Brief reports
5 79
BRIEF REPORT
Localized amyloidosis and transitional cell carcinoma of the same ureter P.W.JOHNSTON & S.W.B.EWEN Utiiversity Department of Putholog!y. Medical Builditigs, Foresterhill. Aberdren. Scotland. U K Date of submission 5 luly 1990 Accepted for publication 17 July 1 990
Keywords: ureter, amyloidosis. transitional cell carcinoma
cm length of ureter which was dilated proximally and displayed. h cm from its distal resection margin, a firm cylindrical segment 1 0 cm long and up to 2 cm in diameter. On section, the ureter was distended by Introduction papillary tumour. Isolated amyloidosis of the ureter is a recognized but Histological sections from the ureter show a papillary unusual entity which generally represents an unextransitional cell carcinoma. (grade 2 ) with variable pected laboratory finding in a nephro-ureterectomy thickness of epithelial investment of tibrovascular specimen removed for ureteric occlusion’. In addition to stroma (Figure l a ) . The ureteric wall was thinned but the 1 3 cases in the literature cited by Farrands and showed no evidence of infiltration by tumour. A few co-workers’. a further four cases have been r e p ~ r t e d l - ~ . collections of lymphocytes and plasma cells were present One case was associated with renal carcinoma’ and in the muscle layers. The ureter distal to the tumour another5 with debatable ureteric epithelial atypia. The showed almost complete obliteration of the lumen by present report is of an unequivocal case of transitional nodules and masses of amorphous eosinophilic material, cell carcinoma associated with amyloidosis of the same compressing the urothelium (Figure 1 b-d). The staining ureter. characteristics of this material are summarized in Table 1 . Electronmicroscopy revealed a meshwork of filaments approximately 7-8 n m in diameter, orientated in a Case report variety of planes (Figure 2). The diagnosis of amyloidosis A 75-year-old farmer had a 20-year history of recurrent of the ureter was made. bladder tumours, classified as low-grade transitional cell Sections from the kidney showed non-specific ‘end papilloma and carcinoma grade 1 . which had been stage’ features, with no evidence of amyloid deposition. treated by local diathermy and regular follow-up. On one such routine cytoscopy. a papillary lesion was noted just Discussion within the left ureteric orifice. Investigation revealed a non-functioning left kidney and ureteric obstruction. A Isolated ureteric amyloid may occur in the absence of left nephro-ureterectomy was subsequently carried out, systemic deposits: such lesions are usually unilateral. but, on the first postoperative day. the patient suffered a although a case where both ureters were involved has cardiorespiratory arrest and died. There was no autopsy. been recorded5.It is uncertain in our patient whether the The past medical history included primary colonic amyloid was isolated or systemic, but the absence of adenocarcinoma 1 1 and 1 7 years previously: on both deposits from vessels and glomeruli in the resected occasions the tumour penetrated the muscularis exterkidney, and from the specimens of bladder and bowel nae but did not involve lymph nodes. received in the past, suggests that the amyloidosis was P A T H O L O G I C A L FINDINGS
The specimen was a hydronephrotic kidney which measured 2 0 cm from pole to pole with a n attached 1 9 Address for correspondence: Dr P.W.Johnston.Department of Pathology. Medical Buildings. Foresterhill. Aberdeen AB9 2 2 3 . LJK,
localized to the left ureter. Ilnlike the case of Mullin et (11. ( 1 984)’ this report provides hard evidence that there was a coexistent papillary transitional cell carcinoma of the ureter. The association of non-neuroendocrine tumours with localized amyloidosis is well-recognized but the mechanism of this association is uncertain’.
580
Hriyf rqmrfs
Figure 1 . a llretcric tumour: papillary transitional ccll carcinoma grade 2. b llreter distal to tumour. showing nodules of amorphous material ompressing urothelium. c (G d IJreter distal to tumour. a (G b H & E. c Congo red. d Congo red in crossed polarized light. x 170.
Brie/ reports
58 1
Figure 2. Electronmicrographs of hyaline material compressing epithelium: a the material has a fibrillary structure which b comprises a 7 - 8 nm filamentous network. a x XOOO. b x 39 900.
Table 1. Staining characteristics of amyloid in a case of ureteric amyloidosis associated with transitional cell cxcinonia
Staining Haematoxylin bi eosin Congo red Sulphated alcian blue Metachromatic blue Thioflavin-T Modified Komhanyi DMAB nitrite Lambda light chain Kappa light chain Human prealhumin P2-microglohulin Serum amyloid A protein* Amyloidt
Eosinophilic Red: green birefringence Bright green Magenta in polarized light Blue in ultraviolet light Red: green birefringence Weakly positive
' negative
* Amyloid A serum component (polyclonal);Calbiochem Corp. La Jolla. CA 92037. USA. Amyloid A component (monoclonal): Dako. High Wycombe, Bucks HP13 5RE. UK.
