Imaging of focal amyloid depositions in the head, neck, and spine: amyloidoma

Fine-needle aspiration of amyloidoma: A critical analysis

BACKGROUND

Amyloid, presenting as a mass, is termed amyloidoma. Among the reported cases, fine-needle aspiration (FNA) of amyloid is often misinterpreted as acellular nondiagnostic material.

METHODS

A computer search of all FNAs was performed and cases diagnosed as amyloidoma were identified.

RESULTS

Among 11,956 cases and 20,634 FNAs, there were six cases and 12 FNAs of amyloidoma. One case with mucin/myxoid matrix was misinterpreted as amyloid, which on our review was Congo red negative. All five other cases of amyloidoma were adequate for evaluation. The smears showed most of the aspirated contents in the middle of the slide and it did not spread when smeared. The amyloid was present as large chunks of waxy, smooth, orangophilic/cyanophilic fragments on Papanicolaou stain and as basophilic fragments on Diff-Quik stain in a clean background. In cases with lymphoma/myeloma, there were admixed lymphocytes and/or plasma cells. Unlike fibrous tissue, amyloid aspirates well and provides adequate material for interpretation. The clean background distinguishes it from mucin/myxoid matrix. Congo red stain was positive with apple green birefringence in all five cases. Further subtyping by mass spectrometry showed AL (κ) type in three patients and AIns (insulin) type in one patient. In one patient with lymphoma, the subtyping was not done.

CONCLUSION

FNA of amyloidoma is rare (0.04%), but an optimal method for diagnosis and subtyping, avoiding unwanted surgical interventions. Although mistaken for fibrous tissue, which aspirates poorly, abundant acellular orangophilic/cyanophilic material on FNA should raise a suspicion for amyloid. Unlike mucin/myxoid matrix, amyloid does not smear the background.

Laryngeal Amyloidosis: What is the Role of Imaging?

OBJECTIVE/HYPOTHESIS

To review the imaging findings of laryngeal amyloidosis and to identify radiological findings suggestive of this disease.

STUDY DESIGN

Retrospective case series.

METHODS

A retrospective chart review of patients with pathologically confirmed laryngeal amyloidosis was performed from 2009 to 2022. Clinical and demographic factors were collected. A fellowship-trained head and neck radiologist reviewed all computed tomography (CT) scans and magnetic resonance imaging (MRI) findings within this cohort.

RESULTS

12 patients were identified and a total of 36 imaging studies analyzed. Localized amyloidosis was found in the supraglottic region (n = 6), glottic region (n = 7), and subglottic region (n = 5); six patients had disease spanning two subsites. The most common finding on the CT scan was a homogeneous and well-defined submucosal soft tissue mass. Punctate calcifications were present in three cases. The presence of contrast enhancement was identified in the majority of patients who underwent MRI (4/5). MRI showed consistent signal intensity, hypointense, or isointense on both T1-weighted and T2-weighted images. Diffusion-weighted sequences were obtained in every patient and did not demonstrate diffusion restriction.

CONCLUSION

This is the largest series searching for unifying imaging characteristics of laryngeal amyloidosis. This research suggests that characteristics from CT and MR provide both similar and unique features of laryngeal amyloidosis on imaging. Both modalities identify a submucosal mass. CT is the preferred modality to demonstrate punctate calcifications, while MRI identifies enhancement and altered signal characteristics. The main benefit of serial imaging is the correlation with patient symptoms, identification of the extent of disease, and assisting in delineating appropriate timing for surgery.

Surgical treatment of laryngeal amyloidosis: a systematic review

PURPOSE

The aim of this review was to study the surgical management of laryngeal amyloidosis and estimate the rate of recurrence after surgery.

METHODS

A systematic review searching PubMed and EMBASE was performed. A qualitative synthesis of data regarding the surgical management of LA and a quantitative analysis of the recurrence rate after surgery was conducted.

