Amyloidosis of the AL type. Clinical, morphologic and biochemical aspects of the response to therapy with alkylating agents and prednisone

Therapy for immunoglobulin light chain amyloidosis: the new and the old

An accurate diagnosis of amyloidosis and its subtype classification are essential for disease prognostication and treatment. In primary amyloidosis, overall median survival is approximately 2 years and may be less in patients with cardiomyopathy. Current therapy for primary amyloidosis is suboptimal. Controlled studies suggest that treatment with melphalan and prednisone may provide marginal survival benefit. A more aggressive approach such as autologous hematopoietic stem cell transplantation may offer potential for long-term benefit. Although patients undergoing autologous hematopoietic stem cell transplantation are highly selected, response rates can approach 60%, and patients with amyloidosis who respond to treatment have potential for long-term survival. New treatment modalities that were shown to have antitumor activity in multiple myeloma (high-dose dexamethasone and thalidomide) may also be of therapeutic value in primary amyloidosis. Systemic chemotherapy would not be expected to have any beneficial effect on other forms of amyloid and carries significant risk.

Abnormal immunoglobulin synthesis in monoclonal immunoglobulin light chain and light and heavy chain deposition disease

The Congo red-binding fibrils of AL amyloidosis are the most common form of monoclonal immunoglobulin tissue deposition (MIDD). Nonetheless, the less structured deposits found in light chain deposition disease (LCDD) and the similar, but distinct, deposits of light and heavy chain deposition disease (LHCDD) and heavy chain deposition disease (HCDD) can produce significant clinical pathology. Analyses of immunoglobulin synthesis by bone marrow cells obtained from 7 patients with LCDD and LHCDD demonstrated the production of excess light chains in all and the presence of incomplete light chains or heavy chain fragments in 5, regardless of the presence of an intact monoclonal protein or related subunit in the serum or urine. Our data indicate that, as is the case with the fibrillar deposits of AL amyloid, the non-fibrillar forms of monoclonal Ig deposition (LCDD and LHCDD) can be associated with the presence of immunoglobulin fragments in bone marrow cells. In some instances these appeared to be synthetic in origin, although rapid intracellular proteolysis or a combination of both could not be excluded. In either case the fragments may be more susceptible to tissue deposition, with subsequent organ compromise, than intact Ig chains.

Treatment of 100 patients with primary amyloidosis: a randomized trial of melphalan, prednisone, and colchicine versus colchicine only

PURPOSE

A clinical trial designed to test whether treatment with melphalan, prednisone, and colchicine (MPC) is superior to colchicine (C) alone was performed in patients with primary amyloidosis (AL), a nonmalignant plasma cell dyscrasia.

PATIENTS AND METHODS

Patients were randomized to MPC or C with stratification according to sex, time from diagnosis to study entry (ie, less than 3 months or 3 to 12 months), and dominant organ system involvement (ie, cardiac, renal, neurologic, or others). Data were gathered monthly from patients, quarterly from physicians, and annually in the Clinical Research Center. One hundred consecutive patients with AL amyloidosis admitted between 1987 and 1992 who met eligibility requirements were treated and followed for a minimum of 18 months. Fifty patients (group A) received daily oral colchicine and 50 patients (group B) received cycles of oral melphalan and prednisone every 6 weeks for 1 year as well as colchicine.

RESULTS

The principal outcome measure was median survival, which was compared in the two treatment groups and in the subgroups. The overall survival of all patients from study entry was 8.4 months. Comparing group A (C) to group B (MPC), the survival was 6.7 months versus 12.2 months (P = 0.087). Both treatment groups had poor survival for patients in the cardiac subgroup, longest survival in the renal group, and significant differences favoring MPC treatment only in patients whose major system manifestations were neurologic (P = 0.037) or other (P = 0.007). Multivariate analysis showed a strongly significant treatment effect (P = 0.003) and improved survival associated with not having cardiac or gastrointestinal involvement.

CONCLUSIONS

MPC was advantageous for patients whose major manifestations of amyloid disease were other than cardiac or renal. Better survival regardless of treatment was noted in patients for whom a satisfactory supportive treatment such as transplant or dialysis exists for their organ failure.

