Correspondence

Combination Chemotherapy for ITP

N Engl J Med 1993; 329:1046September 30, 1993

Article

To the Editor:

Dr. Figueroa et al. (April 29 issue)1 demonstrated that combination chemotherapy is beneficial to some patients in whom immune thrombocytopenic purpura is refractory to corticosteroids and splenectomy. Since all 10 patients had had splenectomies, were studies performed to exclude the possibility of accessory spleens before combination chemotherapy was given? Accessory spleens are common among middle-aged and older adults and are found in about 20 percent of autopsy cases2,3. They have been associated with recurrent immune thrombocytopenic purpura3,4. Among patients from whom accessory spleens have been removed, remission rates have ranged from 27 to 80 percent3,4.

Neil L. Kao, M.D.
G. Wendell Richmond, M.D.
Rush-Presbyterian-St. Luke's Hospital, Chicago, IL 60612

4 References

1. 1

   Figueroa M, Gehlsen J, Hammond D, et al. Combination chemotherapy in refractory immune thrombocytopenic purpura. N Engl J Med 1993;328:1226-1229
   Full Text | Web of Science | Medline

2. 2

   Wadham BM, Adams PB, Johnson MA. Incidence and location of accessory spleens. N Engl J Med 1981;304:1111-1111
   Web of Science | Medline

3. 3

   Rudowski WJ. Accessory spleens: clinical significance with particular references to the recurrence of idiopathic thrombocytopenic purpura. World J Surg 1985;9:422-430
   CrossRef | Web of Science | Medline

4. 4

   Verheyden CN, Beart RW Jr, Clifton MD, Phyliky RL. Accessory splenectomy in the management of recurrent idiopathic thrombocytopenic purpura. Mayo Clin Proc 1978;53:442-446
   Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: Drs. Kao and Richmond make an excellent point in recommending that patients with refractory immune thrombocytopenic purpura be evaluated for a residual accessory spleen. Of the eight patients with chronic immune thrombocytopenic purpura in our study, three were evaluated for accessory spleens; one was found to have an accessory spleen, but did not benefit from its removal. The other five patients were not studied for various reasons. In a review of therapy for chronic immune thrombocytopenic purpura, we found that 13 of 28 patients in four reports entered complete remission after their accessory spleens were removed1-5. Success was more common in patients with late relapse after their initial splenectomy. Of the five patients for whom we have recommended removal of accessory spleens, none have responded. Nevertheless, we believe that removal of an accessory spleen is a useful treatment for some patients with refractory immune thrombocytopenic purpura.

Michael Figueroa, M.D.
2626 Edith Ave., Redding, CA 96001

Robert McMillan, M.D.
Scripps Clinic, La Jolla, CA 92037

5 References

1. 1

   DiFino SM, Lachant NA, Kirshner JJ, Gottlieb AJ. Adult idiopathic thrombocytopenic purpura: clinical findings and response to therapy. Am J Med 1980;69:430-442
   CrossRef | Web of Science | Medline

2. 2

   Verheyden CN, Beart RW Jr, Clifton MD, Phyliky RL. Accessory splenectomy in management of recurrent idiopathic thrombocytopenic purpura. Mayo Clin Proc 1978;53:442-446
   Web of Science | Medline

3. 3

   Wallace D, Fromm D, Thomas D. Accessory splenectomy for idiopathic thrombocytopenic purpura. Surgery 1982;91:134-136
   Web of Science | Medline

4. 4

   Ambriz P, Munoz R, Quintanar E, Sigler L, Aviles A, Pizzuto J. Accessory spleen compromising response to splenectomy for idiopathic thrombocytopenic purpura. Radiology 1985;155:793-796
   Web of Science | Medline

5. 5

   Berchtold P, McMillan R. Therapy of chronic idiopathic thrombocytopenic purpura in adults. Blood 1989;74:2309-2317
   Web of Science | Medline