Localized amyloidosis of the urinary tract: Case series of nine patients

Clinical study on ureteritis observed in contrast-enhanced computed tomography in the emergency department

Objective

We aimed to investigate the causes and clinical and laboratory features of patients with ureteritis observed on intravenous contrast-enhanced abdominopelvic computed tomography (APCT) conducted in the emergency department (ED).

Methods

All APCTs conducted in the ED from November 2017 to November 2020 were investigated for the presence of ureteritis. The incidence of ureteritis, presumed cause of ureteritis, and clinical as well as laboratory features of patients with ureteritis were retrospectively analyzed.

Results

Ureteritis was observed in 422 out of 7,386 patients (5.7%) who underwent APCTs. The two main reasons for undergoing APCT in the ED were abdominal pain (49%) and infection focus workup (33%). The first major cause of ureteritis was urinary tract infection (UTI) (351 of 422, 83%). Most patients (85%) were febrile, but 208 (59%) exhibited no urinary symptoms such as dysuria, increased frequency, or residual urine sense. The second major cause of ureteritis was ureteral stones (42 of 422, 10%). Thirty-two of 42 patients (76%) had simple obstructive uropathy, while 24% of patients had a combined infection along with an obstruction. Other rare causes were malignancy and the spread of adjacent inflammation.

Conclusion

Ureteritis was a common finding observed in 5.7% of patients who underwent APCTs at the ED, and most of them were secondary to UTIs and ureteral stones. UTIs can cause ureteritis even without typical symptoms or signs suggestive of UTI, and diagnosis without an APCT can be difficult. More liberal use of APCTs should be considered when the cause of fever is difficult to diagnose.

Amyloidosis of the Urinary Bladder: A Systematic Review and a Proposed Management Algorithm

OBJECTIVE

To propose an algorithm for the management of bladder amyloidosis based on a systematic review of the literature, given that the bladder is the second most commonly affected organ of the urinary tract in the course of systemic or localized amyloidosis.

METHODS

We searched PubMed, Cochrane Library and Scopus databases utilizing PRISMA methodology from inception to November 30, 2020 (PROSPERO: CRD42020207855).

RESULTS

We included 76 studies with 184 patients (9 case series and 67 case reports). Presenting symptoms of bladder amyloidosis comprised of hematuria, irritative or obstructive urinary symptoms, and cystitis-like symptoms. The diagnosis of amyloidosis was established by histologic examination of specimens retrieved during transurethral resection of bladder lesions. Complete endoscopic resection, the cornerstone of management of localized disease, was feasible in 89.1% cases. The included patients were followed up for a mean of 54 months, within which 65 patients (35.3%) recurred. The time to first amyloidosis recurrence was 20 months (range: 1-168). Additionally, 16 individuals presented with concomitant bladder amyloidosis and bladder cancer, while 4 developed bladder malignancy during follow-up. Due to the frequent and early recurrences of patients with bladder amyloidosis, a check-up cystoscopy at 3, 12, and 24 months' after initial resection is recommended. Recurrences should be managed with transurethral resection, while intravesical instillations of dimethyl sulfoxide (DMSO) and cystectomy should be reserved for refractory cases.

CONCLUSION

We propose a management algorithm for bladder amyloidosis based on the available evidence for this rare benign entity that mimics bladder cancer.

Monotypic Plasma Cell Proliferation of Uncertain Clinical Significance Mimicking Interstitial Cystitis: An Early Lesion of MALT Lymphoma?

