Spinal cord compression by amyloid tissue

Primary cervical spine AL-κ amyloidoma: A case report and review of the literature

Of the myriad of variants of amyloidoses where abnormally folded proteins damage native tissue, primary cervical spine amyloidoma represents one of the rarest forms. Since clinical presentations and imaging findings appear similar to other pathologies, including abscesses, metastatic lesions, and inflammatory lesions, a definitive diagnosis requires a biopsy with specific immunohistochemical stains. We present the first known case of primary cervical amyloid light-chain (AL)-κ subtype amyloidoma and compare the clinical presentations, imaging findings, treatment options, and immunohistochemical subtypes of primary, hemodialysis, and multiple myeloma cervical amyloidomas. Our case is of a 58-year-old man who developed neck pain radiating to the left arm with bilateral upper extremity weakness over several months. Magnetic resonance imaging revealed a circumferential C1-C2 mass extending into the neural foramina inducing severe mass effect. The patient underwent C2 laminectomy and resection of the lesion which was discovered during surgery to be completely epidural. Postoperatively, his pain and weakness improved. A complete work-up was negative for systemic amyloidosis or inflammatory conditions. In the setting of a long clinical history of hemodialysis, this patient required specific staining and laboratory testing to correctly diagnose his primary cervical AL-κ subtype amyloidoma. Cervical amyloidomas comprise a very small minority of amyloid pathology with an exceptional prognosis following successful surgical resection and stabilization. It is recommended these patients undergo surgical resection with appropriate characterization and a complete work-up to rule out systemic disease.

Intradural, extramedullary amyloidoma involving cervical and thoracic spine

We present the case of a 46-year-old woman with insidious lower extremity paralysis and bowel and bladder disruption found to have an intradural, extramedullary amyloidoma from the levels of C4-T4. To our knowledge, this is the first known reported case of amyloidoma occurring in this location. Solitary amyloidoma of the spine is a rare entity typically manifesting as an extradural tumor with bony involvement.

Primary cervical amyloidoma: a case report and review of the literature

BACKGROUND CONTEXT

Primary solitary amyloidosis or amyloidoma is a disease process characterized by the focal deposition of amyloid in the absence of a plasma cell dyscrasia with normal serum protein measurements. Solitary amyloidomas affecting the vertebrae are very uncommon but typically affect the thoracic spine. Primary cervical amyloidosis is an exceedingly rare entity with exceptionally good prognosis, but requires diligence of the treating physician to establish the diagnosis and implement the appropriate surgical intervention.

PURPOSE

This study aimed to present a rare case of primary cervical amyloidosis with long-term follow-up and review the clinical presentation, characteristic imaging findings, diagnostic pathology, differential diagnosis, treatment algorithm, and prognosis of the disease entity. This case demonstrates the progressive resorption of the amyloidoma over time after surgical stabilization. Previous reported cases of primary cervical amyloidosis will also be reviewed.

STUDY DESIGN

This study is a report and review of the literature.

METHODS

A 77-year-old woman presented with a several-week history of gradual progressive weakness in her upper and lower extremities. Computed tomography and magnetic resonance imaging demonstrated a retro-odontoid nonenhancing soft-tissue mass, with erosive bony changes and severe mass effect on the upper cervical cord. The patient was taken to the operating room for decompression and posterior spinal stabilization.

RESULTS

Intraoperative tissue specimens demonstrated amyloidosis and extensive systemic workup did not reveal any inflammatory processes, systemic amyloidosis, or plasma cell dyscrasia. Postoperatively, the patient regained full strength and ambulatory status. The patient remains asymptomatic at a 2-year follow-up. A postoperative follow-up magnetic resonance imaging demonstrated complete resorption of the residual amyloidoma.

