called [R]-High-CHOEP. However, it did not show more effectiveness than standard-dose [R]-CHOEP while adding more
toxicity and cost.[5]

In order to try improving efficacy of the [R]-CHOEP, some researchers tried to escalate chemotherapy to very high doses, requiring
autologic stem cell support in each cycle. Doses in that regimen were increased from cycle to cycle. This regimen was called [R]-
MegaCHOEP. But again, such escalation seemed to not improve effectiveness while adding toxicity.[6]

Standard [R]- [R]-High- [R]-Mega- [R]-Mega-CHOEP, [R]-Mega-CHOEP,

Drug Mode Days
CHOEP CHOEP CHOEP, cycle 1 cycles 2 and 3 cycle 4 (last)
IV Day
(R)ituximab 375 mg/m2 375 mg/m2 375 mg/m2 375 mg/m2 375 mg/m2
infusion 1
IV Day
(C)cyclophosphamide 750 mg/m2 1400 mg/m2 1500 mg/m2 4500 mg/m2 6000 mg/m2
infusion 1
IV Day
(H)ydroxydaunorubicin 50 mg/m2 65 mg/m2 70 mg/m2 70 mg/m2 70 mg/m2
bolus 1

(O)ncovin 1,4 mg/m2 2 mg 2 mg 2 mg 2 mg

IV Day
(max 2 mg) bolus 1

IV Days
(E)toposide 100 mg/m2 175 mg/m2 600 mg/m2 960 mg/m2 1480 mg/m2
infusion 1-3
(P)rednisone or Days
40 mg/m2 100 mg 500 mg 500 mg 500 mg PO qd
(P)rednisolone 1-5

See also
Chemotherapy regimens
EPOCH chemotherapy

References
1. ^ Cullen M, Steven N, Billingham L, Gaunt C, Hastings M, Simmonds P, Stuart N, Rea D, Bower M, Fernando I,
Huddart R, Gollins S, Stanley A (2005). "Antibacterial prophylaxis after chemotherapy for solid tumors and
lymphomas". N Engl J Med. 353 (10): 988–98. doi:10.1056/NEJMoa050078 (https://doi.org/10.1056%2FNEJMoa050
078). PMID 16148284 (https://pubmed.ncbi.nlm.nih.gov/16148284).
2. ^ Fisher RI, Gaynor ER, Dahlberg S, Oken MM, Grogan TM, Mize EM, Glick JH, Coltman CA Jr, Miller TP (1993).
"Comparison of a standard regimen (CHOP) with three intensive chemotherapy regimens for advanced non-
Hodgkin's lymphoma". N Engl J Med. 328 (14): 1002–6. doi:10.1056/NEJM199304083281404 (https://doi.org/10.105
6%2FNEJM199304083281404). PMID 7680764 (https://pubmed.ncbi.nlm.nih.gov/7680764).
 1. "Nordic Protocol (Maxi-CHOP and High Dose Cytarabine) for Mantle Cell Lymphoma (MCL)" (https://web.archive.or
g/web/20140911193023/http://www.londoncanceralliance.nhs.uk/media/36656/MCL_Nordic_protocol_V1.0.pdf)
(PDF). Archived from the original (http://www.londoncanceralliance.nhs.uk/media/36656/MCL_Nordic_protocol_V1.
0.pdf) (PDF) on 2014-09-11. Retrieved 2014-09-11.
2. http://www.macmillan.org.uk/cancerinformation/cancertreatment/treatmenttypes/chemotherapy/combinationregimen/r-
chop.aspx
3. New Combo Replaces CHOP for Lymphoma. Dec 2012 (http://www.medpagetoday.com/MeetingCoverage/ASHHem
atology/36418)
4. Two-weekly or 3-weekly CHOP chemotherapy with or without etoposide for the treatment of young patients with
good-prognosis (normal LDH) aggressive lymphomas: results of the NHL-B1 trial of the DSHNHL (http://www.bloodjo
urnal.org/content/104/3/626?sso-checked=true)
5. Dose-escalated CHOEP for the treatment of young patients with aggressive non-Hodgkin’s lymphoma: II. Results of
the randomized high-CHOEP trial of the German High-Grade Non-Hodgkin’s Lymphoma Study Group (DSHNHL) (htt
p://annonc.oxfordjournals.org/content/19/3/545.full.pdf)
6. Conventional chemotherapy (CHOEP-14) with rituximab or high-dose chemotherapy (MegaCHOEP) with rituximab
for young, high-risk patients with aggressive B-cell lymphoma: an open-label, randomised, phase 3 trial (DSHNHL
2002-1) (http://www.medsci.cn/webeditor/uploadfile/20121126/20121126152738768.pdf)

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