Localized amyloidosis of the parotid gland: a case report and review of the localized amyloidosis of the head and neck

Salivary gland amyloidosis: Proteomic identification and clinicopathologic characterization of 57 cases

Salivary gland amyloidosis is an uncommon diagnosis. Most studies have focused on minor salivary gland biopsies as a surrogate site for diagnosing systemic amyloidosis, while only few studies have investigated major salivary gland amyloidosis. We retrospectively identified 57 major and minor salivary gland amyloidosis cases typed using a proteomics-based method between 2010 and 2022. Frequency of amyloid types, clinicopathologic features, and distribution patterns of amyloid deposits were assessed. The indication for salivary gland biopsy/resection (known in 34 cases) included suspected amyloidosis (N = 14; 41.2%), lesion/mass (N = 12; 35.3%), swelling/enlargement (N = 5; 14.7%), and rule out Sjogren syndrome (N = 3; 8.8%). Concurrent pathology was reported in 16 cases, and included chronic sialadenitis (N = 11), extranodal marginal zone lymphoma (N = 3), plasma cell neoplasm (N = 1), and pleomorphic adenoma (N = 1). We identified 3 types of amyloidosis: immunoglobulin light chain/AL (N = 47; 82.5%); immunoglobulin heavy chain/AH (N = 1; 1.8%), and transthyretin/ATTR (N = 9; 15.8%). The patterns of amyloid deposits (assessed in 35 cases) included: 1) Perivascular and/or periductal distribution (N = 18; 51.4%); 2) Mass formation (N = 9; 25.7%); 3) Stromal micronodule formation (N = 7; 20.0%); and 4) Diffuse interstitial involvement (N = 1; 2.9%). We also identified one case of AL amyloidosis localized to the major salivary gland, where only 6 other cases with adequate staging workup to exclude systemic amyloidosis were previously reported. In conclusion, salivary gland amyloidosis is an uncommon diagnosis but may be underrecognized due to low index of suspicion. Most cases of salivary gland amyloidosis are AL type, but a minority are ATTR. Therefore, proteomics-based typing remains essential for treatment and prognosis.

Oral and Maxillo-Facial Manifestations of Systemic Diseases: An Overview

Many systemic (infective, genetic, autoimmune, neoplastic) diseases may involve the oral cavity and, more generally, the soft and hard tissues of the head and neck as primary or secondary localization. Primary onset in the oral cavity of both pediatric and adult diseases usually represents a true challenge for clinicians; their precocious detection is often difficult and requires a wide knowledge but surely results in the early diagnosis and therapy onset with an overall better prognosis and clinical outcomes. In the current paper, as for the topic of the current Special Issue, the authors present an overview on the most frequent clinical manifestations at the oral and maxillo-facial district of systemic disease.

Amyloidoma of the Tongue: Case Report, Surgical Management, and Review of the Literature

PURPOSE

Localized amyloidosis of the tongue is a benign condition in which surgical management may be considered. The aim of the study was to review the current literature and report a case.

MATERIALS AND METHODS

We searched the PubMed database for all relevant articles reporting cases of localized tongue amyloidosis published between 1980 and February 2020. In addition, we updated 1 case diagnosed and treated in our department.

RESULTS

A 49-year-old male patient presented with an asymptomatic tongue nodule of the dorsum mimicking median rhomboid glossitis. The results of an incisional biopsy showed an amyloid on Congo red staining and positive findings for the κ light chain by immunohistochemical analysis. The findings of the systemic workup were negative. Therefore, a diagnosis of localized κ light-chain amyloidosis was made. The patient underwent a resection of the lesion, and no recurrence or progression was observed during a period of 18 months. The literature review showed 12 reports describing 21 patients (11 men, 52.3%) with localized tongue amyloidosis. The most common clinical presentation was nodular with a single lesion of the tongue dorsum (15 patients, 71.4%). All cases showed positive findings on Congo red staining. Immunohistochemical analysis findings were available for only 9 patients (42.8%) and showed light-chain amyloidosis. No case showed any systemic involvement or the development of systemic disease. Surgical excision was performed in 9 cases, with recurrence at the site of operation in 2 cases.