We prospectively studied our institutional experience of bladder extranodal marginal zone (mucosa-associated lymphoid tissue [MALT]) lymphoma including bladder biopsies in which the possibility of MALT lymphoma was considered. We identified a subset of cases primary to the urinary bladder, presenting with prominent plasma cell infiltrates and symptoms mimicking bladder pain syndrome/interstitial cystitis. These proliferations were designated for this study as "monotypic plasma cell proliferation of uncertain clinical significance" (MPCP-US), as the features were insufficient for diagnosis of MALT lymphoma. We identified 33 patients, consisting of 22 cases of MPCP-US (6 of which were associated with amyloid deposition) and 11 cases of MALT lymphoma. MPCP-US was more prevalent in men (73%), a mass lesion was not identified at cystoscopy, and only 1 case had an accompanying urinary tract infection (4.5%). Histologically, MPCP-US presented as monotypic plasma cells arranged in a superficial band-like distribution in the lamina propria, predominantly kappa restricted (68%) and IgA+ or IgM+ (64% and 23%, respectively) and without a histologic mass of atypical B cells or plasma cells, not diagnostic for established MALT lymphoma or plasmacytoma. Secondary involvement of the bladder by other lymphoproliferative disorders was excluded and there was no evidence of progressive disease. MALT lymphomas are presented for comparison and our analysis demonstrated that MPCP-US represent a different clinicopathologic entity compared with classic MALT lymphoma. We present the first series of cases of MPCP-US. The recognition of this entity is fundamental to the development of management protocols to relieve intractable symptoms mimicking bladder pain syndrome/interstitial cystitis in these patients.

Is corona virus infection a risk factor for hematuria in secondary bladder amyloidosis? The first case report

Urogenital amyloidosis is a rare disease that involved every site of the urogenital system. Involvement of bladder developed with gross hematuria, and any intrinsic or extrinsic stresses exacerbate hematuria. We reported a secondary bladder amyloidosis case that presented with gross hematuria without any risk factor except COVID-19 infection.

Spontaneous remission of untreated primary amyloidosis of the bladder after transurethral resection biopsy: a case report and literature review

We herein present a case involving a 23-year-old woman with gross hematuria. Cystoscopy revealed abnormal areas of the mucosa along the anterior and posterior bladder walls. These abnormalities were suspicious for neoplasia; however, a diagnosis was not established by subsequent biopsy. The patient underwent transurethral resection biopsy in which an isolated lesion along the anterior wall was completely resected and the others were left untreated. Pathologic examination and special staining led to a diagnosis of amyloidosis, and the patient elected to undergo transurethral surgery 1 month later. During the operation, the intravesical lesions were found to have significantly improved in both the treated and untreated sites. The operation was cancelled, follow-up was arranged, and no other treatment was administered. Repeat cystoscopy examinations at 3 and 9 months after surgery showed that the lesions had almost completely disappeared.

New case of secondary bladder amyloidosis with massive hematuria-role of intravesical instillations with dimethyl sulfoxide

Secondary bladder amyloidosis is a rare condition with less than 60 cases published in the world. It is usually secondary to chronic inflammatory processes such as rheumatologic diseases. Hematuria is its predominant and most important symptom, and usually occurs after a bladder catheterization. The diagnostic confirmation is made through a pathological and immunohistochemical study. The treatment must be staggered from less to more invasive. Our objectives are to present a new case of secondary bladder amyloidosis in a woman with a history of chronic bronchiectasis after tuberculosis and frequent super infections, whose main manifestation was a massive hematuria, and review this rare pathology. We have obtained very good initial results using intravesical instillations with dimethyl sulfoxide (DMSO) with complete resolution of the hematuria, the patient remaining asymptomatic for 6 months. After that, there was a recurrence of the hematuria that was treated with embolization of the hypogastric arteries, with good results. We can conclude that, despite being a rare condition, we must consider secondary bladder amyloidosis in patients who have already been diagnosed with systemic amyloidosis and/or chronic pathologies who develop hematuria after bladder catheterization. Based on our experience, instillations with dimethyl sulfoxide are a safe option and provide a quick and temporary resolution of hematuria symptoms.

Primary Vesical Amyloidosis Masquerading as Vesical Calculus in a Retroviral Positive Patient

The common causes of irritative voiding symptoms in women include cystitis, vesical calculi, carcinoma bladder and neurologic disorders. Isolated primary vesical amyloidosis (VA) is a rare cause of irritative voiding symptoms.

