Localized Primary Amyloidosis of the Prostate, Bladder and Ureters

Bladder triangle amyloidosis: A case report and literature review

RATIONALE

Amyloidosis is a group of benign lesions characterized by extracellular deposition of amyloid proteins. Amyloidosis lesions can occur in various organs of the body, but rarely in the urinary system. Amyloidosis in the bladder trigone is extremely rare.

PATIENT CONCERNS

An 80-year-old female patient presented with painless whole-course gross hematuria with reddish urine and no blood clots, accompanied by right lumbar discomfort.

DIAGNOSIS

Based on the patient's medical history and cystoscopy findings, the relevant literature was reviewed and a preoperative diagnosis of bladder tumor was made, although bladder amyloidosis was not excluded. Postoperative pathology ultimately revealed bladder amyloidosis.

INTERVENTIONS

The patient underwent resection of bladder tumor and ureteral stent implantation. Postoperatively, the patient was maintained on antibiotics and oral colchicine treatment.

OUTCOMES

Two months after surgery the patient reported that the gross hematuria had disappeared, and that the right lumbar discomfort was significantly relieved.Cystoscopy showed no obvious recurrence in the operative area, but magnetic resonance imaging (MRI) suggested recurrence. The patient refused partial cystectomy, and the ureteral stent was removed.

LESSON

The clinical manifestations of bladder amyloidosis are nonspecific, and under cystoscopy can be easily confused with bladder tumors. Accurate diagnosis of bladder amyloidosis relies on histopathology. Transurethral resection of bladder tumors or partial cystectomy is an option for surgical treatment; the latter should be performed if the ureteral opening is involved.

Clinical relevance of amyloid in prostate samples: a report on 40 patients

OBJECTIVE

To describe the clinical findings in patients with incidental prostatic amyloidosis.

PATIENTS AND METHODS

Retrospective search in the database of the Department of Pathology, Hospital de Bellvitge, for prostate specimens with amyloid. Congo red and immunohistochemical staining of the sections. Review of the patients' clinical charts for symptoms attributable to systemic amyloidosis.

RESULTS

Amyloid deposition in the prostate was identified and reported in 40 patients between 2001 and 2022. Median age was 76.5 years (range 62-90). Prostate cancer was diagnosed in 25 patients. Only 4 patients had a previous diagnosis of amyloidosis. In the remaining 36 the prostate sample (31 needle biopsies, two transurethral resections (TUR), two simple prostatectomies, one radical cystectomy for bladder cancer) provided the initial diagnosis. Amyloid deposits were mainly located in the wall of small vessels and rarely in the prostatic stroma. Immunohistochemistry was available in 32 cases, 26 of which were positive for TTR. All patients showed at least one symptom indicative of systemic amyloidosis, the most frequent being hearing loss (55%), carpal tunnel syndrome (42,5%) or other osteoarticular symptoms (tendinopathies, osteoarthritis), cataracts (37.5%), and cardiac symptoms (32.5%), among others.

CONCLUSION

The prostate is a target tissue for amyloid deposition. The incidental finding of amyloid in prostate corresponds, in the majority of cases, to previously undiagnosed systemic TTR amyloidosis in patients lacking signs of heart involvement but having mainly osteoarticular symptoms, hearing and visual impairment.

The Clinical Implication of Incidental Prostatic Amyloidosis

OBJECTIVE

To describe the clinicopathologic features of patients with incidental prostatic amyloidosis.

PATIENTS AND METHODS

We queried the genitourinary pathology database at Mayo Clinic Arizona for prostate specimens which showed amyloid deposits. Congo red stain was used for the diagnosis of amyloidosis and amyloid subtype was performed analysis using Liquid chromatography tandem mass spectrometry. We reviewed the patient's medical charts for past or subsequent diagnosis of systemic amyloidosis and clinical course.