CONCLUSIONS

Primary solitary amyloidosis is a rare form of amyloidosis that is important to differentiate given its excellent prognosis with surgical management. Treatment should include surgical decompression and spinal stabilization. This is the first case report to clinically and radiographically demonstrate the progressive resorption of a primary amyloidoma over time after surgical stabilization in the upper cervical spine. It is imperative that surgeons encountering such lesions maintain a high suspicion for this rare disease entity and advise their pathologists accordingly to establish the correct diagnosis.

Fine-needle aspiration diagnosis of an intraosseous amyloidoma

Fine-needle aspiration (FNA) is frequently used as the initial diagnostic procedure for the investigation of bone and soft tissue masses. The majority of the lesions detected will represent metastatic carcinoma. Amyloid is a rare cause of a bone mass, with less than 15 published reports describing amyloid deposition within bone. The majority of reported cases involve the vertebral column. We report the finding of a massive amyloidoma of the iliac wing in a 46-year-old man. FNA smears and cell block preparations demonstrated fragments of waxy acellular material misinterpreted as necrotic debris. Subsequent open biopsy established the diagnosis of amyloid with congo red staining demonstrating apple green birefringence. Subsequent workup disclosed the patient to have anemia, hypogammaglobulinemia and trace monoclonal light chain gammopathy. Bone marrow examination revealed CD138a positive lambda restricted plasma cells consistent with plasma cell dyscrasia. Careful attention to the staining characteristics of amyloid in FNA derived material should allow the diagnosis of amyloidoma.

INTRACAVERNOUS TRIGEMINAL GANGLION AMYLOIDOMA

OBJECTIVE

Isolated amyloidomas rarely manifest in nervous system tissues. To the authors' knowledge, there have been 52 documented cases of primary amyloid tumors of the central nervous system and closely associated structures. The authors present a case of a woman with a history of presumptive trigeminal neuralgia who was found to have an amyloidoma of the trigeminal ganglion.

CLINICAL PRESENTATION

A 32-year-old Caucasian patient presented with a chief complaint of severe numbness and pain throughout the right side of her face. Her symptoms had been progressive over the previous 3 years. Medical management of her presumptive diseases with Zoloft (Pfizer Inc., New York, NY) and Neurontin (Pfizer Inc.) failed to improve or halt her right facial numbness and pain. Brain magnetic resonance imaging was acquired, demonstrating abnormal contrast enhancement and enlargement of the right trigeminal ganglion. The lesion abutted and indented the right internal carotid artery and extended from Meckel's cave into the inferior cavernous sinus and distally to the foramen ovale.

INTERVENTION

The patient underwent a right frontotemporal craniotomy for resection of the gasserian ganglion lesion. A delicate incision was made in the wall of the cavernous sinus, allowing confirmatory biopsy of the lesion. With the site of the tumor within the cavernous sinus verified by pathology, the remainder of the tumor was removed. A final pathological review of the resected tumor confirmed a diagnosis of amyloidoma of the trigeminal ganglion.

CONCLUSION

We present the case of a patient with a rare trigeminal ganglion amyloidoma that closely mimicked idiopathic trigeminal neuralgia. Even in the absence of systemic signs of amyloidosis, this benign protein deposition disease should be considered in the differential for atypical dysesthesias of the trigeminal dermatomes. Furthermore, central and peripheral nervous system amyloidomas respond well to surgical resection and rarely recur.

Primary solitary cervical amyloidosis: case report and review of the literature

STUDY DESIGN

A case report and literature review are presented.

OBJECTIVE

To describe and review the clinical presentations, characteristic findings from imaging studies, types, differential diagnosis, prognosis, and treatment of amyloidoma arising within the vertebrae.

SUMMARY OF BACKGROUND DATA

Amyloidoma can occur in the bone, skin, larynx, lymph nodes, urinary bladder, eye, tongue, and gastrointestinal system. However, amyloidomas affecting the vertebral bones are very rare. To our knowledge, only 3 cases of amyloidoma involving cervical spine have been reported previously.