Amyloidosis: prognosis and treatment

The objective of this study was to review (1) the factors that have been linked to prediction of clinical outcome and survival in amyloidosis and (2) the available studies on the therapy for localized and systemic forms of amyloidosis. We made a retrospective review of the relevant literature on treatment and prognosis in localized and systemic amyloidosis dating back to 1975. The most important prognostic factors in amyloidosis are the presence of congestive heart failure, beta 2-microglobulin, and whether peripheral neuropathy dominates the presentation. The presence of a monoclonal light chain in serum or urine, multiple myeloma, and hepatic involvement are also important adverse factors. Colchicine is beneficial in treating familial Mediterranean fever and may play a role in managing secondary amyloidosis in inflammatory bowel disease. Chlorambucil is particularly useful in juvenile rheumatoid arthritis with amyloidosis. Dimethyl sulfoxide provides benefit in bladder and lichen amyloidosis. A trial of alkylating agent-based chemotherapy is reasonable in symptomatic primary systemic amyloidosis. Advances have been made in the treatment of amyloidosis and include chemotherapy, dialysis, transplantation, and improved supportive care. Definite disease regressions with long-term survival (> 10 years) are seen. Unfortunately, alternatives still need to be developed: Of 859 patients with primary systemic amyloidosis seen at the Mayo Clinic from 1982 to 1992, the median survival was 2.1 years.

Colchicine in the treatment of AA and AL amyloidosis

Colchicine is an effective medication in the prevention and treatment of amyloidosis of familial Mediterranean fever. Its therapeutic effect depends on the stage of renal disease and the drug dose. To evaluate colchicine effect in AA amyloidosis of other diseases and in primary AL amyloidosis, the literature was reviewed. Findings were that (1) the effect of colchicine in reactive amyloidosis has not been methodically studied, but anecdotal reports suggest it may be beneficial; and (2) the results of studies and case reports on the effect of colchicine in primary amyloidosis are conflicting. Because a therapeutic effect of colchicine in primary and reactive amyloidosis has been shown in sporadic cases, a prospective, controlled, multicenter study assessing the effect of colchicine in all types of amyloidosis appears to be justified. Until such a study is available, the addition of colchicine in an appropriate dose to any therapeutic regimen of patients with AA or AL amyloidosis should be considered.

De novo amyloidosis in a renal allograft: a case report and review of the literature

Recurrent amyloidosis is an uncommon but well-documented event in up to 26% of renal allograft recipients transplanted for amyloid renal disease. Both primary and secondary amyloidoses recur. De novo primary and secondary amyloid have not been previously reported. We report the first occurrence of de novo secondary amyloid in a renal allograft recipient. The cause of the secondary amyloidosis is unproven, but possible etiologies include inflammation secondary to occult hepatitis, rheumatoid arthritis, or chronic rejection. Colchicine therapy has not resulted in decreased proteinuria or improved renal function.

Amyloidosis of immunoglobulin origin: useful treatment?

Six patients are presented in whom a diagnosis of amyloidosis of immunoglobulin origin was established by light and electron microscopy of biopsy samples. Treatment with a regimen of intermittent doses of melphalan and prednisone resulted in a survival of 48-82 months in four of the patients while two patients died within three months of diagnosis, too soon for the therapy to have been effective. When compared with published series which suggest that the median survival of this condition is approximately 14 months, our results suggest that this treatment prolongs life successfully. These patients also enjoyed a greatly improved quality of life while receiving treatment.

Recognition of congestive heart failure due to senile cardiac amyloidosis

Senile cardiac amyloidosis has been considered an incidental finding at autopsy in the elderly and of little clinical importance. Autopsy studies have shown that a subset of this group have large deposits of amyloid in their ventricles. Many of these patients had congestive heart failure antemortem. Senile cardiac amyloidosis, however, is rarely diagnosed antemortem and is often confused with primary systemic amyloidosis involving the myocardium. Using endomyocardial biopsy with newly developed immunohistochemical techniques, we have been able to recognize senile cardiac amyloidosis premortem. We have found that these patients have a longer survival than patients with primary systemic amyloidosis. In addition, senile cardiac amyloidosis occurs at a younger age than autopsy studies suggest. Recognition is important because these patients should not be given treatment reserved for the therapy of primary cardiac amyloidosis.

Pathology of dysproteinemia: light chain amyloidosis, non-amyloid immunoglobulin deposition disease, cryoglobulinemia syndromes, and macroglobulinemia of Waldenström

This review has dealt with four syndromes associated with dysproteinemia, and has emphasized studies of the tissue deposits and forms of tissue injury which occur in such patients. However, similar tissue deposits and tissue damage occasionally occur in the absence of a serum or urine paraprotein, in which case other clinical data are necessary to suggest the need for examination of tissue for Ig heavy and light chain determinants in order to provide a correct diagnosis of dysproteinemia. In such cases, one may speculate that there is a low rate of paraprotein production and secretion, in addition to tissue tropism. Some paraproteins are antibodies, in which case they may circulate and/or deposit as immune complexes, or bind to tissue antigens with immune complex formation in situ. Some paraproteins are also cryoproteins, and clues to this property can also be found in the tissue, particularly at the ultrastructural level. Thus, a wide spectrum of clinical manifestations of a B cell proliferative disorder may be associated with any of a variety of circulating paraproteins and a variety of forms of tissue deposit and injury. Consequently, the best understanding of an individual patient requires correlation of the clinical features of the disorder, the immunochemical characterization of the circulating and excreted paraproteins, and an immunohistochemical analysis of the tissue deposits and associated morphologic abnormalities. This should be correlated with histologic and immunohistologic assessment of bone marrow, looking for overt B cell neoplasia, the more difficult to define "lymphoproliferative disorders," or alterations in kappa to lambda plasma cell ratios which may correlate with the deposited material. Studies of the Ig synthesized by cultured bone marrow plasma cells, and biochemical analyses of the deposited material, have demonstrated structural abnormalities of paraproteins which may be responsible for their tissue deposition.

