Lymphadenopathy due to amyloid deposition in non-Hodgkin's lymphoma

Lymphadenopathy as a manifestation of amyloidosis: a case series

Lymphadenopathy as a manifestation of amyloidosis is rare. Of 3008 new patients with amyloidosis evaluated from 1994 to 2013 at a single center, 47 (1.6%) presented with lymph node enlargement leading to a biopsy and the diagnosis. We conducted a retrospective review of the initial presentation, time to progression, and treatment outcomes for these patients. Upon initial evaluation, 14 (30%) had isolated lymphadenopathy while 33 (70%) had evidence of vital organ involvement. Thirty-nine patients (83%) had systemic AL amyloidosis at initial evaluation or developed it on follow up; there was a single case each of AA, wtTTR and V122ITTR and one untyped amyloidosis. Eleven patients (23%) had IgM monoclonal gammopathy and 3 (6%) had histology consistent with lymphoplasmacytic lymphoma. Of the 14 patients with isolated lymphadenopathy, 10 (71%) eventually progressed to other organ disease requiring treatment at a median time of 10 months (range 4-71). This series demonstrates that patients presenting with amyloid lymphadenopathy usually have AL amyloidosis, and should have a thorough evaluation for other organ involvement at diagnosis. If present, treatment should be similar to that of other patients with systemic AL amyloidosis, but if not, patients should be monitored regularly for development of other organ disease over time.

Simultaneous presentation of kappa-restricted chronic lymphocytic leukemia and lambda light chain AL amyloidosis

We report on a 58-year-old man who presented with simultaneous kappa-restricted chronic lymphocytic leukemia (CLL) and a lambda-restricted plasma cell dyscrasia causing AL amyloidosis involving the kidney and GI tract. While monoclonal immunoglobulins occasionally produced by CLL has previously been implicated in AL amyloidosis, this is the first case of AL amyloidosis resulting from a distinct plasma cell dyscrasia that is not clonally related to the concurrent CLL. Appropriate treatment depended on detailed pathologic diagnosis of both disease processes.

Amyloidosis, Evans syndrome and management options of lymphoplasmacytic lymphoma

A 77-year-old man presented with Evans syndrome (ES), hard palate thickening, gastrointestinal (GI) hemorrhage, acute myocardial infarction (AMI) and pleural and pericardial effusions. The patient responded well to emergent ES treatment with high-dose steroids and intravenous immunoglobulin. Investigation revealed lymphoplasmacytic lymphoma (LPL) as well as amyloidosis in the hard palate, lymph nodes, and pericardium. Considering his age, non-myelosuppressive agents were administered, with the exception of dose-reduced cyclophosphamide. The patient developed neutropenic fever, atrial fibrillation and subsequently died. This report describes the first LPL patient with ES. LPL is generally an indolent disease. However, as in our patient, it can be life threatening because of its complications. ES contributed to his GI hemorrhage, severe anemia, and thus AMI at the time of presentation. Probable cardiac amyloidosis played a role in the latter phase (i.e. cardiac arrhythmia and hypotension during sepsis). Although rare, the presence of ES and amyloidosis should be investigated diligently in elderly LPL patients. Instead of aggressive myelosuppressive chemotherapy agents, targeted therapies might be considered in these fragile patients.

AL amyloidosis associated with B-cell lymphoproliferative disorders: frequency and treatment outcomes

AL amyloidosis, a systemic disorder characterized by widespread deposition of amyloid fibrils derived from monoclonal Ig light chains in organs and soft tissues, is typically caused by an underlying plasma cell dyscrasia. However, this disease can also be associated rarely with a B-cell lymphoproliferative disorder. In this report, we describe the presentation and clinical course of 16 patients with this association. Although amyloid-related organ involvement in these patients was typical of AL amyloidosis, the patients in this series were on average older and more likely to be female than patients with disease associated with a plasma cell dyscrasia. They were also more likely to have multisystem involvement. Treatment decisions were based primarily on the dominent hematopathologic features of the associated lymphoproliferative disorder. However, high-dose melphalan and stem cell transplantation was the primary therapy in 5 patients, and each of these patients had prolonged survival, ranging from 36 to 102 months.

Secondary amyloidosis causing nephrotic syndrome in a patient with non-Hodgkin's lymphoma: quite a rare diagnosis

Secondary amyloidosis is usually a complication of chronic inflammation. Amyloidosis cases during the course of non-Hodgkin's lymphoma (NHL) are usually of AL-type, only one NHL patient with secondary amyloidosis has been reported. Our 79-year-old male patient visited us with multiple lymphadenopathies, and he was diagnosed with nodal marginal zone B-cell lymphoma. After four cycles of combined chemotherapy; his urea, creatinine levels started to increase and he developed nephrotic-range proteinuria. His rectal biopsy demonstrated amyloid deposition in submucosal vessel walls. The patient has been under hemodialysis for 10 months and his lymphoma is still in partial remission. We presented this case because it is the second NHL patient who developed secondary amyloidosis during his disease course.

AA-type amyloidosis associated with non-Hodgkin’s lymphoma: A case report

Amyloid-associated protein (AA)-type systemic amyloidosis has been referred to as secondary amyloidosis because it is secondary to an associated inflammatory condition. It is extremely rare in patients with non-Hodgkin's lymphoma (NHL). Here we report an autopsy case of follicular small cleaved cell lymphoma with focal large B-cell lymphoma transformation in association with systemic AA-type amyloidosis. Formalin-fixed, paraffin-embedded tissues from autopsy and the patient's previous surgical specimen were studied by Congo red stain; electron microscopy; and immunostaining with antibodies against AA protein, P component, and kappa and lambda light chains. There was a marked AA amyloid deposition in the glomeruli of both kidneys, the retroperitoneal lymphoma mass, the blood vessels, the adrenal glands, and the adipose tissues. The patient's previous surgical specimens were negative for amyloid. We propose that this patient's systemic AA-type amyloidosis developed along the course of his NHL.

Systemic AL amyloidosis due to non-Hodgkin's lymphoma: an unusual clinicopathologic association

Systemic AL amyloidosis (AL) is a disorder in which light chains form fibrillar deposits, leading to organ dysfunction and death. Rarely, AL has been associated with non-Hodgkin's lymphoma (NHL), although this association has not been well characterized. We report a series of six patients with AL associated with NHL, primarily lymphoplasmacytic lymphoma. Organ involvement was variable, with frequent bulky lymphadenopathy and visceral cavity deposits, but no cardiac involvement. Positron emission tomography scans were negative. Bone marrow and lymph node biopsies showed a mixed population of CD20+ lymphoid and CD138+ plasma cells. Serum free light chains were elevated, and correlated with response to therapy. Immunoglobulin light chain variable region (Ig VL) germline gene use was typical for AL, reflecting previously observed correlations between germline gene use and organ tropism. Five patients received rituximab-based therapies with two responses. Two patients underwent autologous stem cell transplantation with one complete haematological response. Four patients survive at 10-132 months from diagnosis. AL with NHL has distinctive clinical features but employs the same Ig VL gene repertoire as AL with clonal plasma cell dyscrasias. Serial serum free light chain levels are useful for tracking response to therapy. Treatments aimed at both lymphoid and plasma cell components appear warranted.