METHODS

In this report, we present a case of solitary amyloidosis of the cervical spine.

RESULTS

The differential diagnosis of primary solitary spinal amyloidoma includes metastasis, infection, primary bone tumors, plasmocytoma, and Potts abscess. The correct diagnosis can be achieved only after the specific staining of tissue. The prognosis of amyloidosis is related to the specific form of amyloidosis. However, primary solitary amyloidosis has the best prognosis, although a limited number of patients without long-term follow-up studies have been reported.

CONCLUSIONS

Primary solitary amyloidosis is a rare form of the amyloidosis, which is different from the other forms of amyloidosis because of excellent prognosis with surgical excision. Combined surgical excision and spinal stabilization is the best treatment.

Primary Isolated Amyloidoma of the Lumbar Spine Causing Neurological Compromise: Case Report and Literature Review

OBJECTIVE AND IMPORTANCE:

We describe a patient with cauda equina compression secondary to amyloidoma to alert other clinicians to this rare cause of a compressive epidural lesion. It is the fourth published report of primary lumbar amyloidoma causing neurological compromise.

CLINICAL PRESENTATION:

A 53-year-old, previously fit salesman presented with several years history of back pain and recent weakness, especially in the left leg. He also had numbness and tingling radiating down the left leg. On examination, the left knee jerk was diminished, and both ankle jerks were absent. Power was reduced to 4/5 in ankle dorsiflexion bilaterally. A magnetic resonance imaging scan of the lumbar spine revealed an extradural mass, compressing the theca at L3–L4. This was enhancing in T1-weighted images and had low signal intensity in T2-weighted images. There was no evidence of systemic amyloidosis or development of multiple myeloma.

INTERVENTION:

L3–L4 laminectomy was performed, with removal of the epidural mass. The patient had complete resolution of sciatica and regained normal power in both lower limbs. There was no evidence of any recurrence at 1-year follow-up.

CONCLUSION:

Lumbar epidural amyloidoma is an extremely rare cause of cauda equina compression. Clinical presentation can be nonspecific, and radiologically, it can be indistinguishable from a tumor. Diagnosis is made at histological examination of a Congo red-stained section under polarized light. Complete resection of the localized epidural amyloid mass is associated with a good prognosis.

Primary amyloidoma of the axis and acute spinal cord compression: a case report

BACKGROUND

Localized primary amyloidosis is a disease characterized by a single tumor and localized amyloid deposit (amyloidoma) with no evidence of generalized amyloidosis. The occurrence of an amyloidoma in the spine is rare and only three cases affecting the axis have been previously reported. We describe the case of a 79-year-old woman presenting with a mass involving the odontoid process, responsible for an acute tetraparesia. Diagnosis of local primary amyloidosis was made after surgical excision.

RESULTS

Despite the critical presentation, outcome was excellent after total excision of the mass. This case can be classified as a primary localized amyloidoma. The patient did not exhibit any infection, tumor or inflammatory disease, and continued investigations failed to demonstrate other amyloid deposit after one-year follow-up.

CONCLUSIONS

Amyloidoma must be discussed in presence of a tumor-like mass of the odontoid process and may be responsible, as in our case, for spinal cord compression.

Primary amyloidoma of the thoracic spine presenting with acute paraplegia

BACKGROUND

Primary solitary amyloidoma of the spine is a rare disease characterized by localized deposition of amyloid. To the best of our knowledge, there have been only 14 cases previously reported in the literature. Patients with focal spinal amyloidoma usually have relatively long symptomatic periods preoperatively, ranging from 3 weeks to 6 years (mean: 12 months). Only two reported patients had acute paraplegia. We add a third case of a thoracic spine amyloidoma presenting with acute paraplegia.

