Amyloidoma: a review and case report

Localized Foot Amyloidosis From Monoclonal B Cell Lymphoma

Localized cutaneous amyloidosis is a rare dermatologic finding necessitating extensive diagnostic workup to include serum protein electrophoresis, fat pad biopsy, and imaging to rule out underlying hematologic disease or systemic involvement. Herein we detail a case of AL amyloidoma in a 73-year-old male that presented as chronic violaceous patches of the bilateral feet. Punch biopsy of these lesions revealed congo red-positive amyloid deposits, and further testing revealed an underlying monoclonal B cell lymphocytosis that remained stable at 6 months follow up. This case highlights the importance of distinguishing localized amyloidoma from systemic disease and other hematological malignancies.

Primary Localized Cutaneous Amyloidosis Presenting With Tumor-Like Swelling in the Lower Extremity: A Rare Presentation

Amyloidosis consists of a spectrum of disease ranging from primary localized forms to secondary forms due to systemic disease. Amyloidoma, a variant of localized amyloidosis, is the least frequent manifestation of tissue amyloid deposition, which can be either amyloid A (AA) or amyloid light-chain (AL) type. Soft tissue amyloidoma is uncommon and mostly affects the abdomen and mediastinum and rarely affects the extremities. We present a middle-aged woman who developed a tumor-like swelling in the extremity, in which comprehensive investigations revealed features of primary amyloidosis with no evidence of internal involvement, representing a rare presentation.

Long-Term Progression of a Residual Cerebral Amyloidoma: An Illustrative Case and Systematic Review

OBJECTIVE

Cerebral amyloidomas (CA) are exceptionally rare tumor-like lesions composed of cerebral amyloid-beta, which is derived from the cleavage of the amyloid precursor protein.

METHODS

We presented a case of recurrent CA and performed a systematic review, comparing their initial presentation, imaging features, neurosurgical treatment, and natural history of the disease.

ILLUSTRATIVE CASE

A 65-year-old male with a history of right homonymous hemianopsia, who underwent subtotal resection of a CA 19 years before, presents to the emergency department with right hemiparesis, dysarthria, and a new onset of clonic seizures. Imaging revealed a left parieto-occipital lesion with calcifications and vasogenic edema. A gross-total resection was performed. Histopathology revealed a hypocellular eosinophilic lesion consistent with CA. Postoperatively, the patient recovered without new neurological deficits. One-year follow-up magnetic resonance imaging showed no residual or recurrence lesion.

SEARCH RESULTS

Eighty-seven cases, including ours, revealed that 65.5% (n = 57) were females with a median age of 54 years (IQR: 46-62). Most lesions were solitary (82.7%; 72 of 87 lesions). Frontal and parietal lobes were most commonly affected with 32.9% (n = 28) and 30.5% (n = 26), respectively. Seizures were the most common symptom followed by visual compromise. Calcifications were present in 19.5% (n = 17) of the lesions.

CONCLUSIONS

This systematic review provides insights into the epidemiological, clinical, and neurosurgical characteristics, as well as the long-term prognosis of CA. This marks the first case in the reviewed literature with a 19-year period of follow-up where the patient had reoperation due to disease progression.

Nasopharyngeal amyloidoma: report of three cases and review of the literature

BACKGROUND

Nasopharyngeal amyloidoma is a rare, locally aggressive tumor that has been reported in the English literature in only 38 cases to date, most of which were in the form of case reports. The present study was aimed to summarize the characteristics of this rare tumor, with the goal of providing new insights for diagnosis and treatment.

MATERIALS AND METHODS

We report three cases of nasopharyngeal amyloidoma diagnosed in our hospital following comprehensive medical examination and review the current literature on all cases of nasopharyngeal amyloidoma from PubMed. The journey of nasopharyngeal amyloidoma, including presentation, diagnostics, surgeries, and follow-up was outlined.

RESULTS

None of the three patients had systemic amyloidosis. CT and nasal endoscopy showed irregular masses obstructing the nasopharyngeal cavity. Congo red staining confirmed the deposition of amyloid, and immunohistochemical analysis showed that the amyloid deposition was the AL light chain type. Through literature review, we found that nasopharyngeal amyloidoma most commonly occurred in individuals over the age of 40, patients usually had a good prognosis after complete tumor resection; however, there were still cases of recurrence, and unresected patients were at risk of progression to systemic amyloidosis. The efficacy of radiotherapy and chemotherapy was currently uncertain.

