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Case history

image A 76-year-old white woman presented with a 2 month history of fever, weight loss, fatigue, drenching night sweats and new lumps in the neck, axillary region and groin.

Her past medical history included depression, for which she took citalopram, and Parkinson's disease, for which she took co-beneldopa (levodopa and benserazide hydrochloride). She lived alone and had no family nearby. She had struggled with her activities of daily living (ADL) and her instrumental ADL (IADL) for the past few years, even prior to the onset of her new symptoms. She also had mild cognitive impairment (Montreal Cognitive Assessment, 22/30). Prior to her diagnosis, her Eastern Cooperative Oncology Group (ECOG) performance status (PS) was 2, but over the last month it had dropped to 3.

On examination, there was peripheral lymphadenopathy in the cervical, supraclavicular, axillary and inguinal regions. There was also palpable hepatosplenomegaly.

Blood tests revealed Hb 96 g/l and platelets 84×109/l. Her lactate dehydrogenase (LDH) was above the normal range, but electrolytes, renal and liver function were all normal. CT and PET-CT imaging confirmed FDG-avid lymphadenopathy above and below the diaphragm, along with splenic and liver involvement. Excision biopsy of an axillary lymph node confirmed a diagnosis of diffuse large B cell lymphoma (DLBCL). The cells were positive for CD20 on immunohistochemistry. Bone marrow biopsy and trephine did not show any evidence of lymphoma. An echocardiogram revealed a normal ejection fraction. The overall staging was recorded as stage IVB DLBCL.

Following discussion among the multidisciplinary team (MDT), she was treated with six cycles of R-mini-CHOP (full-dose rituximab in combination with low-dose cyclophosphamide, doxorubicin, vincristine and prednisolone [CHOP]) to a complete metabolic response. She is currently in remission.

What is the goal of cancer treatment for this patient?

What prognostic tools are available, and what staging investigations are required?

Which key questions would you address in this patient prior to making a decision on her treatment?

What is the evidence base for the patient's treatment options, taking into account her age, PS and comorbidities?

What is the goal of cancer treatment for this patient?

Non-Hodgkin's lymphoma is the sixth most common cancer in the UK,1 with an incidence of 22 new cases per 100,000 males and 18 per 100,000 females per year in the UK.1 DLBCL is the most common subtype, accounting for nearly half of all non-Hodgkin's lymphoma diagnoses.1 It predominantly affects older age groups, with 63% of cases occurring in patients aged 65 or over.1

DLBCL is an aggressive disease and, if left untreated, is rapidly fatal.2 Surgery or radiotherapy alone are not suitable curative options for first-line treatment of this stage of disease.2,3 It is, however, extremely chemo-responsive and the majority of patients (60% of all patients diagnosed with DLBCL) are cured.2 Therefore, the aim of treatment in this patient is curative.

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