1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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?

10. Case report follow-up slides

11. 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

12. 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

13. 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

14. 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

15. 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

16. 85-year-old lady Geriatricians attitude Treat functional decline
Bladder catheter removed
Physiotherapy
Parallel bars
Reinforcement of lower legs
Treat depression

17. 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

18. 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

19. 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