Combined Subcutaneous Fat Aspirate and Skin Tru-Cut Biopsy for Amyloid Screening in Patients with Suspected Systemic Amyloidosis

Screening for systemic amyloidosis is typically carried out with abdominal fat aspirates with varying reported sensitivities. Fat aspirates are preferred for use in primary screening instead of organ biopsies as they are less invasive and thereby minimize the potential risk of complications. At Odense Amyloidosis Center, we performed a prospective study on whether the combined use of fat aspirate and tru-cut skin biopsy could increase the diagnostic sensitivity. Both fat aspirates and skin biopsies were screened with Congo Red staining, and positive biopsies were subsequently subtyped using immunoelectron microscopy and mass spectrometry. Seventy-six patients were included. In total, 24 patients had systemic amyloidosis (11 AL, 12 wtATTR, 1 AA), and 6 patients had localized amyloidosis. Combined fat aspirate and skin biopsy were Congo Red-positive in 15 patients (overall sensitivity (OS) 62.5%). Fat aspirates were positive in 14 patients (OS 58.3%), and the skin biopsy was positive in 5 patients (OS 20.8%). In only one patient did the skin biopsy add extra diagnostic information. The sensitivity differed between AL and ATTR amyloidosis—81.8% and 41.7%, respectively. Using skin biopsy as the only screening method is not recommended.

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SYSTEMIC AMYLOIDOSIS IN YOUNG MICE INDUCED BY HUMAN SALIVA ADMINISTRATION

Acta medica Eurasica ◽

10.47026/2413-4864-2021-1-40-56 ◽

2021 ◽

pp. 40-56

Author(s):

Vadim A. Kozlov ◽

Vera Yu. Aleksandrova ◽

Yulia V. Vasilyeva ◽

Sergey P. Sapozhnikov ◽

Pavel B. Karyshev

Keyword(s):

Visual Field ◽

Congo Red ◽

Healthy Person ◽

Human Saliva ◽

Systemic Amyloidosis ◽

Chronic Tonsillitis ◽

Relative Area ◽

Congo Red Staining ◽

Number Of Cells ◽

Young Mice

The urgency of the study lies in the fact that for the first time it was proved in the experiment that intraperitoneal administration of human saliva to young mice causes the development of systemic amyloidosis, comparable to hereditary systemic amyloidosis in humans, induced by mutagenic changes in saliva lysozyme. The aim of the research: to test human saliva as an amyloidogen in a model experiment on young mice in comparison with the albumin model of amyloidosis that we developed earlier. White male mice weighing 20.0–25.0 g were divided into six groups: Intact mice (5); 30 days 1 time every other day were intraperitoneally administered to groups: 1 (5) soy cream substitute TU 9199-004-58706213-10 15 10 g/100 ml water 0.1 ml/10 g; 2 (3) saliva of a healthy person (SHP) 0.5 ml; 3 (3) SHP and Ciprofloxacin (C) 0.05 mg/10 g of weight; 4 (3) saliva of a person with chronic tonsillitis (remission, SCT); 5 (3) SCT+C. Kidney weight changed from 176.0±21 mg in intact mice (IM) to 197±43,0, 195,0±18,0, 195,0±18,0, 183,0±44,0, 153,0±25,0 mg, respectively. The number of cells per visual field of the tubular epithelium decreased by 1.3, 1.2, 1.6, 1.4, 1.4 times from the number of cells per visual field in IM 380.0±84.0 (p = 0.00), glomerular cells – by 1.4, 1.1, 1.3, 1.2, 1.2 times from the number of glomerular cells in IM 34.0±11.0 (p = 0.02), in groups 1-5, respectively. The glomerular area decreased by 2.4, 2.7, 2.3, 2.4, 3.0 times from the average glomerular area in IM (3163.7±832.7 mm2, p = 0.0000). The relative area of amyloid lesion when stained with Congo red: 18.4±8.2% (group 1), 26,7±10,6, 35,0±11,9, 45,7±13,2, 63,6±14,0% (groups 1-5). The spleen mass and length increased from 133.0±16.0 mg (IM) by 1.7, 1.7, 1.8, 2.1, 1.7 times and from 17.0±2.0 mm (IM) by 1.2, 1.2, 1.3, 1.4, 1.2 times, the number of cells per visual field decreased from 1318±205 (IM) by 1.7, 2.0, 3.3, 2.1, 2.0 times, groups 1-5, respectively (p < 0.01). The relative area of amyloid lesion in Congo red staining: 11,4±9,4%, 28,2±16,0, 27,9±20,8, 20,9±12,2, 16,5±8,3% (groups 1-5). The liver mass changed from 1.4±0.15 g (IM) to 1,57±0,26, 1,45±0,18, 1,53±0,1, 1,71±0,3, 1,36±0,4 g, the number of cells per visual field decreased from 67.0±15.0 (IM) by 1.9, 1.4, 1.8, 2.5, 1.9 times, the area of hepatocyte nuclei – from 54.0±12.3 µm (IM) by 3.1, 3.6, 4.2, 3.1, 3.3 times (groups 1-5, respectively, p < 0.01). The relative area of amyloid lesion in Congo red staining: 6,8±4,6%, 15,3±11,0, 24,5±12,8, 9,8±8,5, 12,6±2,3% (groups 1-5). Conclusions: 1) human saliva when administered intraperitoneally causes severe systemic amyloidosis in young mice with damage to the liver, kidneys and the spleen, which manifests more by cytotoxic effect than the volume of amyloid deposition; 2) human saliva contains a more active amyloidogen than albumin in combination with fillers of the soy cream substitute formulation; 2) human saliva of a person with chronic tonsillitis in remission is more amyloidogenic than the saliva of a healthy person; 3) Ciprofloxacin, administered in a therapeutic dose during the amyloid model formation, moderately increases the severity of amyloid organ damage; 4) human saliva can be used to simulate amyloidosis in an experiment on young mice; 5) the liver may contain enzymatic systems that perform the function of amyloidoclasia.

