Localized amyloidosis of the larynx: evidence for light chain composition

Airway Amyloidosis: A Retrospective Analysis of 43 Patients

BACKGROUND

Amyloidosis can involve any compartment in the thorax. We aimed to explore the clinical and radiologic presentation, treatment, and clinical course of airway amyloidosis.

METHODS

A computer-assisted search was performed to identify patients who had biopsy-proven airway amyloidosis and were evaluated at Mayo Clinic in Rochester, MN, from January 1, 1997 through December 31, 2019. Demographic, clinical, and radiologic features along with clinical outcomes were analyzed.

RESULTS

We identified 43 patients who had airway amyloidosis. Median age was 60 years (range: 33 to 91 y), and 58% were female. Shortness of breath (63% of patients) and cough (44%) were the most common presenting symptoms. Most patients (82%) had localized amyloidosis with light chain being the most common amyloid type; 63% had tracheobronchial amyloidosis, and 23% had tracheal and upper airway involvement. On computed tomography of the chest, the most common findings were airway wall thickening with nodularity (60% of patients), airway calcification (53%), and airway occlusion without collapse (47%). On bronchoscopy (33 patients), the extent of amyloid involvement was most commonly submucosal (n=15) or nodular (n=8). External beam radiotherapy was the most common treatment modality. Among the 30 patients who had follow-up at our institution, the prognosis appeared to depend on the extent of the disease and whether patients had localized or systemic amyloidosis.

CONCLUSION

Computed tomography of the chest, bronchoscopy, and biopsy are needed to establish the diagnosis of airway amyloidosis, and systemic amyloidosis should be ruled out. Treatment of amyloidosis requires a multidisciplinary approach.

One Hundred Cases of Localized Laryngeal Amyloidosis - Evidence for Future Management

OBJECTIVE/HYPOTHESIS

To update the current understanding of localized laryngeal amyloidosis by analyzing the NHS National Amyloidosis Database and to further clarify the important ongoing management issues.

STUDY DESIGN

Retrospective review, case series.

METHODS

Patients with laryngeal amyloid were identified from the database of the NHS National Amyloidosis Center, UCL, Royal Free Hospital, London between 2000 and 2017. Patient demographics and disease profile were collated, including the exact location of amyloid deposit, treatments if any, and progression of disease.

RESULTS

One hundred and three patients with localized laryngeal amyloid where identified from the database, with a mean age of 54 at diagnosis and female to male ratio of 54:49. Three patients were excluded from further analysis due to limited database information. The majority of amyloid was found in either the supraglottis (44) or glottis (53) but all the laryngeal subsites were involved. One-third of the patients (34) had amyloid in more than one laryngeal subsite. No patients were found to progress to systemic amyloid, but many progressed locally to other subsites or further down the LTB tree (29%). Three patients were successfully treated with radiotherapy after other modalities had failed.

CONCLUSIONS

This is the largest case series reported to date of localized laryngeal amyloidosis. It highlights the high incidence of multifocal disease and the significant proportion of patients who progressed, not to systemic amyloidosis but to more extensive localized amyloid. We recommend that in all cases of laryngeal amyloid, patients should undergo a thorough assessment of the upper and lower airways and have ongoing surveillance for at least 15 years.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E1912-E1917, 2021.

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.

Pharyngo-laryngeal involvement in systemic amyloidosis with cardiac involvement: a prospective observational study

