Elderly LBCL patients have unfavorable clinical and biological features, leading to higher relapse rates. While CD19 CAR-T therapy offers a curative option in second-line, access remains limited by clinical criteria in pts aged ≥ 65 years. In our real-world study, we evaluated 232 LBCL pts ≥ 65 years focusing on first line outcomes and potential CAR-T eligibility. Sixty-four patients progressed or relapsed. Applying AIFA criteria, only 9/37 (24%) R/R LBCL pts aged 65-75 years would have been CAR-T eligible. Among those > 75 years, excluded from CAR-T in Italy, only 3/27 (11%) met eligibility criteria. The main exclusion criteria were ECOG ≥ 2 (34 pts, 53%), CNS involvement (14 pts, 22%) and rapidly progressive disease with life expectancy < 12 weeks (12 pts, 19%) The majority of pts who would have been excluded from CAR-T therapy had multiple criteria (32/52, 61%). Pts not receiving full-dose anthracyclines would have been seldom candidates for CAR-T (only 2/12, 16.5%). This study provides an estimate of the potential eligibility to CAR-T cell therapy in an elderly population of R/R LBCL in a real world setting of a CAR-T center. These findings highlight the urgent need for improved first-line therapies for elderly R/R LBCL pts.