RESULTS

Prostatic amyloidosis was identified in 7 patients between 2008-2018. Median age was 79 years (range 69-84) and median follow-up was 5 years (range 0-11). Benign prostate tissue was found in 4 patients, and prostate cancer was diagnosed in 3 patients. Amyloid subtyping was available in 6 patients and was consistent with Amyloid transthyretin Amyloidosis. Liquid chromatography tandem mass spectrometry did not detect an amino acid sequence abnormality in the transthyretin protein in any of the patients. Five of 6 patients were diagnosed with cardiac amyloidosis, which preceded and followed the diagnosis of prostatic amyloidosis in 1 and 4 patients, respectively. Of these 4 patients, 2 were diagnosed immediately and as a consequence of the diagnosis of prostatic amyloidosis, and the remaining 2 3 and 4 years later.

CONCLUSION

Incidental prostatic amyloidosis should prompt systemic and cardiac evaluation for amyloidosis. In patients with suspected cardiac amyloidosis, prior prostate specimens should be reviewed for the presence of amyloidosis.

Prostate Benign Diseases

Magnetic resonance imaging (MRI) has been increasingly used in the detection, localization, and staging of prostate cancer. Because of its excellent soft tissue contrast and multiplane imaging, it can be also very useful in the evaluation of benign prostate diseases. Prostatic benign disorders have a high prevalence, vastly represented by benign prostatic hyperplasia and prostatitis. On the contrary, benign prostatic neoplasms are extremely rare, represented by multilocular cystadenoma, leiomyomas, hemangioma, and granular cell tumor, although these uncommon tumors have been most encountered due to widespread use of MRI. Congenital prostatic anomalies are associated with defects in the development of the prostate embryology, including hypoplasia, ectopia, and vascular malformations, abnormalities rarely seen on cross-sectional imaging. Prostatic cysts are the most common development abnormalities and occasionally are related to clinical symptoms, mainly due to infection and hemorrhage. As with prostate cancer, multiparametric MRI is a reliable tool for the diagnosis and management of benign prostatic diseases as well, providing additional information such morphological changes of the prostate, more accurate prostatic measurements, and functional characteristics of nonmalignant prostatic lesions. In this review, we discuss MRI findings of these benign prostatic diseases.

Beyond Prostate Adenocarcinoma: Expanding the Differential Diagnosis in Prostate Pathologic Conditions

Recent advances in magnetic resonance (MR) imaging of the prostate gland have dramatically improved the ability to detect and stage adenocarcinoma of the prostate, one of the most frequently diagnosed cancers in men and one of the most frequently diagnosed pathologic conditions of the prostate gland. A wide variety of nonadenocarcinoma diseases can also be seen with MR imaging, ranging from benign to malignant diseases, as well as infectious and inflammatory manifestations. Many of these diseases have distinctive imaging features that allow differentiation from prostate acinar adenocarcinoma. Early recognition of these entities produces a more accurate differential diagnosis and may enable more expeditious clinical workup. Benign neoplasms of the prostate include plexiform neurofibroma and cystadenoma, both of which demonstrate distinctive imaging features. Stromal neoplasms of uncertain malignant potential are rare tumors of uncertain malignant potential that are often difficult to distinguish at imaging from more-malignant prostate sarcomas. Other malignant neoplasms of the prostate include urothelial carcinoma, primary prostatic carcinoid, carcinosarcoma, endometrioid or ductal adenocarcinoma, and mucinous adenocarcinoma. Prostatic infections can lead to abscesses of pyogenic, tuberculous, or fungal origins. Finally, miscellaneous idiopathic disorders of the prostate include amyloidosis, exophytic benign prostatic hyperplasia, and various congenital cysts. Considerable overlap can exist in the clinical history and imaging findings associated with these prostate pathologic conditions, and biopsy is often required for ultimate confirmation of the diagnosis. However, many diagnoses, including cystadenoma, mucinous adenocarcinoma, sarcoma, and abscesses, have distinct imaging features, which can enable the informed radiologist to identify the diagnosis and recommend appropriate clinical workup and management. (©)RSNA, 2016.

