How do you dose chemotherapy (R-EPOCH or R-CHOP) in patients with aggressive lymphoma involving liver leading to elevated bilirubin and liver enzymes?

For patients with newly diagnosed diffuse large B-cell lymphoma presenting with hyperbilirubinemia due either to liver disease or extrinsic compression, I will most often consider a pre-phase treatment either with rituximab, cyclophosphamide, or prednisone (all of which can be safely administered in this setting) to cytoreduce, and then follow with a full course of intended anthracycline-based therapy such as RCHOP.

da-EPOCH-R can also be given despite hyperbilirubinemia given the infusional administration of doxorubicin etoposide and vincristine, and if treating Burkitt lymphoma or high-grade lymphoma (e.g., double-hit lymphoma), it is safe and reasonable to administer da-EPOCH-R at dose-level 1.