A 50-year-old female, a known case of retroviral disease but not on anti-retroviral therapy, presented with right flank and suprapubic pain for six months, worsening over the past 15 days with dysuria. She also presented with increased frequency of micturition with nocturia and urgency for the same duration. She had no hematuria, other lower urinary tract symptoms or fever. Clinical examination revealed suprapubic tenderness. Ultrasonogram (USG) revealed 1.7 cm vesical calculus. Cystoscopy revealed three spiky vesical calculi. There was a fluffy lesion with mucosal edema over the right lateral wall in the region of the right ureteric orifice, which was biopsied. Biopsy showed fragments of urothelial mucosa with focal areas of ulceration. The underlying stroma was edematous with amorphous pale eosinophilic acellular deposits. Congo red stain showed apple-green birefringence under polarized microscopy suggestive of amyloid. Sections were negative for dysplasia, granulomas or malignancies.

VA presents with intermittent gross hematuria in up to 77% patients and irritative voiding symptoms in 23% patients. VA is an uncommon differential diagnosis of cancer urinary bladder, with less than 200 cases reported in the literature. Hence we report this case to highlight that primary VA should also be considered in the evaluation of irritative voiding symptoms.

Primary bladder amyloidosis as a cause of haematuria

We report the case of a 46-year-old man who initially presented with macroscopic haematuria. Although initially concerning for a malignancy in the bladder, histology demonstrated a primary bladder amyloidosis that has remained stable for 6 years since the initial diagnosis. Primary bladder amyloidosis is an important clinical entity that can mimic bladder malignancy on clinical history, radiological investigation and cystoscopic evaluation. Although uncommon, it should not be neglected as a possible diagnosis in patients presenting with haematuria.

Primary localised amyloidosis of the urinary bladder: A recurrent and progressive disease

Primary amyloidosis results from the deposition of amyloid protein fibrils in the extracellular space and rarely involves the urinary bladder. We present a 41-year-old man who was diagnosed with primary amyloidosis of the urinary bladder and underwent two sessions of transurethral resection of the bladder mass 4 years prior. Recently, the patient was admitted through the emergency with painless frank haematuria. Computed tomography of the abdomen and pelvis revealed a bladder mass that was larger than the previously reported mass. A repeat cystoscopy and resection of the mass was performed. Histopathological examination of the resected tissue revealed primary amyloidosis of the urinary bladder. A comprehensive examination was performed to exclude systemic amyloidosis.

Primary localized amyloidoma of the renal pelvis: A case report and literature review

Primary localized amyloidomas of the renal pelvis are challenging to diagnose, due to non-specific imaging results and the unusual location. The present study reports a rare case of primary localized amyloidoma of the renal pelvis and aims to illustrate the challenges in pre-operatively discriminating between this disease and transitional cell carcinomas. The present study identified that the mass was situated in the left renal pelvis using ultrasonography. A nephroureterectomy was performed following careful preparation. Finally, histopathological studies revealed that the tumor consisted of massive diffuse deposits of amyloid and microscopic amorphous eosinophilic material, which stained positively for Congo red, demonstrating potassium permanganate digestion. Consequently, a diagnosis of amyloid light chain-type amyloidoma was determined. Systematic examinations were performed following the unexpected diagnosis, which eliminated the possibility of amyloid associated-type amyloidoma. In total, 4 months post-surgery, the patient remained tumor-free.

Buccal mucosa graft urethroplasty in a case of urethral amyloidosis presenting with long anterior urethral stricture

Urethral amyloidosis is a rare condition, but clinically relevant because it can mimic urothelial carcinoma. We report a case of localized urethral amyloidosis presenting with a long anterior urethral stricture. We used extensive grafts of buccal mucosa for standard augmentation urethroplasty, with a successful outcome at the 2-year follow-up.

Amyloidosis of the renal pelvis: a harbinger of mammary carcinoma?