RESULTS

This systematic review included 14 retrospective studies, one of whom is retrospective controlled. A total of 515 subjects were included, the mean age ranged from 43.3 to 58 years with a male-to-female ratio of 1:1.3. All cases had a localized laryngeal amyloidosis. The supraglottic region was the most affected laryngeal site and multiple sites were commonly involved. Surgical treatment consists of endoscopic excision using laser, cold or powered instruments. Open surgery is required for severe primary case or revision surgery. Surgical complications such as granulomatosis scar tissue formation, tracheostomy, laryngotracheal stenosis, pneumothorax and concomitant malignancy were developed in 17.5% of patients. The time onset to diagnosis varied from 1 months to 15 years and the duration of follow-up from 3 months to 25 years. The rate of recurrence was 28.4% (95% CI 24.5-32.6) and the timing of recurrences ranged from 3 months to 10 years.

CONCLUSION

The recurrence rate after primary surgery for laryngeal amyloidosis is high. A tailored surgical treatment based on the disease extension and a long-term follow up are recommended.

Treatment of Localized Amyloid Light Chain Amyloidosis With External Beam Radiation Therapy

PURPOSE

Localized amyloidosis is a condition characterized by deposits of fibrillary proteins confined to a single organ. The most common subtype is amyloid light chain amyloidosis, which is caused by secretion of amyloidogenic light chain by a monoclonal population of plasma cells. We present a review and discussion of the literature in the context of a case presentation of localized amyloid light chain amyloidosis of the nasopharynx treated with radiation alone.

METHODS AND MATERIALS

We reviewed literature relevant to this topic from 1970 to the present. Relevant studies, reports, and articles were summarized in table form.

RESULTS

Surgical resection has historically been the primary therapeutic modality for these patients, with radiation being reserved for recurrent lesions or for those unfit for surgery. Although the data are limited to small retrospective series, radiation has been shown to provide good control with mild toxicity that is as good as or better than surgery. Doses range from 20 to 45 Gy, conventionally fractionated. There is no known risk of progression to systemic disease without local therapy.

CONCLUSIONS

We recommend local therapy for symptomatic patients after systemic disease has been excluded. We generally recommend radiation in the setting of recurrent lesions, unacceptable toxicity with surgery, poor surgical candidates, and as the initial modality in select patients (elderly individuals with bothersome but nonobstructive lesions).

Magnetic resonance imaging of a temporal lobe cerebral amyloidoma

Amyloidomas are focal solitary amyloid masses without systemic involvement that have been observed to occur in various body locations. When presenting intracranially, they pose a challenging diagnostic and therapeutic course given their location and rarity. We report a case of a 62-year-old man with a 4-year history of seizure and headaches. Magnetic resonance imaging was initially inconclusive but revealed an ill-defined right temporal lobe lesion. Biopsy later confirmed a cerebral amyloidoma. We also review the current literature on the pathogenesis, imaging findings, prognosis, and treatment of cerebral amyloidomas.

Cerebral Amyloidoma Accompanied by Sjögren's Syndrome: A Case Report and Literature Review

We present a 69-year-old woman with colorectal cancer and a left frontal lobe tumor that was diagnosed as a cerebral amyloidoma after surgical resection. Further postoperative systemic evaluation revealed another amyloidoma in her hip as well as Sjögren's syndrome. Systemic amyloidosis was not present. To the best of our knowledge, this is the first case of cerebral amyloidoma presenting as one of the multiple localized amyloidomas accompanied by Sjögren's syndrome. We also present a systematic review of 65 cerebral amyloidoma cases reported in the literature over the past 40 years and discuss patient characteristics and pathological and imaging findings associated with prognosis.

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.

