I have a 73 year old man, with recent diagnosis of CLL [negative for IgHV mutation, FISH panel for TP53, 13q del, 11q], who has received 3 doses of obinituzumab with robust cytoreduction, WBC dropped from 250 to 5. He still have bulky lymphadenopathy in axilla and inguinal area. I wanted to start venetoclax or BTKi but any oral therapy is cost prohibitive. I can only do IV therapy. While making those decisions, he developed hydronephrosis due to retroperitoneal lymph nodes, and is now on indwelling foley. I am reading in NCCN that single agent Obinitizumab could be considered, plus minus chlorambucil. 1. Would FCR be a reasonable option? It is time limited and he has significant non-compliance. He also has RA and rituximab could be of potential benefit. 2. Is there any association of compression fracture and CLL? I dont think so. We attributed that to RA and he got a dose of Zometa.

CLL Specialist

If he’s quite fit and healthy, FCR is a reasonable choice. Bendamustine + Rituximab is more conservative (paper below). https://ascopubs.org/doi/10.1200/JCO.2011.39.2688 If he has unmutated IgH, chemoimmunotherapy is much less effective. That also applies if he had del(17p) and/or TP53 mutation, but I interpret what you wrote to mean he does not have those. If you need chemoimmunotherapy, in order of decreasing efficacy and increasing tolerability, options include: -- FCR -- Bendamustine plus rituximab -- Chlorambucil plus obinutuzumab I’m not aware of an association of compression fractures and CLL. I did a quick search and could only find case reports and this paper, below. There may be an association with compression fractures and CLL. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5479616/