Whilst there is no doubt that the deposits are amyloid. either histochemically or as seen electronmicroscopically. attempts at precise categorization have proved problematical. The weakly positive results with DMAB nitrite and positive findings with the modified Komhanyi method' tend to suggest this is amyloid of light chain (AL) type, but staining by indirect immunoperoxidase was negative for light chains. Similarly, stains for serum amyloid A protein, human pre-albumin and Pz-microglobulin were unhelpful. Although previously reported experience with amyloid associated with non-neuroendocrine tumours suggests it is of amyloid A type, the staining reactions in the present case do not support such a suggestion. In contrast, the staining favours light-chain origin. AI, amyloid.
Acknowledgements The authors are grateful to Mr J.Steyn. Consultant Urologist, Aberdeen Royal Infirmary. for his cooperation: to Mrs I.M.Watson for typing the manuscript and to Mr P.Kelly and Mrs M.Taylor for technical and photographic assistance.
582
Bricf reports
References 1 . Farrands PA. Tribe CK.Slade N. Localked amyloid of the ureter-
case report and review of the literature. Histopathology 198 3: 7: 613-622.
2 . Willen R. Willen H. Lindstedt E. Ekelund L. Localized primary amyloidosis of the ureter. Scarid. /. Urol. Nrphrd. 198 3; 17; 385389.
3 . Robinson CR. Fowler JE. Localized amyloidosis of the ureter. /. Urol. 19x4: 1 3 1 ; 1 1 0 - 1 11.
4. Miller R. Bowley NB. Localised amyloidosis of the ureter. /. Urol. 1984; 131: 112-1 1 3 . 5. Mullin GM. Trostle DR. Petxer At:. Jaffe JS, Suriici A . Shane J J . Bilateral amyloidosis of the ureter associated wil ti carcinoma. /. Urol. 1984; 132; 1181-1183. 6 . Wright JR. Calkins E. Humphrey KI,. Potassiuni pernianganatc reaction in arnyloidosis. A histologic method LOass,ist in differentiating forms of this disease. I , f h I ~ I V P S ~1977: . 36; 2 74-28 l ,
5 79
BRIEF REPORT
Localized amyloidosis and transitional cell carcinoma of the same ureter P.W.JOHNSTON & S.W.B.EWEN Utiiversity Department of Putholog!y. Medical Builditigs, Foresterhill. Aberdren. Scotland. U K Date of submission 5 luly 1990 Accepted for publication 17 July 1 990
Keywords: ureter, amyloidosis. transitional cell carcinoma
cm length of ureter which was dilated proximally and displayed. h cm from its distal resection margin, a firm cylindrical segment 1 0 cm long and up to 2 cm in diameter. On section, the ureter was distended by Introduction papillary tumour. Isolated amyloidosis of the ureter is a recognized but Histological sections from the ureter show a papillary unusual entity which generally represents an unextransitional cell carcinoma. (grade 2 ) with variable pected laboratory finding in a nephro-ureterectomy thickness of epithelial investment of tibrovascular specimen removed for ureteric occlusion’. In addition to stroma (Figure l a ) . The ureteric wall was thinned but the 1 3 cases in the literature cited by Farrands and showed no evidence of infiltration by tumour. A few co-workers’. a further four cases have been r e p ~ r t e d l - ~ . collections of lymphocytes and plasma cells were present One case was associated with renal carcinoma’ and in the muscle layers. The ureter distal to the tumour another5 with debatable ureteric epithelial atypia. The showed almost complete obliteration of the lumen by present report is of an unequivocal case of transitional nodules and masses of amorphous eosinophilic material, cell carcinoma associated with amyloidosis of the same compressing the urothelium (Figure 1 b-d). The staining ureter. characteristics of this material are summarized in Table 1 . Electronmicroscopy revealed a meshwork of filaments approximately 7-8 n m in diameter, orientated in a Case report variety of planes (Figure 2). The diagnosis of amyloidosis A 75-year-old farmer had a 20-year history of recurrent of the ureter was made. bladder tumours, classified as low-grade transitional cell Sections from the kidney showed non-specific ‘end papilloma and carcinoma grade 1 . which had been stage’ features, with no evidence of amyloid deposition. treated by local diathermy and regular follow-up. On one such routine cytoscopy. a papillary lesion was noted just Discussion within the left ureteric orifice. Investigation revealed a non-functioning left kidney and ureteric obstruction. A Isolated ureteric amyloid may occur in the absence of left nephro-ureterectomy was subsequently carried out, systemic deposits: such lesions are usually unilateral. but, on the first postoperative day. the patient suffered a although a case where both ureters were involved has cardiorespiratory arrest and died. There was no autopsy. been recorded5.It is uncertain in our patient whether the The past medical history included primary colonic amyloid was isolated or systemic, but the absence of adenocarcinoma 1 1 and 1 7 years previously: on both deposits from vessels and glomeruli in the resected occasions the tumour penetrated the muscularis exterkidney, and from the specimens of bladder and bowel nae but did not involve lymph nodes. received in the past, suggests that the amyloidosis was P A T H O L O G I C A L FINDINGS
The specimen was a hydronephrotic kidney which measured 2 0 cm from pole to pole with a n attached 1 9 Address for correspondence: Dr P.W.Johnston.Department of Pathology. Medical Buildings. Foresterhill. Aberdeen AB9 2 2 3 . LJK,
localized to the left ureter. Ilnlike the case of Mullin et (11. ( 1 984)’ this report provides hard evidence that there was a coexistent papillary transitional cell carcinoma of the ureter. The association of non-neuroendocrine tumours with localized amyloidosis is well-recognized but the mechanism of this association is uncertain’.
