The Clinical Implication of Incidental Prostatic Amyloidosis

Identification of amyloidosis of the urinary tract and prostate: Opportunities for early diagnosis & intervention in systemic disease

OBJECTIVES

To determine the prevalence of different amyloid types and frequency of associated systemic amyloidosis in the urinary tract/prostate.

METHODS

We studied Congo red-positive prostate (n = 150) and urinary tract (n = 767) specimens typed by a proteomics-based method between 2008 and 2020. Clinical follow up was available for a subset (urinary tract, n = 111; prostate, n = 17). Amyloid types were correlated with various clinicopathologic features. For patients with clinical follow up, chart review was performed to establish localized versus systemic disease, frequency of initial diagnosis of amyloidosis on urinary tract/prostate specimens, presence of cardiac disease, and death from disease-related complications.

RESULTS

The most common amyloid types were AL/AH in urinary tract (479/767, 62 %) and localized ASem1 in prostate (64/150, 43 %). Urinary tract AL/AH amyloid was usually localized, but systemic AL amyloidosis occurred in both sites (urinary tract: 5/71, 7 %; prostate: 2/2, 100 %). ATTR amyloidosis was seen in over a third of cases (urinary tract: 286/767, 37 %; prostate: 55/150, 37 %). Urinary tract/prostate was the site of the initial ATTR amyloidosis diagnosis in 44/48 patients (92 %), and 38/48 (79 %) were subsequently found to have cardiac involvement. Seminal vesicle/ejaculatory duct involvement was pathognomonic for ASem1-type amyloidosis (39/39, 100 %).

CONCLUSIONS

Over 40 % of patients had systemic amyloidosis, with urinary tract/prostate often the first site in which amyloid was identified. Since early recognition of systemic amyloidosis is critical for optimal patient outcomes, there should be a low threshold to perform Congo red stain. Proteomics-based amyloid typing is recommended since treatment depends on correctly identifying the amyloid type.

Isolated prostate amyloidosis; a case report

Identification of amyloidosis on a prostate biopsy specimen raises suspicion for systemic amyloidosis. For patients at risk of prostate adenocarcinoma, a transrectal MRI ultrasound fusion (MRI-TRUS) guided biopsy of the prostate is often needed for further investigation. Our patient is a 70 year old male presenting from his primary care provider with an elevated PSA. The patient underwent MRI-TRUS fusion biopsy of the prostate, which demonstrated AL (lambda)-type amyloidosis, confirmed by mass spectrometry in addition to prostatic adenocarcinoma. He was subsequently diagnosed with primary amyloidosis of the prostate without evidence of other amyloid deposition sites.

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Prostate biopsies rarely have unique pathology, such as amyloidosis in our case.

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Amyloidosis of the prostate should trigger systemic amyloidosis workup.

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Unusually, no further evidence of extraprostatic amyloid deposition was found.

Clinical relevance of amyloid in prostate samples: a report on 40 patients

OBJECTIVE

To describe the clinical findings in patients with incidental prostatic amyloidosis.

PATIENTS AND METHODS

Retrospective search in the database of the Department of Pathology, Hospital de Bellvitge, for prostate specimens with amyloid. Congo red and immunohistochemical staining of the sections. Review of the patients' clinical charts for symptoms attributable to systemic amyloidosis.

RESULTS

Amyloid deposition in the prostate was identified and reported in 40 patients between 2001 and 2022. Median age was 76.5 years (range 62-90). Prostate cancer was diagnosed in 25 patients. Only 4 patients had a previous diagnosis of amyloidosis. In the remaining 36 the prostate sample (31 needle biopsies, two transurethral resections (TUR), two simple prostatectomies, one radical cystectomy for bladder cancer) provided the initial diagnosis. Amyloid deposits were mainly located in the wall of small vessels and rarely in the prostatic stroma. Immunohistochemistry was available in 32 cases, 26 of which were positive for TTR. All patients showed at least one symptom indicative of systemic amyloidosis, the most frequent being hearing loss (55%), carpal tunnel syndrome (42,5%) or other osteoarticular symptoms (tendinopathies, osteoarthritis), cataracts (37.5%), and cardiac symptoms (32.5%), among others.

