74yo M w/ newly diagnosed CLL/SLL. Presented with severe R. hip pain and imaging with a 9cm pelvic mass. Biopsy consistent w/ SLL. He has (+) FLOW for CLL in blood, but normal WBC count/lymphocyte count. TP53 negative. FISH and IGHV pending. Given significant symptoms, was considering treatment with BTKi (zanubrutinib) vs. acalabrutinib/obinutuzumab. In what settings do you typically add obinutuzumab rather than just single agent BTKi.

I think it's reasonable to consider obinu with Acala in this setting. I mostly consider obinu when there is bone marrow disease mostly to help clean the bone marrow where BTKi seems to have hard time clearing the bone marrow. Also ELEVATE trial showed Acala obinu seemed a little bit better than Acala single agent in PFS