Morphologic differences in the pattern of liver infiltration between systemic AL and AA amyloidosis

Biopsy and necropsy tissue from 31 unselected patients with systemic amyloidosis, in which there was histologic evidence of liver involvement, were reviewed with reference to the location and pattern of amyloid deposition in the liver. Amyloidosis was classified into AA and AL types on the basis of immunohistochemistry and permanganate reaction of the amyloid deposits. Nineteen were categorized as AA (secondary) and 12 as AL (primary) amyloidosis. Deposition of AA amyloid was limited to the walls of vessels in the portal tract, constituting a "vascular" pattern. In AL amyloidosis, the deposits exhibited a "sinusoidal" pattern in that they were seen along hepatic sinusoids as well as in vessel walls. This difference was statistically significant (P less than .001). The histologic pattern of liver infiltration offers a valuable clue in the classification of systemic amyloidosis and provides information that may be useful in the selection of patients for therapy.

Amyloid myopathy and myeloma: response to treatment

A 57 year old female presented with an amyloid myopathy in association with lambda light chain myeloma. Treatment with melphalan and prednisolone resulted in remission of both myeloma and myopathy.

Aberrant immunoglobulin synthesis in light chain amyloidosis. Free light chain and light chain fragment production by human bone marrow cells in short-term tissue culture

Bone marrow cells obtained from 14 patients with light chain amyloid (AL) deposition were examined by biosynthetic labeling techniques. These analyses identified free monoclonal light chain (L-chain) synthesis even in those patients whose serum or urine contained no M protein or free L-chains or only an intact M protein. The experiments also identified a subset of patients whose plasma cells synthesized polypeptides bearing constant region antigenic determinants that migrated more rapidly than intact L-chains on polyacrylamide gels. Since most AL fibrils contain L-chain fragments rather than intact L-chains, these studies suggested that the genesis of the fibril components may reflect aberrant synthesis, proteolytic processing, or both. We also noted that in some individuals the pattern of Ig synthesis normalized after several courses of cytotoxic therapy. Thus, we could use bone marrow Ig synthesis as a sensitive biochemical parameter for monitoring therapy. Finally, the presence of aberrant synthetic products in these clones raised questions about their origin with respect to the normal processes of transcription, translation, and posttranslational modification in Ig-producing cells.

Characterization of tissue amyloid by immunofluorescence microscopy

Immunohistochemical classification of amyloid type was possible in 44 of 50 (88%) patients as judged by the concordance of immunofluorescence, clinical, serum, and urine immunoelectrophoresis, and bone marrow data. In frozen tissue sections incubated with a panel of antisera monospecific for immunoglobulin heavy chains, kappa and lambda light chains, and amyloid-A-related protein, the amyloid was classified as AL in 20 and AA in 24. In 6 patients the amyloid could not be classified because of the absence of reactivity in 2 and overlap staining in 4. The findings indicate that routine immunofluorescence examination of diagnostic biopsies is an important adjunct in the classification of amyloid.

Treatment of AL amyloidosis with melphalan, prednisone, and colchicine

Seven patients with immunoglobulin type (AL) amyloidosis were treated with combination chemotherapy, including melphalan, prednisone, and colchicine. Two patients died within 5 months of the beginning of therapy. Both had amyloid cardiomyopathy. Five patients were alive 17-60 months after the start of therapy, and none had shown progression of disease. The most significant findings were the resolution of the nephrotic syndrome in 2 patients, and improvement of liver function, as demonstrated by excretion of indocyanine green, in 2 patients. These results are encouraging and support the need for further studies of this regimen of combination chemotherapy for patients with AL amyloidosis.

Response of primary hepatic amyloidosis to melphalan and prednisone: a case report and review of the literature

We report the first case of biopsy-proven primary hepatic amyloidosis in which histologic regression was demonstrated after therapy with melphalan and prednisone. On the basis of the cumulative reported experience regarding the treatment of this rare plasma cell dyscrasia, we recommend a trial of cytotoxic therapy for patients with primary hepatic amyloidosis.