CONCLUSIONS

Localized amyloidosis of the tongue is a rare disease in which surgical excision may be therapeutic when a multidisciplinary evaluation does not show any systemic disease. We recommend an excision when the lesion is persistent or shows an enlargement or when discomfort is reported. In the case of any further local recurrence, resection may be repeated.

A Rare Nasopharyngeal Presentation of Amyloidosis

Amyloidosis is a heterogeneous group of diseases characterized by the extracellular deposition of insoluble proteins whose pathogenesis is not yet fully understood. The deposition of amyloid proteins can be systemic or localized, idiopathic or related to systemic diseases, mostly multiple myeloma or chronic inflammatory diseases. Localized head and neck amyloidosis is a rare entity, mainly involving the larynx. Given the rarity of the disease and the absence of a lasting follow-up protocol, there is no standard treatment defined for localized amyloidosis. We report a rare case of localized nasopharyngeal amyloidosis, treated with complete transoral resection and confirmed by histological examination.

Localized Nasopharyngeal Amyloidosis: A Clinicopathologic Series of 7 Cases with a Literature Review

Localized nasopharyngeal amyloidosis is an extremely rare entity with only 25 cases described in the English and German literature. We present a case series of seven patients with localized nasopharyngeal amyloidosis and combine the findings with a thorough review the literature.

Involvement of oral tissues by AL amyloidosis: a literature review and report of eight new cases

OBJECTIVE

Amyloidosis is a term used to describe a group of diseases in which there is an extracellular deposition of amorphous fibrillar proteins known as amyloid. The aim of this study was to present clinicopathological data from eight oral amyloidosis-affected patients and a deep review of the literature about the disease.

MATERIALS AND METHODS

A retrospective study was conducted based on the records of oral amyloidosis-affected patients diagnosed in our institution between 1978 and 2012. The clinicopathological features and immunohistochemical (IHC) staining with anti-kappa and anti-lambda light chain antibodies were carried out and analyzed.

RESULTS

Eight patients were diagnosed with the disease; the tongue and women in their sixth decade of life were mostly affected. All lesions demonstrated apple-green birefringence and immunoreactivity for kappa-light chain, and four cases also showed lambda positivity. According to our series, four cases were diagnosed with localized amyloidosis and four with systemic amyloidosis. Prognosis for the systemic ones was gloomy, but good for the localized ones, which was characterized by a slow pattern of deposition without evolution to systemic involvement.

CONCLUSIONS

This study reinforces our knowledge about predilections, outcomes, and the importance of making a correct and quick diagnosis of oral amyloidosis and shows the necessity of more studies detailing oral amyloidosis predilection on a global scale. The importance and utility of IHC in the typing of the biochemical nature of amyloid deposits are becoming increasingly necessary for proper management of the patient. Correct classification of the type of amyloid is important for treatment consequences.

CLINICAL RELEVANCE

This article highlights the clinicopathological data of patients with amyloidosis affecting oral tissues and compare these new findings with other worldwide descriptions. Because of its rarity, such data are often unfamiliar to most clinicians and pathologists.

Unusual parotid gland lesions: a pictorial review

This is a pictorial essay of unusual parotid gland lesions that may be encountered in routine clinical practice.