580
Hriyf rqmrfs
Figure 1 . a llretcric tumour: papillary transitional ccll carcinoma grade 2. b llreter distal to tumour. showing nodules of amorphous material ompressing urothelium. c (G d IJreter distal to tumour. a (G b H & E. c Congo red. d Congo red in crossed polarized light. x 170.
Brie/ reports
58 1
Figure 2. Electronmicrographs of hyaline material compressing epithelium: a the material has a fibrillary structure which b comprises a 7 - 8 nm filamentous network. a x XOOO. b x 39 900.
Table 1. Staining characteristics of amyloid in a case of ureteric amyloidosis associated with transitional cell cxcinonia
Staining Haematoxylin bi eosin Congo red Sulphated alcian blue Metachromatic blue Thioflavin-T Modified Komhanyi DMAB nitrite Lambda light chain Kappa light chain Human prealhumin P2-microglohulin Serum amyloid A protein* Amyloidt
Eosinophilic Red: green birefringence Bright green Magenta in polarized light Blue in ultraviolet light Red: green birefringence Weakly positive
' negative
* Amyloid A serum component (polyclonal);Calbiochem Corp. La Jolla. CA 92037. USA. Amyloid A component (monoclonal): Dako. High Wycombe, Bucks HP13 5RE. UK.
Whilst there is no doubt that the deposits are amyloid. either histochemically or as seen electronmicroscopically. attempts at precise categorization have proved problematical. The weakly positive results with DMAB nitrite and positive findings with the modified Komhanyi method' tend to suggest this is amyloid of light chain (AL) type, but staining by indirect immunoperoxidase was negative for light chains. Similarly, stains for serum amyloid A protein, human pre-albumin and Pz-microglobulin were unhelpful. Although previously reported experience with amyloid associated with non-neuroendocrine tumours suggests it is of amyloid A type, the staining reactions in the present case do not support such a suggestion. In contrast, the staining favours light-chain origin. AI, amyloid.
Acknowledgements The authors are grateful to Mr J.Steyn. Consultant Urologist, Aberdeen Royal Infirmary. for his cooperation: to Mrs I.M.Watson for typing the manuscript and to Mr P.Kelly and Mrs M.Taylor for technical and photographic assistance.
582
Bricf reports
References 1 . Farrands PA. Tribe CK.Slade N. Localked amyloid of the ureter-
case report and review of the literature. Histopathology 198 3: 7: 613-622.
2 . Willen R. Willen H. Lindstedt E. Ekelund L. Localized primary amyloidosis of the ureter. Scarid. /. Urol. Nrphrd. 198 3; 17; 385389.
3 . Robinson CR. Fowler JE. Localized amyloidosis of the ureter. /. Urol. 19x4: 1 3 1 ; 1 1 0 - 1 11.
4. Miller R. Bowley NB. Localised amyloidosis of the ureter. /. Urol. 1984; 131: 112-1 1 3 . 5. Mullin GM. Trostle DR. Petxer At:. Jaffe JS, Suriici A . Shane J J . Bilateral amyloidosis of the ureter associated wil ti carcinoma. /. Urol. 1984; 132; 1181-1183. 6 . Wright JR. Calkins E. Humphrey KI,. Potassiuni pernianganatc reaction in arnyloidosis. A histologic method LOass,ist in differentiating forms of this disease. I , f h I ~ I V P S ~1977: . 36; 2 74-28 l ,