MR Imaging of the Prostate Gland

This article discusses MR imaging of the normal prostate and of disease conditions of the prostate including prostatitis, cystic lesions, amyloidosis, calculi, hematospermia, benign prostatic hyperplasia, and malignancy.

Localized amyloidosis of the genitourinary tract: report of 5 new cases and review of the literature

Primary localized amyloidosis of the genitourinary tract is a rare entity characterized by small pseudotumors localized in the renal pelvis, ureters, or bladder. Amyloid fibrils are derived from immunoglobulin light chains, but no systemic plasma cell proliferation is detected. The clinical and radiologic features mimic urinary tract cancer, and local treatment is indicated. The prognosis is excellent in most cases, although disease recurrence is possible. We report 5 new cases of localized amyloidosis of the urinary tract, with lambda (4/5), or kappa (1/5) chain amyloid protein, involving the bladder (5/5), and the ureter and renal pelvis (1/5), with multiple, bilateral lesions in 1 case. The presenting complaint was painless hematuria in 4 cases. All cases were of primary (AL)-type amyloidosis. All patients underwent extensive investigation, and none presented any signs of generalized amyloidosis. A favorable outcome was observed in every case. We performed a comprehensive review of the literature, and summarize the data.

Primary bladder amyloidosis--case report of a patient with delayed upper urinary tract obstruction 3 years after the diagnosis

Primary bladder amyloidosis is a rare disease. There are approximately 100 reported cases. The lesions can be confused with bladder neoplasm and are characterised histologically by the classical apple green birefringence under polarised light. In this article, we report a 51-year-old lady with known history of primary bladder amyloidosis presenting with gross hydronephrosis 3 years after the first diagnosis. Laparoscopic ileal replacement of bilateral ureters was performed. There was no recurrent ureteric obstruction 2 years after surgery. This case demonstrates the progressive nature of primary amyloidosis of bladder. The diagnosis of primary bladder amyloidosis warrants long-term surveillance of upper urinary tract.

Amyloid formation by the pro-inflammatory S100A8/A9 proteins in the ageing prostate

Background

The conversion of soluble peptides and proteins into polymeric amyloid structures is a hallmark of many age-related degenerative disorders, including Alzheimer's disease, type II diabetes and a variety of systemic amyloidoses. We report here that amyloid formation is linked to another major age-related phenomenon − prostate tissue remodelling in middle-aged and elderly men.

Methodology/Principal Findings

By using multidisciplinary analysis of corpora amylacea inclusions in prostate glands of patients diagnosed with prostate cancer we have revealed that their major components are the amyloid forms of S100A8 and S100A9 proteins associated with numerous inflammatory conditions and types of cancer. In prostate protease rich environment the amyloids are stabilized by dystrophic calcification and lateral thickening. We have demonstrated that material closely resembling CA can be produced from S100A8/A9 in vitro under native and acidic conditions and shows the characters of amyloids. This process is facilitated by calcium or zinc, both of which are abundant in ex vivo inclusions. These observations were supported by computational analysis of the S100A8/A9 calcium-dependent aggregation propensity profiles. We found DNA and proteins from Escherichia coli in CA bodies, suggesting that their formation is likely to be associated with bacterial infection. CA inclusions were also accompanied by the activation of macrophages and by an increase in the concentration of S100A8/A9 in the surrounding tissues, indicating inflammatory reactions.

Conclusions/Significance

These findings, taken together, suggest a link between bacterial infection, inflammation and amyloid deposition of pro-inflammatory proteins S100A8/A9 in the prostate gland, such that a self-perpetuating cycle can be triggered and may increase the risk of malignancy in the ageing prostate. The results provide strong support for the prediction that the generic ability of polypeptide chains to convert into amyloids could lead to their involvement in an increasing number of otherwise apparently unrelated diseases, particularly those associated with ageing.