CONCLUSION

Early clinical and pathological diagnosis is crucial, and surgical intervention is the primary treatment option for this disease. Although patients usually have a favorable prognosis, long-term monitoring is necessary to detect potential relapses and initiate timely intervention.

Comprehensive investigation of insulin-induced amyloidosis lesions in patients with diabetes at clinical and histological levels: A systematic review

INTRODUCTION

Insulin-derived amyloidosis (AIns), a skin complication in patients with diabetes, causes impaired insulin absorption. This systematic review aims to get a better understanding of this overlooked condition.

METHODS

Comprehensive literature searches were performed in Scopus, PubMed, EMBASE, and Web of Science databases until June 17, 2023. From 19,343 publications, duplicate and irrelevant records were eliminated by title, and the full texts of the remaining studies were examined for validity. Clinical, pathological, and therapeutic findings were extracted from 44 papers.

RESULTS

Forty-four articles were studied that covered 127 insulin-treated patients with diabetes. From the 62 patients with reported age and sex, males had a mean age of 58 years, and females 68.5 years. While AIns were twice as likely to develop in men (66.13 %) as in women (33.87 %), the administered insulin dose was significantly higher in males (p = 0.017). The most common insulin injection site was the abdominal wall (77.63 %). Histological findings showed the presence of amorphous material with the occasional presence of lymphocytes, plasma cells, macrophages, adipocytes, histocytes, and giant cells. The mean HbA1c level was 8.8 % and the need for receiving insulin was increased in AIns. Changing the site of insulin injections and/or surgically removing the nodules were the most common treatments to obtain better insulin uptake and controlled serum glucose levels.

CONCLUSION

This study highlights the importance of AIns, proper rotation of insulin injection site, and post-treatment patient follow-up to recognize and prevent the development of amyloid nodules.

Differences in clinicopathological characteristics between lipohypertrophy and localized insulin-derived amyloidosis: A scoping review

Insulin is used as a therapeutic agent in patients with diabetes, and cutaneous lipohypertrophy (LH) and localized insulin-derived amyloidosis (LIDA) are well-known adverse effects associated with insulin injections. The clinical implications, management, assessment methods, and pathological differentiation of LH and LIDA have been recently updated. This review was to update our knowledge of the pathological differentiation, effects of insulin absorption, hypoglycemic events, and recent assessment methods for LH and LIDA. A scoping review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses extension for Scoping Reviews guidelines. Original studies and case reports in English were also included. PubMed and Scopus databases were searched for keywords to identify papers published up to January 2022. A total of 113 studies were identified through a database search, and 31 were eligible for inclusion in this scoping review. In the 31 studies included in this review, patients with type 2 diabetes had high frequencies of LH and LIDA. LH outcome parameters were assessed using pathological findings and imaging. LIDA is mainly determined by pathological methods, such as hematoxylin and eosin and Congo red staining. Several in vitro and in vivo LIDA models of LIDA have been developed. These results suggest that pathological analysis is required to identify LH and LIDA. It is important to consider LIDA, as it likely influences insulin adsorption and glycemic control. Although several studies have evaluated the LIDA process, little is known about the mechanisms underlying the development of adverse effects associated with insulin injections.

Localized amyloidoma of the chest wall: diagnostic and surgical perspectives

BACKGROUND

An amyloidoma is defined as a solitary, localized, tumor-like deposit of amyloid in the absence of systemic amyloidosis. Amyloidomas occur most frequently in the bladder, followed by the lungs, trachea and bronchi, larynx and vocal cords, tonsils, conjunctivae, orbits, lymph nodes, gastrointestinal tract, and skin. It is extremely rare for an amyloidoma to present in the chest wall. Indeed, only 5 cases of chest wall amyloidoma have been reported. Moreover, all reported lesions were > 10 cm in size and involved the ribs. Herein, we report our experience with a patient who had a chest wall amyloidoma 3 cm in diameter without rib involvement.

