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

Cutaneous Malignant Melanoma Presenting as an Isolated Splenic Metastasis: An Update

Although the spleen is a highly vascularized organ, metastatic deposits from non-hematolymphoid solid malignancies are rare. This is reasoned to the inherent resistance of the splenic parenchyma to harbor metastases. The splenic capsule, lack of afferent lymphatics, contractile properties of the spleen, and the angular and gyroid course of the splenic artery form several barriers against the metastatic spread of malignant tumors. Moreover, the immune cells in the white and red pulps of the spleen have strong defensive ability against the tumor cells. Metastasis from solid tumors to the spleen often occurs only during widespread distant spread. Malignant melanoma is a rare but fatal malignancy. Isolated splenic metastasis from malignant melanoma is exceptionally rare. Studies that addressed the splenic metastasis from cutaneous malignant melanoma are scarce. This minireview was performed to address this subject. Here we present an overview of the clinicopathologic features of isolated splenic metastatic melanoma. The diagnostic biochemical markers in melanoma are also discussed.

Dermatofibromas with Aberrant Expression of CD34 Protein: A Systematic Review and a Reappraisal of Clinicopathological Features and Histogenesis

BACKGROUND

Dermatofibromas (DFs) are benign fibrohistiocytic lesions that usually do not express CD34 protein. This study aimed to analyze the literature concerning the immunohistological and ultrastructural features of DFs. It also related these features to the histogenesis of these lesions.

METHODS

This study included a PubMed literature search for studies addressing the clinicopathological, ultrastructural, and immunohistochemical features of DFs. It also presented some current cases of CD34-negative DFs and a subset of these lesions with aberrant expression of this protein.

RESULTS

Analysis of the PubMed literature revealed that DFs with an aberrant expression of CD34 are rare tumors that commonly affect the extremities of adult females. Separating these tumors from dermatofibrosarcoma protuberans (DFSP, CD34-positive tumors) requires using a large panel of immunostains. Ultrastructurally, DFs are composed of diverse cell types, including cells with histiocytic, myofibroblastic, and fibroblastic features. An analysis of the DFs described by this study revealed that cases with an aberrant expression of CD34 protein had slightly high mean age and male sex predominance when compared to CD34-negative cases. The former commonly affected the extremities. There was no evidence of local recurrence or distant metastasis on follow-up.

CONCLUSIONS

DFs have the potential to express CD34 protein, defining a rare aberrant phenotype, which was not associated with any differences in the outcome as compared to CD34-negative DFs.

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.

Primary Amyloidosis of the Genitourinary Tract

CONTEXT.—

Amyloidosis is caused by the deposition of misfolded proteins as insoluble eosinophilic material in the extracellular tissues of the body, leading to impairment of organ function. It can be systemic or localized. Localized genitourinary tract amyloidosis is rare and can be incidentally seen; however, in some cases, it can be the only presenting disease.

OBJECTIVE.—

To review the clinical presentation and pathologic findings related to primary amyloidosis of the urogenital system and highlight some of the associated pathologic findings based on our personal experience.

DATA SOURCES.—

Published peer-reviewed literature and personal experience of the senior author.

CONCLUSIONS.—

Primary localized amyloidosis within the urogenital tract can present as a neoplastic process and may be clinically and radiologically considered as a mass. Awareness of primary amyloidosis by pathologists and clinicians is required for accurate diagnosis and proper patient management.

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.

Localised amyloidosis of the bladder: A rare mimic of urinary tract malignancy (case report and literature review)

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Localised amyloidosis of the urinary tract is rare but invariably mimics urinary tract malignancy.

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Urologists should consider amyloidosis where malignancy is not evident.

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The disease is course is typically benign.

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Most patients can be treated conservatively, without radical surgery.

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This is the most up to date literature review describing the disease.

Introduction

Localised amyloidosis of the urinary tract is rare and often presents with haematuria.

Presentation of case

A 59 year old male presented with recurrent episodes of frank haematuria exacerbated by anticoagulation after a minor stroke. He had a background of hypertension, hypercholesterolaemia, and Parkinson’s disease. Initial investigations did not reveal a cause, but eventual cystoscopic biopsy showed bladder mucosa expanded by deposits of amorphous, pale, eosinophilic, proteinaceous material and immunohistochemical staining revealed the presence of amyloid deposition. Workup for systemic amyloidosis was negative. A diagnosis of primary localised amyloidosis of the bladder was made. Trans-urethral resection was performed and annual cystoscopic surveillance was commenced. He was followed up for 11 years without recurrence.