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AMYLOID GOITER AS THE FIRST RECOGNIZABLE MANIFESTATION OF IMMUNOGLOBULIN LIGHT CHAIN AMYLOIDOSIS

AACE Clinical Case Reports ◽

10.4158/accr-2019-0161 ◽

2019 ◽

Vol 5 (5) ◽

pp. e326-e329 ◽

Cited By ~ 1

Author(s):

John J. Orrego ◽

Joseph A. Chorny

Keyword(s):

Light Chain ◽

Congo Red ◽

Monoclonal Gammopathy ◽

Amyloid Deposition ◽

Systemic Amyloidosis ◽

Cardiac Conduction ◽

Light Chain Amyloidosis ◽

Amyloid Goiter ◽

Congo Red Staining ◽

Bethesda System

Objective: Clinically apparent thyroid enlargement due to massive amounts of amyloid deposition, known as amyloid goiter, is rare. Endocrinologists should become familiar with this manifestation of systemic amyloidosis, which may be diagnosed by Congo red staining of the specimen obtained by fine-needle aspiration. Methods: We describe a 70-year-old man who presented with a slowly enlarging goiter. It was asymptomatic, predominantly left-sided, nontoxic, and multinodular with atypia of undetermined significance (Bethesda System category III) by cytology. The goiter tested negative using the ThyraMIR miRNA Gene Expression Classifier kit (eviCore Healthcare, Bluffton, SC). Results: Left thyroid lobectomy produced a 220-g specimen with nodular hyperplasia and prominent amyloid deposition confirmed by Congo red staining. Liquid chromatography tandem mass spectrometry detected a peptide profile consistent with light chain amyloid deposition of the lambda type, formerly called primary amyloidosis. In retrospect, he had been diagnosed with restrictive cardiomyopathy, cardiac conduction system disease, coronary artery disease, non-nephrotic range proteinuria, and chronic kidney disease, which had been attributed to his longstanding type 2 diabetes mellitus. Extensive workup subsequently demonstrated cardiac amyloidosis and monoclonal gammopathy of unknown significance, consistent with light chain amyloidosis. Conclusion: Amyloid goiter should be included in the differential diagnosis of enlarging goiters with Bethesda System category III cytology in patients with monoclonal gammopathy of uncertain significance, clinical manifestations of systemic amyloidosis, or known diagnosis of monoclonal cell dyscrasia.

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Diagnosis and Classification of Amyloidosis in Abdominal Subcutaneous Fat Aspiration Specimens Using Mass Spectrometry Based Proteomics

Blood ◽

10.1182/blood.v112.11.2710.2710 ◽

2008 ◽

Vol 112 (11) ◽

pp. 2710-2710 ◽

Cited By ~ 1

Author(s):

Julie A. Vrana ◽

Steven R. Zeldenrust ◽

Jason D. Theis ◽

Jeffrey D. Gamez ◽

Paul J. Kurtin ◽

...

