Hello, I am Dr. Naveen Pemmaraju, and I’m happy to be partnering with Incyte Corporation to share my perspective on why it is vital to routinely assess the spleen in patients with myelofibrosis, or MF.
Splenomegaly is an important clinical indicator in patients with MF. And in my practice, I find that spleen assessment can be a powerful tool to help monitor disease progression. This is why I proactively assess the spleen at diagnosis to establish a baseline, and at every visit throughout the course of their disease.
Spleen assessment is something we all learned in medical school, but for many of us, it is performed infrequently in our busy practices. This is why it is worth taking a few minutes to provide a brief refresher where I will review my tips and technique for examining the spleen.
We know that most patients with MF experience splenomegaly. In fact, one study showed approximately 90% of patients with MF had palpable splenomegaly at diagnosis. For this reason, I always palpate the spleen when evaluating my patients at diagnosis, as recommended by the NCCN Guidelines. Another reason to actively assess the spleen in our patients is that a growing spleen indicates the patient’s MF may be worsening. According to the IWG-MRT and ELN response criteria, a spleen that is palpable 5 cm or more below the left costal margin, or LCM, constitutes progressive disease. Additionally, splenomegaly may be associated with pain, early satiety, abdominal discomfort, and other symptoms.
In my practice, performing spleen assessment is part of my standard examination. I routinely evaluate the spleen and record my findings, whether or not spleen-related symptoms are reported.
Assessing the spleen is as easy as ABCD. Accurately measure the spleen at Baseline and routinely at every follow-up using a Consistent technique and then Document your findings. And remember, baseline evaluation of the spleen provides a reference point for future measurements.
This is key in tracking progression that will influence your management decisions. Palpation can be a quick and easy method for detecting and tracking splenomegaly and will be most informative if you use a consistent technique.
To begin, your patient should be in the supine position. For a successful palpation, the abdomen should be relaxed, this may require your patients to bend their knees. Take a second to warm up your hands before placing them on the patient. I start by palpating placing my right hand just above the left costal margin and feel for the edge of the rib, as the exact position differs from patient to patient. The left costal margin is located here. Once you are just below the LCM, instruct your patient to take a deep breath, as this allows the spleen to descend where palpation may be felt.
Now gently push down, moving upwards anteriorly. Release and repeat this maneuver, walking your way down toward the umbilicus. Generally, I only use my right hand, but in some instances I do use my left hand to support and position. As the spleen enlarges, its anterior pole continues to descend below the rib cage and across the abdomen toward the right lower quadrant. Thus, I continue to palpate over the lower abdomen until I am confident that a massive spleen has not been missed. I personally standardize spleen measurements using a tape measure in cm. However, the finger breath maneuver is an alternative that may be used.
The key is to measure at baseline and utilize the same system every time to ensure precision over time. And I document my findings in the patient’s chart. Even in experienced hands, sometimes the spleen is difficult to find, or a patient is unable to lie on the exam table due to body habitus or comorbid illness. In these cases, I confirm my suspicions with imaging. Imaging may also be helpful to evaluate the spleen and obtain data if you are unable to perform a physical exam in person, such as when a patient is seen via telemedicine. Assessing the spleen at diagnosis and routinely during follow-up allows longitudinal tracking of your patient’s disease progression. I believe incorporating routine spleen assessment can help improve care for my patients with MF.