Amyloidosis: Multisystem Spectrum of Disease with Pathologic Correlation

Amyloidosis is a group of conditions defined by extracellular deposition of insoluble proteins that can lead to multiorgan dysfunction and failure. The systemic form of the disease is often associated with a plasma cell dyscrasia but may also occur in the setting of chronic inflammation, long-term dialysis, malignancy, or multiple hereditary conditions. Localized forms of the disease most often involve the skin, tracheobronchial tree, and urinary tract and typically require tissue sampling for diagnosis, as they may mimic many conditions including malignancy at imaging alone. Advancements in MRI and nuclear medicine have provided greater specificity for the diagnosis of amyloidosis involving the central nervous system and heart, potentially obviating the need for biopsy of the affected organ in certain circumstances. Specifically, a combination of characteristic findings at noninvasive cardiac MRI and skeletal scintigraphy in patients without an underlying plasma cell dyscrasia is diagnostic for cardiac transthyretin amyloidosis. Histologically, the presence of amyloid is denoted by staining with Congo red and a characteristic apple green birefringence under polarized light microscopy. The imaging features of amyloid vary across each organ system but share some common patterns, such as soft-tissue infiltration and calcification, that may suggest the diagnosis in the appropriate clinical context. The availability of novel therapeutics that target amyloid protein fibrils such as transthyretin highlights the importance of early diagnosis. Online supplemental material is available for this article. ^©RSNA, 2021.

Localised laryngotracheal amyloidosis: a differential diagnosis not to forget

We present a case of multifocal laryngotracheal amyloidosis (LTA) in a 43-year-old man with persistent and progressive dysphonia and dyspnoea, and a first inconclusive histology. Although laryngeal amyloidosis accounts for fewer than 1% of all benign laryngeal tumours, it is in fact the most common site of amyloid deposition in the head, neck and respiratory tract. The clinical scenario is non-specific and diagnosis depends on a high degree of suspicion and on histology. Imaging is useful in mapping lesions, which are often more extensive than they appear during laryngoscopy. Despite being a benign entity, the prognosis is variable with a high-rate and long-latency recurrences, requiring long-term follow-up.

Amyloidosis in the head and neck: CT findings with clinicopathological correlation

PURPOSE

To characterize the CT imaging features of head and neck amyloidosis and correlate with extent of disease and clinical outcomes.

MATERIALS AND METHODS

This retrospective study included 80 patients with head and neck amyloidosis who underwent soft tissue neck CT imaging between November 2003 and April 2018. The CT imaging features including lesion distribution, morphology (focal, diffuse/circumferential, or combined), presence and pattern of calcification, (punctate or diffuse), and thickness of airway lesion were evaluated and compared with the extent of amyloidosis (localized or systemic), and clinical course (stable, no recurrence, or progression requiring repeated surgical treatment).

RESULTS

Localized disease (83.8%, 67/80) was most common with AL type (97.6%, 41/42) representing nearly all cases of head and neck amyloidosis. The larynx was the most frequently affected organ (60.0%, 48/80), specifically the glottis (43.8%, 35/80). Calcification was seen in 65.0% of cases (52/80). Non-airway or tongue lesions were significantly associated with systemic (92.3%, 12/13) as opposed to localized amyloidosis (4.5%, 3/67; P < 0.001). Repeated surgical treatment was significantly associated with laryngeal amyloidosis (35.3%, 12/34; P = 0.002) and multi-centric disease (33.3%, 10/30; P = 0.048). Airway wall thickness in patients who required repeated surgical treatment was significantly greater than in patients with stable or no recurrent disease (P = 0.016).

CONCLUSION

Knowledge of the imaging features of head and neck amyloidosis can aid the diagnosis, disease monitoring, and prediction of patients requiring repeated surgical intervention.

A Rare Nasopharyngeal Presentation of Amyloidosis

Amyloidosis is a heterogeneous group of diseases characterized by the extracellular deposition of insoluble proteins whose pathogenesis is not yet fully understood. The deposition of amyloid proteins can be systemic or localized, idiopathic or related to systemic diseases, mostly multiple myeloma or chronic inflammatory diseases. Localized head and neck amyloidosis is a rare entity, mainly involving the larynx. Given the rarity of the disease and the absence of a lasting follow-up protocol, there is no standard treatment defined for localized amyloidosis. We report a rare case of localized nasopharyngeal amyloidosis, treated with complete transoral resection and confirmed by histological examination.

