Localized amyloidosis of the lower genitourinary tract: a clinicopathological and immunohistochemical study of nine cases

A series of nine cases of localized amyloidosis of the lower genitourinary tract are reported. The patients comprised six males and three females with an age range of 50-79 years at initial presentation. Clinically and on cystoscopy, the lesions were often diagnosed as neoplasms. Histologically, seven cases had typical features of localized amyloid deposits, while two cases had an unusual appearance with a florid histiocytic and giant cell reaction. Using an immunoperoxidase staining method the deposits were non-reactive with antibodies to serum amyloid A protein, prealbumin and beta 2 microglobulin, while equivocal immunoreactivity was seen with anti-light chain antibodies.     

Amyloid in prostatic corpora amylacea.

AIM: To determine the presence and nature of amyloid in prostatic corpora amylacea using immunohistological studies. METHODS: Prostatic tissue from 18 transurethral and two open resection specimens was studied. Paraffin wax embedded tissue sections were stained with haematoxylin and eosin and the alkaline Congo red method with and without previous treatment with potassium permanganate. Sections were also stained with antibodies to amyloid A, beta 2 microglobulin, lambda and kappa light chains, prealbumin IgA, G, M, S100 protein, prostatic specific antigen, amyloid P component and CAM 5.2 (control and blocking studies were performed). RESULTS: The prostatic corpora amylacea universally showed the presence of amyloid. In all instances this contained beta 2 microglobulin. CONCLUSION: Prostatic corpora amylacea represents a localised amyloidosis of beta 2 microglobulin origin that is unrelated to chronic renal failure and haemodialysis.     

Systemic amyloidosis of beta 2 microglobulin type.

A patient receiving haemodialysis for 15 years developed systemic amyloidosis of beta 2 microglobulin type. Noticeable deposits of amyloid were present in the myocardium, intervertebral discs, joint cartilages and tendons. Less conspicuous amounts were present in blood vessel walls in the lungs, liver, adrenal glands and brain, and within the stroma of the prostate, testis and kidney, often with foci of calcification.     

Systemic amyloidosis of beta 2-microglobulin type: a complication of long-term haemodialysis.

A patient receiving long-term haemodialysis developed systemic amyloidosis, which was shown immunohistochemically to be of beta 2-microglobulin type, a previously unrecognised form of systemic amyloidosis. Histologically, the amyloid deposits were closely associated with foci of acute and granulomatous inflammation and vasculitis, although it was not clear if the amyloid deposits directly caused the inflammatory process, or if amyloid was deposited preferentially in areas of inflammation of uncertain aetiology.     

Gastrointestinal beta2microglobulin amyloidosis in hemodialysis patients: biochemical analysis of amyloid proteins in small formalin-fixed paraffin-embedded tissue specimens.

We present here a first report on the biochemical analysis of intestinal amyloid deposits found in two cases of hemodialysis-related amyloidosis. A new microtechnique was applied for extraction and immunochemical/chemical characterization of amyloid proteins in small amounts of fixed tissue, thus allowing precise identification of beta2microglobulin amyloid (Abeta2M) in both cases studied. The molecular mass of the identified amyloid beta2M was close to that of intact beta2M (12 kDa), with no evidence of the products of proteolytic fragmentation of these molecules. The isoelectrofocusing of the purified Abeta2M demonstrated a shift to more acidic pI as compared to the normal beta2M analyzed under the same experimental conditions. The obtained data suggest that the intestinal amyloid deposits in dialysis-related amyloidosis contain disease-specific beta2M isoforms, which could play a role in the pathogenesis of amyloid disease. The new methodology used might be useful in obtaining precise diagnosis of amyloidosis that is necessary for appropriate therapy, and also provide new important information on the chemical structure of amyloid proteins.     

Osteoarticular amyloidosis associated with haemodialysis: an immunoultrastructural study.

Osteoarticular amyloidosis occurred in a patient receiving long term haemodialysis. Histological examination showed that the amyloid deposit was surrounded by inflammatory cells and macrophages filled with haemosiderin. Electron microscopy showed that the amyloid fibrils were in close contact with cytoplasmic expansions, or located in intracytoplasmic pockets of the infiltrating cells. Immunohistological and immunoultrastructural observations confirmed that beta 2-microglobulin was a major constituent of amyloidosis associated with dialysis. Amyloid P component was also detected within the amyloid deposits. These findings suggest that amyloid P component, iron overload, or macrophage derived factors could have a role in the polymerisation of beta 2-microglobulin into amyloid deposit.     