We describe a rare case of light chain immunoglobulin amyloid (AL) accumulation in the central and lower pole renal calyces. Our patient, a woman aged 60, presented with several episodes of gross haematuria. Radiological imaging detected a filling defect in the left renal pelvis. Rigid ureteroscopy showed a corresponding mucosal abnormality resembling transitional cell carcinoma. A definitive preoperative tissue diagnosis could not be reached. Laparoscopic-assisted left nephroureterectomy was indicated. Histopathological examination excluded malignancy, revealing congophilic deposits of submucosal amyloid. A constellation of findings confirmed localised or primary amyloidosis with an AL immunophenotype but no evidence of clonal B-cell disease in the amyloid-associated lymphoplasmacytic cell infiltrate. Investigation for systemic plasma cell dyscrasia and echocardiography and scintigraphy for visceral amyloid deposits were negative for systemic disease. At a follow-up period of 30 months, there is no recurrence. However, our patient was diagnosed with breast cancer 21 months ago.

Primary localized amyloidosis of urinary bladder: a case report and review of literature

Amyloidosis is a disorder of protein metabolism characterized by extracellular deposition of abnormal protein fibrils. It may either be localized to any organ or systematically distributed throughout the body. The biochemical nature of proteins varies but the physical and tinctorial properties are shared by all the amyloidogenic proteins. In the West, it is mainly composed of amyloid light (AL) type immunoglobulin (Ig) light chains. Amyloidosis of the genitourinary tract is rare except for the kidney and isolated primary amyloidosis of the urinary bladder is even rarer. It mainly presents as intermittent painless gross hematuria. It mimics transitional cell carcinoma on imaging and endoscopic examination. We herein present a case of fifty six-years-old male with history of painless hematuria for three months. Cystoscopy revealed a 1 cm hyperemic area on the posterior wall of urinary bladder. The biopsy showed features of amyloidosis and amyloid A (AA) immunostaining was negative. Extensive workup was done to exclude other sites of involvement and a final diagnosis of primary localized amyloidosis of the urinary bladder was made. The patient is on regular follow-up.

Primary localized amylodoisis of bladder: Is there a need for cystoscopic surveillance?

Amyloidosis is a heterogeneous group of disorders characterized by extracellular deposition of amorphous proteinaceous material in various tissues. Amyloidosis of bladder is of significant clinical interest to the urologist because of its presentation as urothelial cancer. Transurethral resection and histology examination is essential to exclude malignancy and to establish the benign nature of amyloidosis. Apart from managing the localized bladder amyloidosis, it is important to exclude systemic amyloidosis. Here in we describe two cases of localized, primary amyloidosis and discuss briefly their management and follow-up.

Modern approaches to the treatment of amyloidosis: the critical importance of early detection in surgical pathology

The amyloidoses comprise a group of disorders of diverse etiology, in which different proteins undergo abnormal folding, leading to their deposition in tissues and concomitant tissue toxicity. This process ultimately leads to tissue destruction, with organ failure and progressive disease. Recent progress in the treatment of the systemic amyloidoses has dramatically changed the outlook for affected patients and their families. From a relatively rare and esoteric disorder that was typically diagnosed only at autopsy, or was invariably fatal if diagnosed during life, it has now become a disease for which, with modern therapies, durable responses and long-term survival can be achieved. The clinical symptoms are largely nonspecific, and therefore misdiagnosis, or late diagnosis, have been major detriments in achieving better treatment outcomes. Despite advances in laboratory medicine, amyloidoses are still diagnosed on the basis of the pathologic detection of deposits in tissues. Thus, effective primary screening for these diseases requires the active engagement of the pathology community at large, while specialized laboratories and treatment centers can offer secondary consultation and assistance with further steps. This review provides an update on pathogenesis, the clinical and pathologic features, and treatments of various amyloidoses, as well as the current terminology, classification, and practical considerations that are relevant to the diagnosis.

Localized amyloidosis of the ureter: A case report and literature review

Localized amyloidosis of the ureter is a rare disease and can easily be confused with a neoplasm. We report the case of a 55-year-old woman who presented with loin pain and painless gross hematuria. We also reviewed the English literature about localized ureteral amyloidosis. Middle-aged women were likely to suffer from this disorder. Loin pain and hematuria were the main clinical features. There were no specific performance on radiologic imaging and ureteral calcification was not widespread. Compared to upper ureter and middle ureter, the lower ureter was the easiest involved part. Nephroureterectomy was the predominant treatment. Biopsies via a ureteroscope prior to surgery or intraoperative frozen section examination, which yielded the diagnosis of amyloidosis, could help to avoid unnecessary surgery. The use of dimethyl sulfoxide or follow-up with serial imaging may become a promising treatment.