Localized Sinonasal Amyloidosis

Localized amyloidosis involving the nasal mucosa is rare, with only 38 published cases reported to date. We report a case of amyloidosis localized to the sinonasal tract. A 61-year-old man presented with a 1-year history of left-sided nasal obstruction. Endoscopic examination and computed tomography revealed the presence of a nasal mass originating from the left inferior turbinate. The patient subsequently underwent an examination under anesthesia and an excision biopsy of the nasal mass. Histology confirmed amyloidosis with no immunospecific stains. Systemic amyloidosis testing was negative, leading to a diagnosis of localized sinonasal amyloidosis of nonamyloid A (AA) subtype. To our knowledge, this is the second reported case of non-AA subtype of the sinonasal tract. The patient was managed conservatively and is currently under close follow-up.

Immunophenotyping Oral Amyloidosis for the Precise Identification of the Biochemical Forms: A Retrospective Study

Background:

Amyloidosis refers to a group of systemic and localized disorders associated with the accumulation of misfolded protein aggregates called amyloids in different parts of the body. Owing to the existence of multiple forms of amyloids with similar tertiary structures, precise identification of their biochemical form is critical for correct therapy.

Objective:

This retrospective study aimed to determine whether typing of oral amyloid deposits can help diagnose a serious systemic condition in the early phase of the disease

Methods:

All histopathologically confirmed cases of amyloidosis managed over a 14-year period (January 1, 1997 to December 31, 2011) were retrieved for analysis. Two board-certified oral and maxillofacial pathologists reviewed the histopathological findings of amyloidosis on the basis of its classic Congo red staining characteristics. This was followed by immunohistochemical analysis of biopsy samples using a panel of antibodies specific for different forms of amyloidosis.

Results:

The most common location of amyloidosis was the tongue, and women were more commonly affected than men. The patient age ranged from 11 to 83 years (average 59.3 years). In patient 9, light-chain and pre-albumin (transthyretin) antibodies were related to arthritis and senile amyloidosis, respectively. The biopsy sample of patient 10, who was reported to have multiple myeloma, was positive for light chains and β2 microglobulin. All other samples exhibited localized (solitary) amyloidosis.

Conclusion:

Histological analysis coupled with immunostaining with a panel of specific antibodies might assist in identifying early systemic amyloidosis in patients with localized oral forms of the disease.

Calcium pyrophosphate dihydrate crystal deposition disease of the spinal dura mater: a case report

Calcium pyrophosphate dihydrate (CPPD) crystal deposition disease is characterized by the accumulation of CPPD crystal in articular and periarticular tissues, but CPPD crystal deposition along the spinal dura mater has not been previously reported. We report a 54-year-old male presenting with progressive neck pain and numbness of the extremities. CT showed diffuse dorsal epidural calcification from C3-T6 which resulted in spinal canal stenosis. On MR imaging, the lesion was hypointense on both T₁ and T₂ weighted images. From these findings, CPPD crystal deposition in the ligamentum flavum was suspected preoperatively. Biopsy at the level of C5-6 were performed to confirm the diagnosis. Perioperative and histopathological findings revealed that CPPD crystals were deposited along the dorsal dura mater, not in the ligamentum flavum. We firstly report the CT and MR imaging features of a possible new concept in the differential diagnosis of CPPD crystal deposition disease.

Neurosurgical aspects of dialysis-related spinal amyloidosis: Report of three cases and a review of the literature

BACKGROUND AND PURPOSE

Osteoarticular manifestations of beta-2 microglobulin amyloidosis are often diagnosed in long-term dialyzed patients. However, spinal involvement is rare (10-25% of patients), and generally not associated with neurological deterioration. Compression of the spinal cord or roots is extremely rare, and probably under-recognized.