Visceral organ involvement and extracellular matrix changes in β2-microglobulin amyloidosis – a comparative study with systemic AA and AL amyloidosis

 Patterns of amyloid distribution and extracellular matrix changes in the heart and gastrointestinal tract were compared among β₂-microglobulin (B2M), AA (secondary), and AL (primary and multiple myeloma-associated) amyloidosis cases. B2M amyloid was found to be mainly distributed in the small arterioles, venules, endocardium and muscularis propria of these organs, the deposits characteristically forming subendothelial nodular lesions in the vessels. A marked increase of chondroitin sulfate (CS) was consistently detected in B2M amyloid. Heparan sulfate (HS) also showed an increase in amyloid deposits, but with less reactivity than CS in the small arterioles or venules. Basement membrane structures stained positively for laminin and collagen type IV were replaced by negative amyloid deposits. In the AL cases, the muscularis propria of the gastrointestinal tract was involved in amyloid deposits, as seen for the B2M type, but the vascular amyloid deposits were localized in the media and adventitia of larger vessels. Immunoreactivity for HS was more intense than that for CS, and no increase in laminin or collagen type IV was observed. In the AA cases, amyloid deposits were distributed in the capillaries, small arterioles, interstitium of the myocardium and mucosa. Immunoreactivity for laminin and collagen type IV was marked, and more intense than that for HS and CS. Although the existence of a direct relationship between increase in extracellular matrix material and amyloidogenesis remains to be proven, the observed variation in extracellular matrix changes in the background of each type of amyloidosis may indicate different binding sites of the amyloid precursor proteins, resulting in the specific histological features and distribution. Received: 23 August 1996 / Accepted: 9 January 1997     

Amyloidosis of pancreatic islets in primary amyloidosis (AL type)

Seven cases of primary amyloidosis (AL-type) were studied immunocytochemically for the possible involvement of pancreatic islets. The two cases with extensive organ involvement by AL-amyloidosis revealed amyloid deposits in pancreatic islets by routine HE and Congo red staining, which were positive for amyloid p and amyloid a, but were only focally positive for light chains kappa and lambda. Positive staining for amyloid p and amyloid a was also noted in the scattered pancreatic acinar tissues, and this positive staining was not specifically located in pancreatic islets as seen in type 2 diabetes mellitus. It is concluded that amyloid deposits in pancreatic islets occur in systemic AL-amyloidosis by a different mechanism from type 2 diabetes. Islet amyloidosis in AL-amyloidosis appears to deposit via circulation, depositing in both pancreatic islets and acinar tissue through blood vessels. In type 2 diabetes, beta islet cells die by cytotoxic effects of smaller amylin (islet amyloid polypeptide, IAPP) aggregates, and the interstitial space created by the necrotic beta cells is replaced by larger IAPP aggregates, to form complex, polymerized islet amyloid. In AL-amyloidosis, the amount of amyloid and light chain deposits in pancreatic islets is much less than that of the other organs and appears to have no connection to type 2 diabetes because the patients did not present diabetes or hyperglycemia. However, considerable islet amyloidosis can be seen in severe AL-type amyloidosis.     

Generalized amyloidosis from β2-microglobulin,with caecal perforation after long-term haemodialysis

Summary A 73-year-old man with chronic renal failure of undetermined aetiology had received haemodialysis for 12 years when he died of acute purulent peritonitis due to caecal perforation. Amyloid deposits detected in a cystic bone lesion in the left hip had caused a pathological fracture 17 days before death. At autopsy, extensive amyloid deposits were found in the osteoarticular system, in the cartilaginous surface and the capsular tissue of joints, ligaments, vertebral discs and bone. In addition, vascular amyloid deposits were diagnosed in the heart, kidneys, testes, lungs, skin and in the gastrointestinal tract. A special feature of this case were interstitial amyloid deposits forming a fine-meshed structure in the myocardium and plate-like deposits in the gastrointestinal tract. Immunohistochemically, all these deposits reacted strongly with antibody to human ₂-microglobulin but showed no reaction with antibodies to AA, Alambda, A-kappa and AF. The present case demonstrates that extra-osteoarticular manifestations of AB-amyloidosis can cause serious complications.     