CASE PRESENTATION

A 3.1 × 1.5-cm tumor situated in the fifth intercostal space of the chest wall was found in an 83-year-old male during a routine health checkup. Chest magnetic resonance imaging showed a mass of intermediate intensity on T1-weighted imaging and low intensity on T2-weighted imaging with heterogeneous contrast enhancement. The tumor was resected during video-assisted thoracoscopic surgery. No adhesions were observed between the tumor and the lung. The tumor was white, hard, elastic, and located in the extrapleural fat without bone involvement. The tumor was removed in a piecemeal fashion because the tumor was fragile and the surgical margin was unclear. A wide resection was achieved, including the intercostal muscle. Pathologic examination of the tumor using Dylon and Congo red staining confirmed amyloid deposition with tumor spread from the fat to the intercostal muscle and vascular walls but no pleural invasion. Without clear evidence of systemic amyloidosis, this patient was diagnosed with an amyloidoma of the chest wall. The postoperative course was uneventful, and he is doing well 1 year after surgery.

CONCLUSION

Amyloidoma of the chest wall can present in various ways. An amyloidoma can be a small tumor, as in our patient, or the amyloidoma can be a large, destructive mass with rib involvement. Diagnosis of an amyloidoma should be kept in mind when patients present with chest wall tumors because an amyloidoma can be characterized by invasion within the chest wall independent of size.

Surgical Treatment of Ischial Ulcers Associated with Deposition of β2-Microglobulin in Two Cases of Dialysis-related Amyloidosis

The accumulation of β2-microglobulin due to long-term hemodialysis is known as dialysis-related amyloidosis, a rare phenomenon that manifests as a subcutaneous mass. Subcutaneous β2-microglobulin amyloidomas are predominantly located on the buttocks. Owing to the load-bearing properties of this location and proximity to the anus, amyloidomas on the buttocks may be prone to pressure ulcers and infection. This report presents two cases of long-term hemodialysis patients who required surgical treatment for infected ulcers caused by buttock amyloidomas. In the first case, treatment failed after the amyloidoma was excised and covered with a single-stage skin flap. In the second case, successful treatment was accomplished by reducing the volume of the amyloidoma, followed by a pause to allow for granulation growth and a two-stage skin graft. Amyloids of this nature are known to be cytotoxic; thus, a robust wound preparation technique should be used until the excision site is fully covered with granulation tissue before wound closure is initiated at the time of surgery. In addition, buttock amyloidomas often extend subcutaneously through the hip joint, and repeated infections may lead to more severe outcomes, such as hip joint infections. The number of dialysis-related amyloidosis patients has been increasing in recent years; thus, we report these case studies to improve patient outcomes in similar cases.

Amyloidosis and the Kidney: An Update

Various types of systemic amyloidosis can wreak havoc on the architecture and functioning of the kidneys. Amyloidosis should be suspected in patients with worsening kidney function, proteinuria, and multisystem involvement, but isolated kidney involvement also is possible. Confirming the amyloidosis type and specific organ dysfunction is of paramount importance to select the appropriately tailored treatment and aim for better survival while avoiding treatment-associated toxicities. Amyloid renal staging in light chain amyloidosis amyloidosis helps inform prognosis and risk for end-stage kidney disease. Biomarker-based staging systems and response assessment guide the therapeutic strategy and allow the timely identification of refractory or relapsing disease so that patients can be switched to salvage therapy. Kidney transplantation is a viable option for selected patients with amyloidosis. Because of the complex nature of the pathophysiology and treatment of amyloidosis, a multidisciplinary team-based approach should be used in the care of these patients.

A rare case of isolated thoracic AL-amyloidoma causing complete atelectasis of the right lung

Tumoral amyloidosis, or amyloidoma, is a benign, but rare form of amyloidosis that has been reported with a favorable prognosis following surgical resection in some case reports. We present a case of acute on chronic respiratory failure secondary to extensive growth of a thoracic amyloidoma causing atelectasis of the right lung. Our case patient had greater morbidity due to late presentation and extensive disease at diagnosis, precluding any surgical intervention. Radiation therapy and medical management were unsuccessful in reducing disease burden. Early diagnosis and detection are pivotal to improving survival in patients with isolated thoracic amyloidoma.

Isolated pulmonary amyloidoma: A rare cause of solitary pulmonary nodule

Pulmonary nodules are a frequent finding on imaging, especially given screening guidelines for lung cancer with low dose computed tomography (CT) scan. Here, we report a case with a single pulmonary nodule in a patient exposed to coal dust and asbestos. The nodule had benign features, but it showed an increase in size on repeated imaging. A CT-guided biopsy followed by mass spectrometry of the sample identified the nodule as the AL subtype of amyloidoma. A bone marrow biopsy was without evidence for malignancy including lymphoma. Nodular pulmonary amyloidosis (NPA) is rare, and a biopsy is required to establish the diagnosis. NPA generally does not affect lung function or impact survival; thus NPA does not require specific therapy. This case is the first documented case associated with coal-dust exposure. High-risk patients need to be followed longitudinally due to association of amyloidosis with lymphoma and other systemic conditions.

