Jason Gotlib, MD, MS
	Associate Professor of Medicine (Hematology) Stanford University School of Medicine/Stanford Cancer Institute Stanford, California

I haven’t recommended splenectomy in the last year for a patient with MF. In general, I recommend splenectomy in patients with symptomatic splenomegaly that is refractory to medical therapy, including JAK inhibitors, with the primary indications being pressure or pain and perhaps concerning portal hypertension. I am not likely to recommend splenectomy for anemia or thrombocytopenia where longer-term response rates for improvement after splenectomy are low.

	Elias Jabbour, MD
	Associate Professor Leukemia Department The University of Texas MD Anderson Cancer Center Houston, Texas

In the past year I have recommended splenectomy for a 65-year-old patient who had symptomatic splenomegaly with severe anemia and thrombocytopenia, for whom supportive care and an IMiD failed and who was not a candidate for ruxolitinib.

	John O Mascarenhas, MD
	Myeloproliferative Disorders Program Tisch Cancer Institute Division of Hematology/Oncology Mount Sinai School of Medicine New York, New York

I recommend splenectomy infrequently. In the past year I have recommended splenectomy for a patient with advanced MF, pancytopenia and massive, symptomatic splenomegaly who was not responsive to or eligible for other therapy due to baseline thrombocytopenia.

The incidence of complications after splenectomy, such as thrombosis, bleeding or infections, is about 10% to 15%. This increases with age and larger spleen size. This is not a procedure that can be done laparoscopically. So it can be a big procedure for a patient is their 70s to have a laparotomy for a big spleen. With the availability of ruxolitinib the reason for splenectomy in many patients is removed. Currently, I only recommend splenectomy for patients who essentially can’t receive ruxolitinib because their platelet count is 10,000 or 15,000. Of interest, after these patients have undergone splenectomy, platelet sequestration stops and platelet count comes up and then you can put them on ruxolitinib. I’ve done this in several cases.

	Ruben A Mesa, MD
	Chair, Division of Hematology and Medical Oncology Deputy Director, Mayo Clinic Cancer Center Professor of Medicine Mayo Clinic in Arizona Scottsdale, Arizona

In the past year I recommended splenectomy to a patient with MF who experienced failure of multiple JAK2 inhibitors.

	Jerry L Spivak, MD
	Professor of Medicine and Oncology Director, The Johns Hopkins Center for the Chronic Myeloproliferative Disorders Johns Hopkins University School of Medicine Baltimore, Maryland

I try to avoid splenectomy in these patients because it usually leads to death or disability. Lately, with thalidomide or ruxolitinib (and some times together), I have avoided splenectomy in my patients. I haven’t recommended splenectomy in the past year.

	David P Steensma, MD
	Attending Physician Dana-Farber Cancer Institute Associate Professor of Medicine Harvard Medical School Boston, Massachusetts

In the past year I recommended a splenectomy to a patient who had mechanical symptoms from splenomegaly despite treatment with hydroxyurea and ruxolitinib and who was not eligible for any clinic trials.

Today, I think we struggle with identifying the patients that will benefit from a splenectomy now that we have ruxolitinib, an agent that is better at shrinking down the spleen, than what we had before. Splenectomies are becoming less common. But for a patient who’s had a splenic hemorrhage or someone who’s had a fair trial of ruxolitinib, a fair trial of cytoreductive agents and still has spleen-related symptoms, splenectomy is still indicated. The procedure should be done at an experienced center.

	Moshe Talpaz, MD
	Alexander J Trotman Professor of Leukemia Research Associate Director of Translational Research UM Comprehensive Cancer Center Associate Chief, Division of Hematology/Oncology Director, Hematologic Malignancies University of Michigan Medical Center Ann Arbor, Michigan

Definitive treatments for this disease don’t exist beyond ruxolitinib. One question is: What is the value of splenectomy? I must emphasize that splenectomy is not a treatment for the systemic disease. It doesn’t change the disease, but the Mayo Clinic has studied this question extensively, and there is clearly a benefit as far as improvements in patients’ quality of life, weight, appetite and sense of well-being. The trade-off is that the procedure is not innocuous and there is a certain mortality, which ranges from 3% to 7%, depending on the patient’s condition. In the past year I recommended splenectomy to a patient who initially responded to a JAK2 inhibitor but subsequently developed disease resistance with a rapidly growing spleen.

Splenectomy can have benefits that tend to be short-lived in duration, for about a year, when the disease reactivates and probably the liver becomes the predominant site of extramedullary hematopoiesis and starts to cause problems. I don’t view splenectomy as a long-term solution. I see therapy with drugs based on better knowledge of the disease as a long-term solution. But for the time being, this is something that can be used.

These days when we have a treatment that is effective systemically we have no reason to go with a topical approach that doesn’t have a major impact on the disease. I don’t recommend splenectomy prior to treatment with a JAK2 inhibitor. I infrequently recommend splenectomy after disease progression on ruxolitinib. For some of my young patients, when the spleen grows so rapidly at the stage of resistance, I will recommend it occasionally.

	Srdan Verstovsek, MD, PhD
	Professor of Medicine Chief, Section for Myeloproliferative Neoplasms (MPNs) Department of Leukemia Director, Clinical Research Center for MPNs The University of Texas MD Anderson Cancer Center Houston, Texas

In the past year I have recommended splenectomy to a patient with massive splenomegaly after relapse on ruxolitinib.