Discussion

A comprehensive literature review revealed 349 published cases of localised amyloidosis of the urinary tract, with a median age of 57 (interquartile range 49–69), and a male preponderance (1.5 to 1). Painless visible haematuria (65%) was the most frequent presenting complaint and the bladder was the most common site of involvement (71%). Transurethral resection was the most common form of management (42%) but a proportion of patients underwent more radical surgery (nephroureterectomy/nephrectomy 9%, cystectomy 1%). Median follow up was 33 months (interquartile range 12–108) and 35% of patients had recurrent disease. This patient represents a typical case of localised amyloidosis of the urinary tract.

Conclusion

This is the most up to date review of the literature describing localised amyloidosis of the urinary tract. The disease is rare, but salient to the urologist as it invariably mimics urinary tract malignancy.

Primary Localized Amyloidosis of the Intestine: A Pathologist Viewpoint

Background

Localized amyloidosis of the intestine is a rare entity, which can clinically masquerade several conditions such as colitis, polyps, and malignant tumors. This study aims to evaluate the clinicopathological features of this entity.

Methods

To evaluate the clinicopathological features of this entity, a comprehensive search of the literature (1960 to 2019) was done using the following keywords: "amyloidosis" and "small intestine" or "duodenum" or "ileum" or "jejunum" or "colon". We identified 756 studies about gastrointestinal amyloidosis. Data were examined for 27 studies about localized intestinal amyloidosis. The clinicopathological features were described.

Results

The age at presentation ranged from 29 to 88 years. The male to female ratio was 3:1. The jejunum and sigmoid colon were the most commonly involved sites. Abdominal pain and intestinal obstruction (small intestine), or rectal bleeding (sigmoid region) were the most common clinical presentations. Colonoscopic findings included wall thickening, mucosal ulcerations (small intestine), and tumor-like masses (colon).

Conclusions

The clinical presentations of localized intestinal amyloidosis depend on the site of the deposition of the amyloid. In most cases, amyloid deposits consisted of light chain protein.

[LOCALIZED AMYLOIDOSIS OF THE RENAL SINUS: A CASE REPORT]

An 80-year-old man was accidentally diagnosed with a left renal pelvic tumor by computed tomography (CT), and visited our hospital. A tumorous lesion with an inhomogeneous contrast effect occupying the left renal pelvis was confirmed by the contrast-enhanced CT scan, and enlargement of multiple lymph nodes around the aorta and inferior vena cava was recognized. Urine cytology of the left renal pelvis was pseudo-positive. In the preoperative diagnosis of left renal pelvic carcinoma cT3N2M0, left nephroureterectomy and lymph node dissection were performed. Pathological findings revealed an amyloid tumor confined to the renal sinus and diagnosed as localized amyloidosis.

A Surgically Treated Case of Ureterovesical Amyloidosis of the Bladder in a Patient with Idiopathic Thrombocytopenia

Idiopathic thrombocytopenia (ITP) is a bleeding disorder involving the destruction of platelets by the immune system. Systemic amyloidosis is another bleeding disorder involving amyloid deposits that create defects in coagulation and increased prothrombin and thrombin times. We report a 52-year-old man with ITP and new two-month-duration, painless gross hematuria without clot formation resulting in amyloidosis involving the ureterovesical area of the bladder. He had osteopenia, hypertension, and moderate thrombocytopenia due to ITP diagnosed 7 years previously. Cystoscopic examination with urine cytology and computed tomography imaging detected a 2-cm protruding solid bladder mass involving the left ureteral orifice and trigone and left mild hydroureteronephrosis, suggesting bladder cancer. Transurethral resection of the bladder mass was performed to confirm amyloidosis involvement in the ureterovesical junction of the bladder and ureter. Four weeks postoperatively, intermittent gross hematuria remained; hence, left ureteroneocystostomy was performed. Regular follow-up showed no signs of hematuria or intravesical recurrences for 14 months.

Localized amyloidosis of the epididymis: a previously unreported phenomenon

BACKGROUND

Localized amyloidosis has not been documented in the epididymis; we report this phenomenon for the first time.