Keyword(s):

Mass Spectrometry ◽

Congo Red ◽

Subcutaneous Fat ◽

Negative Control Group ◽

Great Accuracy ◽

Negative Control ◽

Systemic Amyloidosis ◽

Control Group ◽

Diagnosis And Classification

Abstract Abdominal subcutaneous fat aspiration is one of the most practical, sensitive and specific methods for the diagnosis of systemic amyloidosis. One limitation of this method, compared to more invasive tissue biopsy based approaches, remains the technical difficulties in further classification of the amyloidosis as commonly used methods, such as immunohistochemistry, are not readily applicable to fat aspiration specimens. To overcome these difficulties we developed a method using nano-flow liquid chromatography electrospray tandem mass spectrometry (LC-MS/MS) that could identify amyloid subtypes in freshly obtained Congo Red positive fat aspirate specimens with great accuracy. Abdominal subcutaneous fat aspirate specimens were obtained from 73 patients with clinical suspicion for systemic amyloidosis. One half of the specimen was stained with Congo red and used for diagnosis of amyloidosis and the other half was processed and enzyme digested for LC-MS/MS analysis. The resulting LC-MS/MS data was correlated to theoretical fragmentation patterns of tryptic peptide sequences from the Swissprot database using Scaffold (Mascot, Sequest, and X!Tandem search algorithms). Peptide identifications were accepted if they could be established at greater than 90.0% probability and protein identifications were accepted if they could be established at greater than 90.0% probability and contain at least 2 identified spectra. The identified proteins were subsequently examined for the presence or absence of amyloid related peptides. Of the 73 cases studied, 41 were positive for Congo red consistent with systemic amyloidosis. In Congo red positive cases, LC-MS/MS peptide profiles consistent with AL-lambda (28/31), AL-kappa (6/7), and ATTR (2/3) were observed. Only one case in the Congo red negative control group (31/32) gave a kappa light chain profile which was attributed to a high level of kappa in the serum (285 mg/dL). Of the 35 out of 41 cases of systemic amyloidosis successfully classified by LC-MS/MS, additional clinical and pathology data validating the amyloid type was available. In each of these cases the MS/MS results accurately predicted the amyloid type. In conclusion, LC-MS/MS proteomic analysis of abdominal subcutaneous fat aspiration specimens involved by amyloidosis provides a highly specific (97% specificity) and sensitive (>85% sensitivity) method for diagnosis and classification of amyloidosis. The method is rapid and readily applicable in a clinical setting and will greatly improve the clinical management of amyloidosis patients.

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Skin Involvement in Primary Systemic Amyloidosis

Mediterranean Journal of Hematology and Infectious Diseases ◽

10.4084/mjhid.2013.005 ◽

2013 ◽

Vol 5 (1) ◽

pp. e2013005 ◽

Cited By ~ 19

Author(s):

Susheel Kumar

Keyword(s):

Blood Vessel ◽

Congo Red ◽

Peripheral Nerves ◽

Index Patient ◽

Skin Lesions ◽

Systemic Amyloidosis ◽

Skin Involvement ◽

Amyloid Deposits ◽

Common Skin ◽

Congo Red Staining

Primary systemic amyloidosis is a rare disease. It primarily involves kidney, heart, peripheral nerves and liver. Intracutaneous hemorrhage manifesting in the form of petechiae, purpura and ecchymoses due to infiltration of blood vessel walls by amyloid deposits are the most common skin lesions. We report a case of primary systemic amyloidosis with multiple, non-itchy, papular lesions in lower eyelids and lower chest wall bilaterally. Diagnosis was confirmed in this case by biopsy of skin lesions using congo red staining. Papular eruptions as seen in index patient are relatively uncommon form of skin manifestations.

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Two kinds of rare light chain cast nephropathy caused by multiple myeloma: case reports and literature review

BMC Nephrology ◽

10.1186/s12882-021-02250-z ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Li-Jun Sun ◽

Hong-Rui Dong ◽

Xiao-Yi Xu ◽

Guo-Qin Wang ◽

Hong Cheng ◽

...

Keyword(s):

Multiple Myeloma ◽

Renal Biopsy ◽

Light Chain ◽

Congo Red ◽

Central Area ◽

Systemic Amyloidosis ◽

Pathological Examination ◽

Cast Nephropathy ◽

Congo Red Staining ◽

Distal Tubules

Abstract Background Light chain cast nephropathy (LCCN) is the most common renal disease caused by multiple myeloma (MM). In addition to ordinary light chain protein casts, there are a few rare casts with unique shapes, including light chain amyloid casts (LCAC) and light chain crystal casts (LCCC). Case presentations Here, we report two patients. Patient 1 is a 72-year-old man who was clinically diagnosed with MM and acute kidney injury (AKI). Pathological examination of a renal biopsy revealed that there were many amyloid casts in the distal tubules that had a lightly-stained central area and a deeply-stained burr-like edge. The marginal zone of the cast was positive for Congo red staining and contained numerous amyloid fibers, as observed by electron microscopy. No systemic amyloidosis was found. The patient received 4 courses of bortezomib-based chemotherapy, and then, his MM achieved partial remission. Patient 2 is a 57-year-old man who was also clinically diagnosed with MM and AKI. Pathological examination of a renal biopsy showed that there were many crystalline casts in the distal tubules that were fully or partially composed of crystals with different shapes, including rhomboid, needle, triangle, rectangle and other geometric shapes. Congo red staining was negative. Crystals were also detected in the urine of this patient. After 9 courses of treatment with a bortezomib-based regimen, his MM obtained complete remission and his renal function returned to normal. Conclusions LCAC and LCCC nephropathy caused by MM are two rare types of LCCN, and both have their own unique morphological manifestations. LCAC nephropathy may not be accompanied by systemic amyloidosis. The diagnosis of these two unique LCCNs must rely on renal biopsy pathology, and the discovery of urine crystals is of great significance for indicating LCCC nephropathy.