METHODS

The authors describe three cases of spinal stenosis presenting with neurological signs in long-term dialyzed patients, prospectively collected over 2 years in two different institutions and treated by surgical decompression. In all three cases, the main cause of neural compression was amyloid deposition in the spine, either extradurally in the ligamentum flavum or intradurally.

RESULTS

All patients improved after surgery and did not present any postoperative complications. However, two out of three patients with amyloid in the cervical spine required surgical revision to obtain a satisfactory decompression of the spinal cord.

DISCUSSION

The authors discuss spinal amyloidosis which is a well-known complication of long-term dialysis. However, neurological complications such as spinal cord or radicular symptoms have been rarely reported and, when present in dialyzed patients, are symptoms that are often attributed to other causes. To our knowledge, this is the first case series that demonstrates the relationship between neurological deterioration and amyloid depositions in the spinal canal that occur in long-term dialyzed patients. The prevalence of spinal stenosis related to the presence of amyloid in this specific subgroup of patients is probably underestimated.

Laryngotracheal Involvement in Systemic Light Chain Amyloidosis

Laryngotracheal amyloid deposition is an uncommon manifestation of systemic light chain amyloidosis. Diagnostic imaging, such as CT, is useful for suggesting the possibility of amyloidosis and delineating the extent of the lesions for surgical management; however, the diagnosis is confirmed with the histologic finding of amorphous eosinophilic material which stains positively for Congo red and may show apple green birefringence on polarization. These features are exemplified in this sine qua non radiology-pathology correlation article.

Pharyngeal amyloidomas: Variable appearance on imaging

Amyloidomas are rare tumor-like depositions of abnormally folded, insoluble proteins that may be seen in the setting of systemic amyloidosis or as isolated tumoral deposits. Focal, isolated amyloidomas carry an excellent prognosis whereas systemic amyloidoses do not. The ability to identify or suggest amyloidoma on imaging studies may help direct laboratory testing and eventual diagnosis. Amyloidomas involving the head and neck have been variably described from homogeneously T2 hypointense to iso-slightly hyperintense relative to skeletal muscle. Herein we present two patients with pharyngeal submucosal amyloidomas of differing sizes and imaging characteristics to emphasize their potential widely variable imaging appearance and broaden our knowledge of these rare lesions.

Nonamyloid tumoral light-chain-deposition disease (aggregoma) of the paraspinal region

Aggregomas are rare localized masses of monoclonal nonamyloid immunoglobulin light-chain deposits. To date, there have been only a few reports of isolated aggregomas, with the majority detailing renal, lymph node and brain deposition. We present a rare case of paraspinal aggregoma in a 67-year-old female who presented with a complaint of cough and chest pain. Imaging demonstrated a left-sided paravertebral mass extending from T7-T10. Pathological analysis showed lamellar deposition of extracellular eosinophilic material with an associated lymphoplasmacytic nonamyloid infiltrate. To our knowledge, this is the first report of a paraspinal aggregoma. While exceedingly rare, this tumor can be included in the radiologic differential diagnosis of paravertebral soft tissue tumors in adults. The observation of our case adds to the limited understanding of the etiology, pathogenesis, natural history, and treatment of nonamyloid light-chain depositions.

[Cervical epidural β2-microglobulin amyloidoma presenting with acute paraplegia 5 months after introduction of hemodialysis]

A 66-year-old man was admitted to our hospital with acute paraplegia. He has suffered from hypertension with renal dysfunction for 7 years. Five months before admission, hemodialysis was introduced to him because of chronic renal failure due to renal sclerosis. One week before hospitalization, he noticed dizziness, sensory disturbance below the chest, and a urinary difficulty. Two days prior to admission, he could not walk independently. Spinal MRI revealed a mass at the 7th level of the cervical spine, showing low intensity on T(1)-weighted image and surrounding hypointensity with inner mixed intensity on T(2)-weighted image. An urgent surgery removed the cervical epidural mass and the following pathological evaluation established the diagnosis of β2-microglobulin amyloidoma. Hemodialysis-related amyloidoma generally emerges after a long duration of hemodialysis, demonstrates an insidious onset of symptoms, and is very rare. The current case indicates that we need to be aware of the possibility of β2-microglobulin amyloidoma even in patients with a short history of hemodialysis with a rapid presentation.