Primary systemic amyloidosis. Comparison of melphalan/prednisone versus colchicine

This is the first prospectively randomized study of the use of melphalan/prednisone and colchicine in the treatment of primary systemic amyloidosis. One hundred one patients were stratified according to their dominant clinical manifestation. Forty-nine patients initially received melphalan/prednisone and eight subsequently had colchicine added to their regimen. Fifty-two patients initially received colchicine and 35 subsequently required melphalan/prednisone because of progressive disease. There was no difference in survival when the two groups were analyzed in aggregate (melphalan/prednisone, 25.2 months versus colchicine, 18 months; p = 0.23). When the survival of patients receiving only one regimen was analyzed or when survival was analyzed from the time of entry into the study to the time of death or progression of disease, significant differences (p less than 0.001 and p less than 0.0001, respectively) were evident, favoring melphalan/prednisone. This study suggests that melphalan/prednisone is superior to colchicine in the treatment of primary amyloidosis, but to confirm this impression, a study without a crossover group is necessary.

Prolonged dimethylsulphoxide treatment in 13 patients with systemic amyloidosis

Continuous oral dimethylsulphoxide (DMSO) treatment (7-15 g/day) was given to 3 patients with amyloidosis of familial Mediterranean fever (FMF), 3 patients with idiopathic amyloidosis, and 7 patients with secondary amyloidosis. The nephrotic syndrome and various degrees of renal insufficiency were the major clinical manifestation in all case. Renal function was used as the main parameter for evaluation of therapy. DMSO treatment for 7-16 months produced no effect in the FMF patients and in the patient with idiopathic amyloidosis; they all ran the predictable clinical course of their disease and either died of cardiac failure or have been maintained on chronic haemodialysis. In the 7 patients with secondary amyloidosis an unequivocal improvement of renal function was observed following 3-6 months of DMSO treatment. It was shown by a 30-100% rise of creatinine clearance and a decline in proteinuria. This new equilibrium has been maintained as long as DMSO was administered. No serious side effects of DMSO wee encountered. Mild nausea and an unpleasant breath odour were the patients' main concern. We conclude that a therapeutic trial with oral DMSO is warranted in all patients with secondary amyloidosis. This treatment is unpleasant but bears no exceptional risks. It may significantly prolong life, though its effect on amyloid deposits themselves is doubtful.

Subepithelial argyrophilic spicular structures in renal amyloidosis--an aid in diagnosis. Pathogenic considerations

Eighteen cases of amyloidosis with renal involvement were classified utilizing clinical and laboratory data as to the most likely major amyloid fibril protein type and studied as to their histological, tinctorial, immunofluorescence, and electron microscopic features. No differences could be appreciated between the AA and AL types of amyloidosis. Immunofluorescence did not aid in the diagnosis of amyloidosis and was confusing in some cases owing to apparent absorption of serum proteins. Subepithelial spicular structures were noted in the glomerular capillary loops in 14 of 18 cases (78 per cent), and similar structures were found related to tubular epithelial cells in six of these cases and were related to the parietal epithelium of Bowman's membrane in one case. These spicular structures were a valuable aid in the diagnosis of early amyloidosis by light microscopy, but electron microscopy was essential for confirmation. We postulate that because of the intense staining quality of spicular structures using argyrophilic techniques, these spicules result from a unique interaction between amyloid fibrils and locally produced substances, most probably renal epithelial basement membrane glycoprotein.

Amyloidosis of the stomach. Report of a case with ultrastructure

The author reports on a rare case of local amyloidosis (amyloid tumour) of the stomach. The first electron-microscopic study of such case was performed by her. She observed a large number of microfilaments in the mucus producing cells of the stomach mucosa, and assumed this to be indicative of a pathologic mucus secretion. The epithelial cells involved also changes indicating the disorder of protein secretion. She treats in detail the electron-microscopic characteristics of cellular elements found in amyloid. The closest relationship to amyloid deposits was shown by myofibroblasts. They probably play an important role in the formation of local amyloid.

Synthesis of abnormal immunoglobulins in lymphoplasmacytic disorders with visceral light chain deposition

Three patients presented with renal or more diffuse tissue deposits of a nonamyloid material reactive with anti-kappa antibody by immunofluorescence. All patients had progressive renal failure with the nephrotic syndrome and extensive tubular basement membrane deposits. Glomerular lesions were conspicuous but heterogeneous. One patient also had hepatic deposits with peliosis at histopathologic examination. An underlying lymphoplasmacytic disorder was found in all patients: multiple myeloma in one, pleomorphic lymphoplasmacytic malignancy analogous to Waldenström's macroglobulinemia in one and bone marrow monoclonal plasmacytosis without overt myeloma in one. Biosynthesis experiments in two cases showed production of abnormal kappa chains which were not detected in appreciable amounts in serum and urine. These light chains had an aberrant size (abnormally short or large), their apparent molecular weight was larger in secretion than in cytoplasmic extracts (suggesting their glycosylation) and they were secreted as polymers. These results suggest a causal relationship between production of abnormal light chains and tissue deposition.