Histopathological diagnosis of amyloidosis

For the diagnosis of amyloidosis, histological evidence of amyloid deposition is essential. Histologically, an amyloid deposit is stained orange red with Congo red and shows green birefringence under polarized light. When amyloidosis is clinically suspected, endoscopic biopsy of the stomach, duodenum or colon, or aspiration biopsy of abdominal fat is usually performed. If clinicians suspect amyloidosis, they should advise pathologists. Identification of the chemical type of amyloid is necessary with respect to treatment and prognosis. Immunohistochemical examination of amyloid in formalin-fixed, paraffin-embedded sections is simple to perform in most pathological laboratories. In Japan, almost all cases of systemic amyloidosis are classified as AL, AA, ATTR or Abeta2M amyloidosis, so the use of anti-immunoglobulin light chain, anti-amyloid A, anti-transthyretin and anti-beta2 microglobulin antibody is recommended for the classification of systemic amyloidosis. Formic acid pretreatment, which is often used for immunohistochemical detection of amyloidosis, is useful and easy for antigen retrieval. Amyloid deposits of AL amyloidosis are sometimes not immunostained well with commercial anti-immunoglobulin light chain antibody. Previously, we generated polyclonal antibodies against synthetic peptides corresponding to positions 118-134 of immunoglobulin lambda light chain and positions 116-133 of immunoglobulin kappa light chain. These antibodies are very useful for detecting AL amyloidosis because they react with amyloid deposits on formalin-fixed, paraffin-embedded specimens in almost all AL amyloidosis cases. Exact diagnosis and typing of amyloidosis are necessary for therapy.     

Pseudotumoral amyloidosis of beta 2-microglobulin origin in the buttock of a patient receiving long term haemodialysis.

A 52 year old man who had been receiving haemodialysis for 13 years, with a history of renal tuberculosis, right ischial tuberculous osteomyelitis, and dialysis arthropathy, developed a soft tissue tumour in his left buttock. Histological analysis, immunohistological staining, and electron microscopic examination of the surgically removed tumour showed massive deposits of beta 2-microglobulin (beta 2-M) amyloid. This case shows the expanding clinical spectrum of this type of amyloidosis, and it is suggested that amyloid infiltration should be considered in the differential diagnosis of gluteal tumours in these patients.     

Diagnosis and treatment in systemic amyloidosis

Systemic amyloidosis is characterized by the involvement of multiple organs and the presence of an amyloid precursor protein in serum. This disorder is classified into four major forms: immunoglobulin light chain-derived (AL), reactive AA, dialysis-related (beta2M) and hereditary transthyretin (ATTR) type. Heart, kidney, gastrointestinal tract and peripheral nerves are commonly affected by amyloid deposition in systemic amyloidosis and histopathological demonstration of amyloid deposits on any of affected organs is the first step leading to the diagnosis of this disease. Immunohistochemical analysis of amyloid protein on tissue amyloid deposits is necessary to make classification of the disease and DNA testing is also useful in a hereditary form. Amyloidosis had been considered to be an incurable disease but during the past one decade several therapeutic approaches have been employed for the amyloidosis patients with diverse pathogenetic backgrounds: intravenous large dose of melphalan accompanied by autologous peripheral blood stem cell transplantation for AL amyloidosis and liver transplantation for hereditary ATTR type amyloidosis. As a result some amyloidosis patients have been rescued and are now enjoying their own social lives. It is likely that recent advance on the research of amyloidosis has changed the concept of this disease.     

Vascular amyloid of unknown origin and senile transthyretin amyloid in the lung and gastrointestinal tract of old age: Histological and immunohistochemical studies

The histological and immunohistochemical characteristics and the incidence of amyloid deposits in the tissues of the lung and gastrointestinal tract were investigated in 64 autopsied individuals who were 80 years and older (age range: 80-92 years; mean: 83.3 years). Immunohistochemical examination was performed with antibodies against amyloid A, transthyretin, immunoglobulin lambda and kappa light chain amyloid fibril proteins, beta2-microglobulin, beta protein, apolipoprotein AI, apolipoprotein AII, atrial natriuretic peptide, apolipoprotein E, and amyloid P component. Transthyretin amyloid fibril protein (ATTR) deposits were observed in five cases (7.8%). Gastrointestinal amyloid deposits of unknown origin were observed in the veins of the gastrointestinal tract in 26 cases (40.6%). This amyloid was regarded as portal amyloid with respect to distribution pattern. Pulmonary vascular amyloid deposits of unknown origin were observed in 12 cases (18.8%). These amyloid deposits were found mainly in medium-sized veins in the lungs and did not react with any antibodies against amyloid fibril proteins except apolipoprotein E and amyloid P component. Eleven of the 26 cases (42.3%) showing portal amyloid also showed pulmonary vascular amyloid of unknown origin. The pulmonary vascular amyloid deposits were similar to the portal amyloid deposits with respect to their morphological features and their relation to elastic fibers in the vessels. Further morphological investigation and biochemical analysis of the pulmonary vascular amyloid and portal amyloid will resolve questions of their origins and relation.     