The myriad of diseases that present with polyostotic bone lesions

Many diseases result in polyostotic bone lesions including benign entities, benign entities with malignant potential, intermediate entities, and malignant entities. Imaging plays a key role in identifying complications of these disorders, most importantly malignant transformation of a benign lesion. The most common polyostotic bone lesions are reviewed and examples of malignant transformation are highlighted.

Multiple myeloma-associated iliopsoas muscular amyloidoma first presenting with bilateral femoral nerve entrapment

We report a 38-year-old man of multiple myeloma with bilateral femoral nerve entrapment caused by bilateral huge protruding masses in the inguinal areas. The masses were identified as iliopsoas muscular amyloidoma after the operation. He was diagnosed with multiple myeloma 1 year ago before he was admitted to our hospital. He complained of muscle weakness in the bilateral thigh and protruding lumps in the bilateral inguinal areas with tenderness for 6 month. The pelvic MRI revealed round masses in the iliopsoas muscles of bilateral inguinal areas. To implement the nerve decompression, the resection of the bilateral masses was done. The pathological result showed Congo red-positive substance with green birefringence to polarized light in a dense fibrous background. Before the operation, six cycles of chemotherapy with VAD (vincristine, adriamycin, dexamethasone) and two cycles of chemotherapy with PAD (bortezomib, adriamycin, dexamethasone) regimen were performed. One month after the operations, one cycle of chemotherapy with PADT (bortezomib, adriamycin, dexamethasone, thalidomide) regimen was used and the patient reached complete remission. The function of the bilateral femoral nerves restored to normal 7 months after the operation with a Karnofsky score of 100. Twenty-two months follow-up showed that there was no evidence of the recurrence of the iliopsoas muscular amyloidoma and no progression of multiple myeloma.

Amyloidosis

The term amyloid describes the deposition in the extracellular space of certain proteins in a highly characteristic, insoluble fibrillar form. Amyloidosis describes the various clinical syndromes that occur as a result of damage by amyloid deposits in tissues and organs throughout the body. The clinical significance of amyloid varies enormously, ranging from incidental asymptomatic deposits to localized disease through to rapidly fatal systemic forms that can affect multiple vital organs. Currently available therapy is focused on reducing the supply of the respective amyloid fibril precursor protein and supportive medical care, which together have greatly improved survival. Chemotherapy and anti-inflammatory treatment for the disorders that underlie AL and AA amyloidosis are guided by serial measurements of the respective circulating amyloid precursor proteins, i.e. serial serum free light chains in AL and serum amyloid A protein in AA type. Quality of life and prognosis of some forms of hereditary systemic amyloidosis can be improved by liver and other organ transplants. Various new therapies, ranging from silencing RNA, protein stabilizers to monoclonal antibodies, aimed at inhibiting fibril precursor supply, fibril formation or the persistence of amyloid deposits, are in development; some are already in clinical phase.

Computed tomography and magnetic resonance imaging appearance of prolactinoma with spheroid-type amyloid deposition

We report a rare case of prolactinoma with deposition of amyloid and calcifications. Magnetic resonance imaging and/or computed tomography findings have been described in only a few cases. Possible mechanisms of amyloid deposition and calcification were discussed, and literatures were reviewed. In pituitary adenomas, particularly in prolactinomas, amyloid deposits should be included in the differential diagnosis, when hypointense areas are noted on T2-weighted images. Stippled calcifications in the tumor seem to be another characteristic finding.