KTP Laser in Laryngeal Amyloidosis: Five Cases with Review of Literature

To study the clinical presentation and review the options in the management of laryngeal amyloidosis. To study the efficacy of KTP 532 laser in the excision of laryngeal amyloidosis. Study was conducted in our department in a tertiary care hospital between Jan 2001 and Feb 2010. We report five patients who presented with hoarseness of voice and localized laryngeal lesions. The biopsy proven laryngeal amyloidosis lesions were excised microendoscopically using KTP 532 laser in three patients and other two patients were kept only on follow-up as they refused further surgery. The patients were evaluated for systemic amyloidosis. The average duration of follow up was 2.6 years (3 months 6 years). All the five patients in our study were asymptomatic with no evidence of recurrence at their last follow up. In our small case series, KTP 532 laser excision of the laryngeal amyloidosis had a favorable outcome. Long term follow up is required to rule out recurrence and systemic involvement.

Pediatric extranodal marginal zone B-cell lymphoma presenting as amyloidosis in minor salivary glands: a case report and review of the literature

We report an unusual case of an extranodal marginal zone B-cell lymphoma (EMZL) arising in the labial minor salivary gland in an immunocompetent 11-year-old boy. The initial histopathologic review favored localized amyloidosis. However, further evaluation supported the diagnosis of low-grade B-cell lymphoma with plasmacytic differentiation, surrounded by deposits of AL κ-type amyloid. Clinical management consisted of excision with no recurrence at 1-year follow-up. This case demonstrates that a diagnosis of lymphoma must be considered in cases of amyloidosis associated with minor salivary gland involvement, even in children. In addition, we provide a literature review of extranodal marginal zone B-cell lymphoma arising in salivary glands.

Localized nasopharyngeal amyloidosis

OBJECTIVES

To illustrate, via a case report, how a differential diagnosis of amyloidosis is to be suspected in case of a nasopharyngeal mass.

CASE REPORT

A 59-year-old woman presented with bilateral nasal obstruction with associated episodic tubal dysfunction. Physical examination found a mass occupying the entire nasopharynx, initially suggestive of tumor.

DISCUSSION

Amyloidosis was diagnosed on histopathologic study of the biopsy and surgical specimens. Exploration for systemic disease proved negative. The localized amyloidosis was managed conservatively. At 9 months' follow-up, there was no recurrence.

CONCLUSION

Localized amyloidosis, however rare, should be considered as differential diagnosis in any case of nasal obstruction with tubal dysfunction, even if bilateral. ENT physicians need to recognize and understand this pathology for adapted diagnostic and treatment planning.

Head and neck amyloidosis: clinicopathological features and immunohistochemical analysis of 14 cases

BACKGROUND

Amyloidosis is associated with or caused by amyloid deposition. These fibrillar proteins may be deposited extracellularly causing tissue damage or impairment.

OBJECTIVES

The aim of the study was to retrospectively review pathology archives in two oral diagnostic centers for cases fulfilling criteria of amyloidosis and to differentiate AA and AL types of amyloidosis.

METHODS

The clinicopathological features, alkaline Congo red staining, with and without pretreatment with potassium permanganate, and immunohistochemical (IHC) staining with anti-AA, anti-kappa (κ), and anti-lambda (λ) light chain antibodies were carried out and analyzed.

RESULTS

The search identified 14 cases. Ten patients were women and four were men, with a mean age of 58 years. Eleven patients had systemic involvement by amyloidosis (associated either with multiple myeloma or plasma cell dyscrasia/monoclonal gammopathies), while three presented the localized type, one of them associated with plasmacytoma. All cases showed positivity for κ or λ light chains (AL-amyloid) and presented resistance to the potassium permanganate pretreatment.

CONCLUSIONS

Our results show that the head and neck region is preferentially affected by systemic AL-amyloidosis, usually associated with plasma cell dyscrasia. Interestingly, two cases affected by inflammatory rheumatic diseases presented AL-amyloid deposition. Moreover, even after pretreatment with potassium permanganate, which was helpful in highlighting the presence of AL-amyloid, in agreement with the IHC findings, clinical classifications should be carefully made in systemic amyloidosis.

Macroglossia due to Systemic Amyloidosis: Is There a Role for Radiotherapy?

