84-year-old man with B cell lymphoma and new sinus masses

Background

• Diffuse large B cell lymphoma, secondary to mycophenolate
• R-CHOP chemotherapy
• New onset headaches and diplopia – PET-avid sinus lesions

Issues

• Profoundly frail and deconditioned. CFS = 6, DASI 2.9 METS
• Multiple hospital admissions this year including ICU stay for neutropenic sepsis and 40-dayhospital admission
• Renal Transplant 2014 – live donor kidney from wife. Native polycystic kidney disease.
• IDDM – secondary to methylprednisolone for acute transplant rejection
• Severe MR – Mitraclip in Nov 2020 post chordae rupture.
• Regular cardiology follow-up until lymphoma diagnosis, current plan to focus on cancertreatment.
• Recent echo – mild to moderate residual MR, Moderate concentric LVH, low-normal systolicfunction, moderate to severe pulmonary hypertension, and severe LA enlargement.
• Paroxysmal AF – not currently anticoagulated
• VRE

Discussion

Reason for procedure

• Diagnostic vs therapeutic – patient and family believe it may help to resolve his headaches
• Discussed with ENT – diagnostic procedure only. Requested by oncologist. The Surgeon doesnot think it will add any therapeutic benefit.
• Surgeon and oncologist to have further discussions

Opportunity for optimisation

• Discussed with Prof Fletcher, last echo reassuring. Patient on optimal cardiac therapy.
• Significant level of frailty and deconditioning are concerning
• High-risk patient and low risk procedure
• Ascertain if biopsy will significantly affect the management of his malignancy

Advanced care planning

• No documented advanced care directive in notes

Plan

• Await outcome of discussions between oncologist and ENT surgeon
• Liaise with patient regarding ACD