Occlusive dressing therapy using dimethyl sulfoxide in a patient presenting with primary localized amyloidosis of the urinary bladder: a case report

INTRODUCTION

Amyloidosis is characterized by extracellular deposition of abnormal insoluble fibrils, which cause structural and functional disorders. Amyloidosis is classified into primary and secondary disease. We report a case of localized amyloidosis of the urinary bladder. In the English literature, this is the first case effectively treated with occlusive dressing therapy using dimethyl sulfoxide.

CASE PRESENTATION

A 58-year-old Japanese woman was introduced to our department with asymptomatic gross hematuria. Cystoscopy revealed a gently raised nodule at the right lateral wall. Histopathological findings of this lesion revealed extensive amorphous eosinophilic deposits that stained positive with Congo red and Dylon. The patient was diagnosed with primary localized amyloidosis of the urinary bladder. To treat residual amyloidosis of the bladder, we performed occlusive dressing therapy using dimethyl sulfoxide. After treatment, cystoscopy and magnetic resonance imaging showed no relapse of the mass-like lesion of the bladder wall.

CONCLUSIONS

Occlusive dressing therapy using dimethyl sulfoxide is efficacious and tolerable for amyloidosis of the urinary bladder. The maneuver of occlusive dressing therapy was simpler and easier than that of intravesical instillation, and occlusive dressing therapy was advantageous in that the patient could perform the therapy herself every day. However, invasive surgical management including cystectomy should be considered if conservative management is inefficacious.

Incidental seminal vesicle amyloidosis observed in diagnostic prostate biopsies--are routine investigations for systemic amyloidosis warranted?

Seminal vesicle (SV) amyloidosis is a well-documented histological entity, but it is observed infrequently. Its incidence is on the rise, which is probably related to the increasing use of prostate biopsies to investigate patients with elevated serum prostate-specific antigen levels. Here, we report seven cases of incidental SV amyloidosis over a 3-year period and consider their relationship to the previously suggested aetiological factors. Based on our series, we conclude that incidental localized SV amyloidosis observed in diagnostic prostate biopsies does not warrant formal investigations for systemic amyloidosis.

Localized AL amyloidosis: a suicidal neoplasm?

Although AL amyloidosis usually is a systemic disease, strictly localized AL deposits are not exceptionally rare. Such case reports form a considerable body of published articles. Although both AL amyloidosis types are formed from an N-terminal segment of a monoclonal immunoglobulin light chain, a typical localized AL amyloid differs from the systemic counterpart by the morphological appearance of the amyloid, and presence of clonal plasma cells and of giant cells. In this article it is pointed out that localized AL amyloidosis ('amyloidoma') represents a true plasma cell neoplasm and not a pseudotumor. The pathogenesis of localized AL amyloidosis may differ from that of the systemic type, a suggestion underlined by the fact that localized AL amyloidosis of kappa type is as common as that of lambda origin, in contrast to the systemic form where lambda chains constitute the overwhelming majority of cases. It is suggested that oligomeric assemblies of the produced immunoglobulin light chain are toxic to plasma cells, which in this way commit suicide.