Background: Systemic amyloidosis with cardiac involvement (CA) is a severe disease caused by the aggregation of misfolded proteins infiltrating organs and tissues and leading to their dysfunction. No study has yet focused on potential pharyngo-laryngeal impairments associated to CA. Our objective was to define its prevalence and describe pharyngo-laryngeal involvement patterns in a population with CA (light chain: AL, wild-type transthyretin: ATTRwt, variant transthyretin: ATTRv). Methods: Consecutive patients with a confirmed diagnosis of CA were prospectively investigated for pharyngo-laryngeal involvement. This included questionnaires on symptoms of dysphonia/dysphagia and quality of life Voice Handicap Index (VHI). In cases of dysphonia, a nasofibroscopy was performed to evaluate potential laryngeal organic lesions of amyloid infiltration and induced laryngeal dysfunction (mobility, glottic air leak). In cases of dysphagia, Video Endoscopy Swallowing Study (VESS) was performed to evaluate the presence of hypopharyngeal pooling at rest and during swallowing and the time of swallowing 80 ml of water. Results: Ninety-five CA patients were enrolled, of whom 19 were ATTRv, 36 AL and 40 ATTRwt. Their mean age was 73.8 ± 9.2 years and the sex ratio was 2.6 in favor of men. Dysphagia was reported in 17% of the patients and 40% had more specific oropharyngeal symptoms (food sticking, regurgitation, change in dietary habits), preceding the CA diagnosis by 7 (0-24) months. Recent weight loss was reported in 60% of the patients (mean loss of 10 ± 6.3 kg). VESS showed functional swallowing impairment in only 4 patients without any macroscopic organic lesion. Dysphonia was reported in 36% of the patients (44% and 47% in AL and ATTRv sub-groups, respectively) of whom 40% had functional or organic laryngeal abnormality (14% of vocal fold mobility dysfunction and 26% of abnormal mucosa) without any macroscopic-specific lesions of amyloid infiltration in these patients. Conclusions: This prospective study suggests, for the first time, that amyloid associated with CA could infiltrate the various anatomical structures of the pharyngo-larynx, responsible for functional impairment and potential nutritional depletion and poor quality of life.

Curative effect of cold micro forceps and CO2 laser in the treatment of laryngeal amyloidosis

Background: Amyloidosis is a benign, slowly progressive disease. However, the treatment of laryngeal amyloidosis (LA) has not been studied systematically.Objectives: To investigate the treatment results of cold micro forceps or carbon dioxide laser under microlaryngoscope in the treatment of LA.Methods: A retrospective review was conducted for the cases collected from January 1990 to March 2016 at our department.Results: One hundred and eighteen patients (44 males and 74 females, with an average age of 51.7 years) with LA were identified. The amyloidosis was not found in organs other than the larynges and tracheas. The patients most commonly presented with hoarseness and dyspnea. All patients underwent surgical removal of the amyloid deposits (via micro forceps or CO₂ laser). Twenty-nine patients developed recurrences requiring further treatments. The mean interval from treatments to recurrences in these patients was 16.5 months. Five patients were treated more than once. No significant difference was found between cold micro forceps and CO₂ laser methods in recurrences.Conclusions: LA generally behaves as a benign disease. Resection of LA either via cold micro forceps or CO₂ laser under microlaryngoscope is both safe and effective methods. Regular follow-up with laryngoscopy is indicated for early diagnosis of recurrence.

Risk factors for recurrence of laryngeal amyloidosis treated by microforceps and CO2 laser

INTRODUCTION

Laryngeal amyloidosis is a benign, slowly progressive disease. The factors affecting the recurrence of LA have not been studied before for the rarity and incomplete understanding of this disease. To investigate the risk factors for the laryngeal amyloidosis treated by microforceps or carbon dioxide laser under microlaryngoscope, a retrospective review was conducted.

MATERIALS AND METHODS

One hundred and four patients (42 male and 72 female, with an average age of 51.3 years) with laryngeal amyloidosis were identified. The cases were collected from January 1989 to May 2014 at the Eye, Ear, Nose, and Throat Hospital of Fudan University.

RESULTS

Seventy-five patients complained of hoarseness, 36 patients complained of hoarseness and dyspnea, and 3 patients complained of foreign body sensation. All patients underwent surgical removal of the amyloid deposits (via microforceps, CO₂ laser and tracheotomy). Thirty patients developed recurrences requiring further treatments. The duration from onset to the treatment and age affected the recurrence of laryngeal amyloidosis, the surgery method, stenotic degree and stenotic area of subglottic area and trachea did not affect the recurrence of the disease.

CONCLUSION

Early diagnosis and treatment of laryngeal amyloidosis may reduce the recurrence of the disease. Regular follow-up is necessary to find any recurrence.

Amyloidosis and the lung

Amyloidosis is a disorder of protein folding in which normally soluble plasma proteins aggregate in an abnormal fibrillar form causing progressive disruption to tissue structure and organ function. This review covers systemic AA and AL amyloidosis which may arise as a consequence of chronic respiratory conditions; the manifestations of both systemic and of localised amyloid deposition within the respiratory tract and provides a summary of current approaches to diagnosis and management.