CASE DESCRIPTION

A 65-year-old man presented with a three-day history of progressive paraplegia and urinary retention. He was found to have severe cord compression at T2 on magnetic resonance imaging. He underwent emergent decompressive laminectomy with instrumentation for spinal stabilization. Histopathology revealed abundant amyloid deposits. A systemic work-up was negative for amyloidosis. The patient showed marked neurological improvement with residual mild spastic gait after 1 year.

CONCLUSIONS

Primary spinal amyloidoma with acute paraplegia is rare. One-stage surgery combining prompt decompression and stabilization of the spinal column is mandatory in cases of spinal amyloidoma with acute myelopathy, because primary solitary amyloidoma carries a good prognosis.

Amyloidoma of the thoracic spine. Case report

The authors report the case of a patient with amyloidoma of the thoracic spine. A 34-year-old man presented with a 2-month history of upper-back pain, bilateral lower-extremity weakness, and numbness below the nipple. A computerized tomography study revealed an extradural mass with destruction of the T-2 lamina and pedicle. Intraoperatively, there was a pinkish, partially suctionable mass infiltrating the muscle plane and causing destruction of the T-2 lamina. Histological examination showed typical amyloid masses that demonstrated apple-green double refraction on examination of the Congo red-stained section under polarized light. Amyloidomas are rare benign lesions that, unlike other forms of amyloidosis, have an excellent prognosis. A cure is possible with complete resection of the mass.

Primary amyloidoma of the spine. A case report and review of the literature

STUDY DESIGN

A rare case is reported of primary or idiopathic amyloidoma of the spine derived from production of light chain immunoglobulins. The tumor was successfully treated by anterior decompression and fusion with a fibula strut allograft.

OBJECTIVE

To describe a rare case of AL amyloidoma of the spine.

SUMMARY OF BACKGROUND DATA

Radiographic characteristics of this benign deposit are similar to harmful aggressive conditions afflicting the spine.

RESULTS

The patient returned to full function after the surgery with no evidence of systemic amyloidosis or development of multiple myeloma.

METHODS

An isolated AL amyloidoma of the spine was resected and successfully reconstructed with a fibula strut allograft and internal fixation.

CONCLUSIONS

Isolated deposits of amyloid in the spine occur very rarely. When no evidence of myeloproliferative disease or systemic amyloidosis is found, prognosis is excellent. The deposit, when it occurs in the spine has a predilection for the thoracic region and can cause neurologic compromise, pain, and deformity that is responsive to decompression and fusion. The diagnosis of primary amyloidoma requires histologic studies for confirmation.

Cervical amyloidoma of C2. Case report and review of the literature

STUDY DESIGN

Second published report of a patient with amyloidoma of the upper cervical spine.

OBJECTIVES

To describe a patient with rare radiculopathy to alert other physicians to consider amyloid tumor as a differential diagnosis of locally destructive spine lesions.

SUMMARY OF BACKGROUND DATA

Localized amyloid tumor of the bone is a rare disease. Only seven cases of spine involvement have been reported. Appropriate tissue sampling is required to establish the diagnosis. Histopathologic examination shows pathognomonic apple-green birefringence under polarized light. When bone is involved with amyloid, it is most commonly associated with multiple myeloma or other plasma cell-dyscrasias.

METHOD

This case was described, and pertinent literature was reviewed.

RESULTS

The patient showed persistent neurologic improvement after transoral complete tumor removal, followed by a secondary posterior stabilization procedure using transarticular C1-C2 screws.

CONCLUSIONS

Amyloidomas are benign lesions with no associated documented risk for the development of plasmocytoma-related diseases. The clinical and radiographic manifestations of this lesion are nonspecific. A cure is possible with complete resection of the tumor and no adjuvant management procedures.

Primary solitary amyloidosis of the spine: a case report and review of the literature

BACKGROUND

Amyloidosis is a term that encompasses a group of disorders that have as their common feature the intercellular deposition of the amyloid protein by several different pathogenetic mechanisms. Primary solitary amyloidosis, or amyloidoma, is a rare subset of amyloidosis in which the amyloid deposition is focal and not secondary to a systemic process or plasma cell dyscrasia. We present the second reported case of a cervical spine amyloidoma and discuss its presentation and management.

