How would you treat stage IV DLBCL with severe liver involvement?

I assume liver involvement with lymphoma has resulted in liver dysfunction and elevated bilirubin? If so, then I would use the direct bilirubin as a marker to dose adjust doxorubicin and vincristine. Elevated liver enzymes are not a reason to hold therapy in the absence of elevated bilirubin.

Generally, in these cases when direct bilirubin is > 2-3 g/dL, a pre-phase treatment with a single dose of rituximab and prednisone daily may bring down the bilirubin and allow safe administration of doxor...