Urogenital amyloidosis: clinico-pathological study of 8 cases

Amyloidosis of the genito-urinary tract is uncommon. We report 8 cases, often misdiagnosed as a neoplastic process (6/8). Amyloidosis was localized in the bladder (3 cases), in the ureter (1 case) and in the prostate and/or seminal vesicles (4 cases). The amyloid protein was characterized in 7 cases by immunohistochemistry. Among the bladder and ureter amyloidosis, 2 cases were classified as AL lambda amyloidosis and one case as AA amyloidosis in a patient with long history of chronic arthritis. In the fourth case, the deposits could not be identified. Nevertheless an AL amyloidosis might be suggested. Two cases of prostate and/or seminal vesicles amyloidosis were stained with an anti-B2M antibody, in hemodialyzed patients. The 2 others, positive with the anti-Transthyretina antibody, were classified as senile amyloidosis. This small series illustrated the heterogeneous pathogenic types of amyloidosis in the urogenital tract and emphasized the interest of immunohistochemistry to identify the chemical composition of these deposits.     

Portal amyloid: novel amyloid deposits in gastrointestinal veins?

OBJECTIVE: To specify uncharacterized amyloid deposits in gastrointestinal vessels of the elderly. MATERIALS AND METHODS: The gastrointestinal tracts from 110 consecutive autopsies of individuals aged 85 years and older were examined for amyloid using Congo red staining. Immunohistochemical classification of the amyloid deposits was conducted using antisera directed against amyloid A, apolipoprotein A-I, apolipoprotein A-II, apolipoprotein B, apolipoprotein C-I, lysozyme, lambda and kappa light chain amyloid fibril proteins, transthyretin, beta2-microglobulin, and amyloid P component. Electron microscopic examination assessed the ultrastructural features. RESULTS: Thirty-eight (35%) of the 110 cases had gastrointestinal amyloid deposits. In 17 cases the amyloid fibril proteins were defined immunohistochemically. In five cases (5%) the amyloid could not be classified because amyloid deposits were not present in the deeper serial sections used for immunohistochemistry. In 13 cases (11%) the vascular amyloid deposits could not be characterized because they did not demonstrate immunoreactivity with any of a panel of antibodies specific for the fibril proteins of all major extracerebral amyloids. In three individual cases, the vascular amyloid deposits showed variable immunoreactivity, with deposits being negative in some vessels. The immunohistochemically nonreactive vascular amyloid in these 16 cases had several consistent features: it affected only vessels of the small and large intestine, it was limited to mesenteric veins, it consisted of small dot- or comma-like deposits located in close proximity to fragmented elastic fibers, and it demonstrated inconsistent immunostaining for amyloid P component. CONCLUSIONS: The similar morphologic characteristics of nonreactive gastrointestinal amyloid deposits, which we have designated "portal amyloid," suggest a common origin. Determination of whether portal amyloid represents a new type of amyloid will require chemical analysis.     

Beta 2-microglobulin amyloidosis in hemodialysis patients. An autopsy study of intervertebral disks and posterior longitudinal ligaments

Ninety-five autopsy cases of chronic renal failure, which had or had not been treated by hemodialysis, were examined histologically and immunohistochemically for evidence of amyloid deposition in the intervertebral disks and posterior longitudinal ligaments of the spine. beta 2-Microglobulin (beta 2M) amyloid was not present in non-dialyzed patients with chronic renal failure. In cases showing beta 2M amyloid deposition, the shortest term of hemodialysis was 2 years and 5 months. The incidence of beta 2M amyloidosis tended to increase as the dialysis period was prolonged. An inverse correlation was present between dialysis period and age in 22 cases showing beta 2M amyloid deposition (correlation coefficient: -0.43, p less than 0.05), and beta 2M amyloidosis tended to occur earlier in elderly patients than in younger patients. This suggests that elderly patients are more susceptible to beta 2M amyloidosis. beta 2M amyloid was absent in all of 8 cases of systemic lupus erythematosus which were treated by dialysis for periods ranging from 2 days to 12 years. In these patients, beta 2M amyloidosis may have been prevented by steroids, which had been administered for long periods in all cases. Another amyloid of unknown composition was also frequently present in the intervertebral disks and posterior longitudinal ligaments not only in patients with chronic renal failure but also control patients without chronic renal failure. This amyloid was immunohistologically negative for beta 2M, amyloid A protein, light chain kappa or lambda, prealbumin, and apolipoprotein A-II.     

Clinicopathological importance of deposits of amyloid in the femoral head.