Imaging evaluation of amyloidosis of the urinary tract and retroperitoneum

Amyloidosis is a heterogeneous group of disorders and may be classified as systemic or localized on the basis of the distribution of amyloid deposition. Infrequently, the urinary tract and supporting retroperitoneum may be involved, and the imaging findings are nonspecific and diverse. Localized amyloidosis usually involves the bladder and often mimics malignancy. Less frequently, the ureter, renal pelvis, and urethra are involved. The most common findings of amyloid deposition are focal or diffuse wall thickening in the urinary tract with intramural calcification that often results in ureteral obstruction. When the renal parenchyma is involved, patients generally develop nephrotic-range proteinuria, and the kidneys appear atrophic with cortical thinning. In systemic amyloidosis, amyloid may infiltrate the retroperitoneal and pelvic soft tissues, encasing the urinary tract, with diffuse soft-tissue thickening and slowly progressive calcification. In both localized and systemic amyloidosis, amyloid lesions are characteristically hypointense at T2-weighted magnetic resonance imaging. Because myeloma or lymphoma is often present with systemic amyloidosis, biopsy is necessary to diagnose the condition. Amyloid lymphadenopathy characteristically appears as nodal enlargement with calcification and low attenuation at computed tomography. Radiologists should be familiar with the imaging features of amyloidosis that, in the appropriate clinical context, may indicate the diagnosis.

How to manage primary amyloidosis

Immunoglobulin light chain amyloidosis is a protein deposition disorder where the precursor protein represents a monoclonal immunoglobulin light or heavy chain. Deposition in viscera results in restrictive cardiomyopathy, nephrotic range proteinuria, demyelinating peripheral neuropathy, hepatomegaly and malabsorption syndrome. Diagnosis requires biopsy with Congo red staining. Invasive biopsies are not required generally. It is essential that after a histologic diagnosis is obtained, the tissue is validated to have an immunoglobulin light chain composition so patients are spared unnecessary chemotherapy. The disease prognosis and patient monitoring are linked to serialized measurement of cardiac biomarkers and immunoglobulin-free light chains. Most patients require cytotoxic chemotherapy. For some patients, this therapy involves stem cell collection and myeloablative chemotherapy; for others, chemotherapy includes an alkylator and a corticosteroid; and for some, it involves addition of a novel agent in the form of an immunomodulatory drug or a proteasome inhibitor. Delays in diagnosis continue to be an obstacle to initiating effective therapy. Early mortality rates remain high. Effective chemotherapy can result in reversal of organ dysfunction and recovery. Reductions in light chain production translate to improved survival.

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.

Localised primary amyloidosis of the urinary bladder: case series of two patients

Isolated amyloidosis of the lower urinary tract is rare. This report presents localised primary amyloidosis of the urinary bladder as a rare cause of macroscopic haematuria. Treatment of bladder amyloidosis mainly consists of controlling the haematuria. For small localised lesions, the favoured approach is transurethral resection (TUR) of the lesion.

Benign Diseases of the Bladder

Benign diseases of the bladder often present diagnostic challenges to practicing pathologists due to their diverse nature and ability to mimic a variety of epithelial or mesenchymal neoplasms. Categories of benign bladder disease include infectious cystitis, noninfectious cystitis, reactive proliferative processes, and benign processes that secondarily involve the bladder. An understanding of the key clinical and morphologic features of these lesions and the useful ancillary techniques specific for these entities is critical to the correct diagnosis of these lesions. This article reviews the key features of these benign bladder diseases and highlights methods to distinguish these lesions from other benign and malignant processes involving the bladder.

[Localized amyloidosis of the ureter]

Localized amyloidosis of the ureter is a rare condition. Because of the difficulty in differentiating between localized amyloidosis and an obstruction due to other benign or malignant conditions of the urinary tract, in some cases even an unnecessary nephroureterectomy is performed. We describe a patient with obstructive amyloidosis of the right ureter. Diagnosis was confirmed by endoscopy with biopsies. The patient was treated successfully by partial ureterectomy and ureteroneocystostomy. No systemic involvement of other organs was detected and after a 2-year follow-up no local recurrence developed.

[Primary localized amyloidosis of glans penis. A new case and review of the literature]

Primary localized amyloidosis urinary tract is rare. Localized amyloidosid only glands is a very rare entity. The clinical impression may resemble neoplastic disease but the diagnosis is confirmed by histochemical study. Biopsy of the lesion revealed dermal deposits of amorphous eosinophilic material. A case of patient with primary amyldosis of glands penis is reported. The literature is reviewed and the diagnostic and therapeutic options are discussed. This is the seventh reported case of localized amyloidosis of the glands penis.