Background

Macroglossia due to amyloid depositions can cause cosmetic problems and functional disability, and can lead to life-threatening airway obstruction. Management of macroglossia in systemic amyloidosis is controversial, and the role of surgery is unclear.

Case Description

We present a case of a 66-year-old woman affected by macroglossia due to light chain amyloidosis who presented with eating and breathing difficulties. Because of prior successful results of radiotherapy for localized amyloid disease, our patient was treated with external beam radiation therapy (20 Gy in 10 fractions). The treatment was well tolerated by the patient. However, her systemic amyloidosis progressed, with a subclinical increase in tongue width.

Conclusions

This is the first reported use of radiotherapy for amyloidosis of the tongue. There was no evidence of benefit using a total dose of 20 Gy. This therapeutic modality is not recommended for the routine management of macroglossia.

Primary localized amyloidosis of the nose

Two rare cases of primary localized amyloidosis of the nose are described. A 14-year-old woman presented with anosmia, facial pain, and recurrent episodes of bilateral epistaxis persisting for 2 years. Endoscopic sinus surgery was performed and amyloidosis was diagnosed. Amyloid was also found in the trachea. A 27-year-old woman presented with decreased bilateral hearing and recurrent episodes of bilateral epistaxis. Tympanostomy tube placement was performed and observation continued. The optimum treatment of amyloidosis of the nose has not yet established. We consider that the treatment should depend on the extent of the amyloidosis.

[Amyloidosis of the external auditory canal]

Amyloidosis involving the external ear is extremely rare. We present the case of a 76-year-old man who referred unilateral otorrhea and hypoacusis of six months' duration. The external auditory canal (EAC) was narrowed by a subcutaneous nodule. After its extirpation, unilateral localised amyloidosis of the EAC was diagnosed. In these rare cases, it is crucial to rule out systemic amyloidosis.

Local amyloidosis in the hard palate: a case report

Amyloidosis is a rare disease of multifactorial pathogenesis. Localized amyloidosis of the palate is extremely rare and only four cases have been reported. We present the fifth case in which amyloidosis occurred as a nodule in the hard palate of a 74-year-old woman. The nodule was diagnosed as amyloid light-chain amyloidosis. Further investigations did not show systemic involvement. The patient was kept under observation and during 17 months of follow-up had no progression of the lesion and systemic amyloidosis did not develop.

The spectrum of localized amyloidosis: a case series of 20 patients and review of the literature

Localized deposition of amyloid may occur in individual organs, in the absence of systemic involvement. The reason for localized deposition is unknown, but it is hypothesized that deposits result from local synthesis of amyloid protein, rather than the deposition of light chains produced elsewhere. We identified 20 cases of localized amyloidosis at our institution between 1993 and 2003. There were 11 males and nine females in the group. The mean age at the time of diagnosis was 65.5 years. Organs involved included skin, soft tissues, oropharynx, larynx, lung, bladder, colon, conjunctiva, and lymph node. In six of nine patients typed, the amyloid light chain was lambda. In those patients where follow-up was available (mean 7.6 years), none developed systemic disease. Localized amyloidosis occurs in a variety of organ systems. Evolution into systemic amyloidosis was not seen in our series of patients, supporting the hypothesis of local production of amyloid protein in these cases.

Bullous amyloidosis of the oral cavity: A rare clinical presentation and review

Bullous amyloidosis (BA) is a rare cutaneous manifestation primarily of systemic amyloidosis, a disease in which abnormal proteinaceous material is formed and deposited in response to inflammatory conditions and plasma cell dyscrasias. Hemorrhagic bullae indicative of BA are usually associated with purpura and may be the initial clinical signs of systemic amyloidosis or monoclonal gammopathies, such as multiple myeloma and Waldenstrom's macroglobulinemia. Bullous amyloidosis of the oral cavity is highly uncommon and can mimic other vesiculobullous lesions of the oral mucosa. This article highlights an unusual case of oral BA and reviews important aspects of the disease.

