Purpose:
- High-dose conditioning regimen before autologous stem cell transplantation (ASCT), mainly for relapsed/refractory Hodgkin lymphoma and non-Hodgkin lymphoma.
- The “R” refers to the addition of Rituximab, usually given in CD20+ lymphomas (e.g., DLBCL, mantle cell lymphoma).
Components
B – Carmustine (BCNU)
- Alkylating agent (nitrosourea)
- Cross-links DNA → cytotoxicity
- Key toxicities: pulmonary fibrosis, hepatotoxicity, myelosuppression
E – Etoposide
- Topoisomerase II inhibitor
- Induces DNA strand breaks
- Key toxicities: mucositis, myelosuppression, risk of secondary AML
A – Cytarabine (Ara-C)
- Antimetabolite (pyrimidine analog)
- Incorporates into DNA → chain termination
- Key toxicities: cerebellar toxicity, conjunctivitis, myelosuppression
M – Melphalan
- Alkylating agent
- DNA cross-linking → apoptosis
- Key toxicities: mucositis, myelosuppression, infertility
R – Rituximab
- Anti-CD20 monoclonal antibody
- Depletes B-cells
- Key toxicities: infusion reactions, risk of HBV reactivation, infections
Typical Schedule (example for ASCT)
- Day –7: Rituximab
- Day –6: Carmustine (BCNU)
- Days –5 to –2: Etoposide + Cytarabine
- Day –1: Melphalan
- Day 0: Stem cell infusion (rescue)
- Rituximab may also be given on Day +1 or later depending on protocol.
(Exact timing varies by institution and protocol.)
Clinical Considerations
- Requires inpatient setting with full supportive care (antimicrobials, growth factors, transfusions).
- Monitor for organ toxicities (pulmonary, hepatic, renal).
- High risk of febrile neutropenia → prophylactic antibiotics/antifungals/antivirals.
- Fertility preservation counseling recommended.
- Vaccination schedule reviewed post-transplant.