The pattern of amyloid deposits in the femoral head is described in four cases, two of which had deposits of amyloid related to age and two of which had generalised systemic amyloidosis (one of primary amyloidosis, one of multiple myeloma). The deposition of amyloid in the articular cartilage of the femoral head was similar in all four cases. Heavy deposits of synovial amyloid were identified in the case with primary amyloidosis and in one of the cases with amyloidosis related to age. Both cases of generalised systemic amyloidosis showed abundant deposits of amyloid in the bone marrow. Amyloid was not present in the bone marrow of either case with amyloidosis related to age. The importance of these findings is discussed in relation to the pathogenesis of the arthropathy syndrome of a rheumatoid type described in cases of primary amyloidosis and multiple myeloma.     

Immunohistochemical characterization of amyloid proteins in sural nerves and clinical associations in amyloid neuropathy.

To test whether immunohistochemical characterization of proteins in amyloid deposits in biopsied sural nerves gives reliable and useful diagnostic information using commercially available reagents, biopsy specimens of sural nerves from 38 patients with amyloid neuropathy were studied. Transthyretin (TTR) was detected in the amyloid deposits of 11 nerves, lambda light chains (LC) in 8 nerves, kappa LC in 7 nerves, and both lambda and kappa LC in 3 nerves. In 9 nerves, the amyloid deposits were too small to allow adequate immunohistochemical characterization of amyloid proteins in serial sections. Evidence that immunohistochemical characterization was correct came from: 1) evaluation of kin, 2) search for monoclonal proteins in the plasma, and 3) sequencing of the gene abnormalities in TTR+ cases. In 9 of 11 TTR+ cases, in which DNA could be obtained, sequencing of the gene showed that each of the 9 cases was heterozygous for a gene mutation; 7 had previously described mutations and 2 undescribed mutations. Therefore, in the nine sporadic cases without plasma monoclonal light chains, the immunohistochemical characterization correctly identified the protein in amyloid as transthyretin. Likewise, there was a high concordance between immunoglobulin light chains in plasma and light chains in amyloid in primary amyloidosis. Evaluation of the type, distribution, and severity of the neurologic symptoms and deficits showed: 1) the sensorimotor and autonomic neuropathy of amyloidosis characteristically affects proximal as well as distal limbs, and 2) the type of amyloidosis probably cannot be determined from the characteristics or severity of the neuropathy alone or from the location or size of amyloid deposits in nerve.     

Amyloidosis presenting in the lower respiratory tract. Clinicopathologic, radiologic, immunohistochemical, and histochemical studies on 48 cases

We studied 48 cases of amyloidosis localized to the lower respiratory tract. Fourteen cases were classified as tracheobronchial amyloidosis. Twenty-eight cases showed solitary or multiple nodules, and six cases had a diffuse interstitial parenchymal pattern. Almost all patients with tracheobronchial and diffuse interstitial amyloidosis had respiratory symptoms (usually dyspnea), whereas most with nodular amyloidosis were asymptomatic. Nodular parenchymal and, less frequently, tracheobronchial amyloidosis had contiguous cellular infiltrates of plasma cells, lymphocytes, and giant cells. Immunohistochemical staining of specimens from 18 cases showed these plasma cells to be polytypic, except for two tracheobronchial lesions that had a disproportionate number of lambda light chain-bearing plasma cells. Permanganate oxidation of specimens from 19 cases showed patterns in keeping with immunoglobulin-derived amyloid in 12. Local deposits of amyloid in lung may arise from deposition of circulating precursor proteins.     

Secondary amyloidosis in chronic polyarthritis

Systemic secondary amyloidosis was a post-mortem finding recorded from 24% of patients with classical chronic polyarthritis. In 80 to 100% of all cases, amyloidosis was present in heart, thyroid gland, kidneys, adrenal gland, pancreas, spleen, and gastro-intestinal canal. It was recordable, in 50 to 70% of all cases, from liver, aorta, lungs, and lymph nodes. Nerves, muscles, skin, and synovial membrane were less often affected (10 to 40% of all cases). No amyloidosis was recorded at all from the brain. Amyloid depositions differed greatly in intensity by organs. The most massive deposits were found in the gastrointestinal tract, kidneys, adrenal glands, thyroid gland, and spleen. Amyloid depositions were moderate in heart, pancreas, lungs, and liver. They were extremely low in lymph nodes, muscles, nerves, synovial membrane, and skin. The author assumes amyloid deposition to be associated with increase in arterial or venous concentrations of circulating amyloid precursors. Frequency and intensity of amyloid depositions in different organs may be linked to blood supply to the latter. The higher the minute volume of a given organ, the more strongly pronounced is the amyloidosis in it. In the context of amyloidogenesis, consideration should be given, as well, to locally delimited factors, such as organ motility.