CASE PRESENTATION

The first aim of this work is to report three cases of localized epididymal amyloidosis. Two cases were clinically detected as epididymal nodules, and a third after reviewing 120 epididymides obtained with neighbouring pathological processes. Amyloid deposits showed Congo red positivity, with yellow-green birefringence, and immunohistochemical expression for light chains kappa and lambda, transthyretin, amyloid P and cytokeratin AE1 AE3. No immunoreactivity for amyloid A was seen. Amyloid deposit location was intraluminal, with partial or total loss of the epididymal epithelium and subsequent passage to the interstitium, forming large masses. No amyloid deposits were observed around blood vessels. A secondary objective was to explore in normal epididymis the amyloid tested in epididymal amyloidosis. In normal epididymides, expression of amyloid P and transthyretin was detected in the apical surface of epithelial cells. Amyloid P also showed strong expression in spermatozoa.

CONCLUSION

We contribute the existence of localized epididymal amyloidosis, which presents a distinctive, initial intratubular location, where there is a unique proteome and where functional amyloids act during sperm maturation.

Presentation and Outcomes of Localized Immunoglobulin Light Chain Amyloidosis: The Mayo Clinic Experience

OBJECTIVE

To describe treatment types, outcomes, and relapse patterns in patients with localized immunoglobulin light chain amyloidosis (AL_L).

PATIENTS AND METHODS

We included all patients with AL_L seen at Mayo Clinic in Rochester, Minnesota, from January 1, 1968, through June 30, 2014. The diagnosis of AL_L was predicated on the presence of a Congo red-positive biopsy specimen and negative serum and urine immunofixation. Treatment response categories were response, stability, and progression. Localized and systemic progressions were defined as progression of disease at the site of origin or appearance of clonal plasma cells in a bone marrow biopsy sample, respectively.

RESULTS

Of 5551 patients with AL, 413 (7%) had AL_L. The most common site involved was urothelial tissue (n=85, 21%), followed by the larynx (n=57, 14%). Coexisting autoimmune diseases were reported in 7% of patients (n=28). The most common first-line treatment was excision of the amyloid deposits (61%), followed by observation or supportive care (28%). When considering symptomatic patients only (n=284), 205 (72%) improved, 23 (8%) had stable disease, and 55 (19%) could not be evaluated for response. Ten-year survival was 78% and was not different from that of the general population. There were no systemic progressions, but 17% of patients (n=72) had localized progression.

CONCLUSION

Localized AL is associated with a relatively distinct pattern of organ involvement. The initial laboratory evaluation to exclude systemic disease could be limited to serum and urine immunofixation in most patients. Recurrence after first-line therapy is common, but long-term outcomes are excellent.

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.

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.

Pathophysiology and treatment of cardiac amyloidosis

Amyloid cardiomyopathy should be suspected in any patient who presents with heart failure and preserved ejection fraction. In patients with echocardiographic evidence of ventricular thickening and without a clear history of hypertension, infiltrative cardiomyopathy should be considered. If imaging suggests the presence of amyloid deposits, confirmation by biopsy is required, although endomyocardial biopsy is generally not necessary. Assessment of aspirated subcutaneous fat and bone-marrow biopsy samples verifies the diagnosis in 40-80% of patients, dependent on the type of amyloidosis. Mass spectroscopy can be used to determine the protein subunit and classify the disease as immunoglobulin light-chain amyloidosis or transthyretin-related amyloidosis associated with mutant or wild-type TTR (formerly known as familial amyloid cardiomyopathy and senile cardiac amyloidosis, respectively). In this Review, we discuss the characteristics of cardiac amyloidosis, and present a structured approach to both the assessment of patients and treatment with emerging therapies and organ transplantation.

Amyloidosis in the bladder: three cases with different appearance

Amyloidosis refers to a number of diseases characterized by extracellular deposition of misfolded proteins, called amyloid fibrils, in the tissues and organs of the body. Amyloidosis in the bladder is a generally localized, rare condition, with approximately 200 cases reported in the literature. This report presents three cases of amyloidosis in the bladder, two of which had coexisting transitional cell carcinoma. Evaluation for systemic disease is recommended in patients with newly discovered amyloidosis, even if first recognized in an area with the localized form, as in the bladder.

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.

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.