Amyloid Deposition: An Unusual Case of Deep Gluteal Syndrome and Sciatic Nerve Compression: A Case Report

CASE

Soft-tissue amyloidomas are exceedingly rare, with only a few cases reported in the literature. There are no reports of sciatic nerve compression secondary to a soft-tissue amyloidoma. We report a unique case of a 71-year-old man with an incidentally found amyloidoma who was initially believed to have deep gluteal syndrome. He had a favorable outcome after surgical decompression.

CONCLUSION

For patients who do not have classic examination and electromyography/nerve conduction findings of piriformis syndrome, providers should explore other etiologies of peripheral nerve compression including soft-tissue amyloidoma.

Primary nodular chest amyloidoma: A case report and review of literature

Primary nodular chest wall amyloidoma, in which a solitary mass of amyloid is deposited in and around the lungs with no evidence of systemic amyloidosis, is extremely rare, most often asymptomatic, and may resemble primary bronchogenic carcinoma. As a result, there are fewer than 100 cases published in the literature and no controlled clinical trials. Primary nodular chest wall amyloidoma is typically diagnosed either as an incidental radiological finding or after very serious and destructive mass growth at which point late-stage respiratory and pain symptoms finally develop, most often in elderly patients. We present imaging studies of a 61-year-old male patient with an unusually massive and destructive chest wall mass, originating in the chest wall, diagnosed as chest wall amyloidoma by histopathology analysis. Our CT, MRI, and PET scan findings are consistent with and contribute to the developing pattern of imaging characteristics seen in other case studies, which can be used to identify amyloidoma before it becomes destructive using non-invasive imaging analyses.

Localized Amyloidosis of the Nasal Mucosa: A Case Report and Review of the Literature

Amyloidosis is a disorder of protein folding in which various proteins automatically aggregate into a highly abnormal fibrillar conformation. Amyloidosis is classified into systemic and localized forms depending on whether the abnormal proteins deposited in several different organs or only a single organ. In localized amyloidosis of the head and neck regions, laryngeal amyloidosis is common; however, localized amyloidosis of the nose is extremely rare. We herein report a case of localized amyloidosis of the nose and review the relevant literature on localized sinonasal amyloidosis. A 41-year-old man presented with a history of severe nasal obstruction, which had persisted for two decades. Nasal endoscopy and imaging studies showed extensive thickening of the bilateral nasal mucosa and diffuse submucosal deposition of calcification. After histopathological and systemic examinations, he was diagnosed with localized amyloidosis of the nasal mucosa. Septoplasty and bilateral inferior turbinoplasty, which consisted of mucosal resection using an ultrasonic bone curette, was performed and his symptoms markedly improved. Localized sinonasal amyloidosis has a good prognosis and surgical resection should be selected as a first-line treatment; however, clinicians should recognize the high probability of recurrence.

Differential diagnosis of T2 hypointense masses in musculoskeletal MRI

Many soft tissue masses have an indeterminate appearance on MRI, often displaying varying degrees and extent of T2 hyperintensity. However, a subset of neoplasms and tumor-like lesions may exhibit prominent areas of T2 hypointensity relative to skeletal muscle. The hypointensity observed on T2-weighted MRI can be caused by a variety of substances, including evolving blood products, calcifications or other inorganic crystals, or fibrous tissue. Carefully evaluating the presence and pattern of T2 hypointensity in soft tissue masses and considering potential causes in their associated clinical contexts can help to narrow the differential diagnosis among neoplastic and non-neoplastic possibilities. These include endometriosis, aneurysmal bone cysts, tenosynovial giant cell tumor, arteriovenous malformation and pseudoaneurysm, calcium pyrophosphate and hydroxyapatite deposition diseases, tumoral calcinosis, gout, amyloidosis, hemangiomas with phleboliths, low-grade fibromyxoid sarcoma, ossifying fibromyxoid tumor, collagenous fibroma, desmoid-type fibromatosis, myxofibrosarcoma, peripheral nerve sheath tumors, dedifferentiated liposarcoma, and treated sarcoma.