Detection of nodular pulmonary amyloid by PET positive scan--deception for lung cancer

Amyloidosis results from proteins being deposited as insoluble β-pleated sheets and disrupting organ function. Each precursor protein induces a separate spectrum of organ involvement, and different disease manifestations within the lung. Although autopsy findings often demonstrate amyloid deposits in various compartments of the lung, few are manifested pathologically. Amyloid lung nodules with positron emission tomography (PET) uptake are rare. We describe a rare case where PET uptake was detected in a pulmonary amyloid nodule. To our knowledge there are six previously reported cases in the English literature. This review also focuses on amyloid derived from immunoglobulin light-chain protein (AL disease), which most frequently involves the lung in both systemic and localized forms of the disease. Manifestations of AL-related lung disease range from nodules identified on incidental chest films to diffuse alveolar and septal deposition mimicking malignancy and or diffuse alveolar damage.

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.

External beam radiation therapy for tracheobronchial amyloidosis

BACKGROUND

Tracheobronchial amyloidosis is a rare form of primary amyloidosis. There have been no regimens for treatment of this disease that have proven to be effective. There have been case reports of external beam radiation therapy (EBRT) providing marked improvement in symptoms and the appearance of lesions. We report a series of seven consecutive patients who were treated with EBRT.

METHODS

All patients with tracheobronchial amyloidosis were identified who had received EBRT at Mayo Clinic, Rochester, MN. A retrospective chart review was performed. Data were collected including symptoms, method of diagnosis, treatments, result of treatments, and side effects.

RESULTS

All patients received 20 Gy of radiation in 10 fractions. All patients had a favorable response to treatment ranging from symptom relief to a decrease in the frequency of pulmonary infections and objective improvement in pulmonary function. The time to subjective improvement ranged from 1 month to 1 year from the completion of EBRT. Grade 1 esophagitis developed in four patients, and grade 2 esophagitis developed in one patient. Grade 2 pneumonitis that resolved after 10 days of treatment with antibiotics and corticosteroids developed in one patient. FEV(1) was the most consistently used method of objective follow-up, and three of seven patients showed improvement. Follow-up ranged from 10 to 69 months (median, 40 months). The recurrence of asymptomatic endobronchial narrowing requiring no additional treatment was noted on bronchoscopy in one patient after 17 months.

CONCLUSIONS

Tracheobronchial amyloidosis has been difficult to treat due to the limitations of treatment, recurrence, and complications. EBRT appears to be safe and can provide symptomatic as well as objective improvement.

Primary localized laryngeal amyloidosis: report of 3 cases with long-term follow-up and review of the literature

CONTEXT

Localized laryngeal amyloidosis is an uncommon condition with limited long-term follow-up studies. The precise etiology and pathogenesis are not entirely clear.

OBJECTIVE

To further characterize the histopathologic features and possible pathogenesis of localized laryngeal amyloidosis.

DESIGN

Three cases of primary localized laryngeal amyloidosis were identified at our institutions from 1980 to 2003. The clinical features and histologic and immunohistochemical patterns were evaluated. Systemic workups were pursued during the long-term follow-up.

RESULTS

The common presentation of the patients was hoarseness. The lesions involved vocal cords, anterior commissure, and ventricle. Microscopically, the amyloid was present within the submucosa with an adjacent lymphoplasmacytic infiltrate. The plasma cells and amyloid demonstrated monoclonal light chain restriction in all 3 cases (2 lambda, 1 kappa). No evidence of systemic amyloidosis or an overt B-cell lymphoma was found in these patients. Two patients with long-term follow-up underwent subsequent surgical removals for multiple recurrences, which occurred within 1 year of the initial diagnosis.

CONCLUSIONS

The demonstration of monoclonal light chain expression in the plasmacytic infiltrate and amyloid component in the absence of systemic lymphomas indicates that localized laryngeal amyloidosis may represent a form of benign monoclonal plasma cell dyscrasia. A close follow-up of the patients may be indicated for early detection of recurrences.

Amyloidosis of the upper aerodigestive tract

OBJECTIVES/HYPOTHESIS

To delineate the clinical and pathologic characteristics of upper aerodigestive tract amyloidosis with particular attention to laryngeal amyloidosis.

STUDY DESIGN

Retrospective chart review of patients with amyloidosis of Thomas Jefferson University and its affiliated hospitals.