Localized oral amyloidosis of the palate

BACKGROUND

Amyloidosis is a rare disease with multifactorial pathogenesis. Localized amyloidosis affecting the head and neck region is an uncommon and benign process, which has almost no clinical consequences. The most reported characteristic features of localized oral amyloidosis appear as multiple soft nodules of the tongue, lip and cheek.

METHODS

We report the case of a 68-year-old woman suffering from a primary localized amyloidosis presenting as a purple patch on the palate.

CONCLUSIONS

The presence of systemic amyloidosis or underlying plasma cell dyscrasia have to be ruled out in patients presenting with a diagnosis of amyloidosis of the oral mucosa. If a primary localized amyloidosis is proven, the surgical therapy may be useful to eliminate a functional impairment.

Localized amyloid deposition in the nasopharynx and neck, mimicking nasopharyngeal carcinoma with neck metastasis

Amyloidosis results from the deposition of amyloid proteins in organs and tissues. Clinically, it can be classified into systemic and localized forms. Here, we report a case of localized amyloidosis of the nasopharynx and neck. The initial presentation was a nasopharyngeal mass, and bilateral neck masses, mimicking nasopharyngeal carcinoma with neck metastasis. Computed tomographic scans of the neck revealed asymmetry between the bilateral nasopharyngeal walls, and multiple radio-opaque masses in both sides of the neck. A nasopharyngeal biopsy was performed and confirmed amyloid deposition. Subsequent neck-mass excision biopsies confirmed that the neck masses were also amyloid deposits. Further laboratory examinations revealed no systemic involvement. There was no disease progression after local excision. Localized amyloidosis in the head and neck is rare, but can have various manifestations that may sometimes mimic neoplasms.

Unsuspected systemic amyloidosis diagnosed by fine-needle aspiration of the salivary gland: case report

Amyloidosis of the head and neck region may represent a local amyloidoma or a manifestation of systemic disease. Involvement of major salivary glands by either primary or secondary forms of amyloidosis is very rare. We describe a case of systemic amyloidosis that initially presented as submandibular gland mass and was diagnosed by fine-needle aspiration (FNA). A 69-year-old male presented with submandibular mass. His past medical history was significant for left forearm melanoma that was excised 6 years ago and tricuspid valve endocarditis after valvular replacement 3 months prior to FNA of the submandibular gland. The patient had no symptoms or clinical and laboratory data suggestive of amyloidosis. FNA specimen showed salivary gland tissue and abundant amorphous material, which stained positive for amyloid with Congo red stain and showed typical birefringence when examined by polarized microscopy. Further workup of the patient revealed generalized amyloidosis with multiorgan involvement by the disease. This case demonstrates that FNA can be a useful technique in the diagnosis of unsuspected amyloidosis.

[Voice-improving laser-surgical therapy in amyloidosis of the larynx]

Laryngeal amyloidosis is relatively uncommon, accounting for only 0.2-1.5% of all laryngeal tumours. Hoarseness, dysphagia and stridor are potential clinical symptoms. A systemic amyloidosis should be excluded even though symptoms are only apparent in the head and neck region. For the localised form, surgical excision of the excess tissue is performed. We discuss the development of the disease, together with its diagnostics and therapy, based on the case report of a 42 year old female patient.

Amyloid deposition in the oral cavity: a retrospective study and review of the literature

OBJECTIVE

A retrospective study was conducted to investigate the anatomic location and characteristics of amyloid deposition in the oral cavity.

STUDY DESIGN

Seventeen biopsy specimens that were conclusive for a diagnosis of amyloidosis were assessed in terms of their anatomic location and histopathologic characteristics.

RESULTS

Biopsy specimens were received from 13 patients-9 females and 4 males. Six specimens were taken from the buccal mucosa, 4 from the tongue, 3 from the palate, 2 from the gingiva, and 2 from the floor of the mouth. Fifteen of 17 specimens (88%) had amyloid deposition in the subepithelial connective tissue in all locations.

