In patients with post-PV myelofibrosis who are ineligible for allogeneic stem cell transplant, how do you approach symptomatic splenomegaly refractory to splenic radiation and ruxolitinib?

This is always a tough situation. First, I would make sure the patient is truly not a candidate for transplant. With reduced intensity conditioning and the addition of ruxolitinib before and after transplant, transplant is better tolerated than it once was. Otherwise, would consider switching to another JAK inhibitor- federatinib if there are no cytopenias, momelotinib is a good option (especially with those with anemia), and pacritinib can also be considered, especially if cytopenias are more significant. A clinical trial that adds ok therapy to ruxo is also an excellent consideration.