MATERIAL AND METHODS

The charts of 16 patients with upper aerodigestive tract amyloidosis identified from the databases of the Thomas Jefferson University pathology department were reviewed and included in the study.

RESULTS

Sixteen patients (9 male and 7 female, with an average age of 49.8 years) with upper aerodigestive tract amyloidosis were identified. The most common site of amyloid involvement was the larynx. Consequently, patients most commonly presented with hoarseness (14 of 16). All patients underwent surgical removal of the amyloid deposits. Fourteen patients had primary localized amyloidosis. Two experienced systemic involvement. Seven of the 16 patients developed recurrences requiring further treatment.

CONCLUSIONS

Amyloidosis of the upper aerodigestive tract generally behaves as a benign, localized condition treatable by surgical resection. Regular follow-up with laryngoscopy is indicated for early diagnosis of recurrence, and multiple surgical procedures may be required to control symptoms.

CT and MR imaging of localized amyloidosis

The localized form of amyloidosis affecting the head and neck region is rare. The characteristic features of localized amyloidosis appeared as multiple nodules on the tongue, lip, and cheek on computed tomography (CT) and magnetic resonance imaging (MRI). Contrast-enhanced CT scans represented this lesion as a marked nodular enhancement. MR features of this lesion appeared slightly low on T1-weighted images and slightly high on T2-weighted images compared with T1-T2 images of residual normal tongue. Time contrast intensity curves obtained from dynamic MRI rapidly increased to reach a plateau and gradually decreased during the late and delayed phases. MR findings suggest that such lesions might be comprised of fibrous tissue with abundant vessels. This report suggests that dynamic MRI might be helpful for diagnosing localized amyloidosis.

Amyloidosis of the larynx: a clinicopathologic study of 11 cases

Laryngeal amyloidosis (LA) is uncommon and poorly understood, with limited long-term clinicopathologic and immunophenotypic studies in the literature. Eleven cases of LA were retrieved from the files of the Otorhinolaryngic-Head & Neck Tumor Registry from 1953 to 1990. The histology, histochemistry, immunohistochemistry, and follow-up were reviewed. All patients (three women and eight men) presented with hoarseness at an average age of 37.8 years. The lesions, polypoid or granular, measured an average of 1.6 cm and involved the true vocal cords only (n = 4), false vocal cord only (n = 1), or were transglottic (n = 6). An acellular, amorphous, eosinophilic material was present in the stroma, often accentuated around vessels and seromucous glands, which reacted positively with Congo red. A sparse lymphoplasmacytic infiltrate was present in all cases that demonstrated light chain restriction by immunohistochemistry in three cases (kappa = 2, lambda = 1). Serum and urine electrophoreses were negative in all patients. Treatment was limited to surgical excision, including a single laryngectomy. Six patients manifested either recurrent and/or multifocal/systemic disease: two patients with light chain restriction were dead with recurrent disease (mean, 11.1 years); two patients were dead with no evidence of disease (mean, 31.7 years); and two patients were alive, one with light chain restriction and recurrent and multifocal disease (41.6 years) and one with no evidence of disease after a single recurrence (43.4 years). The remaining five patients were either alive or had died with no evidence of disease an average of 32.4 years after diagnosis. No patient developed multiple myeloma or an overt B-cell lymphoma. LA is an uncommon indolent lesion that may be associated with multifocal disease (local or systemic). The presence of an associated monoclonal lymphoplasmacytic infiltrate and recurrent/multifocal disease in the respiratory or gastrointestinal tract of a few cases and the lack of development of a systemic plasma cell dyscrasia or overt systemic B-cell malignancy suggest that some LA may be the result of an immunocyte dyscrasia or tumor of mucosa-associated lymphoid tissue.