CONCLUSION

On the basis of our pilot data, a previously overlooked intraoral anatomic location, the buccal mucosa, may prove to be of higher diagnostic value than others previously reported in terms of obtaining a diagnosis of amyloidosis. In addition, the manner in which tissue biopsies are conducted for amyloid detection may be altered to create less morbidity.

Nasopharyngeal amyloidosis

PURPOSE

To discuss the presentation of localized amyloidosis affecting the nasopharynx and discuss the management options. Amyloidosis in the head and neck is a rare and benign condition that usually takes the form of localized amyloidosis. Because systemic amyloidosis markedly shortens life expectancy owing to its involvement with vital organs, rectal biopsy or fat aspiration of the anterior abdominal wall must be carried out to exclude systemic involvement. Localized amyloidosis in the head and neck can involve the orbit, sinuses, nasopharynx, oral cavity, salivary glands, and larynx.

METHODS

We present the case of a patient with conductive hearing loss and serous otitis media with effusion secondary to nasopharyngeal amyloidosis, as well as present a review of the literature.

RESULTS

Only a few cases of nasopharyngeal amyloidosis have thus far been reported. Patients with this disease can also present with recurrent epistaxis, postnasal drip, nasal obstruction, and eustachian tube dysfunction. Localized amyloidosis of the nasopharynx, which is slow growing, has proved difficult to treat because it can persist or recur despite surgical treatment. Furthermore, bleeding may be a major complication in treating patients with nasopharyngeal amyloidosis by transpalatal excision because the amyloid deposits cause vascular wall fragility. Finally, there is no evidence that surgical treatment of nasopharyngeal amyloidosis can prolong survival or that localized amyloidosis can progress to systemic amyloidosis. For these reasons, we elected to treat our patient with a tympanostomy tube and observation.

CONCLUSION

In the absence of systemic disease, localized amyloidosis of the nasopharynx may be treated conservatively.

Otologic manifestations of amyloidosis

OBJECTIVE

To describe otologic manifestations of amyloidosis.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary referral center.

PATIENTS

Case report of a patient with bilateral external auditory meatal stenosis secondary to amyloidosis.

RESULTS

The patient is a 60-year-old man who presented with several months' history of bilateral ear blockage and drainage. Physical examination revealed markedly thickened skin in each ear in the area of concha and meatus that was associated with fissuring. The meatus were markedly stenosed. The medial aspect of the external auditory canal and the tympanic membrane were normal. He had partial improvement on medical therapy with topical steroid-containing eardrops and ointment. Past medical history was positive for multiple myeloma. Meatal biopsy was performed. Grossly, the tissue was hypovascular and markedly thickened. Histopathologic examination was consistent with amyloidosis. The patient was continued on topical steroid ointments, frequent ear cleaning, and close follow-up. He was subsequently diagnosed with systemic amyloidosis. A review of the literature was done. Head and neck involvement with amyloidosis is reviewed, with emphasis on otologic manifestations.

CONCLUSION

Otologic involvement with amyloidosis is extremely rare. The pathophysiology may be related to the local factors in the external auditory canal.

CT and MR imaging of localized amyloidosis

The localized form of amyloidosis affecting the head and neck region is rare. The characteristic features of localized amyloidosis appeared as multiple nodules on the tongue, lip, and cheek on computed tomography (CT) and magnetic resonance imaging (MRI). Contrast-enhanced CT scans represented this lesion as a marked nodular enhancement. MR features of this lesion appeared slightly low on T1-weighted images and slightly high on T2-weighted images compared with T1-T2 images of residual normal tongue. Time contrast intensity curves obtained from dynamic MRI rapidly increased to reach a plateau and gradually decreased during the late and delayed phases. MR findings suggest that such lesions might be comprised of fibrous tissue with abundant vessels. This report suggests that dynamic MRI might be helpful for diagnosing localized amyloidosis.