Pierre Soubeyran, Institut Bergonié, Bordeaux Management of haematological malignancies in older vulnerable/frail patients Case presentation 1: A case of diffuse large B-cell lymphoma Pierre Soubeyran, Institut Bergonié, Bordeaux

Disclosure Research Support/P.I. Employee No relevant conflicts of interest to declare Consultant Major Stockholder Speakers Bureau Honoraria CELGENE, TEVA Scientific Advisory Board TEVA, SANDOZ, BMS

85-year-old lady 58 kg, 1,54 m Lives with her husband in Royan Independent Rides her bicycle for shopping every day One son living closely No major clinical background No severe comorbidities

85-year-old lady January February Abdominal pain Low intensity then intensified Left flank then epigastric February General practitioner CT scan Bulky retro-peritoneal and coeliac lymph nodes (16 cm) Right pleural effusion Biopsy by laparoscopy Diffuse large B-cell lymphoma, germinal center type

85-year-old lady February : consultation at Institut Bergonié PS = 3 Weight loss 4 kg (58 to 54 kg) No fever, no sweats Dyspnea, Insomnia, lower back pain Superficial epigastric mass 4 cm Palpable abdominal mass 8 x 10 cm Left inguinal lymph node 2 cm Leg edema

85-year-old lady February : consultation at Institut Bergonié PS = 3 Weight loss 4 kg (58 to 54 kg) No fever, no sweats Dyspnea, Insomnia, lower back pain Superficial epigastric mass 4 cm Palpable abdominal mass 8 x 10 cm Left inguinal lymph node 2 cm Leg edema

85-year-old lady Stage IVA, aaIPI 3 Creatinine clearance (Cockroft) 58 ml/mn after hydration LVEF (ventriculography) = 35% Albumin = 25 g/l CRP = 146 mg/l Anemia = 10 g/dl hemoglobin LDH = 2947 U (N<480) Stage IVA, aaIPI 3

85-year-old lady Geriatric assessment MMS 24 IADL/8 2 ADL/6 4,5 Get up and go 23 s MNA 21 GDS15 6

Questions What are the options for the treatment of this aggressive lymphoma? Should we propose geriatric intervention on the observed geriatric impairments and, if yes, how? What should be your objective at the end of treatment and what should be your attitude is there are discrepancies with patient’s will at baseline?

Case report follow-up slides

85-year-old lady Proposal of FRAIL06 trial Received R-CVP cycle 1 Randomized phase II study R-CVP vs R-COPY (liposomal doxorubicin 40 mg/m²) ) Received R-CVP cycle 1 prophylactic G-CSF and EPO

85-year-old lady Follow-up of R-CVP cycle 1 Day 2 = PS 4 Confused Slow ideation, disoriented Increase of dyspnea Need for oxygen, evacuation of pleural effusion Day 11 = Febrile neutropenia Staphylococcus identified

85-year-old lady Follow-up of R-CVP cycle 1 Day 15 = improvement of general status Apyrexia Improved consciousness Improved LVEF: 56% Still PS 4

85-year-old lady Follow-up of R-CVP cycle 1 Day 15 = improvement of general status Apyrexia Improved consciousness Improved LVEF: 56% Still PS 4 Disappearance of any palpable mass

85-year-old lady Second R-CVP cycle at d27 R-CVP with 50% reduction cyclophosphamide Day 7: improvement of general status One hour per day in armchair Stop O2 PS 4 Transfer to the Geriatric Department

85-year-old lady Geriatricians attitude Treat functional decline Bladder catheter removed Physiotherapy Parallel bars Reinforcement of lower legs Treat depression

85-year-old lady After 3 cycles of R-CVP After 6 cycles of R-CVP Complete remission PET-negative After 6 cycles of R-CVP CR confirmed Five years later 90 years old Persistent CR Does not ride bicycle anymore

85-year-old lady After 3 cycles of R-CVP After 6 cycles of R-CVP Complete remission PET-negative After 6 cycles of R-CVP CR confirmed Five years later 90 years old Persistent CR Does not ride bicycle anymore Swims everyday up to 2 km in the bay of Royan

85-year-old lady After 3 cycles of R-CVP After 6 cycles of R-CVP Complete remission PET-negative After 6 cycles of R-CVP CR confirmed Five years later 90 years old Persistent CR Does not ride bicycle anymore Swims everyday up to 2 km in the bay of Royan