Tracheobronchial amyloidosis. The Boston University experience from 1984 to 1999

Tracheobronchial amyloidosis (TBA), an idiopathic disorder characterized by deposition of fibrillar proteins in the tracheobronchial tree, occurred in 10 patients referred to the Amyloid Program at Boston University over the past 15 years. Fewer than 100 cases of TBA have been described; only 1 series encompassed more than 3 patients. We analyzed our experience with biopsy-proven TBA to define better its natural history. Follow-up averaged approximately 8 years and was obtained in all cases, making this outcome reporting the largest and most complete to date. Three of these patients were prospectively studied for up to 24 months to examine the utility of bronchoscopy, computerized tomography (CT) imaging, and pulmonary function tests (PFTs) in monitoring disease progression. No patient with TBA developed signs or symptoms of systemic amyloidosis during the period reviewed. Conversely, tracheobronchial disease was not diagnosed in 685 patients with primary systemic (AL) amyloidosis during the 15-year study period at Boston University. Bronchoscopy proved most useful in establishing the diagnosis by biopsy. Narrowing of major airways limited its inspection of the tracheobronchial tree, however. In contrast, CT imaging provided quantitative assessment of airway narrowing and mural thickening--2 major consequences of amyloid infiltration. These CT features, in the presence of mural calcifications sparing the posterior tracheal membrane, have been reported in few disorders other than TBA. The ability of CT to map airway involvement and identify extraluminal manifestations of TBA made it the study of choice for establishing disease extent. Three patterns of disease were evident by CT imaging and bronchoscopic examination: proximal, mid, and distal airways involvement. Those with severe proximal disease had significantly decreased air flows, air trapping, and fixed upper airway obstruction on PFTs. Patients with distal disease had normal airflows. PFTs could not clearly distinguish proximal from severe mid airways disease. Thirty percent of patients died within 7-12 years after diagnosis, all having proximal or severe mid airways disease. Repeated rigid bronchoscopic debridement and laser treatments did not prevent progressive airways narrowing in patients dying from TBA. Most patients with mid airways involvement, and all distal airway cases, had either stagnant disease or slowly increasing amyloid deposits when followed for up to 14 years. In a small subset of patients followed prospectively, serial PFTs were most sensitive to disease progression. CT-derived measures of airway lumen diameter and wall thickness did not change significantly despite marked improvements in airflow after rigid bronchoscopy. Our experience suggests that serial PFTs and CT imaging together offer the best assessment of airway involvement and disease progression in patients with TBA. In the future, radiation therapy may provide more definitive treatment of TBA than debulking procedure have to date.

Localized amyloidosis of the parotid gland: a case report and review of the localized amyloidosis of the head and neck

BACKGROUND

Localized amyloidosis in the head and neck is a rare and benign process.

METHODS

We present the first case report in the literature of localized amyloidosis of the parotid glands and also comprehensively review the literature regarding localized amyloidosis of the head and neck.

RESULTS

Amyloidosis affecting the head and neck region is uncommon and is mostly in the form of localized amyloidosis. Larynx is the commonest site of involvement and accounts for 0.2% to 0.5% of benign laryngeal tumors. Laryngeal involvement could be either diffuse subepithelial deposition or discrete tumor nodules. Although localized amyloidosis occurs much more frequently in the oral cavity and pharynx, only seven cases of nasopharyngeal amyloidosis and eight cases of nasal septum amyloidosis have been reported. There is no documentation to suggest that localized amyloidosis can progress to systemic amyloidosis. Local surgical excision is the treatment of choice for laryngeal amyloidosis and laser excision is probably the best.

CONCLUSION

While localized amyloidosis of the head and neck region is rare, it should be recognized, understood, evaluated, and properly treated.

Monoclonal origin of localised orbital amyloidosis detected by molecular analysis

AIMS

Primary localised orbital amyloidosis is a rare disease. The purpose of this study was to describe two cases of primary orbital amyloidosis and emphasise the value of molecular analysis of immunoglobulin gene rearrangement in identifying a monoclonal population of cells responsible for the amyloid production.

METHODS

Charts and biopsy specimens of each case were reviewed. Conventional light microscopy, immunohistochemistry, and polymerase chain reaction (PCR) analysis for immunoglobulin gene rearrangement were performed in both cases.

RESULTS

An unusual presentation of localised primary amyloidosis with bilateral and extensive enlargement of multiple extraocular muscles was seen in case 1. The presence of amyloid deposits was confirmed by biopsy in both cases. Evidence of a monoclonal population of plasma cells was shown by immunohistochemical analysis in case 2 only. The monoclonal origin of the cells responsible for the amyloid deposition was determined by PCR analysis demonstrating immunoglobulin heavy chain gene rearrangement in both cases.

CONCLUSIONS

A monoclonal population of plasma cells responsible for the amyloid deposition was present in these two cases. PCR analysis is extremely helpful in determining monoclonality, a finding that may have important therapeutic and prognostic implications.