METHODS

This 58-year-old man presented with a 1-year history of intermittent chest pain that would radiate into both legs precipitated by valsalva maneuvers. A magnetic resonance imaging (MRI) of the cervical spine revealed a homogenously enhancing lesion focally involving the C-7 vertebral level with significant spinal cord compression. He underwent combined anterior and posterior decompressive procedures with instrumentation for spinal stabilization. Histopathology revealed amyloid deposits and a systemic work-up was negative for amyloidosis.

RESULTS

The patients is free of any tumor recurrence at 24 months and has a stable spine construct.

CONCLUSIONS

Primary solitary amyloidosis is a rare subtype of amyloidosis which, unlike other forms of amyloidosis, has an excellent prognosis with local resection. Diagnosis requires special stains and therefore a degree of suspicion for the disease. Management of vertebral amyloidoma involves aggressive local resection of the tumor when feasible and stabilization of the spine as mandated by the degree of tumor involvement. Complete evaluation for the diagnosis of systemic amyloidosis is essential for the management and prognostication of each case.

Tumour-like localized amyloid of the brain is derived from immunoglobulin light chain

A patient is presented in whom the amyloid component of an intracerebral 'amyloidoma' has been purified and characterized by amino acid sequence analysis. The material originated from an autopsy of a 76-year-old man who 15 years earlier had been operated for an intracerebral 'amyloid tumour'. The tumour had recurred and grown to an almost walnut-sized mass in the right cerebral hemisphere. It was located in the parietal lobe close to the lateral ventricle and had a close connection to the choroid plexus. Histological examination showed large masses of amyloid surrounded by some plasma cells and a few macrophages of the foreign body type. Amino acid sequence analysis of a major fibril subunit protein showed homology with the variable region of a monoclonal lambda immunoglobulin light chain, subgroup III or IV. This shows that the amyloid in the 'tumour' was of AL type and presumably derived from local synthesis by plasma cells.

Skull base amyloidoma. Case report

A mass lesion of amyloid involving the central nervous system is a rare finding. A 64-year-old woman presented with a large amyloidoma at the skull base causing neural tissue compression. The only accompanying disease was an asymptomatic renal cyst. The mass had caused destruction of the bone elements and pathological calcification as seen on x-ray films, computerized tomography (CT) scans, and magnetic resonance (MR) images, and was enhanced after injection of contrast medium on both CT scans and MR imaging.

Dialysis myelopathy: quadriparesis due to extradural amyloid of beta 2 microglobulin origin

Images

Focal intracerebral accumulation of a novel type of amyloid protein. An early stage of cerebral amyloidoma?

The brain of a 60-year-old patient with bronchial carcinoma presented a focal amyloid deposit in the white matter associated with myelin and axonal destruction. An additional lesion was found in the basal ganglia. This silent focal intracerebral accumulation of amyloid substance may be a prestadium of a "cerebral amyloidoma". The histochemical and immunohistochemical analysis of the accumulated amyloid indicated that it may belong to a novel type of amyloid.

Surgical complications of amyloid disease

The case of a man with primary systemic amyloidosis without myelomatosis and long-term survival is described. The patient has had major surgical complications from large amyloid deposits in the colon, dorsal spine and peritoneal cavity. The patient remains well 14 years after diagnosis.

Amyloidomas in the cerebellopontine angle and jugular foramen. Case report

The 47-year-old man reported here showed large encapsulated masses in the left cerebellopontine angle and 6 years later in the enlarged left jugular foramen. Histologically, the tumors demonstrated a large deposit of amyloid composed of immunoglobulin light chain-derived proteins (AL). There was no evidence of chronic inflammatory or infectious processes or immunoglobulin abnormalities.