CONCLUSION

The prostate is a target tissue for amyloid deposition. The incidental finding of amyloid in prostate corresponds, in the majority of cases, to previously undiagnosed systemic TTR amyloidosis in patients lacking signs of heart involvement but having mainly osteoarticular symptoms, hearing and visual impairment.

Amyloidosis of the Urinary Bladder: A Systematic Review and a Proposed Management Algorithm

OBJECTIVE

To propose an algorithm for the management of bladder amyloidosis based on a systematic review of the literature, given that the bladder is the second most commonly affected organ of the urinary tract in the course of systemic or localized amyloidosis.

METHODS

We searched PubMed, Cochrane Library and Scopus databases utilizing PRISMA methodology from inception to November 30, 2020 (PROSPERO: CRD42020207855).

RESULTS

We included 76 studies with 184 patients (9 case series and 67 case reports). Presenting symptoms of bladder amyloidosis comprised of hematuria, irritative or obstructive urinary symptoms, and cystitis-like symptoms. The diagnosis of amyloidosis was established by histologic examination of specimens retrieved during transurethral resection of bladder lesions. Complete endoscopic resection, the cornerstone of management of localized disease, was feasible in 89.1% cases. The included patients were followed up for a mean of 54 months, within which 65 patients (35.3%) recurred. The time to first amyloidosis recurrence was 20 months (range: 1-168). Additionally, 16 individuals presented with concomitant bladder amyloidosis and bladder cancer, while 4 developed bladder malignancy during follow-up. Due to the frequent and early recurrences of patients with bladder amyloidosis, a check-up cystoscopy at 3, 12, and 24 months' after initial resection is recommended. Recurrences should be managed with transurethral resection, while intravesical instillations of dimethyl sulfoxide (DMSO) and cystectomy should be reserved for refractory cases.

CONCLUSION

We propose a management algorithm for bladder amyloidosis based on the available evidence for this rare benign entity that mimics bladder cancer.

Wild-type ATTR amyloidosis of the prostate: a case review

The amyloidoses are a rare group of disorders caused by the deposition of amyloid fibrils in organ tissues. Transthyretin-mediated amyloidosis is a subcategory of amyloidosis, which can be further subdivided into hereditary transthyretin-mediated or wild-type (‘senile’) amyloidosis. Involvement of the prostate by any type of amyloidosis is rare, with only a handful of cases reported in the literature. We report here a case of a 64-year-old Caucasian man who was incidentally found to have wild-type transthyretin-mediated amyloidosis of the prostate following a radical prostatectomy for treatment of a localised, Gleason 7 (4 + 3) adenocarcinoma of the prostate. TTR subtyping was confirmed by mass spectrometry. His family history was negative for known amyloidosis, and sequencing of the entire TTR gene was negative for any mutations, so he was therefore considered to have wild-type TTR amyloidosis. He was subsequently found to have additional foci of amyloid deposition in the gastrointestinal tract. Wild-type transthyretin-mediated amyloidosis as an incidental finding in a prostate biopsy is an extremely rare finding. Treatment options for transthyretin-mediated amyloidosis are limited, and further research and treatment options are needed in this rare and difficult to manage disease.

Level of evidence: The level of evidence according to the Oxford Centre of Evidence-based Medicine levels of evidence is not applicable to this case report. Given that this is a rare entity, decisions made in managing this case were based on a level of evidence of 5.

The Etiology and Pathophysiology Genesis of Benign Prostatic Hyperplasia and Prostate Cancer: A New Perspective

Background: The etiology of benign prostatic hyperplasia and prostate cancer are unknown, with ageing being the greatness risk factor. Methods: This new perspective evaluates the available interdisciplinary evidence regarding prostate ageing in terms of the cell biology of regulation and homeostasis, which could explain the timeline of evolutionary cancer biology as degenerative, inflammatory and neoplasm progressions in these multifactorial and heterogeneous prostatic diseases. Results: This prostate ageing degeneration hypothesis encompasses the testosterone-vascular-inflamm-ageing triad, along with the cell biology regulation of amyloidosis and autophagy within an evolutionary tumorigenesis microenvironment. Conclusions: An understanding of these biological processes of prostate ageing can provide potential strategies for early prevention and could contribute to maintaining quality of life for the ageing individual along with substantial medical cost savings.