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Systemic light-chain amyloidosis incidentally diagnosed after subtotal parathyroidectomy and thyroid lobectomy

BMJ Case Reports ◽

10.1136/bcr-2020-241282 ◽

2021 ◽

Vol 14 (4) ◽

pp. e241282

Author(s):

Karen Tsai ◽

Alice Chen Yu ◽

Masha J Livhits ◽

Dipti Sajed ◽

Angela M Leung ◽

...

Keyword(s):

Light Chain ◽

Congo Red ◽

Systemic Amyloidosis ◽

Subtotal Parathyroidectomy ◽

Endocrine Organ ◽

Amyloid Deposits ◽

Thyroid Lobectomy ◽

Pacemaker Placement ◽

History Of ◽

Congo Red Staining

A 74-year-old woman with a history of primary hyperparathyroidism, thyroid nodules, atrial fibrillation and pacemaker placement for sick sinus syndrome presented with fatigue, constipation and persistent lower extremity oedema. She underwent subtotal parathyroidectomy and left thyroid lobectomy. Histopathology revealed amyloidosis affecting the thyroidand parathyroids confirmed by Congo Red Staining with Mayo Clinic subtyping of light chain kappa-type amyloidosis. She was found to have combined systolic and diastolic cardiac dysfunction, carpal tunnel neuropathy and pre-diabetes suggestive of systemic amyloidosis with involvement of the heart, nerves and pancreas. Congo red stain was positive for amyloidosis on bone marrow biopsy suggestive of a diagnosis of systemic amyloidosis. She was treated with daratumumab with good clinical response. This case illustrates the necessity of considering systemic amyloidosis in patients with incidentally discovered diffuse amyloid deposits on biopsy of an endocrine organ, as endocrine effects are a rare but likely underdiagnosed consequence of systemic amyloidosis.

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Clinicopathological predictors of postoperative upstaging to invasive ductal carcinoma (IDC) in patients preoperatively diagnosed with ductal carcinoma in situ (DCIS): a multi-institutional retrospective cohort study

Breast Cancer ◽

10.1007/s12282-021-01225-0 ◽

2021 ◽

Author(s):

Kiyo Tanaka ◽

Norikazu Masuda ◽

Naoki Hayashi ◽

Yasuaki Sagara ◽

Fumikata Hara ◽

...

Keyword(s):

Invasive Ductal Carcinoma ◽

Ductal Carcinoma In Situ ◽

Tumor Size ◽

Medical Records ◽

Carcinoma In Situ ◽

Ductal Carcinoma ◽

Palpable Mass ◽

Combined Use ◽

A Prospective Study

Abstract Background We conducted a prospective study with the intention to omit surgery for patients with ductal carcinoma in situ (DCIS) of the breast. We aimed to identify clinicopathological predictors of postoperative upstaging to invasive ductal carcinoma (IDC) in patients preoperatively diagnosed with DCIS. Patients and methods We retrospectively analyzed patients with DCIS diagnosed through biopsy between April 1, 2010 and December 31, 2014, from 16 institutions. Clinical, radiological, and histological variables were collected from medical records. Results We identified 2,293 patients diagnosed with DCIS through biopsy, including 1,663 DCIS (72.5%) cases and 630 IDC (27.5%) cases. In multivariate analysis, the presence of a palpable mass (odds ratio [OR] 1.8; 95% confidence interval [CI] 1.2–2.6), mammography findings (≥ category 4; OR 1.8; 95% CI 1.2–2.6), mass formations on ultrasonography (OR 1.8; 95% CI 1.2–2.5), and tumor size on MRI (> 20 mm; OR 1.7; 95% CI 1.2–2.4) were independent predictors of IDC. Among patients with a tumor size on MRI of ≤ 20 mm, the possibility of postoperative upstaging to IDC was 22.1%. Among the 258 patients with non-palpable mass, nuclear grade 1/2, and positive for estrogen receptor, the possibility was 18.1%, even if the upper limit of the tumor size on MRI was raised to ≤ 40 mm. Conclusion We identified four independent predictive factors of upstaging to IDC after surgery among patients with DCIS diagnosed by biopsy. The combined use of various predictors of IDC reduces the possibility of postoperative upstaging to IDC, even if the tumor size on MRI is larger than 20 mm.

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